Surface washes of living cats: an improved method of obtaining clinically relevant allergen

Washing the surface of live anesthesized cats with water results in a solution rich in allergen 1 and low in albumin. CIE and CRIE analysis showed the presence of at least seven antigens. All were shown to be immunologically identical to antigens that occur in pelt extracts and saliva. The only allergens that could be detected in surface washes were allergen 1 and albumin. The animals could be washed at monthly intervals to yield approximately the same quantity of allergen 1. This simple procedure could provide an excellent source of potent cat allergen extracts.

Extrahepatic biliary obstruction associated with pancreatitis

A total of 40 patients with pancreatitis had associated extrahepatic biliary obstruction. Eighteen had biliary-induced pancreatitis. Comprehensive correction of the biliary tract disease, including cholecystectomy, common duct exploration and, when indicated, transduodenal sphincteroplasty, resulted in a high recovery rate (83%) with no recurrence of pancreatitis. Twenty-two patients had chronic pancreatitis with involvement of the terminal biliary tract by a long tapering stenosis. Nineteen of these patients had chronic fibrocalcific pancreatitis secondary to chronic alcohol abuse. In five patients, the stenosis produced a high grade obstruction which required biliary bypass with choledochoduodenostomy (four) or cholecystoduodenostomy (one). The remaining 14 patients maintained patency of the biliary tract following correction of the underlying pancreatic pathology. The latter consisted of drainage (nine) or resection (five) of 14 associated pseudocysts (present in 64% of the 22 patients), combined with side-to-side pancreaticojejunostomy to decompress an obstruction of the major pancreatic duct. In assessing the degree of terminal bile duct stenosis, calibration of the duct with Bakes dilators or rubber catheters was a useful aid. Two of the 22 patients ultimately proved to have carcinomas, producing obstruction of the pancreatic duct in the head of the gland. Both were treated initially with choledochoduodenostomy. This possibility must be considered in the management of these patients.

Prognostic significance of herpes simplex virus antibody status in women with cervical intraepithelial neoplasia (CIN)

A total of 107 women with abnormal cervical smears showing cytological changes consistent with cervical intraepithelial neoplasia (CIN) 1 or CIN 2 were kept under regular cytological, colposcopic, virological and serological surveillance for an average of 18 months (range 9 months-3 years). Regression of the cervical lesion was noted in 31 (29%) and progression to CIN 3 in nine women (8.4%). We found a positive correlation between the presence of type 2 antibody and progression of CIN 1 and 2 to CIN 3 and a negative association with the presence of type 1 antibody and suggest the antibody status of a woman with CIN 1 or CIN 2 may provide a useful basis for follow-up. We found no association between the outcome of the cervical lesion and active infection with herpes simplex or cytomegalovirus or any other infectious agent or sex-related factors.

Isotopic identification of intestinal strangulation

A small series of eleven dogs prepared with a strangulating segment of jejunum demonstrated that a radionuclide, 99mTc-labelled albumin, concentrates in the lumen and bowel wall of the affected intestinal segment. Modern scanning equipment accurately localized the strangulating loop. This technique has the potential of identifying patients with intestinal obstruction, in whom strangulation is a factor, prior to the development of impaired arterial inflow and frank gangrene. These findings confirmed earlier obstructions that were reported when nuclear scanning instrumentation was less sophisticated. Identification of patients at risk for intestinal strangulation requires a high index of suspicion. Excruciating cramping abdominal pain out of proportion to physical findings, roentgenogram evidence, and laboratory studies should alert the physician to the possibility of intestinal ischemia and closed loop obstruction. Radionuclide scanning in such cases may be of assistance in defining or excluding the diagnosis of a strangulating mechanism. The test is simple, relatively economical, and represents a low risk procedure to patients. It would have no place when the classic physical and laboratory findings of intestinal infarction are present.

A standardized quantitative skin-test assay of allergen potency and stability: studies on the allergen dose-response curve and effect of wheal, erythema, and patient selection on assay results

A quantitative skin-test assay of allergenic potency was developed and tested on 28 allergic patients. The best-fit linear regression line was calculated from the sum of erythema or wheal diameters obtained from four intradermal threefold serial dilutions near the endpoint. Each line must have a correlation coefficient greater than 0.85 and the slopes of reference and test extract lines must not be significantly different. The relative potency can be calculated from the horizontal distance between the reference and test lines. The between-assay reproducibility was determined by comparing references against themselves. The 95% confidence limits were 54% to 186% when erythema was used and 27% to 367% when wheal was used. The narrower limits for the assay using erythema maybe due to the 5.5 times steeper slope of erythema lines than wheal lines. Potency results on five commercial extracts were highly correlated with potency results by RAST, AgE assay, or rye I assay. Extracts with isolectric focusing patterns dissimilar from the references were of significantly lower potency by in vivo and in vitro assays. The measured potency of two low-potency short ragweed extracts varied significantly with patient sensitivity to heat-stable and heat-labile ragweed allergens, indicating that patient selection may significantly affect assay results. Dose-response lines using either histamine or short ragweed by puncture (P) and intradermal (ID) techniques in the same patient showed that P/ID dose for equal erythema response was 909 for histamine and 31,250 for ragweed. This quantitative skin-test assay is highly re[rpdicob;e, yields potency data comparable to those of in vitro tests, can be applied to studies of extract stability, and is suitable as a primary bioassay of allergenic activity.

Origin of tubular complexes in human chronic pancreatitis

Tissue samples from seven patients with chronic pancreatitis were studied by light and electron microscopy, using samples from the pancreas of seven organ donors as a reference group. Tubular complexes were observed in four of the patients with chronic pancreatitis. Tubular complexes, which have been interpreted as resulting from "ductular reduplication" in other studies of chronic pancreatitis, and "ductular proliferation" in studies of pancreatic adenocarcinoma, were studied carefully to determine their origin. Extensive retrogressive changes in acinar cells leading to diminished zymogen granules, decreased cell height, and concomitant increase in luminal diameter were consistent with the interpretation that phenotypic modulation of acinar cells to take on the characteristics of ductular cells produced the tubules. This it is concluded that in chronic pancreatitis, as has been shown for pancreatic adenocarcinoma, the tubular complexes originate from acinar cells rather than from proliferation of preexisting ductules. Fibrosis and thickening of the basal lamina of exocrine pancreatic cells and capillaries were consistent with an altered capability for transmission of material between blood vessels and exocrine cells.

Treatment of cervical intraepithelial neoplasia with the carbon dioxide laser: report of 543 patients

Five hundred forty-three patients with cervical intraepithelial neoplasia were treated with the carbon dioxide laser and 441 have been seen for follow-up. The success rate was 76.4% after 1 treatment and 98% after 2 treatments. Many patients who returned with apparent minor abnormalities at the first follow-up visit had normal colposcopic results and Papanicolaou smears 6 months later. The complication rate was low, and no significant problems were caused by pain or bleeding at the time of treatment. Postoperative hemorrhage requiring hospital admission occurred in 1% of patients. Laser treatment should be carried out only in departments with colposcopic expertise.

Reliability of endometrial aspiration cytology in the assessment of endometrial status

One hundred twenty women attending routine gynecologic clinics were investigated by endometrial aspiration cytology to determine whether outpatient assessment of endometrial status could be used to determine subsequent patient management. The results show that this technique allows recognition and distinction between cystic hyperplasia, adenomatous hyperplasia, and carcinoma, and the time of the menstrual cycle can be assessed when the endometrium is normal. Endometrial aspiration cytology is valuable in gynecologic practice for determining which women with abnormal bleeding, both premenopausal and postmenopausal, require further investigation. Furthermore, the technique has a role to play in monitoring the status of the endometrium in women at high risk of endometrial malignancy, particularly those receiving hormone replacement therapy.

Antigenic and allergenic changes during storage of a pollen extract

The changes that occur in the antigens and allergens of a timothy grass pollen extract during storage were measured by radioallergosorbent test (RAST) inhibition, isoelectric focusing, (IEF), crossed immunoelectrophoresis (CIE) and crossed radioimmunoelectrophoresis (CRIE) and a dye-binding protein assay. Storage intervals varied from 7 to 92 days at temperatures of 4 degrees, 22 degrees, and 35 degrees C and the freeze-dried extract was rehydrated and stored in either phosphate-buffered saline with 50% glycerol (PBSG) or Coca's solution (CS). For extracts stored in CS at 35 degrees C, allergenic activity as measured by RAST inhibition dropped by almost one half at 7 days and certain of the IEF, CIE, ad CRIE bands were no longer visible, showing that these properties correlated with allergenic activity. After 65 dys, no IEF bands were visible but three CIE bands could be visualized. At 22 degrees the changes were slower and at 4 degrees C no changes were observed for the 92-day storage time. Extracts stored in PBSG showed some of the same changes but were much more stable at all temperatures. During storage, the protein content as measured by dye binding was also reduced, showing tha proteins were fragmenting. Because some of the allergenic proteins disappeared more rapidly than others, there was not only a loss in total allergenic activity but also a change in specificity. This raises serious questions concerning the use of such extracts, especially for diagnosis.

Diffuse nonlobular ovarian androblastoma usually associated with feminization

The unusual pleomorphism of ovarian androblastoma calls for the definition of further subgroups and fuller use of the available interpretative ideas. A set of six cases forming a possible subgroup is presented. Functionally these were mainly estrogenic. Structurally they showed a diffuse fibrothecomatous or thecogranulosal background with foci of limited and sexually equivocal differentiation. Lutein cell clusters were present in all cases and tubules were present in five. The ideas developed for interpreting the androblastoma family are reviewed historically and related to the foregoing. The criteria of testicular differentiation, and the relation of endocrine function to morphology and age, are discussed.

Hemorrhagic complications of severe pancreatitis

Massive hemorrhage associated with pancreatitis is a rare but frequently lethal complication. Fifteen patients with this complication are presented. Bleeding occurred in four patients with necrotizing pancreatitis, in three patients with pancreatic abscesses, in seven patients with pseudocysts, and in one patient with chronic relapsing pancreatitis following longitudinal pancreaticojejunostomy. The initial presentation of hemorrhage was gastrointestinal in eight patients and retroperitoneal or intraperitoneal in seven. Abdominal pain with associated nausea and vomiting was present in all patients on admission. Duration of symptoms prior to hospitalization averaged 6 days. During hospitalization the 15 patients received a total of 512 units of blood for transfusions ranging from 8 to 177 units. Admission amylase values were of no benefit in assessing severity of the disease, but application of Ranson's criteria accurately predicted both severity and prognosis. The common denominator in all cases of bleeding appeared to be the presence of an overwhelming or continuing inflammatory process with necrosis and erosion of adjacent vascular and visceral structures. The overall mortality rate in the series was 53.3%. Those patients with hemorrhage associated with pseudocyst formation had the highest survival rates, whereas those with necrotizing pancreatitis and hemorrhage had an extremely poor response to aggressive medical and/or surgical management.

Allergenically active components of cat allergen extracts

The allergens involved in cat allergy have been studied in pelt extracts, saliva, serum, and urine. Using crossed immunoelectrophoresis (CIE) to examine the antigenic content, and crossed radioimmunoelectrophoresis (CRIE) and RAST to examine the allergenic content, it was found that allergen 1 of Dr. Ohman is the most important allergenic component, whereas albumin and several unidentified proteins play a minor role. Allergen 1 was not detectable in serum and urine. The allergenic and nonallergenic proteins of pelt extract and saliva were identical by CIE, suggesting that pelt extract proteins are mainly of salivary origin.

Allergenically active components of cat allergen extracts

The allergens involved in cat allergy have been studied in pelt extracts, saliva, serum, and urine. Using crossed immunoelectrophoresis (CIE) to examine the antigenic content, and crossed radioimmunoelectrophoresis (CRIE) and RAST to examine the allergenic content, it was found that allergen 1 of Dr. Ohman is the most important allergenic component, whereas albumin and several unidentified proteins play a minor role. Allergen 1 was not detectable in serum and urine. The allergenic and nonallergenic proteins of pelt extract and saliva were identical by CIE, suggesting that pelt extract proteins are mainly of salivary origin.

Yolk sac and allied tumours of the ovary

A review is presented of the histological appearances of 38 yolk sac tumours of the ovary and four so-called embryonal carcinomas together with the associated clinical features. It is suggested that these neoplasms belong to a single taxonomic group of embryonal ovarian tumours differing only in the concomitant types of differentiation. One yolk sac tumour occurred in an individual of 46 XY chromosome constitution and another in a patient with a gonadoblastoma in the contralateral ovary. The value of post-operative serial assays of serum AFP is stressed.

Sertoli-Leydig cell tumors: a clinicopathologic study of 34 cases

Thirty-four cases of Sertoli-Leydig cell tumor were studied. All tumors were limited to the ovary at the time of initial surgery. Eight tumors were well differentiated, 15 were of intermediate differentiation, and 11 were poorly differentiated. Six cases contained heterologous elements. The less differentiated tumors occurred in patients with a lower median age and were more likely to produce androgenic manifestations. Follow-up of one year or longer was obtained in 15 patients, with an average follow-up in these patients of 6.1 years. Only one patient, who had a poorly differentiated tumor, died of the neoplasm in this series. Although follow-up was limited in this study, our findings suggest that the better differentiated tumors have a relatively favorable prognosis. This neoplasm is composed of sex-cord and stromal elements, and its components have the capacity to a greater or lesser extent to recapitulate the cells of the testis at different stages of development.

The surgical therapy for perforated gastric cancer

The treatment of nine cases of perforation secondary to gastric carcinoma was reviewed. Resectional therapy appears to be the preferred approach to perforated gastric cancer. When the patient's condition or the extent of the disease preclude gastrectomy, the technique of plication with omental patch proved to be a satisfactory alternative in this small series. A review of the literature disclosed conflicting views on the usefulness of this procedure for perforated gastric cancer.

Aspiration cytology versus histology in the assessment of the endometrium of women attending a menopause clinic

The endometrium of 100 women attending a menopause clinic was assessed cytologically, using the Isaacs cell sampler, and then histologically, using the Vabra suction curette. Satisfactory specimens for diagnosis were obtained in 96 per cent of cases with the Isaacs cell sampler and in 62 per cent of cases with the Vabra suction curette. There were eight discrepancies between the diagnoses obtained by the cytological and histological methods and these are analysed. Thirty patients were asked to grade the discomfort experienced during the procedures, and of these 26 found the Vabra method more painful than the Isaacs method.

The heat stability of short ragweed pollen extract and the importance of individual allergens in skin reactivity

A short ragweed pollen extract that was heated in a boiling-water bath remained skin reactive for some allergic individuals and lost reactivity for others. Comparison of heated and unheated extract by immunodiffusion showed that AgE, AgK, and Ra3 could not be detected in the boiled extract but Ra5 was present. By inhibition of the radioallergosorbent test the concentration of Ra5 remained essentially unchanged, but the concentrations of AgE and Ra3 were greatly diminished. The sera of these ragweed-allergic individuals were analyzed for IgE antibodies to AgE, Ra3, and Ra5. Skin reactivity in 17 ragweed-allergic individuals to the heated extract correlated significantly with the levels of IgE antibodies to Ra5. However, the large number of individuals reacting to the boiled extract indicates that Ra5 is not likely to be the only heat-stable allergen. Skin reactivity of the unheated extract did not correlate with IgE antibody levels to any allergen. The results underscore the importance of individual allergens in the materials used for skin testing.

Cervical crypt involvement by intraepithelial neoplasia

Knowledge of the frequency and extent of crypt involvement by cervical intraepithelial neoplasia (CIN) is important when treatment by electrodiathermy, cryosurgery, or the laser is considered. Three hundred forty-three therapeutic cone biopsies carried out at The Samaritan Hospital for Women, London, have been reviewed histologically. Measurements were made of the deepest crypt in each specimen and of the deepest crypt that contained CIN. The mean depth of involved crypts was 1.24 mm, and the mean depth of uninvolved crypts was 3.38 mm. Thus, destruction of tissue to a depth of 2.92 mm (mean + 1.96 SD) would eradicate all involved crypts in 95% of patients, whereas destruction to a depth of 3.80 mm would eradicate 99.7% (mean + 3 SD). There is also an increase in the depth of crypt involvement with increasing age, but the differences between the age groups are not statistically significant.

Ovarian sex cord tumours with annular tubules

Five cases of ovarian sex cord tumours with annular tubules are presented. The ages of the patients ranged from 8 to 45 years and the size of the tumours varied from 1 to over 18 cm in diameter. All patients presented with evidence of hormonal disturbance and two appeared to have excess gonadotrophin production. The Peutz-Jeghers syndrome was not described in any patient. The possible origin of the tumour is discussed.

Successful embolization of the dorsal pancreatic artery to control massive upper gastrointestinal hemorrhage

Selective arterial embolization is an established technique to control gastrointestinal bleeding in patients who are poor surgical risks and in whom bleeding is uncontrolled by other methods. This article describes the control of upper gastrointestinal bleeding by subselective embolization of a bleeding branch of the dorsal pancreatic artery in a patient with severe pancreatitis. This is the first recorded successful embolization of the dorsal pancreatic artery to control hemorrhage.

Pseudocyst of the head of the pancreas: relationship to the duct of Santorini

A series of 14 patients with chronic alcoholic pancreatitis is presented which illustrates that cysts originating in the superior segment of the head of the pancreas communicate with the duct of Santorini which normally drains this area of the gland. Cysts in this location do not communicate with the major pancreatic duct (Wirsung) in most instances, and therefore may be overlooked in the standard retrograde drainage procedures employed to relieve pancreatic exocrine obstruction.

Pancreatic enzyme levels in bile of patients with extrahepatic biliary tract disease

A total of ninety three patients with biliary tract disease were studied to determine the concentration of the pancreatic enzymes, amylase and lipase, in bile obtained from the gallbladder and/or common bile duct. Of seventy gallbladder bile samples, amylase levels were higher than actual or predicted serum levels in 87 per cent, while bile lipase were higher than serum lipase values in 66 per cent. Bile obtained from the common bile duct had enzyme concentrations which fluctuated from values similar to those in serum to remarkably high levels. This suggests that pancreatic enzymes enter the biliary system through a common terminal ampulla which is known to exist in 60 to 90 per cent of human subjects. The premise is advanced that pancreatic enzymes may initiate inflammatory changes in the gallbladder and could play a role in gallstone formation by altering the constituents which maintain cholesterol in a soluble state. Biliary reflux of pancreatic enzymes could play a role in the pathogenesis of some cases of cholecystitis can cholelithiasis.

Pancreatic enzyme levels in bile of patients with extrahepatic biliary tract disease

A total of ninety three patients with biliary tract disease were studied to determine the concentration of the pancreatic enzymes, amylase and lipase, in bile obtained from the gallbladder and/or common bile duct. Of seventy gallbladder bile samples, amylase levels were higher than actual or predicted serum levels in 87 per cent, while bile lipase were higher than serum lipase values in 66 per cent. Bile obtained from the common bile duct had enzyme concentrations which fluctuated from values similar to those in serum to remarkably high levels. This suggests that pancreatic enzymes enter the biliary system through a common terminal ampulla which is known to exist in 60 to 90 per cent of human subjects. The premise is advanced that pancreatic enzymes may initiate inflammatory changes in the gallbladder and could play a role in gallstone formation by altering the constituents which maintain cholesterol in a soluble state. Biliary reflux of pancreatic enzymes could play a role in the pathogenesis of some cases of cholecystitis can cholelithiasis.

Meckel's diverticulum of the proximal jejunum

There are no well-substantiated reports, to our knowledge of a Meckel's diverticulum arising outside the limits of the terminal ileum. We saw a diverticulum located in the proximal jejunum that fulfilled the anatomic and histologic criteria for the diagnosis of a Meckel's diverticulum. This was an incidental finding during the treatment of a sliding esophageal hiatus hernia and caused no apparent difficulty to the patient.

Education as a hidden cost in ambulatory care

Since nearly a quarter of this nation's hospitals' outpatient and emergency rooms engage in medical education, it is of critical importance for administrators to determine the extent to which medical training influences the operational costs and efficiency of patient care for those services in their facilities. A computer simulation model has been developed at a midwest adult medical clinic to study the effects of ambulatory medical training on clinic operations. The model is capable of showing changes in the facility without disrupting the work flow and thus reduces the problems associated with long-term data collection. Various staffing patterns, both with and without medical training, were compared for the operational effects, patient convenience, and costs. The article offers probability distributions based on actual clinic experience. The research identifies and evaluates the trade-offs that must be considered when medical education is incorporated in an ambulatory program. Since both the faculty and students must take time away from direct patient care for consultation, more clinic time is required, causing staff costs to increase and patient care efficiency to decrease. The model demonstrates that when teaching loads increase, the faculty become less available to residents which results in resident inefficiency and longer patient waiting time. These operational consequences demonstrate the basic management problems of the need for balance between the demand for clinical teaching time and the demand for efficient service delivery in a solid ambulatory care/teaching program.

Endometrial assessment with Isaacs cell sampler

The value of the Isaacs endometrial cell sampler in the cytologic assessment of the endometrium was studied in 121 unanaesthetised patients aged over 40. Satisfactory aspirates for cytological diagnosis of endometrial state were obtained in 111 patients (91%) whereas endometrial specimens for histological diagnosis were obtained in only 89 patients (79%). In only four out of 83 cases were there diagnostic discrepancies between the aspirates and the curettings. It is concluded that the technique is safe, quick, comfortable, and reliable for assessing endometrial state. It should therefore prove valuable for screening, particularly in the management of menopausal women requiring oestrogen treatment.

A clinico-pathological study of gonadoblastoma

The clinico-pathological features of 12 patients with a gonadoblastoma are analyzed.

Adenocarcinoma of the uterine cervix a clinical and pathological appraisal

Twenty-six cases of primary adenocarcinoma of the cervix are analyzed. Their clinical features are described and attention is drawn to the variable histological pattern of these tumors.

Microcirculation of the normal and inflamed canine pancreas

Pancreas of normal dogs and the inflamed gland of experimental pancreatitis were studied by intra-arterial injection of Microfil, a silicone-rubber compound especially suited for study of the microcirculation. Duodenal vasculature and lobular vessels of the pancreas were studied as were those supplying the duct. Inter-lobular vessels were well visualized in the normal pancreas and intralobular vessels formed a fine reticular pattern throughout the cleared lobules. A complex network of vessels in the pancreatic duct was observed using this technique, apparently derived from the interlobular vessels. The blood supply of each layer of the duodenum was evaluated. Intraductal trypsin injection produced focal areas of pancreatitis associated with edema, poor vascular filling and spastic changes of the lobular vessels. Extravasation of Microfil, although not apparent on normal specimens, was prominent in inflamed specimens and suggested vascular weakness and disruption. Pancreatic lobules adjacent to inflammatory areas showed definite evidence of dilatation. The inflamed pancreatic ducts were markedly edematous, thickned, and showed incomplete vascular filling. When the duodenum adjacent to pancreatitis was injected with Microfil, edema and vasoconstriction were especially prominent in the duodenal muscular layer.

Gynandroblastoma of the ovary

A gynandroblastoma of the ovary in a 17-year-old girl is reported. Primary amenorrhoea, hirsuties and slight clitoral enlargement were associated with the tumour and high levels of circulating testosterone were found. This is the first gynandroblastoma in which Reinke crystalloids have been identified in the Leydig cell component. The criteria for the diagnosis of this tumour and its histogenesis are discussed.

[A model for global child care in a teaching hospital]

Foi apresentado um modelo de atendimento multiprofissional para uso em hospital escola, embasado numa visão global da problemática de saúde da criança. A utilização do modelo, pela sistematização de dados considerados básicos, permite além da identificação específica das condições físicas e psico-sociais da criança, um conhecimento da situação familiar e caracterização da comunidade. Com estes elementos, torna-se factível a elaboração de um diagnóstico global, visando o tratamento da criança, a modificação de situações ambientais desfavoráveis à criança ou reforço de condições favoráveis a seu melhor crescimento e desenvolvimento. Esta abordagem, com relação à assistência, possibilita um tratamento que atenda às necessidades da criança nos seus aspectos biológico, cognitivo, afetivo e psicomotor. Com relação ao ensino, favorece a formação de profissionais com uma visão biológica e psico-social de saúde, dando oportunidade para desenvolvimento de trabalho em equipe multiprofissional. Em termos de pesquisa, permite a realização de estudos de normalização de atendimento nas áreas médica, de serviço social, de enfermagem, de nutrição e de educação para a saúde.