Passages: fact or fiction?

Four large surveys were examined to establish the existence of "passages" through the use of objective methods. Such passages are the boundaries between age groups formed on the basis of minimum within-group variation and maximum between-group variation. Results from all four data sets indicated that such age groups and their associated passages can be identified. These passages were stable across two surveys taken in the same population at about the same time, even though the surveys measured divergent attitude dimensions. The passages appear to progress with time: two surveys taken seven years apart demonstrated a seven-year shift in passages. However, the passages are not stable across cultures: two surveys taken at about the same time in Canada and the United States showed no similarity of passages. It would appear that developmental schemes as presently espoused by psychologists are inadequate to explain these results, and that the "generational event" theory provides a better model for explanation.

[Computed tomography and the clinical picture of carcinoma of the uterine cervix]

The clinical and computer tomographic findings in 142 patients with carcinoma of the body of the uterus have been compared. The CT findings at the first examination were then compared with the clinical results. The likelihood of a recurrence was related to infiltration of the parametrium. There was strong positive correlation between the CT findings during treatment and the probability of recurrences. The wealth of information provided by computed tomography makes any other form of investigation during tumour staging and during follow-up unnecessary.

Peripheral neuropathy with IgM kappa monoclonal immunoglobulin directed against myelin-associated glycoprotein

Three patients with a monoclonal IgM kappa paraproteinemia had a slowly progressive segmental demyelinating peripheral neuropathy. Sural nerve biopsies showed predominantly large fiber loss, with widening of the intraperiod line of myelin associated with active demyelination. Immunoblot analysis showed reactivity of IgM to myelin-associated glycoprotein (MAG) of human myelin. An enzyme-linked immunosorbent assay (ELISA) was developed to provide a simple quantitative technique for detection of antibodies to MAG. Treatment with corticosteroids, immunosuppressive agents, and plasmapheresis produced no significant improvement.

Incidence of lung cancer among iron miners

A study has been performed using 5300 iron miners from Lorraine (France) with ages ranging from 35 to 55 years, who were working, and had a normal chest radiography. 1173 workers were chosen randomly and given the following examinations: questionnaire, clinical examination and function tests (VC, FEV1, residual volume (RV), acetylcholine test, carbon monoxide steady-state test). This group of 1173 was followed for 5 years. 40 died and the exact causes of death were known. 13 had lung cancer, which is more than three times the number expected in the French male population of the same ages. All subjects who died from lung cancer were underground miners and, at the first examination, had a higher incidence of bronchitis and more functional defects than both the 27 who died from other causes and the underground miner group as a whole. The excess mortality due to lung cancer is discussed with regard to noxious agents that were measured (radioactivity, which was rather low, total and respirable dusts, Nox, CO) and with regard to both the work environment and duration of work.

The effect of danazol on gonadotropin secretion during the follicular phase of the menstrual cycle

The effects of danazol on pulsatile luteinizing hormone (LH) release, basal LH and follicle-stimulating hormone serum levels, gonadotropin release induced by estradiol (E2) and gonadotropin-releasing hormone were examined in five eugonadal women. Danazol administration resulted in a significant suppression of follicle-stimulating hormone serum levels. LH concentrations and LH pulse frequency appeared to be reduced, but these changes did not reach statistical significance. The pituitary response to exogenous gonadotropin-releasing hormone was not altered. The stimulatory effect of E2 on LH secretion was completely abolished in one subject, severely diminished in three subjects, and unchanged in one subject. In addition, the time course of this response was altered. Serum prolactin concentrations were lowered, whereas basal E2 and progesterone levels did not seem to be affected.

Urethritis in men: benefits, risks, and costs of alternative strategies of management

Four alternative strategies for the management of men with acute urethritis were analyzed: treating patients with tetracycline, with or without a urethral culture, without basing the initial treatment decision on the results of a gram-stained smear; treating patients with penicillin, without basing initial treatment on the results of a gram-stained smear; basing initial treatment with tetracycline or penicillin on the results of a gram-stained smear; and basing treatment on the results of both a gram-stained smear and a culture. The tetracycline strategy resulted in fewer days of morbidity, a lower probability of premature death, lower dollar costs, and a much lower rate of uncured nongonococcal urethritis, but in slightly higher rates of uncured gonorrhea and syphilis than more traditional strategies. Use of culture with the tetracycline strategy (1A) permitted tracing of gonorrhea contacts, achieved the same low morbidity, and added little cost. The conclusions were true regardless of the probability of gonorrhea and for reasonable estimates of probable compliance with oral medication regimens. Test-of-cure cultures for patients who were asymptomatic after treatment for gonorrhea required the expenditure of from $4,900 to $109,800 for each case of asymptomatic persistent gonorrhea discovered and cured, depending on the strategy used.

[CEA and the clinical course in advanced carcinoma of the uterine cervix (author's transl)]

The clinical course of six representative patients suffering from advanced carcinoma of the uterine cervix and with elevated and borderline levels of CEA in serum prior to therapy is correlated in detail with the pattern of CEA in serum during and after therapy. It is shown that there is a close correlation between the serum CEA pattern and the course of the disease. Thus, serial CEA measurements in serum appear to be of value in the follow up of patients with carcinoma of the uterine cervix.

Surveillance of bromocriptine in pregnancy

Information was collected on the outcome of 1,410 pregnancies in 1,335 women to whom bromocriptine mesylate (Parlodel) had been given, primarily in the early weeks of pregnancy. These Pregnancies resulted in 197 early terminations (14%) (including 25 induced abortions [1.8%) and in 1,213 births (86%). The incidence rate of spontaneous abortions (11.1%), extrauterine pregnancies (0.9%), and minor (2.5%) and major (1.0%) malformations is comparable with that quoted for normal populations, and the incidence of twin pregnancies (1.8%) is slightly but not significantly raised, if correction is made for concomitant therapy with other agents inducing ovulation. The data suggest that the intake of bromocriptine during pregnancy is not associated with an increased risk to the fetus.

Clinical significance of measurements of carcinoembryonic antigen in serum of patients with carcinoma of the uterine cervix

Serum levels of carcinoembryonic antigen (CEA) were determined radioimmunologically before initiation of therapy in the serum of 88 patients suffering from carcinoma of the uterine cervix. The overall incidence of elevated CEA levels (above 12 ng/ml) was 43%. There was a positive correlation between the incidence of elevated CEA levels and the clinical stage of disease. CEA levels before treatment had no prognostic value as far as median survival time was concerned. In contrast, CEA levels measured immediately after therapy in patients with initially elevated levels turned out to be of prognostic significance. When the posttreatment concentrations of CEA were within the normal range, the median survival time was longer than 990 days (duration of follow-up). When the CEA levels remained elevated, however, the median survival time was only 291 days. Thus, CEA measurements appear to be an additional tool in the follow-up of

Altered consciousness as a precocious manifestation of intussusception in infants

Two infants aged 5 and 8 months respectively who developed a marked alteration in consciousness as a precocious manifestation of ileo-colic intussusception are reported. Previously described abnormalities of central nervous system function accompanying intussusception are reviewed. It is suggested that in the face of acutely altered sensorium without apparent cause in the infant the diagnosis of intussusception should be considered.

Overview: deinstitutionalization of psychiatric patients, a critical review of outcome studies

The authors performed a critical review of experimental studies on the outcomes for psychiatric patients of 1) alternatives to hospital admission, 2) modifications of conventional hospitalization, and 3) alternatives to continued long-term hospitalization. The internal validity of many of the studies was compromised by shortcomings in design and performance and generalizability limited by selection of patient populations. With these qualifications experimental alternatives to hospital care of patients have led to psychiatric outcomes not different from and occasionally superior to those of patients in control groups. This conclusion is best supported for alternatives to admission and for modifications of conventional hospitalization. The available studies do not permit firm conclusions regarding alternatives to continued long-term hospitalization of chronically ill patients or for a critical analysis of the optimal management of specific subpopulations of psychiatric patients. Satisfactory deinstitutionalization appears to depend on the availability of appropriate programs for care in the community.

Coronary artery bypass graft surgery: clinical decision making and cost-effectiveness analysis

Decision-analytic techniques were used to evaluate the choice between an aortocoronary bypass operation and medical management in a set of hypothetical patients with coronary artery disease. The decision framework incorporates variables believed to have an important bearing on the choice of treatment. Probability estimates were obtained from two cardiologists and one cardiac surgeon. Patient preferences for the trade-off between years of survival and the quality of life as reflected by the severity of angina pectoris were made explicit by assigning utility values to alternative health outcomes. The results are expressed in terms of quality-adjusted years of life expectancy. Decision analysis favored operation for 13 of the 14 hypothetical patients, including patients with one- and two-vessel disease. The one patient for whom medical treatment was preferred had mild angina pectoris, severe left ventricular dysfunction, and a poor prognosis regardless of therapeutic modality. The results are sensitive to changes in the probability of long-term survival, but not to changes in operative mortality rates. In five patients, the physicians' clinical judgments favored medical treatment, whereas their decision-analysis-derived estimates of survival favored operation. Possible explanations for these discrepancies are discussed. A simplified cost-effectiveness analysis for patients in whom surgery was the optimal treatment indicated costs ranging from $1,500 to $250,000 per year of life gained and from $1,500 to $32,000 per quality-adjusted year of life gained.

The clinical management of suspected herpes virus encephalitis. A decision-analytic view

This study addresses the issues of brain biopsy and adenine arabinoside (Ara-A) therapy in the clinical management of patients suspected of having herpes simplex virus encephalitis (HVE). The analysis does not speak to experimental studies in which brain biopsy and new therapies are justified by investigational goals outside the scope of this analysis. Decision analytic techniques are used, employing published quantitative data and subjective estimates of probabilities provided by experts in the management of this condition. In patients with features indicative of a high likelihood of HVE--evidence of acute encephalopathy, focal cerebral signs, objective evidence of localization and cerebrospinal-fluid findings compatible with viral infection--a strategy of treating with Ara-A without brain biopsy is consistent with optimal survival under current central estimates for mortality at biopsy, therapeutic effectiveness, drug toxicity, and sensitivity and specificity of brain biopsy. This results depends primarily upon the apparent low toxicity of Ara-A, the relatively high likelihood of HVE in typical clinical presentations and the presence, although at a low rate, of falsely negative biopsy reports expected in the disease. Sensitivity analyses are presented to explore the effects of changes in estimates of values for important variables on the choice of a strategy for clinical management. The analysis provides a structure for assessing the clinical significance of new information on such relevant variables as drug toxicity, biopsy sensitivity and mortality, and the yield of treatable new conditions other than HVE diagnosed by brain biopsy.

Primary ureterocalycostomy for severe hydronephrosis in children

Fourteen children are described in whom primary ureterocalicostomy was performed for severe hydronephrosis due to pyeloureteral obstruction. Seven of them presented a horseshoe kidney. After a follow-up varying from 1 to 6 1/2 yr, clinical and radiologic improvement was obtained in 12 patients. Exclusion of decompensated renal pelvis and formation of strictly declivous drainage system, especially benefiaial in the case of horseshoe kidney, are two advantages of this procedure. The most important technical consideration is adequate resection of the renal cortex in order to free the large ureterocaliceal anastomosis from the surrounding cortical tissue. It is concluded that primary ureterocalicostomy is the operation of choice for hydronephrosis associated with a horseshoe kidney. This procedure is not advised, however, for simple though severe, hydronephrosis.

Surgical correction of caudal duplication

The authors report the rare case of a dipygus monster. The infant had an omphalocele, a secondary pelvis with two limbs, an accessory pelvic kidney, and two bladders. At operation, the secondary pelvis and extremities were removed, and the omphalocele was repaired. The postoperative course was complicated by wound infection, urinary infections, proteinuria, cardiomegaly, and hypertension of renovascular origin. The infant died after right nephrectomy, 5 mo after the first operation.

Pituitary tumours during pregnancy in mothers treated with bromocriptine

1 Out of 805 previously infertile women in whom pregnancy was achieved on bromocriptine treatment, 137 were diagnosed as having pituitary tumours. 2 In nine of these, tumour-related complications occurred during pregnancy, chiefly visual field impairment. Surgical intervention was considered necessary in two patients. In a third patient reinstitution of bromocriptine produced remission of symptoms. 3 Although the frequency of serious complications was low, the present state of knowledge indicates that surgery or irradiation of pituitary tumours should be preferred, at least as the first line of treatment, for patients contemplating pregnancy.

[Should the lung cancer of iron-miners in Lorraine be considered an occupational disease? (author's transl)]

The occupational group composed of the iron-miners working at the bottom of the mines in Lorraine makes up a high risk population for lung cancer (The carcinogenic index is 5 to 12 times as high as that of the population of non-miners). The authors report a new series of 270 cases in support of this assertion. The cancers have few particular characteristics. Their genesis appears to be related with the action of many co-factors: tobacco, various gases and noxious dust, iron particles. Our findings are similar to those of the Swedish, British and Russian authors. The occupation of iron-miner at the bottom of the mine appears then to favorize the manifestation of lung cancer. So it would be fair to consider this tumor an occupational disease, as with asbestosis.

[A case of endothelial splenic cyst in an infant]

The authors report a case of isolated splenomegaly in a healthy 7-year-old boy, not showing any other clinical or biological anomaly. The radiological examination (selective arteriography of left renal artery) and spleenscan were compatible with an intrasplenic process. The splenectomy was performed. The spleen was large (15/20 cm) and demonstrating a cystic lesion in the inferior pole. Histological examination revealed polycystic formations covered with endothelial type cells and associated with angiomatous multifocal lesions. Differential diagnosis of cystic lesions of the spleen is discussed and complete preoperative investigation is stressed.

Outcome of pregnancy in mothers given bromocriptine

1 Information has been obtained on the outcome of 448 completed pregnancies in mothers who had been given bromocriptine at some stage in the early weeks of pregnancy. 2 The frequencies of spontaneous abortions, twin pregnancies and malformations have been compared with those reported for 'normal' populations. 3 Based on this limited material, we conclude that the use of bromocriptine to restore fertility in hyperprolactinaemic women is not associated with an increased risk of abortion, multiple pregnancy or the occurrence of malformations in the infants.

Intramural diverticulosis of the esophagus in an eight-year-old boy

A third pediatric case of intramural diverticulosis of the esophagus is reported in an 8-year-old boy. A hiatal hernia, chronic nonspecific esophagitis and defective esophageal motility was also documented in his 10-year-old brother.

[Pseudo-correlation between neurotic somatic diseases and social class]

The hypothesis that neurotic bodily complaints are dependent on social class, sex, and age, was tested using a representative sample of size N=1549. It is shown that bodily complaints are dependent on age and sex, but independent of social class. Correlations of -.41 between age and education and of -.22 between education and sex were obtained, suggesting that the correlation found in earlier investigations between social class and neurotic bodily complaints were in fact due to the common dependence on sex. It is shown, however, that psychosomatic conceptions of bodily complaints are dependent on social class. People from higher social classes interpret their complaints significantly more frequently as being due to psychological factors. The consequences for the doctor-patient-relationship, which may be drawn from these results, are discussed.

[Significance of plasma-protein paracoagulation test in the diagnosis of thromboembolic the disease]

Fibrinogen degradation products were examined by plasma protamine paracoagulation test in 235 cases. The test was positive in about 60% of thrombosis of deep veins, pulmonary embolism, and myocardial infarction cases examined. The test was also positive in 23,4% of women taking oral contraceptives who were free of complaints and symptoms. Because of its easy applicability the test is recommended for screening.

Short term hypothermic perfusion for intestinal preservation with dimethyl sulfoxide

Morphologic changes, resulting from intracellular or extracellular perfusates with dimethyl sulfoxide as a cryophylactic agent, are similar and probably due to the anoxic period, after short term perfusion. These changes are temporary and are followed by complete recovery. No statistically significant changes in disaccharidase activity between intracellular and extracellular perfusates are found in the jejunal mucosa. No differences are found between normal disaccharidase activity and values obtained experimentally. Results of this study support the suggestion that vascular endothelial damage, as observed in evaluations utilizing the electron microscope, is certainly an important factor in the limitation of perfusion techniques of the intestine.

Preservation of canine small bowel by freezing

A total of 133 canine small bowel segments were isolated in 51 dogs according to a previously described technique that permits an in vivo freeze-thaw experiment to be carried out after perfusion with various cryoprotective agents. All control segments (33) survived. One hundred segments were frozen with cold intra-arterial helium and ambient cold nitrogen gas after perfusion with dimethyl sulfoxide (DMSO), inositol, or glycerol in 5% and 10% concentrations, alone, or combined, and with chlorpromazine and hydrocortisone added. Inositol had no cryoprotective effect. Approximately one half of segments frozen after protection with DMSO and with glycerol alone or combined with inositol survived the freeze-thaw injury and were intact on long-term follow-up.

The pathogenesis of intestinal atresia

The records of 28 patients with duodenal and 31 with jejunoileal intestinal atresia or stenosis were studied. Vomiting and abdominal distention were the most prominent symptoms; an unusual colon may be present in jejunal as well as ileal obstruction and is not pathognomonic for ileal obstruction. Intestinal atresia is associated with a high incidence of preterm babies but with a low incidence of intrauterine growth retardation. Fifty-three infants were operated upon; the overall survival rate was 79 per cent. The high percentage of mortality in duodenal obstruction is due to associated malformations. Theories of the pathogenesis of intestinal atresia do not seem to fit current clinical and experimental evidence in all patients. Possibly, different factors play a role in separate situations.

[Hemangiomatosis of the liver in infants: Diagnosis and treatment]

The authors present 7 patients with hemangiomatosis of the liver together with about 100 cases reported in the literature. 6 of 7 patients survived; 4 with supportive treatment only. Follow-up is from 2 to 12 years. Hepatomegaly, heart failure and cutaneous angiomas constitute the classical clinical triad. Arteriography is the best method to diagnose this lesion, and biopsy can thus be avoided. Clinical features and histological examination of these benign vascular tumors seem to confirm the theory that hemangioendothelioma and hemangioma represent only two different developmental stages of one disease. These lesions can regress spontaneously if left alone. Despite contrary prevailing opinion the conservative treatment is recommended as the first choice of the clinician.