The association of dyslipoproteinemia with symptoms and signs of peripheral arterial disease. The Lipid Research Clinics Program Prevalence Study

Intermittent claudication, leg pain during a graded exercise test (GXT), and resting systolic pressures in the upper and lower extremities were recorded as indicators of peripheral arterial disease at visit 2 of the Lipid Research Clinics (LRC) Prevalence Study. Systolic pressures of the upper and lower extremities were measured in a subsample of participants. We compared lipid levels of persons with and without claudication and with or without GXT-induced leg pain. We also compared lipid levels between groups with high and low arm:ankle systolic blood pressure ratios. Twenty-one (1.0%) men, 10 (1.0%) female nonusers and six (1.0%) female users of gonadal hormones had intermittent claudication determined by standardized questionnaire. Men with claudication had lower high-density lipoprotein (HDL)-cholesterol (35.6 vs 46.4 mg/dl), and their mean triglyceride level and cigarette consumption were higher and regular exercise less frequent. Men with type IIb dyslipoproteinemia were more likely to report claudication. One hundred sixty-nine (4.0%) men, 101 (3.8%) female nonusers, and 47 (4.1%) female users of hormones stopped the GXT because of leg pain. Mean HDL-cholesterol levels were lower for those with GXT-induced leg pain in all three sex-hormone usage groups (42.0 vs 46.9, p less than .001; 53.9 vs 59.4, p less than .001; 65.3 vs 67.2, p = NS) and mean low-density lipoprotein cholesterol levels were higher in those with leg pain on GXT in two of three groups (146.4 vs 146.2, p = NS; 155.7 vs 144.6, p less than .01; 144.4 vs 133.5, p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the repeatedly suicidal patient

Although repetitive suicidal behaviour is commonly encountered, a relatively small number of very difficult patients engage in it. These individuals suffer primarily from severe personality disorders, as well as alcoholism and drug abuse. They are at high risk for eventual suicide. Although as a group they receive a great deal of hospital treatment, inpatient management is fraught with difficulties. Extended inpatient treatment is unlikely to be of benefit and may perpetuate the behaviour by leading to regression and excessive dependence on hospitalization. A model of management is described which couples the use of a brief-stay, crisis, inpatient unit and community-based outpatient treatment. Communication between institutions and agencies involved in the patient's care as well as coordination of services is essential. Acceptance by therapists of the risk of suicide and the realistic limitations to meeting these patients' needs can help such patients assume more responsibility and independence.

An evaluation of an inpatient cardiac patient/family education program

A study to (1) evaluate the impact of a patient education program on the patient's knowledge regarding his/her illness and (2) identify obstacles to compliance behavior after discharge was conducted over a 2-year period. A population of 342 patients with ischemic heart disease was assigned to an inpatient cardiac patient education program consisting of five daily 1-hour classes. The following patient data were gathered: (1) assessment of the individual's knowledge of his/her illness; (2) selected sociodemographic information, (3) measures of general intelligence and problem-solving ability, and (4) motivation to alter risk factors. A measure of compliance with the prescribed treatment plan was obtained by telephone for all patients 4 weeks after discharge. Patients were randomly assigned such that one group received a pretest and a posttest assessment of knowledge while a second group received only the posttest assessment. A difference score t test on knowledge scores was statistically significant. A regression analysis of predictors of overall compliance scores after discharge demonstrated that indicators of motivation were most highly correlated with compliance. It was concluded that additional research is needed to identify: (1) types of information that enhance the patient's awareness of his/her illness and (2) program structures and techniques that enhance patient motivation to comply with a prescribed treatment plan.

Changes in hormone levels in relation to breeding behavior in male bullfrogs (Rana catesbeiana) at the individual and population levels

Fluctuations in plasma androgen (testosterone and 5 alpha-dihydrotestosterone), corticosterone (B), and luteinizing hormone (LH) of male bullfrogs in central California were measured during the spring mating season. Androgen and LH levels generally increased in the population prior to the initiation of chorusing and establishment of territories, whereas plasma B peaked in a 2-week period at the start of heavy chorusing; this coincided with a transitory, 1 week decline in androgen. Individual males showed fluctuations in plasma androgen and LH levels throughout the breeding season, often within 1 day, but there was no clear correlation between changes in the two hormones. No time of day effect was apparent on any of the hormones. B and androgen levels were significantly but weakly correlated, (r = 0.35) but LH and androgen were not. Although the seasonal trend of increasing androgen corresponded with the start of intense chorusing (and presumably sexual activity) by the population, behavior of individuals and their circulating androgen levels did not correlate. After acquiring territories, males showed no overall trend of increased plasma androgen. Moreover, males that showed no vocal or territorial behavior had significantly higher androgen and lower B levels than calling males. Increased B levels suggest that territorial behavior and especially direct agonistic encounters represent stresses that could have an inhibitory effect on androgen secretion.

Calorie and protein intake and balance of men and women consuming self-selected diets

The calorie and protein intakes of 16 women and 13 men consuming self-selected diets over a 1-yr period were determined. During four 7-day balance periods, corresponding to the four seasons of the year, duplicates of diets consumed and urine and feces excreted were collected for analysis and calculations of available energy and nitrogen balance. During the four balance periods, the food intakes and thus the calorie and protein intake of the subjects decreased as documented by 7-day food records immediately before and after the balance periods. This unexpected decrease in food consumption made the nitrogen (N) balance results difficult to interpret. The energy digestibility of these diets ranged from 87 to 98% (mean +/- SD, 93.7 +/- 2.3). The nitrogen digestibility of the diets ranged from 80 to 96% (mean +/- SD, 88.6 +/- 3.4). The analyzed calorie values (heats of combustion) of the diet composites were approximately the same as calorie values of these diets calculated from diet records using food tables. This is surprising since calorie values in food tables are available energies which have been corrected by a coefficient of availability.

Unexpected occupational exposure to asbestos

A 44-year-old woman with mesothelioma of the pleura presented for possible compensation to the Workers' Compensation (Dust Diseases) Board of New South Wales. No obvious asbestos exposure could be obtained from examination of the occupational history, yet examination of lung tissue revealed the presence of elevated levels of brown asbestos (amosite).

Relation between acute pituitary responsiveness to gonadotropin releasing hormone (GnRH) and the ovarian cycle in the bullfrog, Rana catesbeiana

Freshly captured female bullfrogs (Rana catesbeiana) were challenged with a standard dose (2 micrograms) of gonadotropin-releasing hormone (GnRH) shortly before and at the onset of the spawning season (in early April and mid-May) to examine the relationship between pituitary responsiveness and ovarian stage; males were also tested in April. As shown previously, increments in plasma gonadotropins induced by GnRH were consistently lower in females than in males. There was little difference in average responsiveness between the two collections of females and results for these were similar to those obtained at other times of the year. A wide range of ovarian stages was represented at both collection times as evidence by plasma steroid profiles, but there was no correlation between the GnRH-induced increments in plasma FSH and LH and plasma levels of androgens (testosterone and 5 alpha-dihydrotestosterone), estradiol-17 beta, or progesterone in the 71 females tested. Thus, there is no evidence of a feedback effect of ovarian steroids on the pituitary responsiveness to acute GnRH stimulation in the frog as has been demonstrated in mammals.

Hepatic oxygen and glucose metabolism in the fetal lamb. Response to hypoxia

Although the fetal liver is an active metabolic organ, its oxygen and glucose requirements have not previously been described. We measured hepatic blood flows and the oxygen and glucose differences across the liver in 12 late gestation fetal lambs in utero. Four animals were studied at least 1 wk postsurgically and again 2-5 d later to assess daily variations in hepatic blood flow and metabolism (group I). A second group of eight animals was studied 3-5 d postsurgically during a control period and during acute fetal hypoxia (group II). Under control conditions total hepatic blood flow averaged 400 ml/min per 100 g in both groups, and 75-80% was of umbilical origin. Liver blood flow and oxygen consumption were usually similar during repeated measurements, but in one animal varied considerably. During periods of normoxia, oxygen consumption for both the right and left lobes of liver was 4 ml/min per 100 g. Oxygen consumption of the whole liver accounted for 20% of total fetal oxygen consumption. This was achieved with oxygen extraction of 10-15%, so that hepatic venous blood was well oxygenated and provided an important source of oxygen for other fetal tissues. Under control conditions we could demonstrate no net hepatic uptake or release of glucose suggesting that the liver ultimately utilizes another carbon source to support its oxidative metabolism. During acute hypoxia total liver blood flow and its umbilical venous contribution both fell by 20%. Blood flow to the right lobe of the liver fell twice as much as that to the left lobe. Hepatic oxygen consumption was linearly related to oxygen delivery during the control and hypoxic periods. Consequently, right hepatic oxygen uptake fell by 45% whereas left hepatic oxygen uptake was unchanged, suggesting a functional difference between the lobes. During hypoxia glucose was released from both liver lobes; 6 mg/min per 100 g for the right lobe and 9 mg/min per 100 g for the left lobe. Total hepatic release of glucose was estimated to nearly equal umbilical uptake, so that 45% of the glucose available to fetal tissues was of hepatic origin. We conclude that the fetal liver responds to acute hypoxia by reducing its own oxygen consumption and releasing glucose to facilitate anaerobic metabolism.

Seasonal and stress related changes in plasma gonadotropins, sex steroids, and corticosterone in the bullfrog, Rana catesbeiana

Studies of seasonal gonadal cycles combined with direct measurements of plasma levels of the two gonadotropins (FSH and LH), several gonadal steroids (estrogen, E; progesterone, P; testosterone, T; and 5 alpha-dihydrotestosterone, DHT), and the interrenal steroid corticosterone (B) were made in male and female bullfrogs in central California over a 5-year period (between 1976 and 1981). During the course of these studies, we discovered that levels of plasma gonadotropins and steroids are highly labile and particularly sensitive to the effects of captivity, especially in males. In animals captured and sampled repeatedly in the field over a 3-day period, hormone levels remained constant, but if held in collecting sacks, gonadotropin and gonadal steroids began to drop within 2--4 hr and usually reached "baseline" levels within 20 hr. This effect was apparent in all seasons, except occasionally in early spring when hormone levels dropped by only about half. Hormone levels were also generally depressed by the time commercially collected frogs reached local supply houses. Plasma B increased within 30 min of capture and remained high for days in captive animals. Blood samples taken from several hundred animals at the time of capture reveal pronounced seasonal cycles in all hormones measured. These changes are discussed in connection with other gross changes in gonadal condition and with regard to possible interactions among gonadotropins and steroids. Both sexes show a general elevation of hormone levels in spring and early summer, but the sexes differ somewhat both in timing and in magnitude of the changes, as well as in the nature of the dominant steroids. Pronounced "surges" in gonadotropins are evident around the time of gamate release in bot sexes, but the temporal pattern of these surges is not the same for ovulation and spermiation; an elevation in plasma P is associated with the periovulatory surge in gonadotropins. Results were not entirely consistent with expectation of pituitary--gonadal relationships. Levels of plasma gonadotropins and steroids did not show the reciprocal relationship expected from a simple negative feed-back between gonadal and pituitary secretion, nor did changes in gonadotropins and gonadal activities show the consistent positive correlation expected from a direct dependence of gonadal function on circulating gonadotropins. In females, plasma T, but not E, correlated with ovarian growth. Plasma T in females reached much higher levels than in males, but DHT was higher in males. Androgens were generally elevated during the period of sexual activity in males, but absolute levels did not correlate well with individual differences in sexual behavior. Thus, seasonal changes in testicular and ovarian activities cannot be accounted for solely by seasonal cycles in circulating gonadotropin levels.

Dexamethasone suppression test and cortisol circadian rhythm in primary degenerative dementia

Before the dexamethasone suppression test (DST) can be accepted as a valid diagnostic tool for differentiating depression from dementia, it must be demonstrated that dementing illnesses per se are not associated with a positive DST. The authors studied cortisol circadian rhythm and the overnight DST in 15 nondepressed patients with advanced primary degenerative dementia and 15 normal control subjects. Seven dementia patients and no control patients were DST positive. The DST-positive dementia patients had a blunted predexamethasone circadian cortisol rhythm. These results cast doubt on the utility of the DST in diagnosing depression that complicates advanced primary degenerative dementia.

Cardiovascular and antidepressant effects of imipramine in the treatment of secondary depression in patients with ischemic heart disease

The authors report on 12 men with ischemic heart disease who developed secondary depression following myocardial infarction or coronary artery bypass-graft surgery and were treated with imipramine hydrochloride for 4 weeks. Imipramine had an antiarrhythmic effect, manifested by reduction in premature ventricular contractions during treatment. This drug did not produce clinically significant disturbances in cardiac conduction, but orthostatic hypotension led to early termination of the drug treatment in 1 subject. Imipramine treatment was associated with significant improvement in both observer-rated and patient-rated depression scales.

Efficacy of antipsychotic medications in behaviorally disturbed dementia patients

This study compared the therapeutic efficacy of thioridazine, loxapine, and a placebo in the treatment of behavioral disturbances in nursing home patients with dementia. Antipsychotic medications were effective for the specific behavioral problems of anxiety, excitement, emotional lability, and uncooperativeness. Subjects with the most severe symptoms at baseline assessment derived the greatest benefit from treatment. Sedation, extrapyramidal symptoms, and decreased blood pressure were common side effects among patients treated with the antipsychotic drugs. The authors conclude that antipsychotic medication has a definite but limited therapeutic role in the treatment of behavioral disturbances in nursing home patients with dementia.

The relative importance of smoking compared to occupation in decreased pulmonary function

This paper reports a study comparing the forced vital capacity (FVC) and forced expiration volume in one second (FEV1) of 684 workers grouped according to smoking habits and to disability from pneumoconiosis. The study was longitudinal and, although the pulmonary function tests decreased with age, as expected, the fall was greater in smokers without occupational lung disease than in non-smokers with occupational lung disease.

Depression in older persons: diagnosis and management

Depression is a common psychiatric disturbance of late life that is frequently not recognized by nonpsychiatric physicians. Confusion in psychiatric nosology, variability in clinical presentation, increased frequency of medical disease and medication use and cultural biases toward older persons complicate the diagnosis. Detection of depression is important because often this disorder can be successfully treated.

Greenfield vena caval filter experience: late results in 156 patients

In a review of clinical experience with the Greenfield filter in 156 patients, the most common indication for insertion was a contraindication to anticoagulation or recurrent embolism during treatment. Most of the filters (86%) were placed infrarenal, with 7% placed intentionally suprarenal and 7% misplaced but amenable to retrieval. Recurrent embolism was suspected in three patients (2%) on the basis of symptoms and was diagnosed by scan in three patients (2%). Follow-up studies on 119 local patients (11 were lost, 49 died) extended to 63 months (average, 23 months) and showed no migration or deaths due to recurrent embolism. Of 102 venacavograms obtained, occlusion of the cava was seen in only three patients (5%), for a long-term patency rate of 95%.

Complications of transurethral resection of bladder tumors: prevention, recognition and treatment

Between 1931 and 1971, 373 patients underwent transurethral resection of bladder tumors for cure or for control of the neoplasms. Complications included perforation of the bladder wall (5 per cent), hemorrhage requiring transfusion (13 per cent), infection (24 per cent) and postoperative mortality (1.3 per cent). Patients in whom perforations occurred had approximately twice as many infections and twice as much hemorrhage as the entire group but there were no postoperative deaths of those with perforations. Morbidity and mortality can be reduced in patients with perforation by 1) using isotonic irrigating fluid, 2) avoiding over-distension of the bladder, 3) maintaining postoperative free drainage through the catheter and 4) diagnosing and treating hyponatremia.

Effects of acute hemodynamic alterations on pulmonic valve motion. Experimental and clinical echocardiographic studies

The purpose of this study was to assess the effects of acute alterations of the pulmonary circulation on the pulmonic valve echocardiogram. We measured the pulmonic valve opening velocity (PVOV) and right-sided systolic time intervals (right ventricular preejection period-to-right ventricular ejection time ratio [RPEP/RVET] in 22 open-chest dogs subjected to acute hemodynamic alterations produced by inferior vena cava constriction, atrial pacing, isoproterenol infusion and microsphere embolization of the pulmonary artery. We found only fair correlations between PVOV and peak pulmonary artery flow (r = 0.56), right ventricular dp/dt (r = 0.43), stroke volume (r = 0.42), pulmonary artery systolic pressure (r = 0.33) and peak pulmonary artery acceleration (r = 0.31). RVET was shortened by reduced venous return (caval constriction) and by increases in heart rate (atrial pacing and isoproterenol), which resulted in increases in RPEP/RVET that did not correspond well to simultaneous changes in pulmonary artery pressure. In seven patients breathing 10% O2 to raise pulmonary artery pressure acutely, we found no change or a fall in PVOV. Thus, the pulmonic valve echocardiogram is influenced by multiple factors relating to parameters of pulmonary flow and right ventricular contractility, and may be of limited clinical usefulness in predicting pulmonary artery pressures.

Fibrous contracture of bladder neck: cause, prevention, and treatment

Through a retrospective study of bladder neck contracture it was found that bladder neck resection and incision were equally effective for treatment of postoperative bladder neck contractures. It was also found that incising the bladder neck at the end of transurethral resection of the prostate (TURP) did not cause vesicoureteral reflux and did not improve the incidence of postoperative bladder neck contracture.

Changes in grade and stage of recurrent bladder tumors

A retrospective study with adequate followup of 5 years of longer of 114 patients who had transurethral resection for cure or control of bladder tumors and in whom there were 1 or more recurrences is reported. There was recurrence of the tumor in a higher grade in 19 per cent of the cases and in a higher stage in 22 per cent. The interval between the treatment of the original tumor and a recurrence in a higher grade or state varied from 0.25 (3 months) to 27 years. When a low grade or low stage tumor recurs in a higher category in less than 3 years more aggressive treatment should be considered.

Forty years of transurethral prostatic resections

The 4 consecutive series of transurethral prostatic resections compared were done by the senior authors during a period of nearly 40 years: 420 cases in 1937 to 1938, 520 cases in 1940 to 1945, 480 cases in 1950 to 1955 and 270 cases in 1972 to 1973. The most notable improvements in the recent series are the fewer patients with temperatures more than 100 degrees (69 virsus 29 per cent) and the improved mortality rate (5.5 verus 0.7 per cent). In our opinion these improvements are owing to antibacterial medication, improved instruments, more skillful performance of the operation, the use of isotonic irrigating fluid and improved postoperative care.

Failure to suppress theta antigenic expression in progeny derived from pre-immunized maternal recipients

One possible theory concerning the success of the fetus as an allograft has been attributed to maternal modification of foreign fetal antigenic expression. In this respect progeny derived from pre-immunized maternal mouse recipients, have been examined for any modification (reduction) of corresponding theta antigen determinants. Two major groups of mice were examined. The first group of embryo transplantation derived AKR homozygotes born from pre-immunized CBA recipients whilst producing the corresponding anti-thetaAKR antibody activity. The second group of naturally derived reciprocal (CBA x AKR)F1 heterozygotes were also born from pre-immunized maternal recipients. In neither group was theta expression found to be modified and the significance of this finding is discussed in respect of other situations where fetal antigenic expression is known to be altered by maternal influence.

Variations of pulmonary function amongst workers in cotton mills

Lung function studies and clinical examinations of 493 workers in eight cotton mills in New South Wales revealed 12 workers with byssinosis. The reasons for the low incidence of byssinosis in view of relatively high cotton dust in air concentrations are discussed briefly.

Early carcinoma of the prostate: comparison of stages A and B

Stage A--occult, latent, preoperatively undiagnosed, incidentally found, stage I or T0--carcinoma of the prostate has been considered to be an earlier stage than stage B--II, T1 or T2, palpable nodule. In a comparative study of 118 patients with stage A lesions and 115 patients with stage B lesions we have found more focal lesions in A than in B. The A lesions were also less highly malignant than the B. However, the survival of patients with A lesions was a little less than those with B lesions. Age differences and more extensive growth before a detection may account for the differences. Patients with diffuse lesions and those with the more highly malignant lesions had a shorter survival than those with focal lesions and with a lower grade of malignancy in stages A and B. All available preoperative diagnostic data and a through histopathological examination of the surgical specimen are necessary to accurately stage prostatic carcinoma. Other well recognized diagnostic tests, such as the lymphangiogram, acid phosphatase value bone scan and so forth, are also necessary to accurately assess the extent of the disease.

Subcapital fractures of the femur. A prospective review

This abridged account of a report to the British Medical Research Council describes a long-term investigation of 1,503 subcapital fractures of the femur, almost all of which were treated by reduction and internal fixation. With three exceptions, union occurred in all Garden Stage I and Stage II fractures and in 67% of Stage III and Stage IV fractures, of which only 14-5% were united at six months. In women, late segmental collapse was seen after union had occurred in 16% of Stage I and in 27-6% of Stage III and Stage IV fractures. Delay of up to one week before operation had no significant effect on the incidence of non-union or of late segmental collapse. The incidence of union followed by late segmental collapse was higher in women with normal bone density than in those with osteoporosis. Smith-Petersen nailing was found to be the least effective form of fixation in displaced fractures. The age and physical state of the patient, the accuracy of reduction, and the security of fixation had the greatest influence on union.

The relation between sub-capital fracture of the femur and mineral content of the right third metacarpal

Positive correlation between the mineral content of the mid site of right third metacarpal and neck of femur has been established using the psi-ray absorption technique described by Shimmins et al. (1972b) to make measurements on excised human bones. An X-ray method (Anderson, Shimmins and Smith, 1966; Shimmins et al. 1972a) was used to measure the mineral content of the right third metacarpal in 101 female and 22 male patients with subcapital fracture of the ferum. When their metacarpal "whole bone densities" were compared with those of control subjects of the same age and sex, they were found to have significantly lower (P smaller than (0.025) average values. However, groups of patients defined according to Garden's classification of severity of fracture could not be distinguished one from the other on the basis of metacarpal whole bone density measurement.

A family with an unusual occupational hazard

Pneumoconiosis from the carbon-copper-silica rods of film projector arc lamps is a relatively rare disease. There follows a description of a family in which the father and two sons developed radiographic changes after many years working as projectionists in New South Wales.

A bacteriological evaluation of laminar-flow systems for orthopaedic surgery

An evaluation has been undertaken of the efficiency of laminar-flow ventilation in operating-rooms in which conventional operating-room clothing was used. It has been demonstrated that velocities in the region of 0.3-0.4 m./sec. will give maximum returns for effort in both down-flow and cross-flow systems. At this velocity the laminar-flow system, in terms of airborne bacteria measured at the wound site, was about 11 times more efficient using horizontal air-flow and 35-90 times more efficient using vertical air-flow than a plenum-ventilated operating-room.

The electron-transport system of mitochondria from the slime mould Physarum polycephalum

A method is described for the preparation of mitochondria from the slime mould Physarum polycephalum; the mitochondria were not coupled. P. polycephalum mitochondria oxidized added NADH via a rotenone-insensitive pathway, but the oxidation of malate plus glutamate was rotenone sensitive; both of these substrates reduced much less cytochrome b than did succinate, in both aerobic and anaerobic steady states. Spectroscopy at 77 degrees K separated three absorption maxima in the alpha-band region, at 560nm, 553nm and one at 547nm due to cytochrome c. The absorption at 553nm was increased in the aerobic steady state by the addition of 2-heptyl-4-hydroxyquinoline N-oxide, suggesting that it was due to a b-type cytochrome. All three absorption maxima appeared in the aerobic steady state after the addition of a range of substrates. The respiratory activity with different substrates and the response to inhibitors of respiration were similar to those previously described for fungus mitochondria (Weiss et al., 1970; Erickson & Ashworth, 1969). When grown under conditions of haem limitation the mitochondria contained a lower concentration of cytochromes than normal.