Reduction of post-traumatic swelling and compartment pressure by impulse compression of the foot

Following the discovery of a powerful venous pump in the foot that is activated by weight-bearing independently of muscular action, a pneumatic impulse device was developed to actuate this pump artificially. In a multicentre international trial the device was shown to reduce post-traumatic and postoperative swelling; pain also was alleviated. Evidence is also presented that dangerously high compartment pressures may be reduced to acceptable levels and fasciotomy avoided. We present an explanation of the clinical effects of activation of the venous footpump, based on recent improved understanding of the physiology of the microcirculation. The hyperaemic response that follows the liberation of endothelial-derived relaxing factor (EDRF) by sudden changes of pressure after weight-bearing or impulse compression is particularly important.

Effect of gender in centrally induced angiotensin II hypertension in dogs

This study was designed to investigate the relation between gender, an endogenous inhibitor of the Na+-K+ pump, and volume-dependent hypertension induced by stimulation of the brain renin-angiotensin system and increased salt intake. Angiotensin II (20 ng/min i.c.v.) was infused for 4 weeks in five dogs of each sex with saline as the drinking fluid. In male dogs, angiotensin II induced parallel pressor (30%) and dipsogenic responses (70%), whereas no hypertension and no increase in fluid intake were observed in females. In contrast, the activity of the Na+-K+ pump as assessed by 86Rb uptake was independent of gender. Our data provide novel evidence that gender plays a determining role in the physiological properties of centrally administered angiotensin II.

Clinical utility of serum tests for iron deficiency in hospitalized patients

Serum iron and ferritin measurements lack the requisite sensitivity and/or specificity to accurately diagnose iron deficiency. To determine their utility in hospitalized patients, the authors compared the results of these tests with the presence of stainable iron in bone marrow aspirates of 301 patients. Forty (13.3%) had absent marrow iron. The serum diagnosis of iron deficiency was accepted on the basis of the following: iron less than 11 mumol/L, total iron-binding capacity (TIBC) greater than 45 mumol/L, transferrin saturation (%Sat) less than 0.20, and ferritin less than 13 micrograms/L for females and less than 25 micrograms/L for males. Using these criteria, iron deficiency was correctly diagnosed by serum iron in 41%, TIBC in 84%, %Sat in 50%, and ferritin in 90% of the patients. The serum ferritin is clearly the only useful serum test for diagnosing iron deficiency in hospitalized patients but is limited by a low sensitivity. The bone marrow examination is the most sensitive test for diagnosing iron deficiency in hospitalized patients.

Membrane channel protein abnormalities and autoantibodies in neurological disease

Immunological analogues of band 3, the anion transporter of the human erythrocyte, have been identified in all cells, including both isolated neurons and neurons of the central nervous system. We hypothesized that the anion channel is altered in neurological disease associated with choreiform movements because gamma-aminobutyric acid (GABA), the major inhibitory neurotransmitter in mammalian brain, binds to its receptor and opens an integral membrane chloride channel. In order to examine this hypothesis, we studied a family with a serious, progressive, genetic neurologic disorder with acanthocytosis (choreoacanthocytosis) that resembles Huntington's chorea. We selected choreoacanthocytosis because erythrocytes, which are readily obtained, are affected in this disease as well as the central nervous system. Biochemical studies of erythrocytes from the proposita, mother, and brother revealed that sulfate transport Vmax was increased, and glucose efflux was decreased. Erythrocytes exhibited immunological changes indicative of cellular aging/transporter damage. In addition, transporter reactive antibodies were present. This is the first evidence for abnormalities of membrane transport in this neurologic disorder.

Bleeding time. A guide to its diagnostic and clinical utility

Although the bleeding time is the most widely used clinical test employed to assess platelet function, its indications are poorly defined. The test is commonly used as a preoperative screen to predict hemorrhage, but the data supporting this indication are contradictory at best. In this review we highlight the physiologic basis for the bleeding time and survey the literature for data supporting the valid indications for its use. The bleeding time is a useful test for assessing platelet function in patients with hemorrhagic disorders. Its utility in providing helpful clinical information in patients who do not have a known bleeding diathesis by history is minimal. Specific recommendations regarding the rational use of the bleeding time for the preoperative evaluation of patients are presented.

Teenage sexuality: implications for controlling AIDS

A study on 761 teenagers aged 15-17 years showed that 56% of both sexes had had a steady or serious relationship. For about 40% of both sexes intercourse was a part of this relationship. Teenagers know how AIDS is transmitted, but only one third indicated personal concern about the epidemic. Only a fifth anticipate a single monogamous relationship. Significantly more girls than boys are planning to have fewer partners. Of these not anticipating monogamy three quarters mentioned the use of condoms. If education is to be effective in reducing the AIDS epidemic it must be sufficiently relevant to create and maintain changes in life style and must also educate teenagers before they have established patterns of behaviour.

Interpretation of Fatigue Data Surfaces to Optimise Product Evaluation Test Levels

The use of fatigue loading as a test medium for the quality assurance of commercial gas and water pipe components is postulated. The establishment of an appropriate system requires that the many test variables are optimised into a realistic test procedure. A computer‐aided design package was used to reduce this optimising process. The technique described may be used on any multi‐faceted program of similar type.

Modelling of reference values for size at birth

Data from the Swedish Medical Birth Registration, 1977-1981 were used to apply methods of constructing reference standards for size at birth. Using clinical information a 'healthy' sub-population was extracted. The conditional distributions of birthweight (BW) and birthlength (BL) for each week of Gestational age, and the conditional distribution of birthweight given birthlength were modelled using truncated Normal distributions, after making use of Box-Cox power transformations. Spline functions were then used in conjunction with a multiplicative method to obtain appropriate percentage point curves. Examples of this analysis are given.

Who is holding the baby?

A survey of neonatal units has been undertaken to establish how many maternity units have to separate mothers from their well, low birthweight babies or low dependency special care babies. The study also looked at some differences in the hospitals practising transitional care, or shared care with mother, and a group of maternity wards looking after babies down to 1.8 kg on normal maternity wards.

Advanced-stage endometrial cancer: contributions of estrogen use, smoking, and other risk factors

The contributions of estrogen replacement therapy, smoking, and other risk factors to the development of advanced-stage (2-4) endometrial cancer were evaluated in a case-control study of women 40-69 years old from upstate New York. Eighty-four cases and 168 matched community controls were interviewed in person about estrogen exposure and other risk factors. Despite a statistically significant increase in risk with longer use of estrogen pills (P less than 0.05), estrogen exposure actually contributed little to the overall risk of advanced-stage endometrial cancer. Other physical conditions (increased weight, lower parity, diabetes) and socioeconomic factors (education, access to medical services) largely accounted for advanced-stage disease. The evidence in this study does not support the hypothesis that women who smoke have a lower risk than nonsmokers of developing advanced-stage endometrial cancer.

Diagnostic clues in an adult case of Leigh's disease

A previously-well 32-year-old woman presented with episodes of severe headache, neck pain, numbness of the tongue and facial sweating. In the course of her illness she became abulic, blind and quadriparetic and she suffered recurrent episodes of coma during which she became decerebrate and her brain-stem reflexes were absent. She had an adult form of Leigh's disease, which is an extremely-rare degenerative condition of unknown cause. The clinical, neuroradiological and neuropathological features are presented.

Teenage relationships and sex education

Most of the consequences of early intercourse affect the woman and much research has focused upon her. As part of a study on teenage pregnancy, where 137 women were interviewed, 46 men were also interviewed. They were less likely to have had teaching about sex from parents and were subject to less parental supervision than the women. Both sexes had had similar experience of school sex education. Just under half of the men started having intercourse before 16 years. Over half of both sexes were initiated by an experienced partner and for 15/25 (60%) of the men this was within the first month of a relationship. Most men had had several partners and 27/99 (27%) of teenage women at least three, most in the context of stable relationships. 'Serial monogamy' exposes each partner indirectly to their partners previous partners (with the associated medical risks). Education must help teenagers make decisions about sexual involvement that take account of these facts and the implications for their own future health and happiness.

Testing for Long Life Performance Employing Short Term (Routine) Tests

The central issues are listed that affect the implementation of a short‐term test technique that is intended to make the routine quality checks of production of components in plastic pipes that are expected to have a service life of 50 to 60 years. It is concluded that, in view of the needs of industry for a short‐term quality control test procedure and in the absence of a viable alternative, there is much to recommend the adoption of fatigue as the basis of a production quality assurance system.

Functional topography of band 3: specific structural alteration linked to functional aberrations in human erythrocytes

Band 3 is the major anion transport polypeptide of erythrocytes. It appears to be the binding site of several glycolytic enzymes. Structurally, band 3 is the major protein spanning the erythrocyte membrane and connects the plasma membrane to band 2.1, which binds to the cytoskeleton. In the present study, we report an alteration of band 3 molecule that is associated with the following changes: erythrocyte shape change from discoid to "thorny cells" (acanthocytes), restriction of rotational diffusion of band 3 in the membrane, increase in anion transport, and decrease in the number of high-affinity ankyrin-binding sites. Changes in erythrocyte IgG binding, glyceraldehyde-3-phosphate dehydrogenase, fluorescence polarization (indicative of membrane fluidity), and other membrane proteins as determined by polyacrylamide gel electrophoresis were not detected. Cells containing the altered band 3 polypeptide were obtained from individuals with abnormal erythrocyte morphology. Two-dimensional peptide maps revealed differences in the Mr 17,000 anion transport segment of band 3 consistent with additions of tyrosines or tyrosine-containing peptides. The data suggest that (i) this alteration of band 3 does not result in accelerated aging as does cleavage and (ii) structural changes in the anion transport region result in alterations in anion transport.

[Calculation of intracardiac shunt using Doppler echocardiography]

The purpose of this study was to assess the accuracy of a quantitative two-dimensional Doppler echocardiographic method for estimation of intracardiac shunts. The ratio of pulmonary to systemic flow (Qp/Qs) was evaluated by duplex Doppler echocardiography in 20 patients with various intracardiac shunts. Right and left ventricular stroke volumes (RSV, LSV) were determined from the recordings of ejection blood flow velocity and diameter at the level of the pulmonary and aortic orifices in each ventricular outflow tract. The ratio RSV/LSV, determined by duplex Doppler echocardiography, was compared with Qp/Qs by oxymetry. The Doppler echocardiograms were of sufficient quality for shunt calculation in 15/20 patients (75%). The RSV/LSV for ten normal subjects was 0.99 +/- 0.05 (mean +/- SD), whereas the RSV/LSV for 15 patients with intracardiac shunts, 2.6 +/- 0.5, was significantly higher than that for normal subjects (p less than 0.01). In 12/15 patients, the Doppler study estimated the severity of intracardiac shunting correctly. The presence of complex anatomic situations, a wide pulmonary artery or significant semilunar regurgitation seem to have a negative impact on the Doppler echocardiographic shunt calculation. Our findings indicate that, with a few limitations, the Doppler index RSV/LSV is clinically useful in the estimation of the magnitude of the shunt flow in patients with intracardiac shunts.

Smoking, body weight, and early-stage endometrial cancer

The effect of cigarette smoking on the risk of early-stage endometrial cancer was evaluated in a population-based case-control study of women aged 40 to 69 years from upstate New York. Two hundred women with early-stage endometrial cancer diagnosed between 1979 and 1981, and 200 matched community controls were interviewed in person and asked about smoking habits and other risk factors. Statistical analysis revealed a significant decline in relative risk with increased smoking (P less than 0.05). This effect strongly modified the well-known increase in risk with body weight. Among smokers risk did not increase with body weight, whereas among nonsmokers risk increased rapidly with body weight, especially among nonsmokers in whom the peripheral conversion of androgens was the primary source of serum estrogen. Despite this apparent reduced risk for endometrial cancer, smoking remains a major health hazard for women as well as men.

Radiographic abnormalities in coagulation factor VII deficiency

We report the plain film findings as knees and elbows in two patients with congenital coagulation factor VII deficiency. The radiographic features resemble hemophilia, although the joint manifestations are milder, appear later in life, and occur in both men and women.

Distribution of accessible surfaces of amino acids in globular proteins

Globular proteins fold into compact particles with interior amino acid residues shielded from the surrounding aqueous environment. An early hypothesis holds that entropic hydrophobic forces drive this phenomenon. However, previous analyses based on a binary description of the accessible surfaces of amino acid residues in proteins did not support this hypothesis. This report shows that a complete description of accessible surface areas is given by parametric distribution functions with three modes. The modes are formed by partitioning the available accessible surface area of the amino acids into three segments; the data for each segment are characterized by a mode-specific model. In the "repulsive" mode, probabilities of accessibility decrease exponentially with exposed surface area, as predicted by the hydrophobic hypothesis. A distinct "buried" mode is needed to account for an excess of residues at or near zero accessibility for most amino acids, consistent with the use of binary descriptions of accessibility. A third mode exists which is termed "near neutral" because it is described by a nearly uniform distribution of accessibility for the hydrophilic amino acids. Empirical energies calculated for the repulsive mode correlate well with measured free energies of transfer of amino acids from water to organic solvents, while those from the buried mode correlate well with measured free energies of hydration of the side chains. Poor cross correlations between these energies give an explanation for the previous conflict in interpreting these data.

Erythrocyte sedimentation rate during steady state and painful crisis in sickle cell anemia

To define its diagnostic utility in sickle crisis, the erythrocyte sedimentation rates of oxygenated blood were studied in patients with sickle cell anemia and healthy normal subjects using the Guest-Westergren method. A normal range for sedimentation rate as a function of hematocrit was established in 22 normal subjects. Twenty-seven asymptomatic patients with sickle cell anemia had abnormally low sedimentation rates in relation to their hematocrits. Those low sedimentation rates were not increased by substituting plasma from healthy control subjects, which suggests that the low sedimentation rate was a cell-related phenomenon. Sedimentation rates measured in 28 patients with sickle cell anemia at the end of uncomplicated painful crisis increased to levels appropriate for their degree of anemia. In patients with sickle crisis and medical complications, the sedimentation rates were even higher. At the end of an uncomplicated painful crisis, the mean plasma fibrinogen level was significantly higher than at the onset (p less than 0.005). When red cells from patients with sickle cell anemia at the end of crisis were suspended in normal plasma from control subjects, the sedimentation rates remained high. It is concluded that the erythrocyte sedimentation rate of asymptomatic patients with sickle cell anemia is abnormally low due to cellular factors, and the increase during painful crisis is due primarily to red cell changes, modified by plasma factors.

Visual cortical lesions abolish the use of motion parallax in the Mongolian gerbil

Mongolian gerbils received lesions of either the visual cortex, pretectal nuclei, superior colliculus or a sham operation. Visual distance estimation was tested by means of a jumping task on which gerbils have previously been shown to employ motion parallax information generated by head movements. Videotaped jumps were analyzed to determine latency to jump, jump distance, and head movement frequency. While all of the lesion groups showed some changes in performance, the most severe deficits in jump accuracy were seen after the visual cortical lesions. In none of the lesion groups, however, were head movements abolished. The results suggest that the visual cortex subserves a critical aspect of dynamic distance estimation but that the motor program for generating head movements is located elsewhere.

Birefringent hemozoin identifies malaria

The diagnosis of malaria is still sometimes difficult because of the insensitivity of microscopic screening at low levels of parasitemia. The malarial pigment, hemozoin, is a crystalline product of the digestion of hemoglobin by the parasites. Under polarized light at 500X magnification, brilliantly birefringent granules of the pigment were detected in Wright's stained smears, and the parasites easily localized, in 18 cases of malarial infection. Fresh, wet, coverslipped preparations of cultures of Plasmodium falciparum also were examined under polarized light. Serial dilutions of the cultures showed that, even at the very low level of 0.01% parasitemia, intracellular birefringent granules were detected in an average of 45 +/- 16 (SE) seconds at 500X magnification. Using polarized light is a simple, fast, sensitive, and specific method for localizing intracellular pigmented malaria parasites in wet preparations of blood.

Secondary structure model for mouse beta Maj globin mRNA derived from enzymatic digestion data, comparative sequence and computer analysis

A model for the secondary structure of mouse beta Maj globin messenger RNA is presented based on enzymatic digestion data, comparative sequence and computer analysis. Using 5'-32P-end-labeled beta globin mRNA as a substrate, single-stranded regions were determined with S1 and T1 nucleases and double-stranded regions with V1 ribonuclease from cobra venom. The structure data obtained for ca. 75% of the molecule was introduced into a computer algorithm which predicts secondary structures of minimum free energy consistent with the enzymatic data. Two prominent base paired regions independently derived by phylogenetic analysis were also present in the computer generated structure lending support for the model. An interesting feature of the model is the presence of long-range base pairing interactions which permit the beta globin mRNA to fold back on itself, thereby bringing the 5'- and 3'-noncoding regions within close proximity. This feature is consistent with data from other laboratories suggesting an interaction of the 5'- and 3'-domains in the mammalian globin mRNAs.

The influence of chemically-induced modifications of root surfaces on cell migration, attachment, and orientation

Surface demineralization of tooth root surfaces has been shown to improve re-attachment of cells and to promote tissue reconstruction following periodontal surgery. Exposure of collagen fibers has been thought to facilitate migration, attachment, and orientation of fibroblasts on the root surface. However, using an in vitro assay, we have found that both attachment and orientation of human gingival fibroblasts on demineralized dentin surfaces are further improved following digestion of the exposed collagen with bacterial collagenase. In contrast, pronase and trypsin digestion of the surface collagen had no significant effect, whereas heat denaturation had an inhibitory effect. Dissociative extraction of the demineralized dentin slices with 4 mol/L guanidine hydrochloride (GuHCl) also improved attachment and orientation, and when undemineralized dentin was subjected to dissociative extraction, cell attachment was comparable and orientation superior to that on demineralized surfaces. These studies indicate that demineralization is not a prerequisite for facilitating attachment, and that enhanced attachment and orientation of cells are not dependent upon a collagenous substratum.

Red cell distribution width parallels dense red cell disappearance during painful crises in sickle cell anemia

We reported previously that painful crises in patients with sickle cell anemia are accompanied by striking decreases in the percent of densest red cells (fraction 4) when studied with isopyknic Percoll-Stractan gradients. We report that an alternative to density gradients is the red cell distribution width (RDW), an estimate of red cell size variation measured with a Coulter counter. In 17 painful crises in 12 patients with homozygous sickle cell anemia the RDWs decreased in each crisis, from an initial mean of 16.2 +/- 1.8 SD to 12.8 +/- 1.3 (P less than 0.001). In patients in whom serial measurements of both RDW and fraction 4 (very dense) red cells were taken during crisis, the two measurements declined in parallel. The decrease of RDW is a readily observable and objective laboratory concomitant of painful sickle crisis.

Steroid-induced hypersegmentation in neutrophiles

The effect of glucocorticoid administration on the nuclear segmentation of circulating granulocytes was studied in 13 patients with hematologic disorders and in two normal volunteers. In seventeen of eighteen courses, the granulocyte nuclear lobe count increased from 3.24 +/- 0.12 (SD) to 3.41 +/- 0.12 by the third day of treatment (P less than .001). Nuclear segmentation increased even further with continued therapy during a week of observation. Thus, like deficiencies of folate and of vitamin B12, glucocorticoid therapy causes neutrophil hypersegmentation. The cause of this effect is not known.

Monitoring of the neonatal electroencephalogram using an infrared multichannel telemetry system

A 3-channel neonatal medical monitoring system is described which uses infrared light instead of electrical leads to transmit physiological signals from the neonate to monitoring equipment. This system is especially applicable to situations where low level physiological signals such as the EEG need to be monitored in the vicinity of other life support and monitoring equipment that is likely to introduce electrical interference. Examples of EEG activity showing the progress of a neonate, who had experienced asphyxia, are presented.

Broken appointments at a neighborhood health center. Emphasis on weather

Broken appointments have been a major problem at the Anthony L. Jordan Health Center since it opened in 1968. In an earlier 6-month study of broken appointments at the center the authors found 48% of pediatric appointments and 43% of medicine appointments to be broken. Daily broken appointment rates were correlated between the two departments and were associated with day and time scheduled and with certain weather conditions. Specifically, highest broken appointment rates were noted for Mondays, for afternoon and evening hours, and for days with precipitation.

An objective sign in painful crisis in sickle cell anemia: the concomitant reduction of high density red cells

The etiopathologic basis of painful crisis in sickle cell anemia is largely unknown, and no objective criteria for its diagnosis and follow-up exist at present. We have studied 11 patients through 14 painful crises and observed a significant decrease of the densest fraction of red cells in 12 of the 14 crises as determined by isopycnic Percoll-Stractan continuous density gradients. If the first observation is normalized to 100%, the average decrease in dense cells was 77% with a range of 36% to 94%. The time needed for the percentage of dense cells to return to the steady-state level varied from seven to more than 30 days. These findings were in sharp contrast to the stability of the density pattern observed in another group of sickle cell patients, who were studied during crisis-free periods. The mechanism of the disappearance of dense cells could involve selective destruction by the reticuloendothelial (RE) system, selective sequestration in the areas of vasoocclusion, or a combination of both factors.

A randomized double-blind comparison of PUVA-etretinate and PUVA-placebo in the treatment of chronic plaque psoriasis

Twenty-eight patients with chronic plaque psoriasis affecting 20-40% of their body surface were treated with either PUVA and placebo (thirteen patients) or PUVA and etretinate (0.75 mg/kg) (fifteen patients). PUVA was given three times a week for a maximum of 10 weeks after a 2-week period on placebo or etretinate alone. Four patients failed to clear with PUVA and placebo compared with one patient with PUVA and etretinate, and the mean total UV-A dose to clear was lower with etretinate (mean = 62.1 J/cm2) than with placebo (mean = 77.3 J/cm2) but none of these differences were significant. Because the additional response to etretinate was only marginal, whilst unwanted effects were common, we found no advantage in adding etretinate to PUVA.

Inhibition of cold insolubility of an IgA cryoglobulin by decanedicarboxylic acid and related compounds

Cold insolubility of a serum IgA cryoimmunoglobulin was found to be inhibited by the addition of 1.5 mM sodium decanedicarboxylate in vitro. The patient with the cryoglobulin had advanced multiple myeloma complicated by severe hyperviscosity that caused lethargy and episodic loss of consciousness. Decanedicarboxylic acid administered orally resulted in transient relief of symptoms and the loss of cryoprecipitability of the paraprotein. Further in vitro studies revealed that sodium salts of long-chain monocarboxylic acids with a minimum of eight carbons, and dicarboxylic acids with a minimum of 12 carbons inhibited cryoprecipitation. Salts of short-chain carboxylic acids, by contrast, enhanced cryoprecipitation. Sodium phenolate and sodium salts of benzoic acid, 2,4-DNP, phenylpropionic acid, and salicylic acid were also inhibitory. These latter compounds, which have a ring structure, did not cause precipitation at any concentration. It was demonstrated that the presence of a free carboxylic group was required for these activities; conversion of carboxylic acid to amide resulted in the loss of both the inhibitory and cryoprecipitation-enhancing effects. Normal plasma, or plasma from five other patients who had IgG, IgM, or mixed-type cryoglobulinemia, were not affected by any of these compounds. It is suggested that in selected cases of hyperviscosity syndrome associated with cryoglobulinemia, some of these compounds, especially monocarboxylic acids with appropriate chain lengths, or those with a ring structure, may have therapeutic applications.

A noninvasive comparison of left ventricular performance in sickle cell anemia and chronic aortic regurgitation

Abnormalities of the cardiovascular system are common in patients with sickle cell anemia (SS). Noninvasive testing to document left ventricular dysfunction has yielded conflicting results. Left ventricular performance was evaluated in 27 patients with SS by M-mode and 2-D echocardiography, and systolic time intervals. Comparisons were made to 25 normal controls, and to 22 patients with chronic aortic regurgitation. Left ventricular diastolic diameter (LVDD) and cardiac index (CI) were significantly greater in the patients with SS than in controls (LVDD 5.3 +/- 0.4 vs. 4.7 +/- 0.5 cm; CI 4.2 +/- 1.3 vs. 3.1 +/- 0.8 liters/min/m2; both p less than 0.001). Left ventricular ejection fraction (EF) was slightly, but significantly less (62.9 +/- 7.3 vs. 67.0 +/- 5.4; p less than 0.05). In comparison to the patients with chronic aortic regurgitation, the LVDD in the patients with SS was slightly, but significantly lower (LVDD 5.3 +/- 0.4 vs. 5.9 +/- 0.6 cm; p less than 0.05). There was no significant difference between the patients in EF or CI (EF 62.9 +/- 7.3 vs. 63.3 +/- 4.4; CI 4.2 +/- 1.3 vs. 5.0 +/- 1.0 liters/min/m2; NS). Left ventricular EF was below 55 in three patients who also had hypertension at the time of examination. We conclude that patients with SS have resting left ventricular performance consistent with a high output state. Significant left ventricular dysfunction related to sickle cell disease alone was not demonstrated in this population, although the addition of hypertension appears to deleteriously affect resting left ventricular performance.

Home care of the pediatric patient with a tracheotomy

Forty-seven infants and children with tracheotomies were cared for at home for a follow-up period of 1,581 months. There were two relevant fatalities which gave a death rate of 0.13 deaths per 100 months. The average age at the time of tracheotomy was 13 months and the tracheotomy was in place for an average of 33 months per patient. The ability to care for these children was provided through coordinated, intensive training and a home-care program in which the inpatient nurse, nurse practitioner, social worker, pediatrician, and otorhinolaryngologist worked as a team.