In-vitro studies of ineffective erythropoiesis in rheumatoid arthritis

Ineffective erythropoiesis was assessed in a series of 32 patients with rheumatoid arthritis by means of a new in-vitro method which measures the release of haem from a labelled cohort of erythroblasts in culture. Haem release was significantly increased in patients with the anaemia of chronic disorders but was normal in those who were not anaemic or who had an iron-deficiency anaemia. In 2 patients with anaemia of chronic disorders haem release returned to normal after successful antirheumatic therapy. The increased ineffective erythropoiesis in patients with rheumatoid arthritis and anaemia of chronic disorders appeared to be unrelated to functional iron deficiency and was not attributable to a serum factor.

Bacteriological implications in the pathogenesis of secondary aortoenteric fistulas

The role of bacterial infection in the pathogenesis of aorto-enteric fistula was examined by a collective review of the clinical features and bacteriology in 213 patients. The most common presentation, gastrointestinal bleeding, occurred in 49 per cent of patients, although 32 per cent had systemic or local signs of infection as a presenting symptom. Results of intraoperative cultures were available in 115 patients, 33 of whom had two or more isolates. The predominant organisms were Escherichia coli, Staphylococcus aureus, group D Streptococcus and Bacteroides spp. The Gram-positive aerobic cocci predominated in fistulas developing within the first postoperative year which is compatible with a primary infection due to intraoperative contamination with skin flora. The Enterobacteriaceae and anaerobes showed no predilection for early or late occurring fistulas, suggesting that infection in these patients may be secondary to mechanical erosion of the graft through the adjacent duodenum. In either event, the likelihood that the aorto-enteric fistula is complicated by prosthetic infection should be seriously considered by the surgeon in planning the operative procedure.

Sudden infant death syndrome: parents' perceptions and responses to the loss of their infant

Sudden Infant Death Syndrome (SIDS) is the number one killer of infants under one year of age. Families are left in a state of crisis after a baby dies of SIDS. Thus, crisis counseling has been offered routinely to SIDS parents in King County, Washington. The purpose of this retrospective study was to assess whether mothers differed significantly from fathers in their perception of the situation, their feelings experienced and expressed, their approaches to problem solving, and the support they received. Differences in reactions between single and married parents were also studied. The 48% return rate produced a sample of 54 parents, 37 mothers and 17 fathers, who had lost their infant to SIDS. Statistically significant differences were found between mothers and fathers, as well as between single and married parents, in their view of the SIDS event, their problem solving approaches, and support systems. The results provide useful information for nurses in counseling SIDS parents and in working with families during and after subsequent pregnancies.

Idiopathic hereditary pancreatitis: experience with surgical treatment

Idiopathic hereditary pancreatitis is a rate form of primary chronic pancreatitis transmitted as an autosomal dominant trait with a variable clinical penetrance. We studied a Hispanic kindred of 23, seven of whom had the disease. In each of seven cases, abdominal pain had started when the patient was a teenager. The disease was confirmed surgically in three patients, biochemically in three, and roentgenographically in one. No causes were determined. The three patients who had surgery each had a ten- to 30-year history of recurrent severe abdominal pain requiring multiple hospital admissions. In each the pancreatic duct had a "chain-of-lakes" appearance on endoscopic retrograde cholangiopancreatographic examination and was drained by longitudinal pancreatojejunostomy. There was no recurrence of symptoms after surgery. Retrograde drainage of the pancreatic duct reliably relieves the symptoms of idiopathic hereditary pancreatitis.

Penicillinase-producing Neisseria gonorrhoeae

Penicillinase-producing Neisseria gonorrhoeae (PPNG) causes the same clinical picture as nonpenicillinase-producing gonococci. Definitive identification depends on demonstration of penicillin resistance followed by tests for the beta-lactamase enzyme (penicillinase). Spectinomycin is the drug of choice but should be carefully reserved for laboratory-confirmed PPNG. Other drugs are effective. Over 2,000 cases have been reported since 1976, most originating in the Far East. Continuing spread is a certainty.

Development of optical quality in the infant monkey (Macaca nemestrina) eye

Behavioral measures of the development of spatial vision, such as contrast sensitivity and acuity, do not distinguish between optical and neural contributions to the emergence of adult visual sensitivity in primates. The optical contribution to visual development in monkeys was estimated by measuring retinal image quality in the eyes of seven infant monkeys ranging in age from 2 days to 9 months. Results from both longitudinally and cross-sectionally tested monkeys indicate that the optics in infant monkeys are good at birth but that improvements with age can be found. The optical modulation transfer function shows that contrast transmission through the optics increases with age at all measurable spatial frequencies. Adult levels of optical quality are seen by 13 weeks of age. In comparison to the large improvements found during development in contrast sensitivity in monkeys. the optical changes are small and probably pose no major limit to the development of spatial vision in this species.

Uptake of radiolabeled leukocytes in prosthetic graft infection

The utility of radionuclide labeled leukocytes in the demonstration of infection within vascular prostheses was examined. The infrarenal aorta was replaced with a 3 cm Dacron graft in 12 dogs. On the third postoperative day, six of the animals received an intravenous injection of 10(8) Staphylococcus aureus. Labeled leukocyte scans were performed at postoperative days one and three, and then weekly for 8 weeks with indium-111 and technetium-99 labeled autologous leukocytes. When scans showed focal uptake of isotope in the area of prosthetic material, the grafts were aseptically excised and cultured on mannitol-salt agar. Both control and infected animals had retroperitoneal isotope activity in the immediate postoperative period that disappeared by the end of the first week. By the eighth postoperative week, all of the animals that received the bacteremic challenge had both radionuclide concentration in the region of the vascular prosthesis and S. aureus cultured subsequently from the perigraft tissues. None of the control animals had either radionuclide or bacteriologic evidence of infection at the eighth postoperative week. The radiolabeled leukocyte scan is a highly sensitive and specific technique, clinically applicable for the diagnosis of vascular prosthetic infections.

Surgical problems of diverticula of the small intestine

During a 25 year period at this medical center and the UCLA Center for Health Science, we identified 34 patients who had jejunal or ileal pseudodiverticula. Seventeen of these were treated for a more significant pathologic condition, the diverticula being an incidental finding. Of the remaining 17 patients, six underwent an operation for complications of these diverticula; two of them had diverticulitis of the jejunum; two, a perforated ileal diverticulum, and two others, severe malabsorption. Another two patients had laboratory evidence of malabsorption attributed to the presence of the diverticula and were treated medically. In the remaining nine persons, four were diagnosed as having a functional bowel syndrome and five had undiagnosed abdominal pain. For the group of six patients undergoing an operation, there was a 50 per cent mortality. Our experience gives weight to the contention that, although jejunal and ileal diverticula are rare, in any collected experience with them, significant morbidity and mortality accompanies the complications.

Anal cloacogenic carcinoma: classification and clinical behavior

A retrospective study of 35 patients with anal cloacogenic carcinomas showed that the histological characteristics of the tumors were correlated with their biological behavior. The basaloid squamous type of cloacogenic carcinoma was more common in women (3.6:1) and had a more favorable course in both men and women, with a mean survival of 5.0 years. Glandular variants of these tumors, with an adenocystic or mucoepidermoid pattern, occurred predominantly in men and had a more aggressive course, manifested by early metastases to inguinal and mesenteric lymph nodes, liver, and lung, with mean survival limited to 2.5 years. Nine of the 11 patients who survived longer than five years had the basaloid squamous histological pattern and were treated by abdominoperineal resection or pelvic exenteration; five of these patients also received postoperative therapy with radiation. The overall actual five-year survival for patients with anal cloacogenic carcinoma was 41% in this study. The histological pattern of anal cloacogenic carcinoma provides useful prognostic information to the clinician.

Studies on the alkaline phosphatase rise following colon ischemia

The elevation of serum alkaline phosphatase (ALP) that develops in the dog after 24 hours of colon ischemia was studied to determine its tissue origin. Portal, hepatic, and aortic blood were sampled but no difference in ALP level among these sites was found. In sera shown to have a significant rise in ALP, other tests of liver function were unchanged from normal, suggesting the ALP did not originate from the liver. On electrophoresis the "ischemic ALP" migrated faster than a known liver ALP standard but more slowly than an intestinal ALP sample.

Exposure to radio-frequency radiation from an aircraft radar unit

Two airmen exposed to radio-frequency radiation 38 times above the Air Force permissible exposure level were medically evaluated for physical effects from exposure. Initial anxiety and hypertension were found, but these problems resolved with therapy. This case is reported with the hope that further research will be undertaken to understand the behavioral effects of radar beams on exposed aircrew or ground personnel.

Arthroscopic examination of experimentally induced pathologic conditions of the rabbit temporomandibular joint

Because of the difficulty in diagnosing and treating diseases of the temporomandibular joint, there seems to be a need for a simple, safe technique of examination. The purpose of this study was to examine the usefulness of the arthroscope in diagnosing pathologic conditions of the temporomandibular joint. Various pathologic conditions were produced in the mandibular joints of rabbits. These included steroid-induced arthropathy, chronic inflammatory changes in the synovium, acute inflammatory disease, and gross damage to the condyle and disk. The joints were then visualized with the arthroscope and photographed. Biopsy specimens of what appeared to be the involved areas of the condylar surface and joint capsule were taken for histologic study. The arthroscopic findings were correlated with the biopsy findings and histologic sections of the entire joint.

Correlation of alkaline phosphatase with submucosal blood flow and morbid histology of the ischemic colon

In an ischemic Thiry-Vella colonic segment which was constructed to facilitate the serial measurement of submucosal blood flow by radioxenon clearance, we found that, after producing ischemia, the submucosal xenon clearance fell from 68+/-3 to 21+/-4 percent. In the succeeding two hours, a further fall in xenon clearance to 16+/-3 per cent occurred as a result of vasoconstriction in the peripheral mesenteric bed. From 24 hours onward, the submucosal flow increased. However, throughout the 96 hours, no healing of the ischemic necrosis was seen in the mucosa, and submucosa. Serial alkaline phosphatase levels showed a great rise from 24 hours onward, and began to fall as submucosal blood flow increased. This rise in the alkaline phosphatase value appears a useful marker of the degree of ischemia of the intestinal wall.

Development of contrast sensitivity in infant Macaca nemestrina monkeys

During an infant monkey's first 28 postnatal weeks, the visual contrast sensitivity function develops its characteristic adult form. Contrast sensitivity is depressed relative to that of the adult for all spatial frequencies during the early postnatal weeks. Absolute sensitivity to frequencies below 5 cycles per degree approaches adult levels by 20 weeks after birth, whereas sensitivity to fine spatial detail continues to develop through 28 weeks. The results imply that the development of primate spatial vision is more complex than just an improvement in the ability to resolve acuity gratings.

An examination of the relationship between experimentally altered rates of epidermal proliferations and rates of epidermal metabolism assayed in vitro

Continuously regenerating stratified squamous epithelia form an interesting model for examining mechanisms controlling the balance between rates of cell formation and cell maturation and death. Previous investigations of epidermal metabolism have been mainly based on single enzyme assays which may not form a reliable guide to changing rates of flux through metabolic pathways. Methods for in vitro assays of rates of glycolysis, protein synthesis and RNA synthesis of epidermal sheets free from dermal contamination were developed and used to examine rates of epidermal metabolism after experimental alteration of rates of epidermal proliferation. Starvation resulted in a 45-53% reduction in the in vivo epidermal labeling index and a 49-56% reduction in glycolysis and incorporation of amino acids assayed in vitro. Induction of epidermal hyperplasia with hexadecane resulted in a 4-fold increase in labeling index, a 6-fold increase in vitro glycolysis and a 3 to 4-fold increase in in vitro assays of incorporation of amino acids and uridine. Hyperplastic epidermis also showed an increased rate of incorporation of histidine (a marker for keratokyalin synthesis) relative to leucine (a marker for basal cell protein synthesis) indicating a change in maturation. The results suggest mechanisms linking rates of cell proliferation and death and indicate the possible value of such assays investigating these mechanisms.

Effect of intra-arterial vasodilators on blood flow in ischemic dog colon

The vasodilators papaverine hydrochloride, tolazoline hydrochloride, and isoproterenol hydrochloride were infused into the superior mesenteric artery (SMA) of dogs in which an ischemic Thiry-Vella colon loop had been formed. The washout of an intra-arterial injection of xenon Xe 133 to the normal and ischemic colon segments was used to measure bowel wall blood flow. Tolazoline and papaverine significantly increased the washout of 133Xe, but isoproterenol did not. Papaverine increased SMA flow. Neither of these two drugs altered the systemic blood pressure or pulse. However, isoproterenol augmented the SMA flow and pulse by factors of 1.8 and 1.5, respectively. These results support the favorable clinical reports that have found papaverine and tolazoline of use in the treatment of nonocclusive bowel ischemia.

Radioxenon washout for evaluation of vasodilator therapy in mesenteric ischemia

Mesenteric ischemia follows a critical reduction in blood flow to the intestine. Absence of a practical diagnostic test results in delayed diagnosis and inability to evaluate changes in blood flow due to vasodilator therapy. We recorded the disappearance of radioxenon (133Xe) from ischemic bowel to quantitate the decreased perfusion and to assess changes in submucosal blood flow after intra-arterial papaverine. The ischemic colon, its only blood supply from collaterals, was formed into a Thirty-Vella loop. An infusion catheter placed at the origin of the superior mesenteric artery (SMA) was used to deliver saline or papaverine (0.1 mg./kg./min). Eleven control dogs received N.S. only. In nine dogs papaverine infusion was started immediately and in another 12 dogs two hours after the production of ischemia. Submucosal blood flow was determined by the per cent washout at two minutes of an 0.05 ml. injection of 133Xe dissolved in N.S., made into the submucosal space of the colostomy.

Common duct stricture from chronic pancreatitis

Common bile duct stricture secondary to chronic pancreatitis is difficult to detect clinically. Surgical bypass is necessary if complications from biliary obstruction develop. In 21 patients operated on between 1968 and 1979, the earliest typical biochemical finding was a persistently elevated serum alkaline phosphatase level. The SGOT level was minimally elevated in seven patients, but did not correlate with changes in the stricture. An increased bilirubin level was noted either during an acute exacerbation of pancreatitis or late in the course of the stricture development, when obstruction was almost complete. Operative cholangiograms taken in 12 of these patients and transhepatic cholangiograms taken in nine demonstrated a stricture of the intrapancreatic bile duct more than 2 cm long. Operations were performed for treatment of obstructive jaundice (11), ascending cholangitis (three), suspected pancreatic cancer (three), and progressive biliary cirrhosis (two). Sphincteroplasty, initially attempted in four patients, uniformly failed to relieve the obstruction due to the length of strictured duct. Satisfactory drainage was obtained for up to ten years with choledochoduodenostomy (12), choledochojejunostomy (three), and cholecystojejunostomy (six).

Current management of massive lower gastrointestinal bleeding

Massive lower gastrointestinal hemorrhage originates in the colon in 70% of cases. In half the remaining cases it originates in the small bowel, and in the other half in the duodenum. Currently available diagnostic techniques are: mesenteric angiography, barium contrast meal studies, colonoscopy, and laparotomy. Causes of massive lower gastrointestinal bleeding are: diverticulosis, angiodysplasia, ischemic colitis, inflammatory bowel disease and intestinal varices. Accurate localization of the bleeding site is essential if surgical treatment is to be successful.

Septic arthritis due to Pasteurella multocida complicating rheumatoid arthritis

A patient with rheumatoid arthritis treated with corticosteroids developed a septic arthritis of her right knee. She had been bitten on her right leg by her pet cat 2 weeks earlier. Pasteurella multocida, resistant to penicillin, was isolated from the septic joint and from the oropharynx of the cat. The arthritis was successfully treated with ampicillin. No attempt to eradicate the organism from the cat was made because of the expectation of early recolonisation.

The porphyrin pigmentation of subspecies of Bacteroides melaninogenicus

Various subspecies of Bacteroides melaninogenicus differ in their pigmentation. Subsp. asaccharolyticus produces protohaem almost exclusively, subsp. intermedicus both protohaem and a smaller proportion of protoporphyrin, and subsp. melaninogenicus mainly protoporphyrin with a trace of protohaem. As a consequence young colonies can be differentiated by their red fluorescence in u.v. light (365nm): subsp. asaccharolyticus does not fluoresce, subsp. intermedicus shows a limited fluorescence, and subsp. melaninogenicus shows a bright fluorescence. The pigments were isolated as the dimethyl esters of protohaemin and of protoporphyrin and identified by electronic spectroscopy, mass spectrometry and comparisons by t.l.c. Incorporation of delta-aminolaevulinate into these pigments was not detected, nor was porphobilinogen formation observed. Subsp. melaninogenicus grown in the presence of [14C]protohaemin formed [14C]protoporphyrin. This appears to represent a novel biological demetallation.

Sustained effect of orally administered isosorbide dinitrate on exercise performance of patients with angina pectoris

The efficacy of oral isosorbide dinitrate was evaluated in nine hospitalized patients with chronic angina pectoris and positive maximal bicycle exercise tests. Patients were randomized double-blind to receive either 20 mg of isosorbide dinitrate or placebo on successive days after a control maximal upright bicycle exercise test. On each day hourly exercise tests were performed for 4 hours after drug administration to an end point of fatigue or angina pectoris. Mean systolic blood pressure 4 hours after the administration of isosorbide dinitrate was 25 mm Hg less than the control value (P less than 0.001). The values for resting heart rate and exercise-attained heart rate-blood pressure product were not significantly different from the values after placebo. The duration of exercise was prolonged (P less than 0.025) for at least 3 hours, and less ST depression (P less than 0.01) was observed up to 3 hours after the administration of isosorbide dinitrate compared with control values. The demonstration of sustained imporved exercise performance and previously described hemodynamic effects with the use of higher doses suggests that adequate blood levels of isosorbide dinitrate or mononitrate metabolites may be important for the efficacy of oral organic nitrates.

Plague in San Diego

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Synovial cyst causing an inguinal mass

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Late failure in vein grafts: mediating factors in subendothelial fibromuscular hyperplasia

Late failure of autologous vein grafts often results from excessive subendothelial fibromuscular hyperplasia. Varying factors have been implicated in this process, but the exact etiology remains unclear. In this study, three groups of animals were studied which had sections of common carotid artery replaced with autologous vein grafts. Group I had simple replacement, while Groups II and III had grafts supported by either tightly woven or loose mesh dacron prostheses. Thrombosis occurred only in the unsupported grafts. Unsupported grafts also had more subendothelial proliferation when compared to the loose mesh group. The combined thickness of the intima-media correlated inversely with the number of vasa present within the vein graft wall, i.e. significantly more vascularization was found in the mesh supported group when compared to the other groups. Grafts supported with the tightly woven prosthesis were relatively impervious to the ingrowth of vasa vasora. The data suggest that persistent distension of the graft wall by intra-arterial pressure influences the degree of subendothelial fibromuscular hyperplasia and may be interrelated to revascularization of the graft wall per se.

Evaluation of group processes using visual analogue scales

Patients in a general hospital psychiatric unit completed Visual Analogue Mood Scales before and after group psychotherapy sessions, and at corresponding times on days without group meetings. Changes in the dispersion of scores between "before" and "after" measurements differed between days with group psychotherapy and days without. Cohesiveness attributable to the group process is suggested as likely explanation for this difference. Factors influencing measurements are investigated and discussed.

An unusual presentation of carcinoma of the rectum

The case is described of a middle-aged man whose rectal carcinoma presented with meningitis, due to a fistula into the spinal theca.