Sepsis of the hip in paraplegic patients

For the treatment of chronic sepsis of the hip in paraplegic patients, we adopted three measures: (1) a Girdlestone procedure, (2) transposition of the vastus lateralis muscle into the void that was left by the removal of the femoral head and neck and the acetabular wall, and (3) external fixation to prevent unrestrained motion of the femoral shaft, which might damage the transposed muscle. The hip joint was spanned by a posterior pelvic-femoral skeletal external fixator. Nine patients, all of whom had thoracic-level paraplegia, were treated in this manner. The fixator was kept in place for three to six weeks while the patients were cared for in the prone position. All of the infections were fully healed by twelve weeks postoperatively. In two patients, the wound drained at the edge of the flap for a short time.

Calcium-channel blockers for combined angina pectoris and systemic hypertension

Calcium-channel blockers have been successfully used in the treatment of angina of effort and systemic hypertension. Many patients present with concomitant angina pectoris and hypertension. Controlled clinical trials demonstrate that the calcium-channel blockers are safe and effective as monotherapy in the treatment of these patients, and that their use compares favorably with that of propranolol. The effectiveness of these agents in hypertension appears to be primarily due to their ability to induce systemic vasodilation. Calcium-channel blockers have several therapeutic effects in angina pectoris. Beneficial actions on the major determinants of oxygen consumption, i.e. heart rate, blood pressure and contractility, are generally seen. The potent coronary vasodilating actions of these agents allow for increased coronary blood flow. Improvements in ventricular compliance, regression of left ventricular hypertrophy and cardioprotection appear to be additional effects of the calcium-channel blockers; their contribution to the drugs' overall therapeutic efficacy is presently being evaluated. Calcium-channel blockers are a welcome addition to drug regimens available for the management of patients with coexisting angina pectoris and hypertension.

Mental retardation, organic brain dysfunction, and the forensic clinician: some practical considerations

Mental retardation as it is frequently interrelated with a variety of organic brain dysfunctions may present unclear clinical pictures. This has particular relevance for the forensic practitioner who often needs to present his findings to the court in a clearly demarcated manner. This paper outlines the more commonly encountered entities in this area with consideration to forensic science implications.

Lidoflazine and propranolol combination treatment in chronic stable angina

The short-term (1 month) and long-term (6 months) safety of combination lidoflazine-propranolol therapy was investigated in an open trial of 15 patients with stable angina of effort. The possible advantages of adding lidoflazine (titrated to 360 mg daily) to patients having a therapeutic response to propranolol (80-400 mg daily) was also evaluated. Effects on non-invasive indexes of left ventricular function (echocardiography, systolic time intervals, radionuclide ventriculography) and exercise tolerance (treadmill exercise testing) were determined. There was no change in mean resting heart rate with the combination therapy, although one patient developed sinus bradycardia at a rate of 44 and had to have his propranolol dose reduced. Electrocardiographic analysis showed significant prolongation of the QTc intervals on lidoflazine-propranolol therapy compared to propranolol alone, with 3 patients having QTc interval prolongation to above .53 seconds, but there was no evidence of increased arrhythmogenesis with the combination therapy compared to propranolol alone. Left ventricular end-diastolic volume index tended to rise with combination therapy. However, lidoflazine-propranolol therapy did not produce any significant effects on resting ejection fraction determined by M-mode echocardiography or by radionuclide ventriculography. Radionuclide ventriculography determined peak exercise ejection fractions were also not significantly changed with combination therapy compared to propranolol alone. There were only small, insignificant improvements in exercise tolerance with the lidoflazine-propranolol combination treatment compared to propranolol alone. It is concluded that lidoflazine-propranolol combination therapy is generally safe but has the potential of causing serious adverse effects in certain patients, i.e. those with sick sinus disease, prolonged QTc intervals, and severe baseline left ventricular dysfunction, and that caution must be exercised in its use. Furthermore, it would appear that combination therapy provides only slight, if any, improvements in exercise tolerance in patients with chronic stable angina having a therapeutic response to oral propranolol.

Preschool performance of children with normal intelligence who were very low-birth-weight infants

Children who were very low-birth-weight infants (less than 1,500 g), beneficiaries of modern neonatal intensive care, are now of school age. To evaluate their school performance 80 children born in 1976 who had very low-birth-weight (mean birth weight 1.2 kg, mean gestational age 30 weeks) were examined at age 5 years. Sixty-five children were neurologically intact and had normal IQ (greater than or equal to 85) on the Stanford-Binet; five children were neurologically abnormal and ten had IQ below 85. Of the 65 children with normal intelligence and no neurologic impairments, 46 were single births and enrolled in preschool. These 46 children were matched by race, sex, and family background with classmate control children who had been born at full term. Outcome measurements included the Slosson Intelligence Test, the Woodcock-Johnson Psycho-Educational Battery (including subscales of Picture Vocabulary, Spatial Relations, Memory for Sentences, Visual Auditory Learning, Quantitative Concepts, and Blending) and the Beery Developmental Test of Visual-Motor Integration. No significant differences in IQ were found between children who were very low-birth-weight infants and control children; however, children who were very low-birth-weight infants performed significantly less well on the Spatial Relations subtest of the Woodcock-Johnson and on the Visual-Motor Integration test. Similar results were found for nine sets of twins and their control children. Recognition of these perceptual and visual-motor problems may permit appropriate early remedial intervention and prevent the compounding of these difficulties.

The relationship between therapist behaviors and outcome for middle- and lower-class couples in marital therapy

Treated a sample of 77 distressed middle- and lower-class couples by 19 therapists using conjoint therapy. Batteries of tests that assessed marital satisfaction and communications skills were given pre- and posttherapy plus 3 and 6 months later. Couple and therapist therapy behavior were assessed using audio tapes of interview sessions. A variety of sex and social class differences were found that correlated with therapy outcome. The overall thrust of the findings suggests that no one marital therapy technique will be appropriate for the different sexes and with those of different SES backgrounds.

The growth of olfactory neurons in short-term cultures of rat olfactory epithelium

We have found that purified astrocytes will support the growth of olfactory epithelial neurons ( OENs ) in vitro. Candidate OENs were visible by light microscopy within one day after plating of dissociated cells from neonatal rat ethmoturbinates . Electron microscopy showed that OENs expressed the unique ultrastructural features which characterize these cells in situ, showing that regulation of neuronal morphology and ultrastructure can function independently of contact with other cells of the appropriate tissue. Characteristics of the cultures are such that this in vitro system would be useful in electrophysiological investigations of the chemosensory olfactory neurons.

Acquired immunodeficiency with reversed T4/T8 ratios in infants born to promiscuous and drug-addicted mothers

A new syndrome of acquired immunodeficiency has been identified in seven children who were small for gestational age at birth and subsequently have exhibited failure to thrive, lymphadenopathy, parotitis, hepatosplenomegaly, interstitial pneumonia, and recurrent infections. All have a profound cell-mediated immunodeficiency with reversed T4/T8 ratios. Six are hypergammaglobulinemic and one has low IgG levels. The mothers of five of the seven children are sexually promiscuous and/or drug addicts. Three mothers have an immunodeficiency similar to that found in their infants. One of them died at age 33 years with a diagnosis of acquired immunodeficiency syndrome. In five of the children and in three of their mothers, there is evidence of a persistent Epstein-Barr virus (EBV) infection. We speculate that a perinatal or in utero transmission of EBV can induce an "infectious immunodeficiency." The clinical, histopathologic, and immunologic features resemble those described in adult homosexuals and drug addicts.

Comparative effects of abrupt withdrawal of propranolol and verapamil in angina pectoris

The potential hazards of abrupt withdrawal of propranolol have been described in patients with angina pectoris; however, the effects of abrupt withdrawal from long-term therapy with verapamil have not previously been investigated. The comparative effects of withdrawal from long-term treatment with propranolol and verapamil were assessed in a placebo-controlled double-blind randomized crossover study of 20 patients received placebo for 2 weeks, then increasing doses of propranolol (60 to 320 mg/day) or verapamil (240 to 480 mg/day) for 3 weeks. Patients were then abruptly withdrawn from drug onto placebo for 1 week, followed by crossover to the other drug treatment and a second withdrawal period. All 20 patients were withdrawn from verapamil without evidence of a rebound increase in frequency of anginal attacks, blood pressure, heart rate, or rate-pressure product and without a rebound deterioration in exercise tolerance. In contrast, with propranolol withdrawal, 2 patients (with the highest baseline angina attack rate) had a severe exacerbation of their anginal syndrome and could not undergo formal exercise testing; the other 18 patients were withdrawn from propranolol without incident. Plasma catecholamines were increased during exercise compared with rest during all treatments; however, the levels of catecholamines during exercise were significantly higher with propranolol than with verapamil and placebo (p less than 0.05). Levels of exercise catecholamines returned to placebo baseline values after withdrawal of propranolol.

Efficacy of sublingual nifedipine in the acute treatment of systemic hypertension

The effects of sublingual nifedipine, a calcium antagonist vasodilator, were assessed in 43 patients with moderate to severe hypertension in an emergency room setting. Following a no-response placebo treatment period, the patients with supine diastolic blood pressure of less than 110 mm Hg (group A, n equals 17) received 10 mg of sublingual nifedipine, and the patients with supine diastolic blood pressure of much greater than or equal to 110 mm Hg (group B, n equals 26) received a 20-mg sublingual dose. In group A, systolic blood pressure decreased from 172.4 plus or minus 18.6 mm Hg to 140.0 plus or minus 14.6 mm Hg; diastolic pressure from 108.8 plus or minus 3.3 mm Hg to 87.6 plus or minus 9.9 mm Hg (P less than 0.001)., In group B, systolic blood pressure decreased from 203.8 plus or minus 22.1 mm Hg to 160.0 plus or minus 23.6 mm Hg; diastolic pressure from 127.7 plus or minus 11.3 mm Hg to 96.7 plus or minus 14.1 mm Hg (P less than 0.001). Heart rate increased significantly only in the 20-mg dose group, from 76 plus or minus 2 to 89 plus or minus 6 beats/min (P less than 0.005). Th effects of sublingual nifedipine were seen in one to five minutes, and the maximal effect in 20 to 30 minutes, with return to placebo baseline in four to five hours. Adverse reactions were minimal in both treatment groups. Nifedipine is an effective and safe hypotensive drug in the rapid management of moderate to severe hypertension and seems to be an effective nonparenteral agent for treatment of hypertensive emergencies.

Time analysis of patients seen for multiple psychiatric evaluations of competency

Changes over time for a total of 137 individuals who were referred for multiple psychiatric examinations for competency were analyzed, using data on the evaluation of competency, psychiatric diagnoses, and criminal charges. Despite the fact that most of the subjects were repeatedly diagnosed as mentally ill, most of them were found competent. The only diagnoses which seemed to repeatedly be made were schizophrenia and mental retardation. The recurrence of certain serious criminal charges against the same defendants was reported and discussed. Suggestions for future research were made.

Multiple psychiatric competency examinations in borough of the Bronx

The sample of 137 people had been referred for multiple psychiatric competency examinations over an 11-yr. period. The study examined the relationships between the decision on competency and many demographic, psychiatric, and criminal history variables. On many variables there were no significant differences between those found competent and those found incompetent but those subjects deemed incompetent were more likely to be diagnosed as schizophrenic or psychotic. Suggestions for future research are offered.

Insider-out: the health worker as researcher

This article discusses two dimensions related to the insider-outsider dilemma in conducting anthropological research in the health setting. One dimension concerns advantages of the insider's special knowledge in selecting and conducting successful research in a health institution. The other dimension deals with the ambiguity and confusion of roles attributed by staff to the investigator who may be seen as practitioner as well as social scientist. The patient may also see the researcher as performing dual, and possibly conflicting, roles. The advantage gained in the first dimension may be negated, to some extent, by the disadvantages associated with the second.

Human granulocyte lysosomal elastase activity using t-butyloxycarbonyl-L-alanine p-nitrophenyl ester and elastin-rhodamine as substrates

Polymorphonuclear leukocyte lysosomal esterolytic activity on the synthetic substrate, t-butyloxycarbonyl-L-alanine p-nitrophenyl ester was observed to correlate well with polymorphonuclear leukocyte granule elastase activity measured on the natural substrate, elastin, bound to rhodamine. In addition, the effect of highly specific, irreversible chloromethyl ketone elastase inhibitors on leukocyte lysosomal elastase activity was similar, using t-butyloxycarbonyl-L-alanine p-nitrophenyl ester or elastin-rhodamine as substrate. Whether polymorphonuclear leukocyte lysosomal granules contain two different enzymes, a true elastase with esterase activity and a similar esterase without elastase activity, as found in the human pancreas, is, as yet, unknown. Both enzyme activities have been identified in isoenzymes of purified human polymorphonuclear leukocyte lysosomal elastase. The correlations observed between the two enzymes, if present in polymorphonuclear leukocytes, are sufficiently strong to use the esterase assay for clinical purposes.