A method for comparing two systems of acute 24-hour psychiatric care

A quasi-experimental method was developed to evaluate the cost-effectiveness of a public system of 24-hour acute psychiatric care in Santa Clara County, California, before and after a new treatment setting was introduced. The original system relied on a 54-bed psychiatric unit in a county general hospital; the new system consisted of a 20-bed unit in the general hospital plus a 45-bed nonhospital psychiatric health facility. The study demonstrated that the per diem cost of the psychiatric health facility was approximately 60 percent that of the original general hospital unit, but the average difference in cost per episode between the two systems was only about +25, primarily due to longer lengths of stay in the new system. In addition, patients treated in the new, combined system appeared sicker at discharge than those treated in the old system. The findings suggest the importance of simultaneously evaluating both cost and treatment effectiveness to make sure that one element does not dominate program direction at the expense of the other.

Correlation of behavioral and cerebrovascular functions in the aging rat

Regional cerebral blood flow (rCBF), maze performance and the influence of environmental enrichment on these parameters were studied in Sprague-Dawley rats aged 6, 12 and 24 months. Learning ability in a complex sequential T-maze (Stone maze) progressively declined with increasing age in rats which were normally housed in standard caging. Environmental enrichment significantly improved maze performance but did not prevent the age-dependent impairment. Following completion of the learning studies, rCBF was measured in each of 13 brain regions in conscious, unrestrained, resting animals. In the absence of any significant change in cardiac output over the entire age range, rCBF was lower in all brain regions by an average of 16% in 12-14 month old rats and 8% in aged rats (24-26 months old); the occipital cortex, inferior and superior colliculi and hypothalamus were particularly affected regions in both age groups. The sharp reduction of rCBF that occurred between 6 and 12 months of age did not reflect, and probably preceded the progressive decline in maze performance. Such highly significant age-related changes in rCBF were not affected, however, by environmental enrichment procedures. This contrasts with the substantial influence of enrichment on maze performance. Finally, mean brain blood flow and mean cortical blood flow correlated inversely and significantly with average daily numbers of errors made by 24 month old rats during Stone maze acquisition.

Villous adenoma presenting as a vaginal polyp in a rectovaginal tract

A 72-year-old woman had a villous adenoma of endodermal derivation involving the rectovaginal septum and contiguous mucosal surfaces that presented clinically as a vaginal polypoid tumor. To explain the vaginal involvement, we postulate that the adenoma traversed a tract of developmental origin within the rectovaginal septum. This is the first report of such a unique constellation of findings.

Pyloric stenosis and eosinophilic gastroenteritis in infants

Eosinophilic gastroenteritis is known to cause gastric outlet obstruction in adults, but has been reported only rarely in infants presenting with pyloric stenosis, a common form of gastric outlet obstruction in children. We describe two infants who presented with classic clinical and radiographic evidence of pyloric stenosis and who were found to have histologic evidence of eosinophilic gastroenteritis on gastric antral biopsies. Their presentation is compared with the clinical and laboratory findings of 47 other infants with pyloric stenosis.

Relationship between systolic and diastolic blood pressure and cognitive functioning in hypertensive subjects: an extension of previous findings

The relationship between blood pressure and neuropsychological functioning in a group of 15 male hypertensives (mean age = 51.2 years) was studied. Thirteen of the 15 subjects showed cognitive deficits on a battery of neuropsychological tests. More significant negative correlations were found among test scores and systolic pressure than diastolic pressure. Stepwise multiple regression analyses confirmed significant relationships between both systolic and diastolic blood pressure and neuropsychological status. Following biofeedback training, subjects in whom blood pressure decreased the most showed the greatest improvement in Category Test performance. Findings suggest that level of systolic pressure is a sensitive predictor of hypertensives' intellectual and cognitive status, that it may be better than diastolic level, and that decreasing blood pressure is predictive of reversal of at least some of the cognitive impairments associated with hypertension.

Comparative features of esophageal and gastric adenocarcinomas: recent changes in type and frequency

One hundred sixty consecutive cases of esophageal and gastric carcinoma were reviewed to evaluate the impression of recent changes in their types and characteristics. Esophageal adenocarcinomas accounted for 34 per cent of all esophageal cancers and 60 per cent of tumors confined to the lower third of the esophagus; all but one were associated with Barrett's epithelium. Among the gastric cancers, previous observations of an increased prevalence of neoplasms confined to the cardia were extended. Proximal adenocarcinomas (arising from the esophagus, gastroesophageal junction, and cardia) constituted 34 per cent of all adenocarcinomas in this series and appeared to be a distinctive group with common features. Compared with other gastric cancers, the proximal carcinomas were associated with a lower mean age (65 years), higher male-to-female ratio (3.3:1), greater frequency of hiatal hernia (40 per cent), greater incidence of smoking and alcohol use, and lower prevalence of tumors composed predominantly of signet ring cells. Thus, proximal adenocarcinomas may form a specific category etiologically different from distal gastric cancers.

Pulmonary disease in children with acquired immune deficiency syndrome and AIDS-related complex

Two major pulmonary diseases were defined on the basis of lung biopsies in 15 children with acquired immune deficiency syndrome (AIDS) or AIDS-related complex. Pneumocystis carinii pneumonia was observed in eight children, and pulmonary lymphoid hyperplasia in six. One child had nonspecific interstitial pneumonitis. Children with P. carinii pneumonia had more severe hypoxemia, with higher alveolar-arterial oxygen gradients, and higher isomorphic elevations of serum lactate dehydrogenase. Clinically, children with pulmonary lymphoid hyperplasia were older, and had digital clubbing, parotid gland enlargement, and elevated serum IgG levels. Results of serologic assays and lung tissue analysis were suggestive of persistent Epstein-Barr virus infection exclusively in patients with pulmonary lymphoid hyperplasia. Recognition of the clinical and laboratory findings characteristic of each entity may assist in the differential diagnosis without the need of surgical biopsy.

Effect of hypothalamic deafferentation on hypophysial and other endocrine gland blood flows

The effects of partial or complete deafferentation of the medical basal hypothalamus (MBH) on blood flow through endocrine glands was evaluated using a modification of Sapirstein's indicator fractionation method. Adult female Wistar rats were distributed into three groups consisting of normal control animals (n = 12), animals in which rostral deafferentation (Rd) of the MBH was performed (n = 11), and animals in which complete deafferentation (Cd) of the MBH was done (n = 6). Three weeks after the surgical procedures, Cd reduced adenohypophysial weight by 30% and raised its blood flow levels by 80% compared to those values in the Rd and control groups. In contrast to the anterior pituitary, both Rd and Cd led to weight reduction of 22% in posterior lobes, and Cd was also accompanied by a 50% net blood flow decrease. No statistically significant differences were noted in pineal gland weights or decreases in blood perfusion rates in adrenal and thyroid glands. There were no body weight changes in experimental animals compared to values in the control groups. These results suggest that there may be a loss of vasomotor tone in the primary vascular beds of the adenohypophysial portal systems after deafferentation which elicits the 80% increase in adenohypophysial blood flow. This increased circulation may play a role in pituitary function(s) and should be included along with diminished neuroendocrine inputs in interpretations of results obtained after deafferentation procedures.

Detection of HTLV-III/LAV antigens in peripheral blood lymphocytes from patients with AIDS

HTLV-III was searched for in frozen sections of peripheral blood lymphocytes obtained from AIDS patients by an immunofluorescence technique. Human IgG against HTLV-III/LAV and monoclonal antibodies against HTLV-III/LAV P 24 antigen, yielded a strong cytoplasmic fluorescence in frozen sections of the lymphocytes. Some cells containing HTLV-III antigens displayed multinucleated giant forms. They also reacted with monoclonal antibodies against helper/inducer T-cells (OKT4+), as demonstrated by direct double staining immunofluorescence. Similarly, complexes of immunoglobulins and C3 component of complement were also detected on HTLV-III/LAV Ag expressing lymphocytes. Immunofluorescence study of frozen sections of peripheral blood lymphocytes appeared to be a simple, fast and reliable method for detection of HTLV-III/LAV Ag in AIDS patients.

Allergic proctitis and gastroenteritis in children. Clinical and mucosal biopsy features in 53 cases

We have reviewed 53 cases of allergic disorders of the gastrointestinal tract in children, including 15 with principal effects in the rectum (allergic proctitis) and 38 with dominant involvement of the upper and mid portions of the gut (allergic gastroenteritis). Most cases of allergic proctitis had their onset at less than 6 months of age, and all were under 2 years old when they presented with rectal bleeding alone or in combination with diarrhea. Rectal mucosal biopsy revealed in most cases a diffuse increase of eosinophils in the lamina propria together with a focal infiltration of the epithelium by eosinophils. Cases of allergic gastroenteritis affected all age groups and had a lower frequency of overt rectal bleeding. More common were other symptoms (vomiting, pain, and weight loss), an allergic history, anemia, blood eosinophilia, and increased serum IgE. Mucosal biopsy abnormalities were present in the gastric antrum in all cases sampled, the small intestine in 79%, the esophagus in 60%, and the gastric corpus in 52%. The lesions were usually diffuse and marked in the antrum and esophagus; in contrast, they tended to be focal and mild in the small intestine and gastric corpus. All cases of proctitis responded to a dietary change by cessation of symptoms without recurrences, whereas most of those with gastroenteritis had multiple relapses and required corticosteroid therapy.

Chronic diarrhea associated with hypogammaglobulinemia and enteropathy in infants and children

In order to define the gastrointestinal manifestations and small intestinal structure and function in a group of infants with chronic nonspecific diarrhea and hypogammaglobulinemia, we retrospectively identified 55 such patients from a population of 518 children evaluated for chronic diarrhea over a 6-year span (10.6%). All patients had IgG levels 2.0 SD or more below the mean values for age. Patients with biochemical evidence of protein loss (enteropathy or nephropathy) were excluded. There was a 50% incidence of small intestinal mucosal injury among these patients, with a spectrum of morphological findings ranging from healing enteritis to severe active enteritis. Carbohydrate malasorption, and infection with Giardia lamblia or Clostridium difficile occurred in 34% and 24% of patients tested, respectively. These structural, functional, and infectious complications were all statistically more common in patients than in a control group of children with chronic diarrhea, normal growth, and normal immunoglobulin levels. This study suggests that immunoglobulin determination, in children who would otherwise carry a diagnosis of chronic nonspecific diarrhea, identifies a group with hypogammaglobulinemia, having an increased incidence of treatable intestinal dysfunction or infection, and a spectrum of small intestinal histologic abnormalities.

Ureteral endometriosis in post-menopausal women

Ureteral obstruction secondary to endometriosis is an infrequently observed phenomenon, particularly in post-menopausal women. Two patients with obstructive uropathy, aged fifty-five and seventy-four, underwent ureteroplasty procedures with pathologic documentation of endometriosis. The possible pathogenetic mechanisms of ureteral endometriosis and previously reported cases are cited.

Scanning electron microscopic appearance of chronic ulcerative colitis with and without dysplasia

This study was conducted to determine whether scanning electron microscopy of colonic mucosal biopsy specimens can help to detect dysplasia in patients with chronic ulcerative colitis. In the first phase of the study, using light microscopy as the standard for the diagnosis, the scanning electron microscopic appearance of specimens from patients with chronic ulcerative colitis and control patients was examined. Descriptive criteria were established to identify normal, atrophic, and dysplastic colonic mucosa. In the second phase, quantitative techniques were used to develop more objective criteria for the diagnosis of dysplasia in ulcerative colitis. Twenty-one coded colonic specimens from 11 patients were sequentially examined by scanning electron microscopy and by light microscopy. The three morphometric analyses performed on the surface epithelial cells were number of cells per unit area, number of microvilli per unit area, and percentage of microvilli with a normal width. The cell count and percentage of microvilli with a normal width were significantly reduced in the seven specimens with colonic dysplasia as compared with non-dysplastic tissues. Scanning electron microscopy may serve as an adjunct to light microscopy in the diagnosis of colonic dysplasia.

Intraepithelial eosinophils in endoscopic biopsies of adults with reflux esophagitis

A consecutive series of 50 adult patients was reviewed to evaluate the utility of endoscopic grasp biopsies of the esophagus in the diagnosis of reflux esophagitis. Endoscopic and histologic features were independently recorded and correlated. Measurements of basal zone thickness, papillary height, and vascular dilatation were possible in only 14% of the cases because of limited specimen orientation. However, 62% of the patients had other histologic features of esophagitis, including intraepithelial eosinophils, intraepithelial neutrophils, and epithelial necrosis. Intraepithelial eosinophils were the most frequent abnormality; they were noted in 52% of the cases and correlated best with the gross endoscopic features. Eosinophils were easily identified even in the poorly oriented grasp biopsies and were the only histologic finding in seven patients (23% of the abnormal cases). Thus, we conclude that esophageal grasp biopsies taken at the time of endoscopy are of value in the assessment of patients with suspected reflux esophagitis, and intraepithelial eosinophils are the most common and useful histologic criterion. This feature was previously observed in children and occurs as well in adults with reflux esophagitis.

Reduction of amygdaloid kindled seizures by an analog of ACTH/MSH

A behaviorally potent analog of ACTH/MSH(4-9), ORG-2766, markedly reduces both physiologic and behavioral components of convulsive seizures in an animal model of epilepsy--the amygdaloid kindled rat. We believe that such non-endocrine analogs of ACTH/MSH fragments may be clinically useful anticonvulsants, particularly in chronic applications, provided that their permeation of the blood-brain barrier can be improved.

Limitations of the brief form of the Halstead Category Test

This study attempted to cross-validate a short form of the Category Test (subtests 1-4) first used by Calsyn, O'Leary, and Chaney (1980). One hundred and sixty-eight subjects were assigned to one of six neurological categories, and Category Test scores predicted (via regression analysis) from performance on the short form were compared with actual scores obtained from the original long form. While there was a high correlation (r = .91) between the two sets of scores, a large number of normal subjects were misclassified as brain-damaged. Additionally, subjects with focal right lesions could not be differentiated from normals either on the basis of error scores predicted from short form performance or the absolute number of errors made on subtests 1-4. These results suggested that shortening the Category Test may limit its applicability with certain populations.

Severe rectal injury following radiation for prostatic cancer

Between 1970 and 1981, 348 patients underwent definitive irradiation. Of these patients 6 (1.7 per cent) sustained severe rectal injury as manifest by major rectal bleeding, rectal stricture, rectal mucosal slough and rectal ulceration. Severe rectal injury was observed in 0 of 13 patients (0 per cent) treated with 125iodine, 3 of 329 (1 per cent) treated with 6,400 to 6,800 rad external irradiation, 2 of 39 (5 per cent) treated with 7,000 to 7,300 rad external irradiation, and 1 of 7 (14 per cent) treated with 198gold and external irradiation. The impact of radiation dose, radiation therapy technique and surgical trauma was assessed. Rectal injury was managed by supportive measures in 2 patients and by diverting colostomy in 3 with benefit. One patient underwent abdominoperineal resection. A small bowel fistula and an intra-abdominal abscess developed, and the patient died.

Cerebrovascular permeability to 86Rb in the rat after exposure to pulsed microwaves

Microwaves (pulsed, 2,450 MHz) at an average power density of 3 W/cm2 were applied directly to the head for 5, 10, or 20 min, producing a peak specific absorption rate of 240 W/kg in the brain, which, after a 10-min exposure, resulted in brain temperatures in excess of 43 degrees C. A bolus of 86Rb in isotonic saline was injected intravenously and an arterial sample was collected for 20 s to determine cardiac output. Compared with unexposed controls, uptake of 86Rb increased most in those regions directly in the path of the irradiation, namely, the occipital and parietal cortex, as well as the dorsal hippocampus, midbrain, and basal ganglia. In a separate group of animals, regional brain-vascular spaces were found to increase with brain temperature. These results support previous observations indicating that reliably demonstrable increases of blood-brain barrier permeability are associated with intense, microwave-induced hyperthermia, and that the observed changes are not due to field-specific interaction.

Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications

Assessment of epithelial dysplasia in ulcerative colitis has been hindered by inconsistencies in and disagreements about nomenclature and interpretation. To resolve these issues, pathologists from ten institutions participated in three exchanges of multiple slides and, following each exchange, in discussions of the results. A classification system for the epithelial changes that occur in ulcerative colitis was developed, which should be applicable to other forms of inflammatory bowel disease as well. The classification makes use of standardized terminology, addresses specific problem areas, and offers practical solutions. The reproducibility of the system was studied by means of examinations of both inter- and intra-observer variations. The clinical implications of the findings were incorporated into suggestions for patient management. The basis of the classification is that the term "dysplasia" is reserved for epithelial changes that are unequivocally neoplastic and may therefore give rise directly to invasive carcinoma. Specimens are categorized as negative, indefinite, or positive for dysplasia. The negative category includes all inflammatory and regenerative lesions and indicates that only continued regular surveillance is required. The indefinite category is applied to epithelial changes that appear to exceed the limits of ordinary regeneration but are insufficient for an unequivocal diagnosis of dysplasia or are associated with other features that prevent such unequivocal diagnosis. Clinically, it indicates that early repeat biopsy is often required to assess the changes more accurately. The positive category is divided into two subcategories: 1) high-grade dysplasia, for which colectomy should be strongly considered after confirmation of the diagnosis, and 2) low-grade dysplasia, which also requires confirmation and early repeat biopsy or colectomy, depending on other findings.

Serotonin-induced disruption of implantation in the rat: II. Suppression of decidualization

Subcutaneous injection of serotonin (20 mg/kg) on Day 5 of pregnancy disrupts implantation in the rat as indicated by the reduction in number of live fetuses/cornu present on Day 19 (0.9 vs. 6.1, treated vs. control). Such disruption of implantation possibly results from impaired decidualization. To test for suppression of decidualization, serotonin was administered to pseudopregnant rats on the day before, on (Day 4) or after artificial induction of the decidual cell reaction. Relative to saline-treated controls (C), serotonin (S) reduced decidualization when injected either before [C: 1987 +/- 130 vs. S: 1085 +/- 155 mg (Day 3); P less than 0.005] or after [C: 1987 +/- 130 vs. S: 173 +/- 8 mg (Day 5); P less than 0.001] administration of the deciduogenic stimulus. In addition, serotonin markedly decreased uterine blood flow (C: 0.47 +/- 0.05 vs. S: 0.25 +/- 0.06 ml/min per g; P less than 0.01) during pseudopregnancy. However, serotonin altered neither the duration of luteal function in pseudopregnant rats (C: 15.3 vs. S: 14.3 days) nor serum progesterone levels (C: 74-91 vs. S: 53-82 ng/ml) in pregnant animals. It is concluded that serotonin may disrupt implantation, in part, by suppression of decidualization. The loss of endometrial competence to undergo decidualization appears to be a consequence of serotonin-induced uterine ischemia rather than impaired corpus luteum activity.

Spontaneous diabetes mellitus syndrome in the rat. III. Pancreatic alterations in aglycosuric and untreated diabetic BB Wistar-derived rats

The pancreatic alterations in aglycosuric and untreated diabetic BB Wistar-derived rats are described. A common finding, often seen in young aglycosuric rats, is that of discrete foci of periductular and/or acinar aggregates of lymphocytes and macrophages. Sites of periductular mononuclear cell infiltrates usually lack endocrine cells. In contrast, foci of acinar infiltrates, although distinct from the predominant endocrine cell mass in the islets of Langerhans, often contain small numbers of alpha and/or beta cells. It is suggested that these clusters of endocrine cells may in some way be antigenically different from those resident in the principal islets and thus serve as an additional target for the immune system in rats bearing the BB genome. The development of overt diabetes requires a massive destruction of beta cells within the islets of Langerhans. Two forms of diabetes mellitus emerge in untreated animals. The more common, designated unstable diabetes, is severe and lethal unless treated with insulin. Less commonly, a stable type of diabetes mellitus ensues for which insulin therapy is not mandatory. In each, the concentration of pancreatic immunoreactive insulin is profoundly decreased, although relatively greater amounts are present in the stable form. Unstable diabetic rats demonstrate a reduction in the concentration of pancreatic immunoreactive glucagon and somatostatin, suggesting that alpha and delta cells also sustain injury in this model of insulin-dependent diabetes mellitus.

Acquired immunodeficiency in an infant: possible transmission by means of blood products

An infant who received multiple transfusions during the first few days of life for rhesus disease became ill with recurrent infections when 6 months old. Hepatitis, thrush, Candida dermatitis, otitis media, and disseminated Mycobacterium avium intracellulare infection occurred by 14 months of age. Immunological studies showed raised immunoglobulin levels, decreased mononuclear-cell responses to allogeneic cells and mitogen, and a decreased helper/suppressor cell ratio. It was determined that one of the blood donors, who was well at the time of blood donation, had died 17 months after with multiple opportunistic infections and acquired immunodeficiency. The clinical and laboratory findings in our patient suggest that he acquired a transmissible infectious agent from a blood transfusion, resulting in acquired immunodeficiency, and that this agent was not cytomegalovirus, Epstein-Barr virus, or hepatitis B virus.

Massive mural edema in severe pseudomembranous colitis

Three patients had severe acute pseudomembranous colitis due to Clostridium difficile toxin and required surgical resection. In addition to the characteristic mucosal lesions, the colonic specimens showed a marked degree of diffuse mural edema that extended into the muscularis propia and involved areas of the colon with and without pseudomembranes. To our knowledge, such extreme edema has not been previously noted in pathologic descriptions of this disorder; it may possibly result from a toxic effect on the vessels combined with a large parenteral fluid replacement. Lesser degrees may be seen in other forms of acute colitis, but it would appear that the presence of massive and diffuse mural edema is most typical of Clostridia-associated colitis. The detection of such edema in a case of acute colitis should prompt an investigation for antibiotic usage and C difficile toxins.

Development and use of a nonrestraining waveguide chamber for rapid microwave radiation killing of the mouse and neonate rat

The use of microwave energy for rapid killing of small rodents such as the mouse or rat has become a standard pharmacologic technique since approximately 1975. This method allows investigation of rapidly modulated neurochemical indices, neuromodulatory substances, and some neurotransmitters to be determined at basal concentrations in brain regions and microregions. Previously described devices for use with microwave generators have relied on total body restraining holders in order to properly position rodents and neonates within a closed waveguide during microwave energy exposures. The present information describes two alternate chamber designs which do not require restraint of the rodent. A positioning device is described which must be used with the waveguide chambers. The animal chambers are designed to be used with 2450 MHz energy.

A study of the structural and biochemical development of human fetal islets of Langerhans

The structural and biochemical ontogeny of 14 mid-trimester (12.0–19.5 wk) human fetal endocrine pancreata were examined. Each pancreas was halved at the region of the isthmus into duodenal (D) and splenic (S) portions, and islets, isolated from each of the two portions, were aliquoted and grouped according to diameter into 4 categories: (1) > 300 μm (2) 300–200 μm (3) 200–100 μm (4) 100 μm.

At all fetal ages, the number of islets isolated from the splenic half was greater than from the duodenal half, and the number of islets increased as their diameter decreased. The mean total cell number per islet for each of the 4 categories are reported: (1)(D) 30,810 (S) 28,450; (2)(D) 10,970 (S) 10,250; (3)(D) 3,390 (S) 3,460; (4)(D) 1,930 (S) 1,840.

Measurement of islet insulin (IRI), glucagon (IRG), and somatostatin (IRS) by radioimmunoassay showed a progressive increase with time in the content of all three hormones in all islets from both halves of the pancreas (with the exception of the smallest islets of <100 μm diameter). After 18 wk, a dramatic increase in the content of all three hormones was observed particularly in the case of the largest (>300 μm) islets. In contrast, pancreatic polypeptide (IRPP) shows no significant increase. With the exception of the smallest islets (100 μm), all splenic-half islets contain a significantly greater content of IRI, IRG, and IRS compared with their duodenal-half match while the content of IRPP is significantly greater in the duodenal-half islets. In addition, all islets with the exception of the largest (>300 μm), contained equal quantities of IRG and IRS and these results were apparent at 12 wk gestation.

These data provide new insights into the ontogeny of individual islet cells during the mid-trimesteric period and serve as a basis for future studies of both normal and abnormal pancreatic development.

Intraepithelial eosinophils: a new diagnostic criterion for reflux esophagitis

Intraepithelial eosinophils in esophageal biopsy specimens were noted to be an indicator of prolonged acid reflux. The presence of even a few intraepithelial eosinophils correlated with abnormal acid clearance determined by overnight intraesophageal pH probe study. This new marker also appeared to be an early lesion, as evidence by its presence in children under age 2 yr, and in biopsy specimens from the proximal esophagus where traditional histometric features (basal zone thickening and papillary lengthening) were lacking. Furthermore, when intraepithelial eosinophils were seen in the proximal 75% of the esophagus, they served to identify more severe disease by correlation with greater abnormalities in the pH probe study. Although this new marker is a histologic indication of prolonged acid reflux and may be appreciated in routine endoscopic biopsy specimens in children, it has been observed in patients over 18 yr of age and may be applicable to the adult population.

Changes in the location and type of gastric adenocarcinoma

To document our impression of major changes in aspects of gastric adenocarcinoma, we reviewed and compared 62 consecutive cases from 1975 through 1978 and 31 cases from 1938 through 1942. The average age at diagnosis increased from 58 to 68 years, the male to female ratio decreased to approximately 1:1, and carcinomas composed predominantly (50% or more) of signet-ring cells (SRC) increased from 9 to 39% of the total cases. In the recent series, carcinomas with SRC (compared with those without SRC) occurred nine years earlier, were more frequent in women, were located distally, and had an infiltrative growth pattern. Carcinomas originating in the proximal stomach (cardia) were not noted in the old series but formed 27% of the recent cases. These tumors showed a male predominance, contained SRC less often, and were less commonly associated with chronic gastritis. The implications of these observations are discussed.

The long-term outcome of restorative operation in Crohn's disease: influence of location, prognostic factors and surgical guidelines

The course of all 113 patients with Crohn's disease whose initial procedure involved an anastomosis operated upon from 1942 to 1972 was followed through 1980. The calculated cumulative 30-year total mortality was 23.4%, 16.7% disease-related. The cumulative recurrence rate was 29% at five years, 52% at ten years, 64% at 15 years and 84% at 25 years, with no important differences between disease locations and types of operation. Sex, age, duration, granulomas, enteral or perirectal fistulas and length of the resection, the disease, and the proximal resection margin had no significant influence on the rates of development of recurrent disease or on functional outcome. By far the most common site of recurrence was the neo-terminal ileum, but in ileocolitis compared with ileitis, recurrence was 5.2 times more likely (p = 0.0001) to involve the adjacent or remote colon as well. Moreover, only 1/63 ileitis patients eventually required ileostomy, whereas 15/47 patients with ileocolitis or colitis ultimately required this procedure (p less than 0.001). The current status of the patients was excellent or good in 64% and unwell or dead related in 24%. Urolithiasis developed in 19%.

Changes in the location and type of gastric adenocarcinoma

To document our impression of major changes in aspects of gastric adenocarcinoma, we reviewed and compared 62 consecutive cases from 1975 through 1978 and 31 cases from 1938 through 1942. The average age at diagnosis increased from 58 to 68 years, the male to female ratio decreased to approximately 1:1, and carcinomas composed predominantly (50% or more) of signet-ring cells (SRC) increased from 9 to 39% of the total cases. In the recent series, carcinomas with SRC (compared with those without SRC) occurred nine years earlier, were more frequent in women, were located distally, and had an infiltrative growth pattern. Carcinomas originating in the proximal stomach (cardia) were not noted in the old series but formed 27% of the recent cases. These tumors showed a male predominance, contained SRC less often, and were less commonly associated with chronic gastritis. The implications of these observations are discussed.

An analog of ACTH/MSH (4-9), ORG-2766, reduces cerebral uptake of morphine

The uptake of morphine was significantly reduced in most regions of the brains of conscious, unrestrained rats within 10 minutes after treatment with an analog of ACTH/MSH (4-9), ORG-2766. The effect was most obvious in regions with significant densities of enkephalin receptors, namely basal ganglia, hippocampus and cortex. The results explain, in part, how some fragments and analogs of ACTH/MSH may antagonize behavioral actions of morphine, even though some of these peptides lack significant opiate receptor binding properties. We believe that this effect of ORG-2766 is related to an action on the permeability characteristics of the brain microvasculature. The underlying mechanism is unknown.

Pressures on the dental care system in the United States

A number of significant pressures are creating tensions in the dental profession and the dental care delivery system. These pressures may be categorized in five major areas: 1) regulation and deregulation pressures involve changes in the state dental practice acts, court decisions concerning antitrust and advertising, and the inclusion of consumers on State professional regulatory boards; 2) cost of services includes factors involving the out-of-pocket cost of dental care and the growth of dental insurance; 3) dentist-related factors include the increased number of dentists and the indebtedness of dental graduates; 4) the pressures of changes in the American populations include the decline in population growth and the increase in proportion of elderly people; 5) changes in the distribution of dental care are based on new epidemiologic data concerning dental caries and progress in the prevention of periodontal disease. Many of these pressures are inducing competition in the dental care system. It is clear that the dental care system is in the process of change as it responds to these complex pressures.

Mucosal biopsy of the esophagus, stomach, and proximal duodenum

The past decade has occasioned the development and extensive use of flexible endoscopes for visualization of large areas of the alimentary tract. Numerous small grasp biopsies are now performed to determine the diagnosis and course of a large variety of inflammatory and neoplastic disorders. In this review, the authors have concentrated on the uses and interpretation of endoscopy and biopsy of the upper alimentary tract including the esophagus, stomach, and proximal duodenum. They have also commented on the limitations of endoscopic biopsy with respect to its size, superficial nature, and imperfect orientation in the evaluation of some disorders.

The hyperechogenic liver in children: cause and sonographic appearance

The clinical records of 28 patients seen in one institution during a recent 2 year period who, on sonography, had been identified as having a hyperechogenic (bright) liver were reviewed. Seven children were diagnosed as having metabolic diseases, four were malnourished, four were receiving hyperalimentation, 10 were receiving chemotherapy, and three were undiagnosed. The sonograms of all the patients and the histologic sections on those who had biopsies, were reevaluated in order to assess the sonographic pattern in greater detail, and these findings were correlated with fatty infiltration and fibrosis of the liver. The bright liver corresponded to the pathologic finding of fatty change. This sonographic finding in children is important, as further evaluation (hepatic biopsy with fat stain, enzymatic analyses, amino acid screens) can be suggested to identify underlying metabolic disorders in those not on therapy. Often the complications of metabolic diseases can be prevented or delayed by early diagnosis and appropriate therapy.

The psychological parenting and permanency principles in child welfare: a reappraisal and critique

The psychological parenting and permanency of care principles address important problems in child welfare. The focus of the theories, however, draws attention away from the underlying cause of family stress, and may serve to validate child welfare departments' failures to respond to that stress in the context of the family. It is suggested that aspects of the theories are overly mechanistic, and that there exists a substantial subset of child welfare clients for whom they are not relevant.

Dynamic time course studies of the spontaneously diabetic BB Wistar rat. III. Light-microscopic and ultrastructural observations of pancreatic islets of Langerhans

The pancreatic islet alterations were studied in spontaneously diabetic BB Wistar rats and in young (50 and 65 days old) normoglycemic BB rats with the use of light microscopy, immunohistochemistry, and electron microscopy. Three groups of diabetic rats were delineated: 1) early diabetes (1-3 days after detection of glycosuria), 2) stable diabetes (41-63 days after detection), and 3) unstable diabetes (7-22 days after detection). In early diabetes islets were extensively infiltrated by "activated" lymphocytes and macrophages, and B cells demonstrated marked degranulation, injury, and necrosis. Although no consistent changes were recorded in A cells, D cells appeared to be decreased in number. In stable and unstable diabetes, islets were small and markedly depleted of B cells, although more insulin-containing cells were identified in the stable group. The number of A and D cells appeared normal in the stable group, although some A cells appeared altered ultrastructurally. In the unstable group both A and D cells appeared decreased, and ultrastructurally altered A cells were again noted. These findings suggest that although B cells appear to be the principal islet target in this model, A and D cells also sustain cellular injury. Variable degrees of insulitis, B cell degranulation, and necrosis were documented in 65-day-old normoglycemic BB rats, suggesting that the destructive process in the islets is initiated well in advance of the onset of the clinical syndrome. The pancreases from many diabetic and normoglycemic BB rats also demonstrated mononuclear cell infiltrates distinct from insulitis in periductular and/or acinar locations. These infiltrates, not present in controls, appear to represent an additional morphologic expression of the process responsible for initiating the diabetic state.