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Clathrin mediated endocytosis is the primary pathway for receptor and cargo internalization in eukaryotic cells. It is characterized by a polyhedral clathrin lattice that coats budding membranes. The mechanism and control of lattice assembly, curvature, and vesicle formation at the plasma membrane has been a matter of longstanding debate. Here, we use platinum replica and cryo electron microscopy and tomography to present a global structural framework of the pathway. We determine the shape and size parameters common to clathrin-mediated endocytosis. We show that clathrin sites maintain a constant surface area during curvature across multiple cell lines. Flat clathrin is present in all cells and spontaneously curves into coated pits without additional energy sources or recruited factors. Finally, we attribute curvature generation to loosely connected and pentagon-containing flat lattices that can rapidly curve when a flattening force is released. Together, these data present a new universal mechanistic model of clathrin-mediated endocytosis.

Objective: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with mullerian agenesis. Study Design: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. Results: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 ± 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 ± 9.5 and 65.3 ± 18.5 months, respectively (P

OBJECTIVE: Oral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process. DESIGN: Descriptive study. SETTING: Inpatient general medicine service in a university-affiliated public hospital. PARTICIPANTS: Twelve third-year medical students during their internal medicine clerkship and 14 teachers. MEASUREMENTS: One-hundred sixty hours of ethnographic observation. including 73 oral presentations on rounds. Discoursed-based interviews of 8 students and 10 teachers. Data were qualitatively analyzed to uncover recurrent patterns of communication. MAIN RESULTS: Students and teachers had different perceptions of the purpose of oral presentation, and this was reflected in performance. Students described and conducted the presentation as a rule-based, data-storage activity governed by "order" and "structure." Teachers approached the presentation as a flexible means of "communication" and a method for "constructing" the details of a case into a diagnostic or therapeutic plan. Although most teachers viewed oral presentations rhetorically (sensitive to context), most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (e.g., comment "be brief" resulted in reading faster rather than editing) and unintended value acquisition (e.g., request for less social history interpreted as social history never relevant). CONCLUSIONS: Students learn oral presentation by trial and error rather than through teaching of an explicit rhetorical model. This may delay development of effective communication skills and result in acquisition of unintended professional values. Teaching and learning of oral presentation skills may be improved by emphasizing that context determines content and by making explicit the tacit rules of presentation.

Periodontal disease is an infection in which destruction occurs at sites remote from the infection, resulting in pathological pocketing. Intervening between the infection and the destruction is a dense mononuclear inflammatory infiltrate. It has been suggested that this infiltrate might have characteristics and the destructive potential of Th1-type T lymphocytes. To ascertain the nature of the infiltrates we investigated the expression of mRNA for IL-2, IL-5, and IFN-γ by gingival mononuclear cells (GMC) from healthy (n = 8) or adult periodontitis (AP) patients (n = 25) by using cytokine-specific reverse-transcription/polymerasechain-reaction (RT-PCR). GMC, as obtained from patients' tissues, expressed IL-2, IFN-y, or IL-5 mRNA. Significantly higher proportions of GMC from AP patients expressed IL-2 and IFN-γ mRNA than did those from healthy subjects. TFN-γ was the most consistent cytokine message detected. In other experiments, gingival T-lymphocytes (n = 12) and CD4+and CD8+gingival T-lymphocytes (n = 16) were isolated from gingival tissues removed surgically from AP patients. AP gingival T-lymphocytes expressed mRNA for IL-2, IFN-γ, or IL-6 prior to stimulation. After stimulation with Con A, the cells significantly up-regulated IL-5 and IL-6 message expression. Both CD4+ and CD8+gingival T-lymphocytes expressed IFN-γ, IL-5, and some IL-2. This cumulative cytokine profile observed in these experiments is consistent with the predominance of Th1-type cells in pathological tissues and with Th2-type cells, which can also be present, being up-regulated under appropriate stimulation. Importantly, CD4+ and CD8+lymphocytes were shown to express T1- and T2-type cytokine message, emphasizing the potential for CD8-T-lymphocytes to participate in periodontal disease pathology.

The language people use both makes possible and constrains the thoughts they can have. More than just a vehicle for ideas, language shapes ideas--and the practices that follow from them. Thus, in medical education, teaching students how to talk about medical cases also teaches them how to think about patients and medical work, and how to define their relationships to both. Without a theoretical model, however, teaching efforts in this domain tend to be implicit and ad hoc, which can lead to serious problems. Rhetoric is one science that can deepen understanding of communication and improve teaching of this clinical skill. Rhetoric systematically studies the relationships between communication and its effects, between how things are named and how they are experienced, between discourse and socialization. Bringing language to the foreground of education, rhetoric directs attention to the relationship between what medical students learn to say and what they learn to value, believe, and practice.

Recurrent intussusception is defined as an occurrence of intussusception of a bowel loop in a patient with a prior resolution of intussusception, either spontaneously or with an intervention. It is not rare to develop a subsequent episode after a successful reduction of intussusception. We report the cases of 2 children who presented to the emergency department with recurrent intussusception and review the pertinent literature.

It has been speculated that symptomatic seroma, or seroma requiring needle aspiration, is one of the risk factors for lymphedema symptoms following breast cancer treatment. These symptoms exert tremendous impact on patients' quality of life and include arm swelling, chest/breast swelling, heaviness, tightness, firmness, pain, numbness, stiffness, or impaired limb mobility. Our aim was to explore if symptomatic seroma affects lymphedema symptoms following breast cancer treatment. Data were collected from 130 patients using a Demographic and Medical Information interview tool, Lymphedema and Breast Cancer Questionnaire, and review of medical record. Arm swelling was verified by Sequential Circumferential Arm Measurements and Bioelectrical Impedance Spectroscopy. Data analysis included descriptive statistics, Chi-squared tests, regression, exploratory factor analysis and exploratory structural equation modeling. Thirty-five patients (27%) developed symptomatic seroma. Locations of seroma included axilla, breast, and upper chest. Significantly, more women with seroma experienced more lymphedema symptoms. A well-fit exploratory structural equation model [X2(79) = 92.15, p = 0.148; CFI = 0.97; TLI = 0.96] revealed a significant unique effect of seroma on lymphedema symptoms of arm swelling, chest/breast swelling, tenderness, and blistering (beta = 0.48, p0.01). Patients who developed symptomatic seroma had 7.78 and 10.64 times the odds of developing arm swelling and chest/breast swelling versus those who did not, respectively (p0.001). Symptomatic seroma is associated with increased risk of developing lymphedema symptoms following breast cancer treatment. Patients who develop symptomatic seroma should be considered at higher risk for lymphedema symptoms and receive lymphedema risk reduction interventions.

Due to advances in oncological care, the number of patients exposed to and surviving after anticancer chemotherapy is steadily increasing. Anticancer agents, however, are often associated with side-effects including cardiotoxicity which has been identified as one of the most serious and potentially life threatening complications. Cardiotoxicity manifestations range from asymptomatic alterations of heart and vasculature function to arterial hypertension, myocardial ischemia, arrhythmias (including QT-prolongation) and overt heart failure. Post-chemotherapy cardiovascular impairment has been associated with increased morbidity and may also contribute to increased mortality in these patients, both early and late after chemotherapy. This review article describes pathophysiology, clinical manifestation, diagnostic algorithms, monitoring and therapy of cardiotoxicity caused by anticancer agents. We also outline and discuss a variety of problems associated with patient management from the viewpoint of clinical cardiology according to latest published findings.

An increasing incidence of invasive aspergillosis is observed in most immunocompromised patients, and especially patients with acute leukemia and after hematopoietic stem cell transplantation. In order to decrease the mortality due to this infection, the clinicians need to optimise their treatment choice. The objective of these guidelines is to summarize the current evidence for treatment of invasive aspergillosis. The recommendations have been developed by an expert panel following an evidence-based search of literature with regard to current recommendation of European Conference in Infections in Leukemia and Infectious Diseases Society of America.

National working group representing clinicians (hematologists, oncologists, infection diseases and ICU specialists), microbiologists, and different special medical societies and working groups prepared evidence-based guidelines for the treatment established fungal infection--invasive candidiasis in the adult hematology and ICU patients. These guidelines updated those published in the Czech Republic in 2003-2004. Evidence criteria of the Infectious Diseases Society of America (IDSA) were used for assessing the quality of clinical trials, and EORTC/MSG Consensus Group for definitions of invasive fungal disease.

A bilateral oophorectomy at the time of elective hysterectomy is often performed to prevent ovarian cancer. The assumption that endogenous estrogen can be easily replaced with supplemental medication fosters the decision for routine oophorectomy. Published reports on the use of postmenopausal estrogen indicate that compliance is less than perfect. This fact could affect the overall outcome. Decision analysis techniques with Markov cohort modeling were used to evaluate the policy of elective bilateral oophorectomy. Results from studies judged methodologically sound were combined to determine values representing the influence of estrogen on coronary heart disease, breast cancer, and osteoporotic fracture. The decision tree also explicitly incorporated patient compliance. When compliance with estrogen therapy is assumed to be perfect, oophorectomy yields longer life expectancy than retaining the ovaries. When actual drug-taking behavior is considered, retaining the ovaries results in longer survival. This analysis highlights the importance of including the effects of patient compliance with treatment recommendations when the impact of a health policy decision such as prophylactic surgery is assessed.

Interns are expected to teach medical students, yet there is little formal training in medical school to prepare them for this role. To enhance the teaching skills of our graduating students we initiated a 4-hour “teaching to teach” course as part of the end of the fourth-year curriculum. Course evaluations demonstrate that students strongly support this program (overall ratings 2000 to 2005: mean = 4.4 [scale 1 to 5], n = 224). When 2004 course participants were surveyed during the last month of their internship, 84%“agree” or “strongly agree” with the statement: “The teaching to teach course helped prepare me for my role as a teacher during internship” (2005: mean 4.2 [scale 1 to 5], n = 45, response rate 60%). A course preparing fourth-year students to teach during internship is both feasible and reproducible, with a minimal commitment of faculty and resident time. Participants identify it as an important addition to their education and as useful during internship.

An overview concerning different types of kidney involvement associated with monoclonal gammapathy (MG) is given, focused on light-chain deposition disease (LCDD). Pathophysiologic basis of LCDD remains in the light-chain tissue deposition (resp. in tissue deposition of immunoglobulin's stable domain). This mechanism is typical for monoclonal immunoglobulin's overproduction as found in MG. Clinical picture of LCDD reflects multiorgan character of disorder, while renal lesions rank among the most frequent, serious and best documented ones. Clinical data referring to a group of six patients, treated in our nephrologic department are presented. Diagnosis of LCDD was established on basis of the renal biopsy finding. Renal functions were decreased at the time of diagnosis in all patients, whereas haemodialysis treatment was started in one patient. On conclusion therapeutic possibilities of LCDD are discussed, in which number symptomatic therapy of renal failure is combined with corticosteroids therapy and cytostatic therapy; prognosis of most patients remains serious.

Spectrum of antimycotics used in treatment of systemic mycoses is comparatively poor. The oldest and till present received "golden standard" is polyen amphotericin B (AmB). It has the widest spectrum of effects and has the lowest incidence of resistances. However, the therapy can be accompanied by manifestations of toxicity, namely that of nephrotoxicity. "Lipoid" form of AmB (Abelcet, Amphocil, AmBisome) with only 20% risk of nephrotoxicity partly solved the problem. Wider use of these drugs is hindered by their high price. The azoles group (ketoconazole, fluconazole, itraconazole) today represents the most frequently used group of antimycotics; triazols of the 3rd generation (variconazole, posaconazole, ravuconazole) broaden the spectrum of effects namely to aspergil infections. In the future substances with a different target structure will be used. According the mechanism of effect they can be classified as echinocandins (inhibition of beta-glucane synthesis), echinocandins (inhibition of chitin synthesis), sordarines (selective inhibitors of proteosynthesis), pradimicines (cell lysis by binding on manoproteins). The rising occurrence of resistance should be coped with inhibitors of the efflux pump (milbemycine). Clinical testing of all these substances is already in progress, in some of them already in phase III.

The objective of the paper is to draw attention to the not very frequent and thus omitted form of sideropenic anaemia in selective iron malabsorption as the only manifestation of malabsorption syndrome in coeliac sprue. This type should be suspected when examination of blood losses is futile and oral iron administration which is usually administered empirically produces no effect. The authors present the example of two patients with severe sideropenic anaemia where the diagnosis of malabsorption was confirmed only several years after the diagnosis of sideropenic anaemia was established. Evidence of a correct conclusion was permanent normalization of haemoglobin values when the patients adhered to a gluten-free diet.

Injection drug users frequently present to emergency departments with fever. A careful history and physical examination with attention to anatomic localization of symptoms and signs are often necessary to unmask unusual underlying medical conditions. We report a case of a woman with recent injection drug use who presented with fever, a palpable neck mass, and Pancoast's syndrome. She had been seen recently at the ED of another hospital and discharged with oral antibiotics for presumed cellulitis. A mycotic aneurysm of the subclavian artery causing Pancoast's syndrome was later diagnosed by using computed tomography and angiography. A high index of suspicion for anatomically localized infective processes should always be maintained with febrile injection drug users.

A group of workers exposed to elemental mercury was monitored over a period of 14 years (1983-1996) at the Institute of Occupational Medicine and Environmental Health, Sosnowiec. Mercury was used as a catalyst in the synthesis of acetic aldehyde and obtaining of chlorine. Every year medical examination was performed in the group of 163-277 persons. During the first four years of monitoring, excessive absorption of Hg was found in 32.1-45.1% of workers. The highest percentage (46.1-65.0%) was observed in persons engaged in technological processes of acetic aldehyde synthesis. From 1987 workers employed in this department were systematically (every six months) removed from the contact with Hg. Due to preventive removal a gradual decrease in the percentage of those with high Hg absorption (32.0-9.2%) was observed. As the authors point out, it is important to select properly workers to be employed under conditions of mercury exposure, and to determine every six months their urine mercury level. It is also desirable to remove workers temporarily from the most hazardous workposts and to incorporate a wide spectrum of specialistic examinations into periodical checkups.

Divers are exposed to dense gases under hyperbaric and hyperoxic conditions and, therefore, may be at risk of developing respiratory disease. Long-term effects on respiratory function have been found in commercial divers who perform deep dives. This study was conducted to detect possible lung function changes in scuba divers who dive in shallow water using compressed air or oxygen as a breathing gas. A cross-sectional sample of 180 healthy male divers (152 air divers and 28 oxygen divers) and 34 healthy male controls underwent a diving medical examination including body plethysmography, diffusion capacity measurement and a cold-air isocapnic hyperventilation test (CAIH). Air divers and oxygen divers had a lower mid-expiratory flow at 25% of vital capacity (MEF25) than controls (p

Anemia is common complication in multiple myeloma (MM). Its etiology is multifactorial-bone marrow infiltration, cytokines production, renal failure and effect of chemotherapy are main contributing factors. The red cell substitution therapy, which is administrated in 34 - 53% of patients, is frequently associated with the risk of well-known side effects. The use of recombinant erythropoietin (r-HuEPO) is a novel therapy in patients with MM.We have investigated the effect of r-HuEPO (Eprex. Cilag) in the group of 8 patients with MM. The growth factor was administrated in the dose of 150 U/kg. 3 times/ week s.c. The criterium of response was the increase of Hb levels of 20 g/L. All patients responded to r-HuEPO treatment. The medium period of response was 6,5 weeks. In two patients the doses of r-HuEPO could be reduced due to excellent effect of therapy. The energy level, ability to daily activities and overall quality of life significantly improved during the course of therapy. Neither effect of growth factor on thrombopoiesis and/or leukopoiesis nor serious adverse events due to r-HuEPO therapy were observed. The activity of underlying disease did not seem to be affected by r-HuEPO. In one patient the disease rapidly progressed after the end of study. The progression had some features of plasmablastic leukemia and leads to the death of patient.According to our experience, r-HuEPO is highly effective in the treatment of anemia in MM. The stimulation of erythropoiesis was associated with significant improvement of quality of life of patients. The effect of r-HuEPO treatment on activity of MM was not found, however, in one patient rapid progression of disease was observed after the end of study.

The etiology of anaemia associated with tumours is multifactorial. One of the mechanisms of development of anaemia in tumours are so-called chronic diseases anaemias, the main feature of which is inadequate production of endogenous erythropoietin (EPO). The objective of the investigation was to test the effect of recombinant human erythropoietin (rHuEPO) in the treatment of anaemia (rise of haematocrit, Hb) in patients with chronic lymphatic leukaemia (CLL) and multiple myeloma (MM) and the effect of this treatment on the quality of life. The authors evaluated at the same time the impact of the endogenous EPO level before treatment and its predictive value as regards the therapeutic response.The investigation comprised a total of 14 patients (6 CLL, 8 MM). The basic criterion for inclusion in the group was a Ht value lower than 0.32 and Hb less than 105 g/l. The examination protocol was focused on elimination of other causes of anaemia. During the 12-week investigation the patients completed a questionnaire "Quality of life" which reflected their subjective evaluation of the effect of treatment. The patients themselves administered r-HuEPO three times a week by the s.c. route--an initial dose of 150 U/kg with the possibility to increase the dose to 300 U/kg.A therapeutic response was obtained in four patients with CLL and eight patients with MM. Respondents with CLL had endogenous EPO values lower than 300 U/l, seven MM respondents lower than 200 U/l, one 400 U/l. The Hb level of the patients rose and the quality of life improved. All patients tolerated treatment very well and the authors did not observe any serious undesirable effects.The investigation confirmed the therapeutic effect of r-HuEPO in patients with a lower baseline value of EPO. Subjective evaluation (questionnaire) correlated with objective evaluation (Ht, Hb). Assessment of the endogenous EPO level before treatment is according to the authors one of the important primary predictive parameters and EPO values between 200 and 300 U/l are the upper range where a therapeutic effect can be expected with the highest probability. The authors conclude also that a secondary predictive criterion of the response is evaluation of the therapeutic effect after 4-5 weeks treatment when a rise of Hb by at least 20 g/l is an argument for further treatment.

This paper outlines strategies for all nurses to participate in nursing's research agenda, which aims to enhance the scientific basis of nursing practice. The emphasis here is on generating data for the outcomes movement as a tool for transforming the American health care delivery system.

Cigarette smoking is a risk factor for many diseases, and recent evidence indicates that it adversely affects periodontal health. A number of epidemiologic studies have shown strong associations between smoking and the prevalence and severity of periodontitis, as well as interproximal bone loss. Although the pathogenesis of periodontitis in smokers is poorly understood, there are data suggesting that smoking causes defects in neutrophil function, impaired serum antibody responses to periodontal pathogens, and potentially diminished gingival fibroblast function. The prevalence and severity of periodontitis in former smokers is decreased compared to current smokers, providing evidence that smoking cessation is beneficial. Smoking markedly influences response to treatment, and a subset of smokers predominates among refractory periodontitis patients who are resistant to conventional treatment. A patient's smoking history is a useful clinical predictor of future disease activity. Current estimates suggest that smoking is associated with a large proportion of periodontitis cases and constitutes a major public dental health problem.

Cigarette smoking is a risk factor for many diseases, and recent evidence indicates that smoking adversely influences periodontal health. A number of epidemiologic studies have shown strong associations between smoking and the prevalence and severity of periodontitis, as well as interproximal bone loss. Whereas the pathogenesis of periodontitis in smokers is poorly understood, there are data suggesting defects in neutrophil function, impaired serum antibody responses to periodontal pathogens, and potentially diminished gingival fibroblast function. The prevalence and severity of periodontitis in former smokers is decreased compared with current smokers, providing evidence that smoking cessation is beneficial. Smoking markedly influences response to treatment, and a subset of smokers predominates among patients with refractory periodontitis whose disease is resistant to conventional treatment. Smokers are a high-risk group for periodontitis, and smoking history is a useful clinical predictor of future disease activity. Current estimates suggest that smoking is associated with a large proportion of periodontitis cases and constitutes a major dental public health problem. A new disease category, smoking-associated periodontitis, is proposed, given the unique characteristics of smokers with periodontitis.

This article explores the gap that currently exists between nursing research and nursing practice. The aim is to promote the conversion of new knowledge into practical innovations. Barriers to research utilization in practice settings come from both the academic and clinical arenas. Innovative models and strategies are needed to overcome these barriers. The purposes and value of research utilization and the clinical and academic strategies that facilitate research are discussed. Supporting clinical studies are provided as exemplars.

The purpose of this study was to establish construct validity of the Haber Level of Differentiation of Self Scale (LDSS) that measures selected aspects of the construct, differentiation of self, the key concept of the Bowen Theory. During stage one of this study, a 32-item Likert-type LDSS, which contained two subscales, Emotional Maturity, (EM), and Emotional Dependency (ED), was administered to 372 volunteer subjects. Factor analytic and correlational findings indicated support for a 24-item unidimensional rather than a 32-item two subscale instrument. Recalculation of coefficient alpha (.90) also supported the unidimensional structure of the LDSS. During stage two of this study, the revised 24-item LDSS was administered to 372 volunteer subjects, who also completed the State-Trait Anxiety Inventory, the Life Experience Survey, and the Behavior Checklist. Hypotheses predicted that there would be negative relationships between differentiation of self and trait anxiety, state anxiety, adult psychological dysfunction, and negative impact stress. Findings indicate support for all hypotheses at the p.01 level of significance or greater. Data from this study suggest that the 24-item LDSS is a valid and reliable unidimensional family assessment tool that accurately measures specific aspects of the construct, differentiation of self. The LDSS can be used by nurses and other professionals to assess individual and family functioning in a variety of health care settings.

This discussion was selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Homer A. Boushey, MD, Professor of Medicine, and Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith, Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.

The treatment of masticatory muscle and temporomandibular joint pain constitutes an important area in dentistry. Current information supports the use of reversible treatments for these disorders. Several recent references are discussed in relation to reversible treatment, the role of occlusion, and appliance therapy for internal derangement.

Myelodysplastic syndrome (MDS) is frequently associated with monocytosis in the blood and myelomonocytic dysplasia in the bone marrow. In two groups of patients with MDS, all subtypes excluding CMML, the authors demonstrated that monocytosis was present in 15% of the patients in group I according to the haemogram at the time when the diagnosis was established and in 19% in group II where it was required that at least in half the haemograms throughout the course of the disease there were more than 10% monocytes. No difference was found in the prognosis of patients with monocytosis, as compared with patients with monocytopenia as regards the life span and frequency of transformation into AL. The cytogenetic and cultivation findings did not differ either. In some instances, in particular in patients with RA and RAS significant monocytosis was not associated with the expected proliferation of monocytoid cells in bone marrow. The authors assume that proliferation and differentiation of germ cells in the monocytic series is easier than in the granulocytic series and that monocytosis can be considered a manifestation of substituted neutropenia. The work indicates the difficulties associated with the differential diagnosis of RA, RAS and RAEB with monocytosis, MDS with a dominating change of the type of myelomonocytic dysplasia and CMML proper.

A good measure of the efficacy of vaccines should be based on an index that standardizes the exposure to infection of those who have been immunized and those who have not. In addition, the measure should not be influenced by indirect effects. In the case of outbreaks directly transmitted agents that cause acute infections diseases, the household secondary rates of attack are the best indicator of vaccine efficacy provided that the data are collected at the household level. If the data are not collected in this manner, the best indicator will be the estimated probability of transmission, even though this estimator and its meaning less obvious than the secondary attack of rate. Other strategies to estimate the efficacy of an immunization are more appropriate for situations that are more complex than outbreaks caused by acute infectious agents.

Hypophosphatemia occurs in 40 to 60% of patients with acute malaria, and in many other conditions associated with elevations of body temperature. To determine the prevalence and causes of hypophosphatemia in patients with malaria, we retrospectively studied all adults diagnosed with acute malaria during a 12-year period. To validate our findings, we analyzed a second sample of malaria patients during a subsequent 10-year period. Serum phosphorus correlated inversely with temperature (n = 59, r = -0.62; P

1. 1. There is statistical proof that the mortality rate after repair of strangulated hernias is high and that it is markedly increased by bowel surgery. 2. 2. Borderline cases incidental to strangulated hernias are described, in which the damaged part of the bowel has not responded to routine management. At times it is rather difficult to evaluate the viability of such bowel. 3. 3. The advantages of the guide suture, in this type of case, are discussed. 4. 4. Four case reports are given.

Follow-up of 15 women, aged 15-30 who underwent second-trimester abortion by "super-coil" showed that 9 women (60%) had some complications between the insertion of the coil and follow-up examination 1 week later. 7 of the women developed fever, 6 while the coils were still in utero. 11 of the women noted rupture of the membranes before the coil was removed. There were 3 major complications, one lacerated uterus requiring an abdominal hysterectomy, one case of periappendiceal inflamation with intrapelvic adhesions, and one case of postabortal anemia. Overall complication rates were higher for this group of patients than for other patients who underwent second-trimester abortion, as determined by the Joint Program for the Study of Abortion. The lack of experience of the operators and environment in which they were performed may have contributed to the high morbidity rate.

The three-decade long controversy surrounding the status of triglycerides as an independent risk factor for coronary heart disease is presented. The studies that reported an association and the clinical trials of cholesterol-lowering medications are examined. Because of the inconsistency between the observational findings and the consistently negative clinical trial findings, treatment of isolated hypertriglyceridemia cannot be recommended at present.

15 women in the second trimester of pregnancy underwent induced abortions in a private clinic in Philadelphia by the super coil method which was, from the scanty literature then available, purportedly safe and suited for second trimester pregnancies. This method utilizes a plastic strip 40 cm long and 4.6 mm wide, wound into a spiral 2 cm in diameter. The coil is straightened and put in an inserter through which it is introduced via the cervical os into the uterus. The method calls for insertion of several coils, and balsa tents may also be placed in the cervical canal. The coils are removed 12-24 hours after insertion, and if the uterine contents are not totally expelled spontaneously, ovum forceps are used to remove them. Neither of the 2 physicians performing the abortions had had previous experience with this method. 13 of the 15 women who underwent super coil abortions received follow-up medical evaluation. Of these 13, 9 (60%) had complications, 3 of which were major (2 requiring major surgery). Although the small number of women in this series does not permit a definitive judgement of the risks associated with the super coil method, the results do indicate that this method is not without significant risk and is in need of further research.