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Objective To determine the presence of a fibronectin-aggrecan complex (FAC) in the disk space of persons with chronic low back pain as relates to provocative diskography. Design A single-center prospective consecutive case series. Setting A single private practice setting. Patients Thirty-seven patients with symptomatic degenerative disk disease of the cervical, thoracic, or lumbar spine undergoing provocative diskography to identify a source of pain. Methods Diskographic lavage for analysis was simultaneously performed at each disk level injected during diskography. Main Outcome Measures Visual analog scale (VAS) pain scores, Pfirrmann magnetic resonance imaging grade, and biochemical analysis of disk material were statistically analyzed. Results A total of 105 levels in 37 patients had a complete set of data (mean age 43.2 ± 11.9 years; 15 male/22 female). The FAC was present in 43 of 108 levels and in at least one level in 25 of 37 patients. The Pfirrmann magnetic resonance imaging grade did not differ between complex-positive and negative levels ( P = .125), nor did the intraoperative VAS (IO-VAS) score for pain by level ( P = .206). A significant but loose correlation was found between Pfirrmann grade and IO-VAS ( R 2 = 0.4, P R 2 = 0.08, P = .11 and R 2 = 0.003, P = .5). Conclusions The FAC was identified in some painful disks by diskography. There was no significant correlation between the Pfirrmann grade or pre/intraoperative pain scores during diskography and complex concentrations within the disk measured by disk lavage.

Background context The pathophysiology underlying degenerative disc disease and its implication in painful syndromes remain unclear. However, spine magnetic resonance imaging (MRI) can demonstrate changes in disc water content and the annulus; provocative discography purportedly identifies degenerate discs causing serious low back pain; and biochemical assays have identified local inflammatory markers. No study to date has correlated pain on disc injection during discography evaluation with relevant MRI findings and biochemical markers. Purpose The purpose of this study was to correlate concordant pain on during discography to biochemical markers obtained by disc lavage and MRI findings. Study design This is a Phase 1 Diagnostic Test Assessment Cohort Study (Sackett and Haynes). Patient sample The patient sample included 21 symptomatic patients with suspected discogenic pain and three Phase 1 control subjects. Outcome measures The outcome measures included discography pain scores, MRI degenerative grades, and immunoreactivity to various inflammatory cytokine concentrations present in disc lavage samples. Methods Twenty-one symptomatic patients with lumbar degenerative disc disease and three control subjects underwent discography, MRI, and biochemical analysis of disc lavage fluid. Lumbar MRI was scored for Pfirrmann grading of the lumbar discs, and annular disruption was identified by nuclear disc lavage. Disc lavage samples were analyzed for biochemical markers by high-sensitivity immunoassay. Results Eighty-three discs from 24 patients were studied: 67 discs from 21 patients with axial back pain (suspected discogenic pain group) and 16 discs from 3 scoliosis patients without back pain (Phase 1 control subjects). Among the biochemical markers surveyed, interferon gamma (IFN-γ) immunoreactivity was most consistently identified in patients with axial back pain. Discs with annular disruption and concordant pain reproduction at a visual analog scale of 7 to 10/10 had greater IFN-γ immunoreactivity than those without this finding (p=.003); however, at least some IFN-γ immunoreactivity was found in all but one disc in the symptomatic group. Conclusions Among the potential inflammatory markers tested in this Phase 1 study, IFN-γ immunoreactivity was most commonly elevated in discogram “positive” discs but absent in asymptomatic controls. However, this marker was also frequently elevated in degenerative but “negative” discography discs. From these findings, Phase 2 and Phase 3 validity studies are reasonable to pursue. Phase 4 utility studies may be performed concurrently to assess this method's predictive value in outcome studies.

BACKGROUND: Subclinical hypothyroidism (elevated thyroid-stimulating hormone [TSH] with normal thyroid hormone levels) can present with depression. This may be confirmed by an exaggerated TSH response to thyrotropin-releasing hormone (TRH) on the TRH stimulation test (TRH-ST). The objective of this study was to determine the prevalence of exaggerated TRH-ST results in a sample of depressed patients with "high-normal" screening TSH levels. METHOD: Depressed patients with TSH levels of 3.00-5.50 mIU/L underwent a TRH-ST. After baseline TSH was drawn, TRH 400 micrograms was injected intravenously, and TSH samples were drawn at +20 min, +30 min, and +40 min postinjection. A rise in TSH after TRH (peak value minus baseline) of > 25 mIU/L represented an exaggerated TSH response. RESULTS: Twenty-three (38%) of 60 patients had an exaggerated TSH response to TRH. The 38% prevalence is significantly (Chi 2 = 59.65, df = 1, p < .001) greater than the 6% prevalence of positive TRH-ST results reported in the euthyroid general population. The prevalence of positive TRH-ST results was not attributable to differential patterns of psychotropic or thyroid hormone treatment. Unexpected observations were a lack of correlation in TSH levels week to week (r = .17, N.S.) and a lack of correlation between screening TSH value and subsequent TRH-ST results (r = .28, N.S.). CONCLUSION: Subtle thyroid underfunction may be contributing to depression in some patients with TSH in the upper half of the range usually considered normal. If so, then the TRH-ST may be more sensitive in identifying this than measurement of TSH alone.

Objective To investigate the presence of inflammatory cytokines and the fibronectin-aggrecan complex (FAC) in persons undergoing surgical treatment for cervical radiculopathy caused by disk herniation. Design Single-center, prospective, consecutive case series. Setting A single large academic institution. Patients A total of 11 patients with radiculopathic pain and magnetic resonance imaging findings positive for disk herniation elected to undergo single-level cervical diskectomy. Methods or Interventions Lavage was performed by needle injection and aspiration upon entering the disk space for fluoroscopic localization before diskectomy. Main Outcome Measurements The lavage fluid was assayed for pH and the FAC, as well as for the cytokines interleukin-6 (IL-6), interferon-γ, monocyte chemotactic protein (MCP), and macrophage inhibitory protein-1β. Results The subjects were 7 women and 4 men with a mean age of 50.6 years (SE 9.7; range, 36-70 years). The mean concentrations (SE; range) in picograms per milliliter were 7.9 (4.4; 0-44) for IL-6, 25.3 (15.5; 0-159) for interferon-γ, 16.1 (11.9; 0-121) for MCP, and 6.1 (2.8; 0-29) for macrophage inhibitory protein-1β. The optical density of the FAC at 450 nm was 0.151 (0.036; 0.1-0.32), and the pH was 6.68 (0.1; 6.10-7.15). Statistically significant correlations were found between MCP and FAC ( P = .036) and between FAC and pH ( P = .008). Conclusions Biochemical analysis of injured cervical intervertebral disks reveals the presence of inflammatory markers such as MCP, fragments of structural matrix proteins such as FAC, and a correlation with pH. Further evaluation of the FAC as a potential diagnostic biomarker or therapeutic target is warranted in the cervical spine.

Pneumothorax and mediastinal emphysema following tracheotomy are apparently more common than the literature would suggest. The fact that only a few cases are reported signifies not that an accident of this type is rare but rather that it is seldom recognized. The failure to recognize pneumothorax and mediastinal emphysema often results in unnecessary death. Reviews of large series of tracheotomies fail, for the most part, to mention pneumothorax or mediastinal emphysema. Figi,1in reporting a series of 200 consecutive tracheotomies performed at the Mayo Clinic, made no mention of either of these conditions. Pneumothorax complicating tracheotomy has been reported by Iglauer,2Myerson,3Wiethe4and Simpson.5Leiner6cited 9 cases of mediastinal emphysema following tracheotomy in children. After bronchoscopic procedure, pneumothorax has been reported to occur as a more frequent complication from direct perforation of the pleura. Several anatomic factors regarding the mechanisms responsible for pneumothorax must be considered. In the

The fate of 14C-labeled allergens injected intradermally into guinea pigs, namely picryl chloride (PCl*) and 2:4 dinitrochlorobenzene (DNCB*), was followed during the induction period of delayed hypersensitivity. Both chemicals were applied in a single injection into one ear in amounts that approached their minimal sensitizing doses (PCl, 0.25 µg; DNCB, 5.0 µg). Radioactivity in the various tissues was determined by liquid scintillation counting after combustion of tissues to CO2 and H2O. The injected allergens seemed to leave the injection site in three phases. A large proportion of allergen escaped rapidly from the ear, about 50% within 3 hr in the case of PCl, within 15 min for DNCB, the difference probably reflecting their unequal reaction constants. Initially there was a "half-life" escape in 2.5 hr with injected dosage of 0.25 µg PCl and in 18 hr for 5.0 µg DNCB. This escape occurred via the regional veins and not via the lymphatics. Radioactive decomposition products of the allergens were already present in the urine within 3–4 hr. After 6–8 hr, the half-life time of escape lengthened to approximately 28 hr for both allergens used in their respective initial dosages, holding up to 2 days after which there occurred still further slowing; between 2 and 4 days the time was about 43 hr for PCl, much longer (72–88 hr?) for DNCB, apparently reflecting different physicochemical properties of this second fraction. Sensitization seemed to be connected with the portion that was present between 12 hr and 4 days of the induction period. It is not known how far the escape of radioactivity during this period may represent gradual hydrolysis of attached picryl and dinitrophenyl groupings, respectively, to form picric acid and dinitrophenol. Gradual accumulation of the second fraction in the regional lymph nodes could definitely be excluded. It was noted that no hypersensitivity arose and essentially no depot of radioactivity existed between 12 hr and 4 days when DNCB was injected in a dose of 0.25 µg, owing to its ready escape from the ear; but 20 times as much DNCB caused sensitization and provided about the same fixed depot as 0.25 µg of picryl chloride. After delayed hypersensitivity had been established, traces of radioactivity were still measurable at the site. This third fraction, probably representing a different coupling product, escaped at a very low rate and was traceable up through several weeks. No demonstrable radioactivity could be detected in thymus, spleen, and mesenteric nodes when examined at short intervals between ½ min and 17 days. In analogy with findings on transplantation "immunity" and with studies reported in the following paper, the induction of delayed hypersensitivity can be explained by encounters between lymphoid cells and the hapten complex which is found present in the local site for 4 days, in agreement with Medawar's concept of peripheral sensitization.

PRESENT clinical methods used in the differential diagnosis of organic from psychogenic deafness have proved adequate in the majority of cases. However, equivocal and unreliable responses are met with, particularly in psychotic or retarded patients or those with a "compensation fixation." Methods of testing suspect cases of deafness are included in all standard textbooks. Priest 1 has outlined a satisfactory procedure for the uniform testing of patients with unilateral deafness. He has advocated the use of shadow curve audiograms, the Well's modification of the Stenger test, the Lombard reading test, the Marx test and several auxiliary aids. The need for clearcut differentiation in the diagnosis and separation of organic from psychogenic deafness is apparent. Since positive results are not always possible with present established tests, the following objective method of testing was utilized. This method is applicable only to those professing or manifesting total unilateral or binaural deafness. The galvanic skin

Summary 1.A series of 87 cases of bleeding peptic ulcer treated by a combined medicalsurgical approach is presented. The overall mortality is 4.6%. 2.A plan for the treatment and method of classification is presented. 3.Gastrointestinal x-rays were undertaken during active bleeding without any apparent ill effects in 24 cases. A definite diagnosis was established in 22 cases. 4.There were 12 operations performed for the arrest of hemorrhage with two fatalities. Sixteen operations were done as elective procedures during the same hospitalization. 5.Exsanguinating hemorrhage occurred in one patient under 40 and 7 patients over 40 years of age. Severe uncompensated hemorrhage occurred in 7 patients under 40 and one over 40 years of age. 6.It is our feeling that judging by age alone no security can be felt in predicting that an individual patient will not have an exsanguinating hemorrhage.

Summary The most satisfying observation in the use of sulfanilamide in the treatment of gonococcic ophthalmia was the rapid decrease in the swelling and discharge. Patients with red, chemotic, bulbar conjunctivae, with swollen retrotarsal folds and tumefied lids showed a uniformly prompt subsidence. Since this type of case is more apt to have implication of the cornea, if untreated, the rapid arrest noted with sulfanilamide is responsible, we believe, for a much better prognosis. In conclusion, we have observed a reduction of hospitalization of from 28.5 days for a control series of thirty-two patients with gonorrheal ophthalmia to 5.8 days for a series of fifteen patients treated with sulfanilamide. We believe the use of sulfanilamide is warranted in the treatment of gonorrheal ophthalmia for the following reasons: (1) economic importance, sharply reducing the length of hospitalization; (2) the ease of administration; (3) the apparent lack of complications; (4) the rapid improvement found; and (5) the general increase in the comfort of the patient.

Summary 1.A case is presented of intussusception of the ileo-ileo-colic type in which primary resection was necessary. 2.Resection of the involved segment including the inverted Meckel's diverticulum was carried out successfully with end-to-end anatomosis.

A number of cases of acute laryngotracheobronchitis have appeared in the literature in recent years. This is a report of a case of recovery from this disease occurring in a 5 week old infant who required tracheotomy. The prognosis in such a case is unfavorable. This patient is the youngest to recover from acute laryngotracheobronchitis of those reported on in the contemporary literature. REPORT OF CASE History .—P. G., a white female infant of 5 weeks, was admitted to the Parkview Hospital of Pueblo, Colo., on April 22, 1941, with the chief complaint of difficulty in breathing. History .—The patient was a normal, full term infant, whose birth weight was 3,390 Gm. (7 pounds 1 ounce). She was breast fed and showed normal progress until the fourth week, when a nasal discharge and diarrhea developed. A nipple shield had been used in nursing because of the mother's cracked nipples. The infant was

The manpower shortage, proposed national health insurance, and the escalating costs of education will change the demands on the dentist and force reform of the dental curriculum. The dentist will more likely be involved in group practice. He will be the manager of a dental health team, and as such will be involved primarily in treatment planning and case presentation. Also, he will be community-oriented. Concerns in the revision of the dental curriculum are the knowledge explosion, new techniques of communication, electives, early specialization, and altered criteria for graduation.

IN 1941 Kveim1 described a new skin reaction in which the intracutaneous injection of a homogenate of human sarcoidal tissue led to the formation of a nodule at the test site over the course of several weeks in patients with sarcoidosis, but not in normal subjects or persons with other diseases. Numerous investigators have subsequently studied this reaction, and most of them have supported the claim of its specificity for sarcoidosis.2 3 4 5 6 7 8 9 10 However, the dissenting opinion of one group of workers tended to cast some doubt on the validity of the Kveim test.11 , 12 This communication presents the results of a Cooperative . . .

Recent experiments on animals have revived interest in the hot bath as a treatment for syphilis. The hot bath or sweatbox as a part of the armamentarium for the treatment of syphilis is not new. Joan de Vigo, in 1514, said, "If an eruption of pustules, scabs, ulcers and warty excrescences are scattered over the whole body, after proper evacuation let the patient enter the stove for a sweat-bath.... This he should take twice a week." Jean Almenar, in 1512, said that the patient should go into either the sweatbox or the hot bath the day after a purge. Jacob Catanus, in 1516, devoted chapter six of his book on the French disease to "The Treatment of the French Disease by Administration of Baths." Many of the early syphilologists mention the hot baths; of these, particular mention should be made of Lawrence Frisius, 1532, Benedict Victor, 1551, and of William