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Objective: To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes., Methods: Geriatric emergency patients (aged 65 years and older) with a complaint of abdominal pain were participants in this longitudinal case series. Eligible patients were followed by telephone contact and chart review, to determine outcomes and final diagnoses., Results: Of 380 eligible patients, follow-up information was available for 375 (97%), for the two months following the ED visit. Final diagnoses included infection (19.2%), mechanical-obstructive disorders (15.7%), ulcers/hypersecretory states (7.7%), urinary tract disease (7.7%), malignancy (7.2%), and others. Although 5.3% of the patients died (related to presenting condition), most (61.3%) patients ultimately recovered. Surgical intervention was required for 22.1% of the patients. Variables associated with adverse outcomes (death, and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age. Most physical examination findings were not helpful in identifying patients with adverse outcomes. This study demonstrated a higher incidence of malignancy (7.2%) and a lower incidence of disease necessitating surgical intervention (22.1%) than previously reported., Conclusions: The majority of geriatric emergency patients with abdominal pain have significant disease necessitating hospital admission. Morbidity and mortality among these patients are high, and specific variables are strongly associated with death and the need for surgical intervention. Absence of these variables does not preclude significant disease. Physical examination findings cannot reliably predict or exclude significant disease. These patients should be strongly considered for hospital admission, particularly when fever, hypotension, leukocytosis, or abnormal bowel sounds are present.

A 33-year-old white man injected approximately 4 cc of charcoal lighter fluid (99.4% naptha/0.6% inert ingredients) subcutaneously into his left antecubital fossa. The injection resulted in the toxic necrosis of his volar forearm skin extending proximally to mid-humerus and distally to the metacarpophalangeal joints of the left hand dorsally over a 6-day period. The patient ultimately required extensive surgical debridement, secondary operative closure, and approximately 150 cm2 of split-thickness skin grafting. This case demonstrates the potential for widespread, delayed toxic necrosis of the skin resulting from subcutaneous injection of naptha. This patient's case appears to represent the most severe and widespread case of toxic necrosis of the skin resulting from the subcutaneous injection of hydrocarbons reported in the literature. This case also demonstrates extensive toxic thrombophlebitis not reported in prior cases involving subcutaneous injection of hydrocarbons.

Objective: To determine current practice and attitudes among emergency physicians (EPs) regarding the initiation and termination of CPR., Methods: An anonymous survey was mailed to randomly selected EPs. Main outcome measures included respondents' answers to questions regarding outcome of resuscitation, and current practice regarding initiation, continuation, and termination of resuscitation for victims of cardiopulmonary arrest., Results: The 1,252 respondents were from all 50 states, a variety of practice settings, and varying board certification. Most (78%) respondents honor legal advance directives regarding resuscitation. Few (7%) follow unofficial documents, or verbal reports of advance directives (6%). Many (62%) make decisions regarding resuscitation because of fear of litigation or criticism. A majority (55%) have recently attempted numerous resuscitations despite expectations that such efforts would be futile. Most respondents indicated that ideally, legal concerns should not influence physician practice regarding resuscitation (78%), but that in the current environment, legal concerns do influence practice (94%)., Conclusions: Most EPs attempt to resuscitate patients in cardiopulmonary arrest, regardless of futility, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than their professional judgment of medical benefit or futility. Compliance with patients' wishes regarding resuscitation is low unless a legal advance directive is present. Possible solutions to these problems may include standardized guidelines for the initiation and termination of CPR, tort reform, and additional public education regarding resuscitation and advance directives.

Basic fibroblast growth factor (bFGF) and FGF receptors have been localized to photoreceptors and retinal pigmented epithelium (RPE), but the function of bFGF in adult retina and RPE is unknown. Exogenous bFGF has a neuroprotective effect in retina and brain and its expression is increased in some neurons in response to cytokines or stress. In this study, we investigated the effect of light, other types of stress, neurotrophic factors, and cytokines on bFGF levels in cultured human RPE. Some agents that protect photoreceptors from the damaging effects of constant light, including brainderived neurotrophic factor (BDNF), ciliary neurotrophic factor, and interleukin-1 beta, increase bFGF mRNA levels in RPE cells. Intense light and exposure to oxidizing agents also increase bFGF mRNA levels in RPE cells and cycloheximide blocks the increase. An increase in bFGF protein levels was demonstrated by ELISA in RPE cell supernatants after incubation with BDNF or exposure to intense light or oxidizing agents. These data indicate that bFGF is modulated in RPE cells by stress and by agents that provide protection from stress and support the hypothesis that bFGF functions as a survival factor in the outer retina.

Vascular endothelial growth factor (VEGF) is induced by hypoxia and it has been implicated in the development of iris and retinal neovascularization (NV) in ischemic retinopathies in which it has been suggested that Muller cells are responsible for increased VEGF production. VEGF, however, is also known to be a potent mediator of vascular permeability in other tissues and may perform this function in retina. Immunohistochemical staining for VEGF was performed on a variety of human and experimental ischemic and non-ischemic ocular disorders in which blood retinal barrier (BRB) breakdown is known to occur to determine if there is an upregulation of VEGF in these conditions. We found increased VEGF immunoreactivity in ganglion cells of rats with oxygen-induced ischemic retinopathy and in ganglion cells, the inner plexiform layer, and some cells in the inner nuclear layer of rats with experimental autoimmune uveoretinitis (EAU), in which there was no identifiable ischemia or NV. In rats with EAU, VEGF staining intensity increased from 8 to 11 days after immunization, coincident with BRB failure. These results were confirmed using two distinct anti-VEGF antibodies and by immunoblot and the immunohistochemical staining was eliminated by pre-incubating the antibodies with VEGF peptide. VEGF staining was also increased in the retina and iris of patients with ischemic retinopathies, such as diabetic retinopathy and retinal vascular occlusive disease, and in patients with disorders in which retinal ischemia does not play a major role, such as aphakic/ pseudophakic cystoid macular edema, retinoblastoma, ocular inflammatory disease or infection, and choroidal melanoma. VEGF was primarily localized within retinal neurons and retinal pigmented epithelial cells in these cases. In addition or in association with its role of inducing NV, VEGF may contribute to BRB breakdown in a variety of ocular disorders and blockage of VEGF signaling may help to reduce some types of macular edema.

Background: Retinal pigment epithelial (RPE) cells that enter the vitreous in pathologic conditions, such as retinal detachment, may proliferate and contribute to the formation of epiretinal membranes., Objective: To study whether hyalocytes, endogenous vitreous cells, play a role in modulating the proliferation of RPE cells., Methods: Cell proliferation was measured by tritiated thymidine incorporation in density-arrested human RPE cells after incubation with media that had been conditioned by cultured bovine hyalocytes. Preliminary characterization of inhibitory activity in hyalocyte-conditioned medium was performed, including blocking experiments with a neutralizing antibody to transforming growth factor-beta 2 (TGF-beta) and proliferation assays that used MV-1-Lu mink lung epithelial cells. Northern blots were done to asses hyalocyte expression of TGF-beta messenger RNA., Results: Hyalocyte-conditioned medium inhibited tritiated thymidine incorporation in RPE cells and MV-1-Lu mink lung epithelial cells in the presence or absence of serum or protease inhibitors. A portion of the inhibitory activity was neutralized by an antibody directed against TGF-beta. Northern blots of hyalocyte RNA demonstrated the presence of messenger RNA for TGF-beta 2. These data suggest that TGF-beta is responsible for a portion of the inhibitory activity secreted by hyalocytes. Additional inhibitory activity is attributable to one or more low-molecular-weight molecules distinct from TGF-beta., Conclusions: Hyalocyte-conditioned medium inhibits RPE cell proliferation in vitro through TGF-beta and at least one other molecule. Production of these factors by hyalocytes in vivo could provide a deterrent for epiretinal membrane formation that may be perturbed under pathologic conditions.

Study Objective: To determine the clinical significance of fever in geriatric emergency department patients., Design: Case series with follow-up., Setting: Urban, university-affiliated community hospital., Participants: Consecutive patients over the age of 65 years who presented to the ED during a 12-month period with an oral temperature of 100.0 degrees F (37.8 degrees C) or higher., Results: We considered the following features indicators of serious illness: positive blood culture(s), related death within 1 month of ED visit, need for surgery or other invasive procedure, hospitalization for 4 or more days, IV antibiotics for 3 or more days, and repeat ED visit within 72 hours for related condition. Four hundred eighty-nine patients were eligible for study. Of the 470 patients with complete follow-up data, 357 (76.0%) had indicators of serious illness. Clinical features found to be independently associated with serious illness included oral temperature of 103 degrees F (39.4 degrees C) or more, respiration rate of 30 or more, leukocytosis of 11.0 x 10(9)/L or more, presence of an infiltrate, and pulse of 120 or more. At least one indicator of serious illness was present in 63 of 128 patients (49.6%) with none of these independently predictive clinical features. The most common final diagnoses were pneumonia (24.0%), urinary-tract infection (21.7%), and sepsis (12.8%)., Conclusion: Fever among geriatric ED patients frequently marks the presence of serious illness. All such patients should be strongly considered for hospital admission, particularly when certain clinical features are present. The absence of abnormal findings does not reliably rule out the possibility of serious illness.

To define ranges of plasma specific gravity useful for identifying volume depletion in older adults, plasma specific gravity was measured in 170 young adults (mean age 28 years) and 100 retirees (mean age 81 years), and ranges of values likely to be associated with volume depletion were defined. Subsequently, measurements of plasma specific gravity were made in 68 older emergency room (ER) patients (mean age 74 years), a few of whom had obvious reasons for being hypovolaemic, e.g. dehydrating diarrhoea, and these results were compared to those for the control groups. Ranges for plasma specific gravity useful for identifying volume depletion were designated as possible hypovolaemia (1.0265-1.0279), probable hypovolaemia (1.0280-1.0294), and hypovolaemia (> or = 1.0295). Using these definitions, there were more older ER patients compared to both young and old control group subjects, respectively, with probable hypovolaemia (21% vs. 5% and 8%; p < 0.03) and hypovolaemia (16% vs. 0% and 0%; p < 0.03). This study establishes ranges for plasma specific gravity for young and old adults likely to be associated with hypovolaemia, and shows that based upon measurement of plasma specific gravity, older ER patients may often be hypovolemic even in the absence of obvious fluid-wasting illnesses. Future studies are needed to identify the risk factors for hypovolaemia in ER patients, and more vigorously substantiate the findings of this study.

This study evaluated the performance of seven rapid radiographic processing products. A conventional automatic processing solution was evaluated as a standard of comparison. The products were analyzed with respect to image quality and speed. The results indicate that rapid manual processing generally involves some compromise of image quality as well as slower speeds with an accompanying increase in patient radiation exposure. Accordingly, there seems to be little motivation for the use of rapid manual processing solutions unless there is a compelling rationale in terms of time or convenience.

The temperature of freshly voided urine has been shown to be a reliable predictor of body temperature. This relationship was confirmed for the measurement of BBT. A method was described for patients to obtain their BBT in a way that they may find more convenient than obtaining either oral or rectal temperature. The BBT graph patterns generated from the temperature of freshly voided urine closely paralleled those generated by oral temperature.

Relaxin and prostaglandin E2 (PGE2) are present in human semen and have been shown to affect sperm motility. The authors further examined the effects of porcine relaxin and PGE2 on the motility of human spermatozoa. A dose-response study revealed that PGE2 at a concentration of 25 micrograms/ml is most effective in improving the motility of washed human sperm. Relaxin (100 ng/ml), PGE2 (25 micrograms/ml), or the two combined have no effect on the motility of spermatozoa in fresh, normal semen, suggesting that the constituents of fresh semen are optimal for motility. Relaxin and PGE2 individually improve the motility of washed spermatozoa. However, relaxin, but not PGE2, improves the motility of sperm in semen incubated at 37 degrees C for 5 hours (aged). In contrast to the individual substances, a combination of relaxin + PGE2 has no effect on the motility of washed spermatozoa or aged spermatozoa, suggesting that these two substances antagonize each other's actions on sperm motility. The presence of both relaxin and PGE2 in seminal plasma with normal motility spermatozoa suggests that other factors in seminal plasma regulate the effects of these substances on sperm motility.

Caffeine (1, 3, 7-trimethyl-2, 6-dioxypurine), a cyclic nucleotide phosphodiesterase inhibitor, increased the motility of ejaculated human spermatozoa. Both the percent motility and the grade of forward progression were significantly increased (P smaller than 0.001) and maintained in the presence of 6 mM of caffeine for up to five hours at 37 C. Increases in percent motility greater than two-fold occurred among the groups having low initial motility. Increases in samples with a high initial percent motility (greater than 60%) were not as dramatic, but they were still significant. In addition, the grade of motility or forward progression was increased in all groups up to one full unit. The longevity of the spermatozoa, judged by activity, was also increased for up to five hours.

Relaxin has recently been identified in human seminal plasma (SP). This investigation was undertaken to determine the effect of relaxin on sperm motility. Washed ejaculated human sperm were incubated with or without porcine relaxin. In a series of 37 normal specimens (motility greater than or equal to 60%) relaxin attenuated the decline in grade of forward progression and percentage of motile sperm. Relaxin had a similar effect on a series of 47 subfertile specimens (motility 30% to 40%). Endogenous relaxin may play a role in delaying declines of motility and grade of forward progress in ejaculated sperm.

Human seminal plasma contains approximately 50 ng/ml of relaxin (specific activity = 1.3 ng/mg protein). During preliminary purification, semen plasma was delipidated, rehydrated, and loaded onto small octadecyl silica columns that were eluted with a TEAF/acetonitrile gradient system. Results were monitored by radioimmunoassay. The resultant partially purified human relaxin demonstrated biologic activity in the rat uterine segment bioassay. Nine liters of semen plasma was delipidated, rehydrated in TEAF, and subjected to high-performance liquid chromatography by a step gradient followed by a linear gradient. The active eluate was further purified by ion exchange chromatography. Pooled recovery fractions provided a total of 45.8 micrograms of relaxin. An aliquot flash evaporated and desalted by gel filtration chromatography provided 1.85 micrograms of relaxin in 25.2 mg protein, specific activity 73.4. This material is being used as immunogen in the production of antihuman relaxin antibodies by monoclonal technique. Our procedure represents the first and only successful partial purification of human relaxin to yield sufficient quantity and purity for antibody production.

Inhibition of sperm motility by anti-relaxin antiserum has been previously reported. This effect may be secondary to a nonspecific effect of immunoglobulins binding to sperm or to a specific inhibition of relaxin activity at the sperm surface. The current investigation demonstrates that an anti-insulin antiserum does not inhibit sperm motility in the same system in which an anti-relaxin antiserum results in inhibition. This supports the hypothesis that the anti-relaxin antiserum effect is specific.

Radiographic images of teeth and restorations were used to evaluate the radiopacity of 11 light-cured posterior composite resins. The radiopacity of these composite resins provided enough variation on radiographs so that clinicians distinguished the images of the restoration from adjacent tooth structure.

Polyzoospermia is a rare cause of male infertility. In our clinical practice, patients with exceedingly high sperm counts (ranging from 650 million/ml to 1.75 billion/ml) have invariably been found to have associated poor sperm motility and poor sperm migration in postcoital tests, although the sperm appear morphologically normal. Cases of two infertile couples are presented in which each husband had sperm counts greater than 1 billion/ml. Two methods are reported for the successful management of their infertility problems: (1) precoital dilutional douching and (2) in vitro seminal fluid dilution with 5% dextrose-Ringer's lactate solution and artificial insemination homologous. Each method resulted in improved sperm motility, postcoital tests, and pregnancy.

A new Silastic seminal fluid collection device has been tested and compared in vitro with glass jars, latex condoms, and the Milex polyethylene sheath. In a series of tests utilizing 50 different semen samples and observing the effects on motility over a period of 4 hours, the Silastic seminal fluid collection device demonstrated sperm survival slightly better than that with glass jars, superior to that with the polyethylene Milex sheath, and far greater survival (by several hours) than with the latex condom. The Silastic collection device was found to be more comfortable and more pleasurable to the patients than was the Milex sheath. The accuracy of seminal volume measurements was also found to be better in the Silastic collection device.

Radioimmunoassays were performed on the seminal plasma of normospermic, oligospermic, and azoospermic men to determine the levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone. FSH levels in the seminal plasma of all three groups were found to be similar to the levels normally found in blood serum. LH levels in the seminal plasma of azoospermic and oligospermic men were within the normal range found in blood serum but were elevated in the normospermic samples. Testosterone levels in the seminal plasma of all three groups tested were considerably lower than the normal range found in blood serum.

Of the 724 patients examined for circulating spermagglutinating antibodies by the Kibrick spermagglutination test, 95 (13.1%) were found to be positive. Almost 20% of the 406 male patients demonstrated autoantibodies. This high incidence may be explained by the selected population studied. Of 50 males tested who demonstrated more than 10% agglutination in their semen, but otherwise were normospermic, 42% demonstrated autoantibodies. Of the 318 females examined, 14 (4.4%) demonstrated sperm-agglutinating antibodies. Of the 315 male and female patients examined for circulating sperm-immobilizing antibodies by the Isojima sperm-immobilization test, 14 (4.5%) were found to have antibodies. Of the 162 males treated, 10 (6%) were positive for antibodies by this technique, as were 4 (3%) of the 153 women tested.

In an attempt to improve the motility of thawed spermatozoa after 1 week of its being frozen, we treated ten normal semen samples with 16.7 nmol relaxin and 6 mmol caffeine. Motility and grade of forward progression were examined after thawing. Caffeine significantly improved motility of spermatozoa. Relaxin, when added to semen at the time of thawing, improved motility and grade of forward progression significantly. This effect was not seen if relaxin was added before freezing. These results suggest that the biologic activity of relaxin is adversely affected by freezing and thawing in seminal plasma. These observations may have clinical importance for the improvement of motility of frozen spermatozoan samples at the time of artificial insemination and for the possible improvement of pregnancy rates.

The relaxin content of 92 normal semen samples and 85 semen samples selected at random was correlated to the parameters measured on routine semen analysis in those samples. The concentration of immunoactive relaxin in a sample of semen plasma did not correlate with any of the parameters commonly used for semen analysis: count, percent motility, grade of forward progression, volume, and morphology.

The technique of accumulating plaque on removable disks in a complete denture provides a convenient method for investigating plaque on artificial surfaces. Examination of the plaque specimen with a SEM indicated that the plaque consists of microorganisms and a nonstructured matrix. This technique provides results that are consistent for a given individual. However, a group of 12 different individuals had a wide range in the thickness and content of plaque accumulations during equal time intervals. Thin plaque accumulations consisted of a filmlike layer with an apparently small number of microorganisms. Thick layers of plaque consisted of relatively large numbers of microorganisms with some intercellular matrix. The thickness of the plaque layer is apparently determined primarily by the number of microorganisms present.

Fructose, zinc, and prolactin determinations were performed on the seminal plasma of normospermic (n = 30), oligospermic (n = 30), and azoospermic (n = 30) men to determine whether there was a correlation between any of these substances and seminal quality. None of these azoospermic men had congenital bilateral absence of the vasa, but in a separate group of such men (n = 10) these same studies were performed. Fructose was determined photometrically, zinc by atomic absorption, and prolactin by radioimmunoassay. Zinc and fructose levels in all three groups showed no statistical differences. Prolactin was found to be significantly higher in the seminal plasma of normospermic men than was found in the seminal plasma of oligospermic or azoospermic men. In men with congenital bilateral absence of the vasa and seminal vesicles, zinc was elevated, fructose was absent, and prolactin was markedly depressed.

Congenital bilateral absence of the vasa deferentia has been found to be the cause for azoospermia in 101 patients who have been examined in our urologic practice since 1956. This represents approximately 2% of the 5112 patients seen during that time because of problems relating to infertility. Of these 101 men, 29 have had their sera tested for the presence of circulating sperm-agglutinating antibodies. The Shulman15 modification of the macroscopic gelatin sperm-agglutination test of Kibrick et al6 was used. None of these patients had had testicular biopsy. Significantly high titers (1:32 or greater) of antibodies were found in 18 (62.1%) men, low titers (1:16 or less) in five (17.2%), and no antibodies in six (20.7%).

The effect of relaxin, a peptide hormone present in seminal plasma, on the penetration of cervical mucus by washed human sperm in vitro was studied. Penetration was analyzed by two methods. The total number of sperm per 100 X field at the 10-mm, 20-mm, and 30-mm points along a mucus-filled capillary tube was counted and the farthest distance 100 sperm and 5 sperm/100 X field penetrated the capillary tube was measured. These measurements were made at 30, 60, and 90 minutes. Treating washed sperm with physiologic concentrations of relaxin resulted in significantly increased sperm penetration as compared with sperm treated with albumin or buffer. Replacing seminal plasma to washed sperm resulted in equivalently increased penetration. The findings strongly suggest that relaxin is necessary for proper penetration of cervical mucus by human sperm.

A computer program was formulated and verified experimentally to predict the optical density on an image receptor for any given set of radiographic variables including tube kilovoltage, milliamperage, and wave form; x-ray beam filtration; nature of filters and absorbers, and type of x-ray film.

To study its effect on the motility of human spermatozoa, relaxin was added at different concentrations to human semen samples of various qualities as well as to washed spermatozoa. Relaxin in physiologic concentrations (10-100 ng/mL) had no significant effect on sperm motility in normal semen samples. However, the addition of relaxin to semen samples with low sperm motility significantly increased the motility. Addition of relaxin similarly increased the motility of spermatozoa from normal semen samples that were either aged or washed; the treatment resulted in a decrease in motility. When sperm motility was optimal, as in normal samples, addition of relaxin did not increase motility. However, in some situations of decreased motility, addition of relaxin resulted in improvement of spermatozoan motility. Relaxin may have clinical value in the treatment of male infertility.