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We describe two patients with hypertrophic osteoarthropathy, spider naevi and elevated 24 h urinary oestrogen excretion associated with an adenocarcinoma. In one of the patients, the spider naevi and the clinical signs of hypertrophic osteoarthropathy disappeared and the 24 h urinary oestrogen returned to normal following removal of the tumour.

The use of sublingual nitroglycerin spray has been studied in twenty patients referred to our Intensive Care Unit for further treatment of severe left ventricular failure. Within five minutes of spray administration significant falls in pulmonary artery occlusion pressure, mean arterial pressure, heart rate, right atrial pressure and systemic vascular resistance occurred. Similarly significant increases in cardiac index, stroke volume index and left ventricular stroke work index were found. These results show a considerable improvement in the haemodynamic parameters of invasively monitored patients and we believe that its administration undoubtedly "buys time" for the critically ill patient. However, we would caution against its routine use at present in view of the potential problem of hypotension, until further information is available.

Six patients with varying degrees of acute cardiorespiratory failure were seen. All patients deteriorated noticeably when rapid atrial fibrillation developed. In all patients intravenous digitalis failed to slow the ventricular response, and in three patients misguided attempts at electrical cardioversion failed. Haemodynamic monitoring showed a normal or low pulmonary artery occlusion pressure in all patients. Controlled expansion of plasma volume was associated with an immediate slowing of the heart rate in all patients, and the heart rate in all patients returned to sinus rhythm within 30 minutes of transfusion. It is suggested that hypovolaemia in critically ill patients may contribute to the development of atrial fibrillation.

Thirty-seven adults (19 male, 18 female) with mitral valve prolapse (MVP) were examined for evidence of joint hypermobility scored on a 0-9 scale. None of the patients had hypermobility scores exceeding 3, and comparison with 37 healthy age and sex matched controls recruited from hospital staff failed to show an increased prevalence of hypermobility in MVP. There was no evidence that the MVP syndrome is a forme fruste of a heritable disorder of connective tissue.

Ten patients with severe septic shock were studied. After plasma volume expansion to an optimal pulmonary artery wedge pressure, above which there were no further increases in cardiac index, all patients remained hypotensive and oliguric. The arterial hypotension was unresponsive to increasing doses of dopamine and dobutamine alone and to a fixed combination of both. In all patients studied, infusion of norepinephrine alone reversed the hypotension and increased significantly the mean arterial pressure, systemic vascular resistance and left ventricular stroke work index (p less than .005). There were only minor increases in heart rate. Oxygen transport indices measured in six patients demonstrated variable alterations in oxygen delivery and consumption.

An experiment was conducted testing the hypothesis that sources delivering unexpected communications (long-haired males arguing against marijuana usage and seminarians arguing in its favor) would be more persuasive than communicators of expected messages (promarijuana hippies and antimarijuana seminarians). Greater attitude change for unexpected sources was found only when the message was antimarijuana. Unexpected communicators also were rated as more sincere and honest than expected sources. Possible reasons for the failure of the expectancy effect to hold for promarijuana communications were suggested, and the results were discussed in terms of a variety of social-psychological theories.

The responses to therapy of 29 patients in septic shock are described. Patients received controlled plasma volume expansion followed by infusions of norepinephrine, dobutamine, and dopamine to achieve appropriate therapeutic goals. Increases in oxygen delivery (Do2) from 605 +/- 40 (SEM) to 843 +/- 27 ml/min-m2 (p less than .001) were associated with increases in oxygen consumption (Vo2) from 130 +/- 6.8 to 169 +/- 6.2 ml/min.m2 (p less than .001). The overall hospital survival rate was 52%. We suggest that the rational use of adrenergic agents and the achievement of appropriate physiologic end-points for therapy not only result in the reversal of hypotension, but also maintain or increase Do2 and Vo2, and may improve survival.

During the treatment of 26 shocked patients, measurements were made of the central blood to peripheral skin temperature gradient. No significant correlation was found between this gradient and cardiac index (CI), or systemic vascular resistance (SVR) or its index (SVRI). There was no significant correlation between the change in gradient and the changes in CI, SVR or SVRI in any single patient. We conclude that it is incorrect to base any judgment of a patient's hemodynamic status on a core/peripheral temperature gradient during shock, and it is irrational to initiate therapy based on this measurement.

Oxygen consumption (VO2) immediately following major injury in man has been said to be reduced. The evidence for this is poor. We have therefore measured VO2 soon after major injury in 16 patients. VO2 was reduced in only two patients, within the normal range in four and increased in ten. VO2 was maintained by increased oxygen extraction in six patients leading to low levels of mixed venous oxygen saturation. There is no evidence for an 'ebb phase' response in man.

A diurnal rhythm was observed in the responsiveness of mice to nociceptive stimuli and in the hyperalgesic activity of endogenous opioid peptides and may partly account for previous controversy over the direct action of naloxone in opiate-naive animals.

To explore the pathophysiology of the necrotizing enterocolitis caused by polycythemia in the newborn dog, the effect of acute polycythemia on fibrinogen disappearance rate was studied in 38 puppies (3-14 days). All pups received an exchange transfusion removing 65 ml/kg of blood and transfusing 85 ml/kg of either whole blood (control, resulting hematocrit = 37), or packed red blood cells (polycythemia, resulting hematocrit = 68). Necrotizing enterocolitis was found in 15 of 19 polycythemic and four of 19 control pups (p less than 0.01). 125I fibrinogen and Evan's blue (an albumin marker) were injected 2 h after transfusion and the concentration of clottable labeled fibrinogen and albumin tracer were measured at 1/2 and 2 h after injection. The fraction of the tracer that disappeared over the 1 1/2-h period was calculated. In the polycythemic group 45 +/- 18 SD% of the clottable fibrinogen disappeared versus only 28 +/- 15% in the control group (p less than 0.01). In the polycythemic group 36 +/- 21% of the albumin tracer disappeared versus 31 +/- 12% in the control group (NS). Thus polycythemia in the newborn dog is associated with an increased disappearance rate of clottable fibrinogen not associated with a general increase in protein disappearance rate. Thus an intravascular coagulopathy is evident in the polycythemic animals. Whether this coagulopathy is the cause of the necrotizing enterocolitis or is secondary to the necrotizing enterocolitis seen in this animal model cannot be determined from this experiment.