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SMEs often fail to benefit from adequate investment because they are too large for assistance from charitable organizations but too small to interest commercial investment companies. This article describes the work of the Small Enterprise Assistance Funds (SEAF), which brings together private sector mechanisms, public sector funds and not-for-profit sector motives to assist SMEs in Central and Eastern Europe and the former Soviet Union. It provides a number of recommendations on how to assist as well as finance an investment partner, and thus to help the development and growth of budding entrepreneurs.

Among carnivorous plants, Darwin was particularly fascinated by the speed and sensitivity of snap-traps in Dionaea and Aldrovanda. Recent molecular work confirms Darwin's conjecture that these monotypic taxa are sister to Drosera, meaning that snap-traps evolved from a 'flypaper' trap. Transitions include tentacles being modified into trigger hairs and marginal 'teeth', the loss of sticky tentacles, depressed digestive glands, and rapid leaf movement. Pre-adaptations are known for all these traits in Drosera yet snap-traps only evolved once. We hypothesize that selection to catch and retain large insects favored the evolution of elongate leaves and snap-tentacles in Drosera and snap-traps. Although sticky traps efficiently capture small prey, they allow larger prey to escape and may lose nutrients. Dionaea's snap-trap efficiently captures and processes larger prey providing higher, but variable, rewards. We develop a size-selective model and parametrize it with field data to demonstrate how selection to capture larger prey strongly favors snap-traps. As prey become larger, they also become rarer and gain the power to rip leaves, causing returns to larger snap-traps to plateau. We propose testing these hypotheses with specific field data and Darwin-like experiments. The complexity of snap-traps, competition with pitfall traps, and their association with ephemeral habitats all help to explain why this curious adaptation only evolved once.

Cardiovascular and peripheral adaptations to an aerobic conditioning program were studied in 30 hypertensive adults taking either placebo, beta 1-selective beta-adrenergic blocker (metoprolol) or beta 1-nonselective beta-adrenergic blocker (propranolol). The placebo group increased aerobic capacity (VO2max) 24% (p less than 0.002), largely explained by an increased peripheral arteriovenous (AV) oxygen difference with minimal changes in cardiac size and function. Resting blood pressure and total systemic resistance also decreased. The group taking a beta 1-selective beta blocker increased VO2max 8% (p less than 0.05), reduced resting blood pressure but had no significant change of AV oxygen difference or cardiac size or function. The group taking the beta 1-nonselective beta blocker propranolol had no increase in VO2max, no decrease in resting blood pressure and no cardiovascular or peripheral adaptations to the exercise program. Thus, beta 1-selective and beta 1-nonselective beta blockers attenuate conditioning in hypertensive patients to differing degrees, in each case by blocking peripheral mechanisms of conditioning.

The escape of some insects from the traps of carnivorous plants depends on the type of trap and the body size of the insect species. Body size thresholds vary: for "sticky traps" of Pinguicula lutea Walt. and Drosera filiformis Raf. tracyi MacFarlane, they are 5 mm and 10 mm, respectively. In contrast, the "pitfall trap" of Sarracenia leucophylla Raf. retains almost all sizes of insects captured. Differential escape may have provided strong selection pressures for the evolution of large carnivorous plant species, which can trap insect prey of a wide range of sizes.

A reappraisal of the significance of fever in acute myocardial infarction was undertaken in the controlled environment of a coronary-care unit. With the use of standardized criteria, 334 patients were given a diagnosis of acute myocardial infarction. The seven-day point prevalence for fever was 65.3 per cent, with a maximal incidence of 72 per cent on the second day. No significant correlation could be found between maximal temperature levels, degree of enzyme elevation, and leukocyte count. A policy of making cultures from those patients with fever identified infection in 63 (18.9 per cent) with a high correlation in this group with heart failure, atelectasis, and the use of urinary and central venous pressure catheters. High fever or fever beyond the fourth day of illness was most likely caused by respiratory or urinary tract infection, frequently related to gram-negative organisms. These data reinforce the commonness of fever but also indicate that the prevention, recognition, and treatment of infections should be an important part of the management of patients with acute myocardial infarction.

A 23-year-old woman developed 3 degrees AV block with syncope. Insertion of a permanent pacemaker lead was followed by the onset of a persistent murmur in late systole preceded by single or multiple clicks. The murmur was best heard at the left sternal edge, grade 3-4/6 with two major frequencies (60-250 Hz), increased with inspiration and on assuming the erect posture. It was considered to be tricuspid in origin and related to interference of the tricuspid valve apparatus by the pacemaker lead resulting in tricuspid regurgitation. No tricuspid valve prolapse or flutter was seen on echocardiography. Withdrawal of the pacemaker lead resulted in immediate disappearance of the new auscultatory findings. Review of the literature suggests that the appearance of such a murmur following pacemaker insertion could be associated with later complications in relation to tricuspid valve dysfunction. It is therefore recommended that, under these circumstances, permanent pacemaker leads should be appropriately repositioned.

The cardiac changes associated with myasthenia gravis have been reviewed and specific areas explored. There is no doubt concerning the involvement of the myocardium in this disease as indicated by clinical, ECG, vectorcardiographic, and autopsy data. The doubt lies in the precipitating factor for the pathology found. On the one hand the whole picture could be a direct result of the pathologic process of myasthenia gravis. On the other hand the patient with myasthenia gravis, during the natural history of the disease, encounters many iatrogenic and coincidental variables which could influence the nature of the clinical findings and autopsy data. One fact seems reasonably clear: The association of myocardial pathology with thymoma, especially malignant thymoma, is well established for the more severe form of the myocardial disease. Furthermore, the hypothesis that cardiac muscle antibodies give rise to such reactions is attractive, although not fully resolved. If such cases are excluded then there remain others where cardiac pathology could be due to other disease, primarily coronary heart disease, in the older group. In addition, the mode of death of some patients indicates that intercurrent respiratory problems could play a part. Most patients in this group do not seem to have cardiac abnormalities due to the pathologic process of myasthenia. There is in addition a small group where very striking cardiovascular findings suggestive of myocarditis are found. There is not necessarily a thymoma and no other specific etiologic factors can be found. These are rare cases and might still be related to disorders of immune mechanisms. In conclusion it can be stated that, although there is now a considerable body of evidence concerning the heart in myasthenia gravis, the implication of specific pathology for this neuromuscular disorder affecting the heart must be considered, in the traditional Scottish legal sense, as "not proven."

Plasma quinidine half-life values, determined by a relatively specific double extraction method in eight patients with poor renal function, eight with congestive heart failure, and nine controls were similar for all groups. When quinidine was measured by a nonspecific fluorescent method, the half-life values calculated for the uremic patients were longer than those for the controls. The nonspecific method does not differentiate slow biotransformation of quinidine from normal biotransformation but slow excretion of metabolites. Steady-state plasma quinidine concentrations were measured in 14 patients treated for arrhythmias and 12 with congestive heart failure. Therapeutic effectiveness was associated with concentrations of 2.3 to 5.0 μg per milliliter and ineffectiveness with lower levels or complicating illnesses. The relation of dose to steady-state blood level was similar for the two groups. Quinidine elimination appears to be grossly normal in patients with congestive heart failure or poor re...

We analyzed the use of amyl nitrite as a provocative factor in the diagnosis of mitral valve prolapse in a population of healthy young adults. Sixty-five men and 11 women underwent continuous M-mode echocardiographic and phonocardiographic monitoring before, during and after the administration of inhaled amyl nitrite. All of the 76 subjects had normal baseline echocardiograms, and all had a satisfactory hemodynamic response to amyl nitrite. Mitral valve prolapse, defined by echocardiography and phonocardiography, was not provoked in any of the subjects. Therefore, we concluded that, although this technique may be difficult, significant false-positive results should not occur if adherence to strict diagnostic criteria takes place.

The relationship of right atrial inversion, a previously undescribed cross-sectional echocardiographic sign, to the presence of cardiac tamponade was examined. We studied 127 patients with moderate or large pericardial effusions. Cardiac tamponade was present in 19 and absent in 104. Four patients with equivocal tamponade were excluded from analysis. Right atrial inversion was present in 19 of 19 patients with cardiac tamponade and 19 of 104 without cardiac tamponade (sensitivity, 100%; specificity, 82%; predictive value, 50%). The degree of inversion as quantitated by the area-corrected curvature did not improve the ability to discriminate between patients with and without cardiac tamponade. However, consideration of the duration of inversion by the right atrial inversion time index (duration of inversion/cardiac cycle length) and an empirically derived cut-off of 0.34 did improve the specificity and predictive value (100% and 100%, respectively) without a significant loss of sensitivity (94%). We conclude that right atrial inversion, particularly if prolonged, is a useful echocardiographic marker of cardiac tamponade that may be of particular diagnostic value when the clinical picture is unclear.

Summary Experiments were designed to induce hypernatremia and hyponatremia acutely in the intact dog for the purpose of establishing associated electrocardiographic changes. Blood sodium levels were measured simultaneously and continuously by a stable sodium sensitive glass electrode system. Elevation of blood sodium, averaging 41% above the original level (R.28–56%), resulted in diminution in amplitude of P and QRS, an increase in the QT/RR ratio, and divergence of mean T frontal vector from the mean QRS frontal vector. Additional changes were a slight fall in serum potassium, a fall in pH, and a fall in mean blood pressure. Electrocardiographic changes took place when there had been only a 5% to 15% elevation in blood sodium levels. A dilutional fall in blood sodium, averaging 24% below the original level (R.18–34%), resulted in slowing of the heart rate, a diminution in amplitude of P, and an increase in amplitude of QRS and T. QT/RR ratio changes were variable and usually minor. Additional changes were a slight fall in serum potassium and pH. The electrocardiographic changes also took place with a 5% fall in blood sodium. It should be noted that arrhythmias were exceptional and occurred only in one experiment (hypernatremia) out of the 24 performed. The electrocardiographic changes described were consistent and did not appear to be due to other electrolyte changes or alterations in blood volume. The results can be partially correlated with those obtained from action potential measurements with sodium variation.

This study was made to determine whether the A wave of the apexcardiogram (ACG), a reflection of the late diastolic response of the left ventricle to atrial systole, corresponded in a quantifiable way to left ventricular late diastolic stiffness (LVDS). Using a combined ultrasonic and hemodynamic technique, the slope of the late diastolic left ventricular pressure/diameter relationship (ΔP/ΔD) was calculated in 25 patients and used as a measure of effective LVDS. Most patients had valvular heart disease, all were in sinus rhythm and none had regional abnormalities of contraction. An ACG was recorded in all and the ratio of the size of the A wave to the total amplitude of the ACG wave (A/H) was calculated. When A/H was more than 11%, left ventricular hypertrophy (LVH) and the presence of a fourth heart sound were the rule in the group of patients studied. Using A/H as an independent variable, correlation coefficients were obtained for ΔP, ΔD, ΔP/ΔD, left ventricular end diastolic pressure (LVEDP), and left ventricular end diastolic volume (LVEDV). Correlation coefficients ( r ) were: ΔP = 0.68; ΔD = –0.05; ΔP/ΔD = 0.87; LVEDP = 0.73; LVEDV = 0.21. It is concluded that A/H corresponds best to LVDS and is a useful noninvasive measurement of this property of the left ventricle.

The Lillehei-Kaster (L-K) valve is a tilting disc prosthesis currently in use for heart valve replacement. We report data from phonocardiography (PHONO) and echocardiography (ECHO) in 20 patients with a normally functioning mitral valve prosthesis (MVP). The MVP is well recorded by ECHO, resembling a mitral stenosis pattern with a disc excursion of 7 to 12 mm and a mean opening and closing velocity of 37.7 and 59.8 cm/sec, respectively. Combined PHONO and ECHO show that the opening sound of the MVP is small, related to onset of valve opening and not peak opening. It follows the aortic component of the second sound (A 2 ) by 0.05 to 0.09 sec in normals; it may be absent (12/20). Peak opening follows A 2 by 0.08 to 0.12 sec. The closing sound of the MVP, best heard in the mitral area, is always two-fold with a small initial high frequency (HF) component and a second large HF sound separated by no more than 0.03 sec. The first component (A) is related to onset of closure and the second (B) to completion of closure. Systolic and diastolic murmurs were commonly present. These data establish the normal ECHO and PHONO findings for patients with L-K MVP. Two other patients are also reported in whom such data were helpful for the noninvasive evaluation of valve function, indicating in one instance acute mitral regurgitation and in the other an increase in degree of aortic regurgitation.

Right ventricular (RV) volumes determined by echocardiography were compared with those measured using established angiographic formulas. RV cast displacement volumes were first correlated with data derived from radiographic images of the casts corresponding to standard anglographic RV views. Four established anglographic formulas (Ferlinz, Boak, Fisher and Thilenius) correlated well with cast volume, with the corrected prism method of Fisher showing a best fit (r = 0.98, y = 1.1 + 0.9x, standard error of the estimate = 3.6). Cast volumes calculated using our echocardiographic formula were then examined relative to the volumes derived from radiographic images of the RV casts. Volumes Calculated using the corrected area-length Thilenius formula correlated best with those obtained using our derived 2-dimensional echocardiographic formula (r = 0.96, y = 4.6 + 1.0x, standard error of the estimate = 6.8). These data confirm that volume calculated using the suggested optimal echocardiographic formula correlates well with volume obtained using derived angiographic data. Accordingly, confirmation In humans by the use of angiography is a rational step.

TWO major limitations in the taking and interpretation of the conventional electrocardiogram are related to time and physical activity. Much reliance is placed on a record that shows but a fraction of the daily electric impulses from the heart. The electrocardiogram is taken with the patient at rest, and this does not wholly represent the physiologic state of the heart during a major part of the day. Thus, the conventional electrocardiogram may not give sufficient dimension. It follows that a method is required that gives the electrocardiographer the opportunity of recording continuously over long periods and under circumstances in which . . .

The prevalence of congestive heart failure as seen by the physician in the community has been evaluated in two rural counties by means of a physicians' survey. Six-month period prevalence rates for all ages combined have been calculated. These rates were 8.8 and 10.2 per 1000 of the white population of Montgomery County, North Carolina, and Caledonia County, Vermont, respectively. Age specific rates demonstrated the remarkable increase in congestive heart failure with increase in age. Six-month period incidence rates for congestive heart failure occurring in patients aged 45 and over were 1.9 per 1000 of the white population in Montgomery County and 2.5 in Caledonia County. The six-month period prevalence rate for all heart disease in Caledonia County was 18.3 per 1000 of the white population. The validity of this figure is doubtful. The distribution of major disease categories was similar for both counties. Atherosclerotic heart disease and hypertensive heart disease, either separately or combined, accounted for nearly 90 per cent of the diagnoses. Therapeutic habits concerning digitalis, diuretics and salt restriction have been discussed. Based on this study it would appear that congestive heart failure is, and will be, a very considerable chronic disease problem especially amongst older people. By 1970 there will be some 1,700,000 persons aged 45 and over who are or have been in congestive heart failure and this figure will include 250,000 new cases for the year.

Of seven patients with pulmonary hypertension, two had marked and one had moderate retardation of the echocardiographic anterior mitral valve leaflet closing motion, suggestive of mitral stenosis. In each patient, however, mitral stenosis was excluded by hemodynamic or anatomic criteria. The reason for the abnormal mitral valve motion was considered to be a reduced rate of left ventricular diastolic filling. In the group of seven patients it was noted that the ratio of ventricular filling pressures (RVedP/LVedP) was inversely correlated with the anterior mitral valve leaflet closing slope. This observation supports the hypothesis that left ventricular diastolic filling may be secondarily altered by right ventricular overload, and that this impairment of left ventricular filling may result in alteration of the anterior mitral valve leaflet echogram mimicking mitral stenosis.

A population sample, consisting of 142 men and 148 women aged 40–69, resident in Chittenden County, Vermont were screened for blood lipid abnormalities. Type II hyperlipoproteinemia was present in 3.5 per cent of the men and 6 per cent of the women; type IV in 21 per cent of the men and 10 per cent of the women. The sensitivity, specificity, performance and absolute diagnostic reliability of lipoprotein electrophoretic data were only fair for accepted abnormal lipid levels. Statistically significant correlations were present between fasting triglyceride, insulin and subscapular skinfold measurements. If hypertriglyceridemia is associated with coronary heart disease, then on the basis of such a high prevalence rate, it would appear inappropriate without further study to recommend nationwide dietary modifications that aim primarily at hypercholesterolemia.

Eighty-seven University of North Carolina students who had clinical and serologic evidence of infection with type A influenza viruses related to Asian strains were studied electrocardiographically, both during the illness and after recovery. The electrocardiograms were evaluated by comparison with those of a control series similar in age, sex, and social distribution. Extracardiac factors were taken into consideration. Twelve electrocardiograms were considered to be abnormal because of S-T segment deviation, depression of T waves, and auricular arrhythmias. Four of these abnormalities, including all the arrhythmias, occurred in the recovery stage. It was concluded that although these changes were minor, they could have been caused by myocarditis due to infection with influenza virus.

The use of electroconvulsive therapy (ECT) is reported in a patient with a permanent transvenous demand pacemaker (Medtronics 5841). Although electrocardiographic monitoring by telemetry did not demonstrate arrhythmias, ECT is capable of interfering with the proper function of certain types of pacemakers because of the electrical frequencies employed. Those patients who require ECT should undergo careful evaluation of possible contributing risk factors.

The effectiveness of an open referral electrocardiographic monitoring service in identifying an arrhythmogenic cause for syncope was evaluated. Over 5 years, 7,364 patients of all ages underwent ambulatory 24-hour electrocardiographic (Holter) monitoring using a 2-channel recorder. Of these, 1,512 (20.5%) were referred because of syncope. During monitoring, 15 patients had syncope and 7 of the episodes were related to an arrhythmia, usually ventricular tachycardia. Presyncope was reported in 241 patients, with a related arrhythmia in 24. Thus, an arrhythmia-related symptom that could be diagnostic was present in only 2% of the patients monitored. However, syncope or presyncope without an associated arrhythmia might be considered a negative diagnostic clue and occurred in 225 (15%). High-grade atrioventricular block was present in 15 and ventricular tachycardia in 116; only 6 (5%) reported associated symptoms. An age-related incremental increase in atrial and ventricular arrhythmias was found. In 415 of the 1,004 patients (41%) aged 60 years or more, arrhythmias that are conventionally associated with sinoatrial disease were recorded. Using stringent diagnostic criteria, the sick sinus or tachybradycardia syndrome was present in 33 (3%). Many older patients (70%) were taking drugs that could be arrhythmogenic, hypotensive or both. It is concluded that an open referral 24-hour ambulatory monitoring service rarely results in identifying relevant symptom-related arrhythmias in patients with syncope. It records many asymptomatic arrhythmias that can compound rather than resolve the diagnostic problem in older patients, because the data obtained could lead to unnecessary therapy. An iatrogenic cause for syncope should always be considered.

The two-dimensional echocardiographic features of three patients with congenital aneurysms of the left atrium are described. The aneurysm arose from the left atrial appendage in two patients and from the posterior left atrial wall in one. The aneurysms were characterized by their origin from an otherwise normal left atrium, a well-defined neck, their position within the pericardial space, and distortion of the left ventricular free wall by the aneurysmal body. The differentiation of these structures from other abnormalities of the left atrium are also discussed. Two-dimensional echocardiography is a safe and reliable method for diagnosing congenital aneurysm of the left atrium, and such studies should be considered in any patient with an otherwise unexplained abnormality on the chest radiograph.

The volume of the right ventricle can be determined angiographically from its projections in two mutually perpendicular planes. Echocardiographic techniques for measuring right ventricular volume, however, have been more difficult and less successful. In this study, a method was developed for calculating right ventricular volume from two intersecting cross-sectional echocardiographic views: the apical four-chamber and subcostal right ventricular outflow tract views. First, the areas and lengths of casts of 12 human right ventricles obtained at autopsy were directly measured in the chosen views. Actual cast volumes correlated best with a formula giving volume as 2/3 times the area in one view times the long axis in the other view. The degree of correlation was similarly high for calculations involving the area derived from either view and the length of the roughly orthogonal section. This relationship for right ventricular volume was then confirmed with two-dimensional echocardiographic images of hollow latex molds made from the casts (r = .95, p less than .0001). The significance of these findings is discussed in relation to angiographic results and models of the right ventricle.

Serial blood pressure recordings were taken for 72 hours in 112 patients with acute myocardial infarction and in 96 patients with cardiac ischemia, admitted to hospital no more than 6 hours after the onset of chest pain. During the first hour of admission 66 (31.7%) had a blood pressure recorded 160/100 or greater. By the sixth hour, without specific antihypertensive therapy, this number had fallen to 13 (6.3%). This fall was subsequently maintained with very similar trends for both acute myocardial infarction and cardiac ischemia. Such an early blood pressure fall in acute myocardial infarction may indicate that this is too labile a measurement to determine the need for, or efficacy of, antihypertensive therapy aimed at the preservation of myocardium. The hospital course and mortality rate of patients with acute myocardial infarction and early hypertension, as defined, did not differ significantly from the non-hypertensive group.

Incomplete closure of the tricuspid valve without apparent cusp disease was noted on two-dimensional echocardiography in 31 patients. This abnormality was defined as a failure of the tricuspid valve leaflet tips to reach the plane of the tricuspid valve anulus by at least 1 cm in the standard apical four chamber view at the point of maximal systolic closure. This resulted in a final systolic leaflet position deeper within the right ventricular cavity than is normally seen. The finding was present in the following diagnostic subgroups: Group A, pulmonary hypertension (11 patients); Group B, rheumatic heart disease (4 patients); Group C, dilated cardiomyopathy (9 patients) and Group D, previous myocardial infarction (7 patients). Right atrial, right ventricular and tricuspid anulus measurements were made and compared with those from a group of 67 normal subjects. The results were as follows: right atrial endsystolic area = 27.2 ± 8.6 cm2 (normal = 13.4 ± 2.0); right ventricular end-systolic area = 25.6 ± 8.7 cm2 (normal = 10.9 ± 2.9); right ventricular end-diastolic area = 31.5 ± 9.1 cm2 (normal = 20.1 ± 4.9) and tricuspid valve anular end-systolic dimension = 4.0 ± 0.6 cm (normal = 2.2 ± 0.3). The differences from the normal data were all statistically significant (p < 0.001).Incomplete closure of the tricuspid valve, although a nonspecific diagnostic finding, is primarily associated with right-sided chamber enlargement. Tricuspid regurgitation may be present. The mechanism could be related to geometric changes in valve apparatus dynamics secondary to right-sided cardiac enlargement and tricuspid valve anular dilation. It is also possible that previous right ventricular infarction with wall dyskinesia may impede correct closure.

A new technique for quantitatively mapping the three-dimensional left ventricular endocardial surface was developed, using measurements from standard cross-sectional echocardiographic images. To validate the accuracy of this echocardiographic mapping technique in an animal model, the endocardial areas of 15 excised canine ventricles were calculated using measurements made from echocardiographic studies of the hearts and compared with areas determined with latex casts of the same ventricles. Close correlation (r = 0.87, p less than 0.001) between these two measures of endocardial area provided preliminary confirmation of the accuracy of the maps. To further characterize the mapping algorithm, it was translated into computer format and used to map the surfaces of idealized hemiellipsoids. Areas measured with this mapping technique closely approximated the actual areas of idealized surfaces with a wide spectrum of shapes; maps were particularly accurate for ellipsoids with shapes similar to those of undistorted human ventricles. Also, the accuracies of area calculations were relatively insensitive to deviation from the assumed positions of the echocardiographic short-axis planes. Finally, although the accuracy of the mapping technique improved as data from more transverse planes were added, the procedure proved reliable for estimating surface areas when data from only three planes were used. These studies confirm the accuracy of the echocardiographic mapping technique, and they suggest that the resulting planar plots might be useful as templates for localizing and quantifying the overall extent of abnormal wall motion.

This report presents a case of an unusually large unruptured sinus of Valsalva aneurysm complicated by right ventricular outflow tract obstruction, right coronary artery occlusion and incomplete right bundle branch block. Two-dimensional and Doppler echocardiography were instrumental in preoperative diagnosis and postoperative follow-up.

An examination of congestive heart failure as it exists in the community reveals a problem of some magnitude. Extrapolation from available prevalence studies suggests that physicians have under their care nearly two million persons in the United States suffering from congestive heart failure. The evidence also demonstrates that congestive heart failure is primarily a disorder of older people. Past studies that have evaluated certain community services for congestive heart failure have not been sufficiently conclusive to recommend strongly the inclusion of these services in future health programs. They have nevertheless indicated that this problem deserves and requires further consideration. This has been recognized by the United States Public Health Service, and as a result there are several studies currently in operation and planned which may give more valid data. These have as their objective the prevention of recurrent episodes of congestive heart failure, with consequent hospitalization, by the provision of adequate continuing care in the community setting. Such care includes the use of visiting nurses, nutritionists, occupational and vocational therapists, health educators and medical social workers. Programs of this type are being utilized by both private and indigent patients without impairment of the personal physician-patient relationship. Analysis of data from these studies will require some previous standardization of sampling and measurement if it is to satisfy the physician critic. These projects should also provide a unique opportunity for useful research into many inadequately studied areas of congestive heart failure. Such research should include longitudinal epidemiological studies, the development of simple cardiac function tests, the best use of health education, evaluation of the social and emotional impact of congestive heart failure on the patient and his family, and the economics of his illness. The ultimate test of such projects will be their value and acceptability to the physician, whether hospital based or otherwise. Changing patterns of medical care must bring problems related to continuing care of chronic disease closer to the community. The physician can no longer deal in a personal manner with all health problems, and must delegate authority without relinquishing responsibility. It could therefore be expected that such community programs may be of considerable help to the realistic medical practitioner who is interested in optimal continuing care of his patient with congestive heart failure. In the final analysis, the health services of society have no other function than to improve the quality of medical care in order to permit the attainment for the patient of his personal aspirations and self-fulfilment. The priority of community services for congestive heart failure has to be judged accordingly.

A retrospective cohort study of congenital abnormalities was undertaken on all the 1813 children born in 1952 to the residents of Chittenden County, Vermont. Multiple screening procedures were utilized and included questionnaires to parents, review of hospital charts, hospital pediatric-consultant records, death certificates, hospital pathological files and agencies for crippled and retarded children. Information was obtained for 1775 of the 1813 children (89 per cent). Two hundred and thirty-eight children with 270 malformations were discovered, and the incidence of malformations was 152.1 per 1000 live births; 42.6 per cent of the defects were discovered in the perinatal period. An additional 16.3 per cent were detected between the ages of one month and one year, and 36.3 per cent were discovered initially after one year of age. An assessment of the level of professional care required for the abnormalities discovered indicated that 33.6 per cent required no care, 42.9 per cent required short-term care, and 23.5 per cent required long-term continuing care. The early discovery of congenital defects in this study was accomplished less frequently than in many prospective studies in which screening was likely to be more comprehensive and less representative of reality. The only method of improving early medical care for children handicapped by congenital defects is by serial observation of families over long periods by trained personnel.

• A kindred with a high incidence of hypertrophic cardiomyopathy (HC) was studied to identify the presence of clinical hyperthyroidism. Two and possibly three members with HC had associated hyperthyroidism. In the propositus, clinical, ECG, and vectorcardiographic evidence for HC resolved after treatment of the hyperthyroidism. We hypothesize that the disproportionately high correlation of hyperthyroidism and HC and the resolution found in the propositus after treatment may indicate that antithyroid therapy should be considered in this form of cardiomyopathy. ( Arch Intern Med 1983;143:378-380)

Excerpt Body temperatures are routine clinical measurements, easily taken and easily misinterpreted. A reappraisal of the significance of fever in patients with coronary heart disease was considere...