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The mobilized coronary care system in Columbus, Ohio, began with operation of a single vehicle with a physician in attendance. Currently, advanced emergency medical technician-paramedics work without direct physician supervision. When both experiences are compared, the results indicate that advanced emergency medical technician-paramedics working independently perform as well as physician counterparts.

In contrast to usual sudden death seen in the course of coronary artery disease, individuals dying suddenly from other causes form a complex array of situations. In some the causes are readily identifiable. No simple pattern is available to identify the potential candidate, but on review of the many causes some moves by the physician may be helpful. For example, a more complete physical evaluation of young individuals participating in competitive athletics is in order. This is particularly true if the athlete reports an episode of unexplained syncope. This may well be the warning of a propensity towards sudden death under physical and emotional stress. Knowledge of the specific problems in underwater swimming and diving, in high altitude exposure and in various circumstances such as certain weight reduction diets and industrial exposures may lead to control of some types of unusual sudden death. Clearly, more studies are needed to give answers in so called crib death. As the incidence of usual sudden death falls, these unusual forms of sudden death will represent a more important fraction of sudden death in general.

A case of non-myelomatous malignant disease with IgA paraproteinemia is described. A pleomorphic lymphoid/plasmacytoid infiltrate was found in the bone marrow. While the cells studied had some ultrastructural characteristics closer to myelomatosis than Waldenström's macroglobulinemia, immunofluorescence showed IgA in both the cytoplasm and at the cell surface, as seen with IgM in macroglobulinemia but not with IgA in typical IgA myelomatosis. This case illustrates that IgA paraproteinemia may be produced in association with pleomorphic B cell proliferative diseases as well as myelomatosis. There is probably a spectrum of disease states as with IgM paraproteinemia.

The current widespread interest in early (pre-hospital) coronary care has raised questions regarding the safety and efficacy of the use of atropine in these circumstances. Although reports from early coronary care systems have been favorable, serious questions of safety have been raised on the basis of experimental animal studies and isolated case reports. A sample of the experience of a large scale emergency coronary care system in Columbus, Ohio has therefore been reviewed. A group of 70 patients who, during the early phases of myocardial infarction, exhibited bradyarrhythmia (less than 60 beats/min) was identified. When this group was further categorized on the basis of arterial pressure at the time of initial observation, patients with normal or elevated blood pressure had low mortality rates whether treated with atropine or not. In patients with hypotension the mortality rate was 75 percent without therapy, and 25 percent with therapy. Indeed, when normal hemodynamics were restored, the mortality rate was only 11 percent. Unexpected ventricular fibrillation occurred in 1 of 45 treated patients and 2 of 25 untreated patients. Although the study was not controlled, the data strongly suggest that atropine is both beneficial and safe for use in treating bradyarrhythmia and hypotension in the early phase of acute myocardial infarction.

Columbus, Ohio added prehospital coronary care to its Emergency Medical Services System (EMS) in 1969. The EMS System, which is citizen activated and tax supported (+5 per citizen per year), currently sees 32,000 patients a year in a city with a population of 650,000. Ninety-six per cent of the population is aware of the system. Over two thirds of patients with ischemic sudden death or myocardial infarction are seen by advanced life support paramedic (EMT-P) units. The EMT-Ps operate by protocol without telemetry and carry all standard resuscitative drugs and devices. Serial evaluations have shown that within the limits of the protocol, the EMT-Ps perform as effectively as physicians in diagnosis and care of acute cardiovascular emergencies, including endotracheal intubation. One third of ischemic cardiac arrest patients in whom resuscitation is possible (60% of such patients seen) are discharged from the hospital alive (14.2/100,000 lives saved per year). Lives are also saved by treatment of other life-threatening prehospital complications. In Columbus, the estimated annual mortality from ischemic heart disease is only 19%. The EMS System contributes significantly to this low figure.

Indices of nutritional state were measured in 105 surgical patients. The indices were chosen to give information on protein-calorie malnutrition, anaemia, vitamin deficiency. Abnormal values for the various indices were common in the group as a whole and most frequent (50%) in patients who were still in hospital more than a week after major surgery. These patients had a high frequency of anaemia, vitamin deficiency, weight-loss, loss of arm-muscle bulk, and low plasma levels of transferrin and albumin. These abnormalities had gone almost entirely unrecognised, even in patients with sepsis after major surgery, who would benefit from improvement in nutritional state.

Percentage and number of T cells in peripheral blood and severe indices of protein nutrition were assessed in a random sample of 51 hospitalized surgical patients. Whole blood counts of the patients' lymphocytes and E rosette tests (after separation of lymphocytes from whole blood on Ficoll-Metrizoate) showed no difference from a control group of well-nourished people attending hospital for minor complaints. In general there was no consistent relationship between the level of protein nutrition and low T cell numbers, except for 5 malnourished patients tested less than 1 week after major surgery. Although a group of 11 patients who fulfilled the criteria for 'malnutrition' had normal T cell numbers, the percentage of T cells was significantly higher and the number of total lymphocytes was significantly lower than in the controls.

Using various genotypic and phenotypic markers 20 human lymphoid cell lines have been classified as lymphoblastoid, leukaemia or lymphoma subtypes. Each cell line type exhibited characteristic morphological and behavioural properties in suspension culture. Whilst most lymphoblastoid and lymphoma cell lines manifested B-cell phenotypes and contained Epstein Barr virus (EBV) genome, leukaemia lines demonstrated T-cell markers and lacked EBV genome. Individual cell lines demonstrated unique isoenzyme profiles for the seven polymorphic enzymes studied without subtype specificity. None of the cell lines studied was entirely homogeneous although lymphoblastoid lines contained only a minor subpopulation of other cell line types. The mixed population of cells indicate the need for caution in the use of these cell lines as in vitro models of lymphoid cancer and suggests further refinement of classification methods is required. Incubation of different cell line types with prednisolone for 48-168 h revealed most were highly resistant to cytolethal and cytostatic effects of glucocorticoids in vitro. Suprapharmacological doses of steroid (10(-3) M) were required in most instances before significant cytolethal responses occurred. Only one lymphoblastoid, one lymphoma and two leukaemia lines responded to pharmacological doses (10(-5)-10(-6) M) of prednisolone.

In 6 patients with bacterial endocarditis studies were made of the bacterial content of arterial and venous blood. Paired samples were collected, approximately simultaneously, from two different locations in the circulatory system, and colony counts were determined. As many as 48 specimens were taken for culture during a single period of study. Venous blood was drawn not only from different locations in the extremities, but also from the superior and inferior venae cavae, the right auricle, and the hepatic and renal veins. As would be expected, colony counts were highest in arterial blood. Blood from the antecubital veins gave colony counts only slightly lower than arterial blood. In the femoral veins, on the other hand, there were appreciably fewer organisms. This difference is attributed to the type of tissues drained by the two veins. Colony counts in blood from the superior and inferior venae cavae were also lower than arterial counts, the ratio being comparable to that found in femoral vein blood. In the renal veins colony counts were only slightly below the arterial level indicating that few organisms are removed from the blood during passage through the kidneys. The greatest reduction in bacterial content was found in hepatic vein blood. In 3 of the 6 subjects this reduction amounted to more than 95 per cent, and in all subjects the difference was very considerable. Mixed venous blood in the right auricle of the heart gave colony counts which were usually one-half to two-thirds as high as in corresponding samples of arterial blood. An interesting finding in these studies was a remarkable constancy of the bacterial content of arterial blood, during periods of 1 or 2 hours. Despite the fact that a considerable portion of the bacteria which leave the heart in arterial blood appear to be removed during a single circuit of the body, the number of bacteria in successive samples of arterial blood shows little change. This indicates that in bacterial endocarditis organisms are discharged into the blood from the endocardial vegetations at a comparatively even rate, rather than in a haphazard fashion as a result of the breaking off of infected particles.