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OKLAHOMA STATE MEDICAL ASSOCIATION

HEALTH SCIENCES LIBRARY

UNIVERSITY OF M^RY* AMD

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neuron disorders, athetosis, stiff-man syn- drome, convulsive disorders (not for sole therapy).

Contraindicated: Known hypersensitivity to the drug. Children under 6 months of age. Acute narrow angle glaucoma; may be used in patients with open angle glau- coma who are receiving appropriate therapy.

Warnings: Not of value in psychotic pa- tients. Caution against hazardous occupa- tions requiring complete mental alertness. When used adjunctively in convulsive dis-

orders, possibility of increase in frequer and/or severity of grand mal seizures rr require increased dosage of standard ar convulsant medication; abrupt withdrav may be associated with temporary in- crease in frequency and/or severity of seizures. Advise against simultaneous i gestion of alcohol and other CNS depre: sants. Withdrawal symptoms (similar tc those with barbiturates and alcohol) ha occurred following abrupt discontinuar (convulsions, tremor, abdominal and rr cle cramps, vomiting and sweating). Ke addiction-prone individuals under caret

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JANUARY

1975

Vol. 68, No. 1

of th e Oklah oma State M edi cal As so ciati on

EDITORIAL BOARD

MARK R. JOHNSON, MD Editor-in-Chief

HARRIS D. RILEY, Jr., MD Editor

ROBERT G TOMPKINS, MD Editor

ERNEST LACHMAN, MD Corresponding Editor Regents Professor Emeritus of Anatomical and Radiological Sciences, University of Oklahoma Health Sciences Center.

OFFICERS

JACK L. RICHARDSON, MD President

ROGER J. REID, MD Vice-Resident

HAVEN W. MANKIN, MD Secretary-Treasurer

STAFF

DON BLAIR BusinessManager

LOUISE MARTIN EditorialAssistant

THE JOURNAL is the official publica- tion of the Oklahoma State Medical Associa- tion, and is published monthly under the di- rection of the Board of Trustees, 601 N.W. Expressway, Oklahoma City, Okla. 73118. Publication office (printer) 222 East Eufaula St., Norman, Okla. 73069. Second-class postage paid at Oklahoma City, Okla- homa 73125.

SUBSCRIPnON TO THE JOURNAL is included in membership fees. Other subscriptions are $6.50 per year or $1.00 per copy with each request subject to approval of the Editorial Board.

POSTMASTERS: Send all change of address notices to 601 N.W. Expressway, Oklahoma City, Okla. 73118.

CONTENTS

editorial

On Stuffing Crows ....... 1

President’s Page ........ 2

scientific

Civilian Vascular Injuries: A Clinical Review, Thomas A. Marberry, James M. Hartsuck, MD and G.

Rainey Williams, MD ...... 3

Towards Control of Breast Cancer In Oklahoma, Arthur F. Hoge, MD and G. Bennett Humphrey ,

MD, PhD 8

Laboratory Practices In Mycobacteriology : Results Of A Survey Of Oklahoma Laboratories, Dixie E.

Snider, Jr., MD and R. LeRoy Carpenter, MD,

MPH 13

News From the Oklahoma State Department of

Health 18

news

Dues and Finances Dominate AMA House of Dele-

gates Meeting ....... 19

Washington Political Profile for 1975 ... 20

Ford Announces Administration’s Health Insurance

Plan 22

Tulsa Possible Site For AMA Regional Meeting . 22

Medical Information Confidentiality Stressed . . 23

San Antonio To Host International Medical As- sembly ......... 23

One-Third of Health Dollars Spent By Government . 25

Medicare Deductible Up For 1975 .... 25

Fifty Years of Medical Practice .... 27

Death .......... 27

New Doctor’s Office in The State Capitol . . 28

Book Reviews ........ 28

Miscellaneous Advertisements ..... 29

Index To Advertisers ....... xxxvi

Woman’s Auxiliary ....... xxxvii

The Last Word ....... xxxviii

(Cover Art by William Cason )

in

a basic need for life support

Adverse Reactions: May cause nausea, headache, cardiac palpitation and CNS stimulation. Post- prandial administration may help to avoid gastriq discomfort.

Before prescribing, please review complete prod- uct information, a summary of which follows:

Indications: For reli^Lot acute bronchial* asthma and for reversible bronchospasm associated with chronic bronchitis and emphysema.

Precautions: Exercise caution with use in the presence of severe cardiac disease, renal or he- patic malfunction, glaucoma, hyperthyroidism, peptic ulcer, and concomitant use of other xan- thine-containing formulations or other CNS stim- ulating drugs.

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LUFYLLIN Injection: NDC 19-R537-T2, box of 2i x 2 ml. ampuls.

ON STUFFING CROW

I hope that my colleagues in the upper eche- lons of the AMA didn’t impair their digestive tracts during the recent holidays. They will have a lot of crow to eat and it might prove to be quite indigestible, especially to the ones who uttered and wrote those imperious ad- monitions about raising fees for our profes- sional services. They are the ones who urged us to work more efficiently, to operate more economically, to make some sacrifices and to lower our standards of living. With wagging fingers and clucking tongues, they warned us that Big Brother was watching and would con- sider the raising of fees sufficient evidence of felonious greed and criminal selfishness to jus- tify locking us in chains.

All the while these policy-making leaders, these spokesmen of our nation’s physicians were letting the AMA spend itself into bank- ruptcy. More accurately, it seems they were pursuing bankruptcy with shocking candor. At a time when prime interest rates usu-

rious, they were down at the bank, negotiating a multimillion dollar loan. Then, with an-al- most-contemptuous air of self-righteousness, they had the temerity to demand an increase in our dues and a mandatory assessment in order to pay off the note and preserve our solvency.

Costs have risen sharply they explained, and we must reckon with inflation. Also, they have expanded membership services and benefits in

Journal / January 1975 / Volume 68

such ways as publishing an out-sized, artsy periodical wherein non-practicing experts in health care delivery can belabor us with their counsel. And by attacking groups of physicians (AAPS) who are critical of many official AMA positions, deriding the size of their organiza- tions and the small towns in which its mem- bers practice. And by railroading debate at AMA meetings. And by hiring the editors and reporters and staff assistants skilled enough to provide these services.

Clearly, it is terribly expensive to alienate the entire membership of a large organization. But they have succeeded. And at least they have been consistent; their judgment has been unvaryingly bad. They have embraced Medi- caid, Medicare, PSRO and The Bureaucracy. They have endorsed fee schedules, medical merchandising and the piracy of foreign physi- cians. They have been derogatory of their crit- ics, suspicious of their friends and inept in their politics. How perfectly logical that they now demand gratuities from those who have been injured.

Nevertheless, I am going to pay to continue my membership in the AMA. Certainly, I could never again support mandatory membership, but to leave the AMA now would be to abandon a patient at the crisis of his illness. So I am sending in my sixty dollars. I hope part of it, at least, pays for the crow. And I will gladly help stuff it. . .down the deserving throats. MRJ

president' s page

There can be little doubt that peer review is both justified and log- ical — the Oklahoma State Medical Association has been carrying on peer review for profes- sional services for ap- proximately nine years.

In fiscal 1972 Americans spent 7.6% of the gross national product, or $83.4 billion, on personal health care — double the amount spent in 1965, much of which (52%) was in keeping up with inflation. In fiscal 1973 the figure ap- proached $100 billion. This care was delivered in 7,000 hospitals, 29,000 nursing homes and innumerable medical offices by 2xh million personnel, including almost 400,000 physi- cians. This vast industry is the largest and most complex in the United States. Reasonable cost controls and assurance of quality are not unreasonable, but the PSRO law has included sweeping controls that have not been imposed upon any profession in the United States. No such mechanism for monitoring health care has ever been tried in any existing health care delivery system anywhere. While there is thin allusion to quality, the main thrust is at cost control. Administration costs alone are antici- pated to be some $350 million annually and possibly more. Any program involving this much money and this much power will attract supporters, not only from without the profes- sion, but — alas — also from within. It is cer- tain to add to the cost of medical care. Worse than that are other implications in the bill, such as "Professional Standards Review Or- ganizations will have the authority to approve, in advance, the medical necessity of elective

admissions to institutions, as well as extended or costly services.”

The entire proposal — now actual law — was accepted and promoted by our national organi- zation; true, the organization requested numerous modifications, but the modifications have not been forthcoming. The circumspect procedure would have been to obtain the mod- ifications before giving support.

On a happier note, I am delighted to report that our association’s efforts to assist the Health Sciences Center have been finally pro- ductive. In addition to putting on our program in 15 different areas of the state, your Medical Liaison Committee members and your three executive directors have had innumerable meetings with a large number of state legis- lators, civic leaders, faculty members, Univer- sity Regents, Higher Regents, President Sharp and his staff at the University in Norman, na- tional legislators and Governor Boren. Fine cooperation has been exhibited on all sides and I believe the immediate future will reveal a greater support for our medical school and University Hospital than has been experienced in a very long time. I am indeed proud of the contributions of both time and money that you have made in this effort. It proves once again that Oklahoma has a fine medical association. I am honored to be a member of it. Few associa- tions have the firmness of purpose, devotion to duty, loyalty to cause and unity of action as does ours.

Before closing, I should like to call your at- tention to the hard work and fine organization efficiency being exhibited by Chairman Mar- ion Wagnon and his committee to develop an outstanding program for Summit ’75 in April at Lincoln Plaza. Please make the necessary office adjustments and plans at an early date to assure attendance.

2

Oklahoma State Medical Association

scientific

Civilian Vascular Injuries: A Clinical Review

THOMAS A. MARBERRY JAMES M. HARTSUCK, MD G. RAINEY WILLIAMS, MD

Since the volume of civilian vascular injuries has increased over the last decade, aggressive surgical management with early angiography, exploration and operative repair

appears to be justified.

The management of patients with vascular injuries has become more clearly defined and the benefits of precise surgical reconstruction of the vascular system have become apparent as the result of the extensive clinical experience gained from wartime vascular trauma9’ 12. Vascular injuries among civilians have been less well studied but the clincal problem is in- creasing with the present higher incidence of penetrating trauma. As a result of the increased volume of civilian vascular injuries the need for clear policies concerning early exploration, an- giography, and prompt, precise vascular repair has become evident. Many civilian institutions have adopted policies of early exploration when vascular injury is considered likely2 5> 10 ’ 13. In an effort to evaluate these policies a clinical

From the Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

Oklahoma State Medical Association

review of patients from the University of Ok- lahoma Health Sciences Center who were oper- ated upon for possible traumatic vascular in- jury from the period 1963 through 1972 was undertaken. An effort was made to correlate the clinical signs with the actual vascular injury and to evaluate the results of a liberal policy of exploration for penetrating wounds near major vessels.

Review of Clinical Material

The records of all patients at the University of Oklahoma Health Sciences Center who under- went surgical exploration for possible vascular trauma were reviewed for the past ten years. The patient population included the adjacent metropolitan area and referrals from the entire state. Individual cases were considered "posi- tive” if vascular injury was demonstrated through surgery and "negative” if no vascular trauma was found. In both categories the pres- ence of hematomas, absent distal pulses, and associated injuries including trauma to nerves, tendons, and bone was recorded. The method of surgical reconstruction as well as the value of angiography both preoperatively and intra- operatively were evaluated. Patients with only intra-abdominal vascular injury were excluded since nearly all patients with penetrating ab- dominal trauma were routinely explored. A significant number of vascular injuries due to diagnostic or therapeutic maneuvers were also excluded.

The incidence of recognized trauma to the

3

Injuries / MARBERRY et al

E2 POSITIVE EXPLORATIONS

Table 1

vascular system has increased significantly over the past decade and dramatically in the past three years as depicted in Table 1. The total number of patients undergoing surgery each year in the Oklahoma Health Sciences Center has remained relatively constant during this study. It is noteworthy that the percentages of negative and positive explorations have re- mained relatively constant during this ten-year period.

Analysis of the anatomical site of injury re- veals that the upper extremity is the most commonly injured region followed by injuries to

Thomas A. Marberry is a third-year student at the University of Oklahoma College of Medicine.

Since his graduation from Harvard Medical School in 1962, James M. Hartsuck, MD, has been certified by the American Boards of Surgery and Thoracic Surgery. He is presently Clinical Assistant Professor of Surgery at the University of Oklahoma Health Sciences Center. He is a Fellow of the American College of Surgeons, a member of the American Cancer Society and the Southwestern Surgical Con- gress.

A 1950 graduate of Northwestern University Medical School, G. Rainey Williams, MD, has been certified by the American Boards of Surgery and Thoracic Surgery. He is Professor and Chairman of the Department of Surgery at the University of Oklahoma College of Medicine. Doctor Williams is Governor of the American College of Surgeons, Treasurer of the Southern Surgical Association, a member of the American Surgical Association, the American Association for Thoracic Surgery and the Hals- ted Society.

4

the neck (Table 2). The fraction of positive exp- lorations was relatively constant for the various anatomical sites. Negative explorations were also investigated in an effort to evaluate the incidence of "significant” associated injuries which made the exploration a valuable experi- ence for the patient. "Significant” associated injuries were defined as those injuries that were physiologically significant and surgically cor- rectable. Total associated injuries included sig- nificant injuries plus those that were not surgi- cally correctable, eg, fractures treated by splint- ing or casting and nerve contusion which re- sulted in impaired function.

The negative explorations were also evaluated in an effort to define clinical charac- teristics of patients with positive and negative exploration of the various anatomical sites. Neck injuries were associated with the most frequent negative explorations (57%). These neck injuries were commonly accompanied by hematomas and clinical absence of distal pulsa- tion even in the absence of significant vascular injury (Table 3). It is of interest that 3 1% of such negative explorations had surgically treatable injuries including two instances of unsuspected laceration of the esophagus or posterior pharynx, a spinal cord injury which required posterior laminectomy, and two instances of parotid gland injury managed with drainage. The incidence of significant associated injuries is higher when vascular disease is demon- strated by exploration; 45%, when compared to the 22% incidence of significant injuries as- sociated with negative vascular exploration. Significant associated injuries were found in five of six patients with popliteal area arterial trauma. Four of these six patients had major venous injury, four had significant nerve dam- age and two had associated fractures either of the proximal tibia or fibula. The analogous upper extremity brachial artery injuries were also found to have a high incidence of signific- ant associated injuries, 70%.

Hematoma was evident with equal frequency in patients with and without vascular injury. However, the absence of a palpable distal pulsa- tion was documented in 57% of patients found to have significant vascular trauma and only 15% of those with negative exploration (p < 0.0001 that these are the same in a chi squared test). Seven patients underwent preoperative an- giography and later had positive explorations. The preoperative angiography was diagnostic of arterial trauma in each of these instances.

Journal / January 1975 / Volume 68

SITE OF INJURY AND ASSOCIATED INJURY

	Total	Total Significant Associated	Positive	Total Associated	Significant Associated	Negative	Total Associated	Significant Associated
Vessel	Exploration	Injuries	Exploration	Injuries	Injuries	Exploration	Injuries	Injuries
Brachial Artery	20	8	10	8	7	10	3	1
Radial Artery Ulnar Artery	19	10	10	9	7	9	6	3
Carotid Artery	21	5	5	0	0	16	6	5
Jugular Vein	7	1	7	2	1	0	0	0
Femoral Artery	20	5	10	3	3	10	2	2
Popliteal & Tibial Arteries	12	5	6	5	5	6	0	0
Thoracic	12	4	5	2	2	7	2	2
Iliac Artery	2	0	1	0	0	1	0	0
Iliac Vein	2	1	2	1	0	0	0	0
TOTALS	115	39 (33.8%)	56(48%)	30(53%)	25(45%)	59(59%)	19(32%)	13(22%)

TABLE 2

Intraoperative arteriography was also of value. For example, in one instance, routine angiog- raphy after femoral artery reconstruction re- vealed a clot at the popliteal trifurcation. This occlusion was unsuspected clinically and the demonstration by angiography permitted sim- ple extraction at the time of operation (Fig 1, 2.)

The majority of patients with vascular in- juries were managed by resection and reanas- tomosis (Table 5). It was possible to reconstruct all of the brachial artery injuries and to estab- lish pulsatile flow distally. Six of the ten radial-ulnar injuries involved the ulnar artery and five of these were ligated without ill effect. Only one of the four radial artery injuries were managed by ligation. In the five carotid in- juries, vascular reconstruction was possible and adequate flow established. One internal jugular vein was managed by suture repair and the other ligated. Two instances of ligation at the iliac level were performed, one for injury of the iliac vein and the other for injury to the internal

NEGATIVE EXPLORATIONS: CLINICAL FINDINGS

Vessel Explorations Hematoma % Absent Vc

Distal

Pulse

Brachial	10	4	40%	2	20%
Radial- Ulnar	9	2	22%	0	0%
Carotid Jugular	16	10	62%	3	19%
Femoral	10	5	50%	2	20%
Popliteal- Tibial	6	6	100%	1	17%
Thoracic	7	3	43%	0	0%
Iliacs	1	0	0%	1	100%
TOTALS	59	30	50%	9	15.2%

TABLE 3

iliac artery. Only four cases of the 56 positive explorations developed postoperative complica- tions and required amputation of the involved limbs. Analysis of these patients includes one patient admitted 2Vz weeks after a gunshot wound of the popliteal fossa, two patients with gunshot wounds to the brachial artery managed

Fig 1: Routine operative arteriogram demon- strated an unsuspected obstruction of the distal pop- liteal artery.

Oklahoma State Medical Association

5

Injuries / MARBERRY et al

POSITIVE EXPLORATIONS: CLINICAL FINDINGS

Fig 2: Completion arteriogram after Foggarty ex- traction of popliteal thrombus.

by tourniquet with delayed repair which re- sulted in progressive ischemia despite success- ful vascular reconstruction, and a fourth pa- tient admitted two days following popliteal ar- tery injury with established gangrene.

Four deaths occurred (3.5%), all in the posi- tive exploration group. One patient died in the operating room of hypovolemic cardiac arrest secondary to transection of the pulmonary ar- tery before control of the injured vessel could be achieved. Two other deaths occurred in the postoperative period and were attributed to postoperative pulmonary insufficiency. The fourth death occurred in the operative period and was due to ventricular fibrillation secon- dary to hypovolemia as a result of uncontrolled intra-abdominal bleeding.

Discussion

It is obvious from our clinical review and from other published studies3’ 411 that the incidence

6

Absent

# Positive Distal Pre-Op

Exploration Hematoma % Pulse % Arteriogram

Brachial	10	1	10%	7	70%	0
Radial Ulnar	10	1	10%	5	50%	0
Carotid Artery	5	4	80%	3	60%	2
Jugular Vein	7	4	57%	1	14%	0
Femoral	10	7	70%	8	80%	3
Popliteal- Tibial	6	4	67%	6	100%	2
Thoracic	5	3	60%	0	0%	0
Iliac Artery	1	1	100%	1	100%	0
Iliac Vein	2	2	100%	1	50%	0
TOTALS	56	27	48.2%	32	57%	7

TABLE 4

of vascular trauma among civilians has in- creased in the past decade. Since delay in surgi- cal intervention has been responsible for loss of limbs as well as increased morbidity, we have adopted a liberal policy of exploration of penet- rating injuries adjacent to major vascular struc- tures as advocated by Patman, Triman, Pearch, Moore7 9 10, 13. Nevertheless, this liberal pol- icy for exploration has been accompanied by a significant number of negative explorations. Specifically, this has been a common experience with penetrating trauma of the neck when the policy of exploration of wounds which penet- rated the platysma was adopted6.

Analysis of our patients who underwent negative explorations reveals a very low com- plication rate without significant morbidity in 59 consecutive cases. The high incidence of hematoma (50%), and low but significant inci- dence of clinically absent distal pulses, (15%), are noteworthy features. Associated injuries

POSITIVE EXPLORATION: TREATMENT

# Positive Reanas- Suture Venous Operation

Vessel Explorations	Ligation	tomosis Repair	Graft	Arteriogra
Brachial Radial-	10	0	6	1	3	2
Ulnar	10	6	4	0	0	0
Carotid Artery	5	0	3	2	0	0
Jugular Vein	7	6	0	1	0	0
Femoral	10	1	4	3	2	2
Popliteal-Tibial 6	1	1	0	4	0
Thoracic	5	2	0	2	0	1
Iliac Artery	1	1	0	0	0	0
Iliac Vein	2	1	0	1	0	0
TOTALS	56	18	18	10	9	5

TABLE 5

Journal / January 1975 / Volume 68

were found in 19 of these 59 negative explora- tions and 13 of these associated injuries needed surgical correction. Thus, it appears that the benefits of the liberal policy of exploration far outweigh the morbidity.

The management of patients with significant vascular injuries was extremely successful. Vascular patency was achieved in all cases in which restoration of flow was attempted. Only four patients required amputation and in each instance delay in vascular reconstruction was a major factor.

Operative arteriography was not employed routinely but in selected instances and was ex- tremely valuable in documenting technical er- rors or distal intravascular obstruction. Failure of vascular reconstruction appeared related to delay in reconstruction in patients with exten- sive injury1 2.

We conclude that the liberal policy of early exploration for penetrating wounds adjacent to major blood vessels should be continued. A high rate of negative exploratory procedures appears justified when one considers the minimal mor- bidity and the significant number of associated injuries thus discovered. Mufti and his associates8 have demonstrated both clinically and experimentally that arteriography may be unreliable in detecting early arterial injury or later complications; yet, pre-, intra-, and post- operative angiography are worthwhile proce- dures and as advocated by Moore, Perry and others7’ 11 their indications should be liberalized.

Summary

A clinical review of 115 patients who under- went surgical exploration for possible vascular trauma in the past ten years indicates that the incidence of civilian vascular injuries is in- creasing. Aggressive surgical management with early angiography, exploration, and operative repair appears to be justified. Al- though negative explorations are not uncom- mon, the low morbidity and significant inci- dence of associated, correctable injuries found, support this policy. Also, delay in vascular re- construction is a major factor contributing to limb loss. The correlation of vessel injury with anatomic site, hematoma, absent pulse, and as- sociated injuries is presented. □

REFERENCES

1. Adar R, Nerubay J, Katznelson A, Mozes M: Management of Acute Vascu- lar Injuries. J Cardiovasc Surg 11: 435-439. 1970.

2. Annetts DL, Harris JD, Jepson RP, Hudbrook J, Miller JH, Trach GD: Arterial Injuries in Civilian Practice. Aust New Zeal J. Surg 39: 340-345, 1970.

3. Bizer LS: Peripheral Vascular Trauma. Postgrad Med 49: 127-130, 1971.

4. Dillard BM, Nelson DL, Norman HG: Review of 85 Major Traumatic Arterial Injuries. Surgery 63: 391-395, 1968.

5. Drapanas T, Hewett RL, Weichert RF, Smith AD: Civilian Vascular In- juries: A Critical Appraisal of Three Decades of Management. Ann Surg 172: 351-360, 1970.

6. Knightly JJ, Swaminathan AP, Rush BF: Management of Penetrating Wounds of the Neck. Amer J Surg 126: 575-580, 1973.

7. Moore CH, Wolma FJ, Brown RW, and Derrick JR: Vascular Trauma. Amer J Surg 122: 576-578, 1971.

8. Mufti MA, LaGuerre JN, Pochaczevsky R, Kassner EG, Richter RM, Levowitz BS: Diagnostic V alue of Hematoma in Penetrating Arterial Wounds of the Extremities. Arch Surg 101: 562-569, 1970.

9. Patman RD, Poulous E, Shires GT: The Management of Civilian Arterial Injuries. Surg Gynec Obstet 11: 725-737, 1964.

10. Pearch MB, Drez DJ, Gibson WE, Pearch CW: Management of Acute Arterial Injuries. Southern Med J 62: 1509-151.3, 1969.

11. Perry MO, Thai ER, Shires GT: Management of Arterial Injuries. Ann Surg 173: 403-408, 1971.

12. Slaney G, Ashton F: Arterial Injuries and Their Management. Postgrad Med J 47: 257-269, 1971.

13. Treiman RL, Doty D, Gaspar MR: Acute Vascular Trauma a Fifteen Year Study. Amer J Surg 111: 469-473, 1966.

P.O. Box 26901, Oklahoma City, Oklahoma 73190

MARK YOUR CALENDAR NOW!

OKLAHOMA MEDICAL SUMMIT 75

April 23rd-26th, 1975— Lincoln Plaza Forum— Oklahoma City

A combined meeting of the Oklahoma State Medical Association, the Oklahoma City Clinical Society and the Oklahoma Academy of Family Physicians.

Journal / January 1975 / Volume 68

7

Towards Control of Breast Cancer

In Oklahoma

ARTHUR F. HOGE, MD G. BENNETT HUMPHREY, MD, PhD

Breast cancer is becoming a controllable disease. Basic and clinical research are leading to patient management plans capable of producing 80 to 85 percent response rates. The Oklahoma Medical Research Foundation has established a statewide demonstration network to disseminate information to the hospitals of Oklahoma.

When one speaks of cancer control many peo- ple do not quite understand the meaning. Is it an enigmatic expression? Is it a real possibility or merely a challenge? If real progress in the control of cancer is to occur it almost certainly would occur in one or more of five specific areas: prevention, early diagnosis, primary therapy, rehabilitation, or treatment of advanced dis- ease.

Research in breast cancer has made some rather impressive advances in the past decade. A virus which may have an etiologic role has been isolated.1 3 The genetic material of this virus has been identified within the DNA of some tumor cells4 6 and an immunologic specificity can be demonstrated with both human breast cancer and a mouse mammary

Supported by National Cancer Institute Contract #N01-CN-45137 and, Cancer Planning Program Development, Health, Education and Wel- fare, P01 C013749 SRC.

8

cancer.3 7 This does not imply a common causa- tive role for all breast cancers but certainly points toward a viral etiology of many. Further studies in etiologic and immunologic fields would indicate possible methods of prevention within the next decade.

Early diagnosis has been enhanced by the usage of mammography, thermography, and Xeroradiography (a more refined type of mam- mography). Screening centers have been estab- lished across the country and have utilized vis- ual and palpatory breast examinations together with the more highly sophisticated methods mentioned above. These centers have demon- strated a capability of diagnosing preclinical lesions with a high degree of success, having a false-positive rate of only 15% and a false- negative rate of 10% -15%. 8

When one considers the logistics of screening large populations, limitations become evident. Doctor JoAnn Haberman’s screening center at the Health Sciences Center has been strained in managing some 10,000 patients yearly. Even considering the availability of mammography and Xeroradiography in other institutions throughout the state, mass screening of over 1.5 million people is still not practical.

Breast self-examination (BSE) has been ad- vocated by the American Cancer Society for more than 15 years. The vast majority of breast lumps should be palpable when they are 0. 5-2.0 cm in diameter if the technique is properly employed. Patients who have a lesion less than 2.0 cm in diameter and without skin, fascial, or grossly involved lymph nodes have a 95% chance of having a five-year disease-free survi-

Journal / January 1975 / Volume 68

val and a 90% chance of achieving a ten-year disease-free survival.

End results of primary therapy in breast cancer have changed very little in the past 70 years since Halsted described his procedure for radical mastectomy. Lesser operations per- formed prior to that time by other well-known surgeons were followed by recurrences of a very high rate in the neighborhood of 60%-80% as compared to a 45%-50% recurrence rate follow- ing standard radical mastectomy. National statistics indicate a slight increase in the inci- dence of breast cancer in the past 20 years with a rather constant death rate. This indicates a slight improvement in the relative sur- vival rate but is most likely related to earlier diagnosis. Radical mastectomy, as such, is less than optimal therapy in patients who have nodal metastases, as 67% of these patients will demonstrate recurrent disease within five years and only 45% will survive more than five years.10-12 Extending the mastectomy field to include supraclavicular and internal mammary nodal areas either by surgical11 13 14 or adjuv- ant radiation therapy11- 15-17 has not increased the survival rate. We are now witnessing seri- ous challenges to this established and accepta- ble method of therapy. Crile,18 McWhirter,19 Roberts,20 and others have proposed lesser pro- cedures and a great debate has ensued. The NSABP clinical trials21 have not shown any significant difference in survival or develop- ment of metastases when comparing radical mastectomy vs simple mastectomy plus radia- tion therapy or standard radical mastectomy as

Arthur F. Hoge, Jr., MD, who was graduated from Tulane University School of Medicine in 1949, specializes in oncology. He is Assistant Professor of Research Medicine at the Universi- ty of Oklahoma Health Sciences Center. Among his medical affiliations are the American As- sociation for Cancer Research, the American Society of Clinical Oncology, the American Col- lege of Obstetricians and Gynecologists and the Southwestern Surgical Congress.

A 1960 graduate of the University of Chicago, The School of Medicine, G. Bennett Humphrey , MD, PhD, is presently Chief of the Hematology! Oncology Service at Oklahoma Children’ s Memorial Hospital. He is a member of the American Academy of Pediatrics, the American Society of Clinical Oncology, the Soc- iety for Pediatric Research and the XI Interna- tional Cancer Congress.

Oklahoma State Medical Association

compared to standard radical mastectomy plus radiation therapy.

Fisher’s National Surgical Adjuvant Breast Project has two-year results of a randomized prospective clinical trial to determine the rel- ative merits of Halsted radical mastectomy vs simple mastectomy with or without radiation therapy. The two-year results reveal essen- tially no difference in recurrences or the de- velopment of metastatic disease in the patients of any of these three limbs. Another protocol randomizing patients at high-risk for recurrent breast cancer to mastectomy plus or minus phenylalanine mustard has produced statisti- cally significant differences in the recurrence rates favoring those patients who have had ad- juvant systemic chemotherapy.22 Only one of thirty pre-menopausal women treated with chemotherapy has had a recurrence within two years whereas 11 of 37 have had recurrences after surgery alone.

Biological studies of breast cancer have been most rewarding and probably will lead to ra- tional changes in our approach to therapy, both at the time of initial diagnosis and at the time of first or secondary recurrence.

There are numerous types of breast cancer, many of which have a considerably different prognosis than others.23 Intraductal papillary carcinomas behave considerably different from infiltrating ductal carcinomas and can be con- trolled by more limited procedures. Lobular carcinoma in-situ tumors have a relatively be- nign course and can be managed more con- servatively than their more malignant counterparts. The same can be said of localized mucinous carcinomas or medullary carcinomas.

The aggressiveness of the tumor can also be modified by the host resistance and im- munologic mechanisms. Foote and Stewart24 first suggested the possible immunologic signif- icance of the presence of lymphocytes in medul- lary carcinoma in 1946. Tumor specific an- tigens of breast cancer have been identified on the cell membrane,25 within the cytoplasm,26 and intranuclear.27- 28 These antigens are cap- able of inciting both humoral and cell-mediated responses with the production of auto- antibodies and sensitized lymphocytes which are capable of destroying tumor cells in vitro .29- 30 While antibody studies are effective means of demonstrating immunologic reactions and tumor-host relationships, Cytotoxic antibodies have not been demonstrated in breast cancer. The tumoricidal immunologic control mechanisms are mediated through the

9

Cancer / HOGE, HUMPHREY

thymic oriented group of lymphocytes or T-cells.30

Hudson31 has demonstrated a decreased titer of tumor specific antibodies in patients with far advanced and widespread tumor. We do not feel that this is in itself a manifestation of im- munologic failure on the part of the host but is most likely an absorption phenomenon. Tumor cells may act as a large sponge and acquire a coating of antibody onto the cell membranes. This can effectively hide the antigens from the circulating T-cells. Tumors are capable of emit- ting large quantities of soluble antigens with resultant production of antigen-antibody com- plexes.

Competence of the cell-mediated immune system is paramount in considering therapeutic regimens in patient management programs, in- cluding surgical therapy, chemotherapy, and endocrine therapy.33' 36

Studies of non-hormonal chemotherapeutic agents in the control of breast cancer have shown tremendous strides over the past 20 years, with the greatest improvement occurring in the past five years. Many chemotherapeutic compounds have been utilized successfully as individual agents.37 These include the alkylat- ing agents such as nitrogen mustard, cyclo- phosphamide, phenylalanine mustard, which can induce remissions in 25%-30% of patients. Antimetabolites including methotrexate and 5-FU have been effective in 25%-28% of pa- tients and vinca alkaloids can be utilized with a response rate of 20%. Greenspan38 in 1966, utilized the combination of chemotherapy in- cluding thiotepa and methotrexate with a re- sponse rate of 60%. Widespread acceptance of combination chemotherapy developed after Cooper39 reported his five-drug regimen in 1969. He originally reported a 90% response rate but many studies have since been com- pleted and indicate a true response rate of 55%. Hoogstraten’s Southwest Oncology Group study40 has been quite noteworthy. This group encompassed 200 patients and compared differ- ent dosage schedules utilizing the five-drug Cooper regimen to a new agent, adriamycin. The continuous dosage treatment plan was superior in patients below the age of 55 years while an intermittent schedule appeared to be more effective in older patients. This presuma- bly could be related to estrogen stimulation and the proportion of cells in growth proliferative

10

phases of the cell cycle. The median duration of remission has been nine months in the contin- uous schedule and 13 months in the intermit- tent schedule. Adriamycin was shown to have a remarkable capacity to induce remissions as a single agent. The total remission induction rate was 40%. The drawback is a cumulative dose limitation because of cardiac toxicity and the relatively short median duration of remission which is only 4.5 months.

While oophorectomy has been widely ac- cepted and used as the choice of therapy at first recurrence since 1896, the addition of ad- renalectomy or hypophysectomy has been less favorably received. This was because of the early high morbidity and mortality associated with the more extended procedures. This mor- tality has now been reduced to a very acceptable rate of less than 2%, and the combination of oophorectomy and adrenalectomy or hypophysectomy can be expected to produce remissions in 44% of the patients.41 The most appealing thing about endocrine ablation is the median duration of remissions which is 23 months for the extended endocrine ablation as compared to the 4-9 months median duration of remissions in patients treated with chemotherapy.41 A study of the adrenalectomy/oophorectomy patients at the Oklahoma Health Sciences Center42 revealed a strong correlation of response with competence of the cell-mediated immune system. Patients who had or were able to develop a good immune competence after treatment responded dramat- ically to this therapeutic regimen, whereas pa- tients who had a poor immune competence gen- erally failed to respond to treatment. Ad- renalectomy and oophorectomy responses favor those tumors which have a long disease-free interval, have relatively well-differentiated cell types, have estrogen binding receptors, and a good immune competence.

Chemotherapy is more favorable in more ag- gressive and rapidly growing tumors with a short disease-free-interval; the presence of an estrogen-binding receptor is not important.

We felt that combining chemotherapy with endocrine ablation might encompass an admix- ture of tumors; however, the chemotherapy is strongly immunosuppressive. If chemotherapy is stopped, the immune competence quickly re- turns and frequently to a heightened level.43, 44 We have now been utilizing extended endocrine ablation plus limited term combination chemotherapy for 15 months and have observed

Oklahoma State Medical Association

favorable objective responses in 21 of 25 pa- tients, a response rate of 83%. We are currently studying methods of maintaining and ex- tending the duration of these remissions.

The American Cancer Society has recognized the large number of people who are surviving longer periods of time after breast cancer is diagnosed. They have embarked upon an ex- tensive program for rehabilitation of these peo- ple in an effort to return them to normal life- style patterns. This program involves all as- pects of sociological, psychological, and physical rehabilitation efforts and is administered by carefully selected and trained individuals most of whom have experienced a mastectomy.

With this brief review we can readily see that research in breast cancer is beginning to pro- duce rewards. Improvement in research results is being reported regularly and it is imperative that we set up mechanisms whereby this infor- mation can be readily disseminated to primary care institutions.

The Oklahoma Medical Research Foundation has been funded by the National Cancer Insti- tute for the operation of a Network Demon- stration Project. The American Cancer Society has been very instrumental in the development and assistance in operation of the program. Twenty-three representative hospitals have been selected across the state where total man- agement programs can be initiated. While it is true that some hospitals may not have the facil- ities to embark upon some sophisticated pro- grams, they have access to these through their established referring patterns. The program has two major committees as the backbone of the operation. The first of these is a Develop- mental Therapy Committee coordinated by Doctor Michael T. Shaw, a hematologist-on- cologist with the Oklahoma Medical Research Foundation and the Department of Medicine, University of Oklahoma Health Sciences Center. It is composed of representatives from the fields of pathology, radiology, and nuclear medicine; surgery, radiotherapy, and medical oncology. Many of these investigators are en- gaged in private practice and have given val- uable assistance to the program. This commit- tee investigates both clinical and basic research protocols and monitors those in other institu- tions in cooperative group studies. When re- search protocols have proven to be significantly better than others now in vogue, the protocol is re-written into a patient management plan and

submitted through the NCI to a large team of consultants.

The Consultants Committee is coordinated by Joseph M. Parker, MD, surgeon and former President of the American Cancer Society, Ok- lahoma Division. It is composed largely of physicians in private practice representing surgery, radiation therapy, medical oncology, nuclear medicine and pathology. This group meets quarterly to evaluate all protocols re- commended by the Developmental Therapy Committee and to review all clinical activities of the program. Representatives of this commit- tee are to meet with hospital tumor boards at least once monthly for dissemination of current knowledge and to act as a multi-disciplinary team of consultants. In most instances one or more members of the hospital staff will be a part of the consulting team. This team of consultants is also readily available for instant consultation over a tele-communication network. These con- ferences can be arranged by calling the Net- work Project office at the Oklahoma Medical Research Foundation, area code 405-235-8331, extension 254.

Other committees which have been appointed and are active include Professional and Lay Education Committees, a Nursing Committee, and Program Evaluation Committee.

The Program has four District Representa- tives each of whom is a well-educated and spe- cially trained oncologic nurse. These nurses meet with tumor boards at each of the hospitals and are working through the hospital admin- istration and nursing staff to train oncologic nurses in each hospital. Oncologic nurses have the capability of administering cancer chemotherapeutic agents and will have a full knowledge of rehabilitation programs, patient management plans, and experimental protocols including currently used experimental drugs.

While the ultimate mortality of breast cancer may require preventive measures not yet avail- able, we feel that we can initiate long-range patient management programs which can pro- vide a productive longevity of survival with normal life-style patterns. □

BIBLIOGRAPHY

1. Moore, D. H. Evidence for a human breast cancer. Indian J. Ca. 8:80, 1971.

2. McGrath, C. M., and Blair, P. B. Immunofluorescent localization of mam- mary tumor virus antigens in mammary tumor cells in culture. Ca. Res. 30:1963, 1970.

3. Dmochowski, L. Viruses and breast cancer. Hsp. Prac.:73, Jan. 1972.

4. Spiegelman, S., Axel, R. and Schlom, J. Virus-related RNA in human and mouse mammary tumors, J.N.C.I. 48:1205, 1972.

5. Spiegelman, S., Axel, R., Baxt, W., Gulati, S. C., Hehlmann, R., Kufe, D., and Schlom, J. Molecular evidence for a viral etiology of human cancer. J. B. Lippincott Co., Philadelphia. Proc. Seventh Nat’l. Ca.Conf.: 21, 1973.

Journal / January 1975 / Volume 68

11

Cancer / HOGE, HUMPHREY

6. Axel, R., Schlom, J.,and Spiegelman, S. Presence in human breast cancer of RNA homologous to mouse mammary tumor virus. Nature. 235: 32, 1972.

7. Priori, E. S., Anderson, D. E., Williams, W. C. and Dmochowski, L. Im- munologic studies on human breast carcinoma and mouse mammary tumors, J.N.C.I. 48: 1131, 1972.

8. Shapiro, S., Strax, P., Venet, L., and Venet, M. Changes in five-year breast cancer mortality in a breast cancer screening program. Proc. of Seventh Nat’l. Ca. Conf. Phil. J. B. Lippincott, 1972, Pp 663-678.

9. Wanebo, A. G., Huvos, and Urban, J. A. Treatment of minimal breast cancer. CA 33:349, 1974.

10. McLaughlin, C. W. and Coe, J. D. Cancer of the breast — a continuing challenge. Ann. of Surg. 169:844, 1969.

11. Fisher, B. The surgical dilemma in the primary therapy of invasive breast cancer: a critical appraisal. Current Problems in Surg. Pp 2-53, Oct. 1970.

12. Say, C. C. and Donegan, W. L. Invasive carcinoma of the breast: prognostic significance of tumor size and involved axillary lymph nodes. CA 34:468, 197 4.

13. Thai, A. P. The extended radical operation for carcinoma of the breast. In Segaloff, A. (ed) Breast Cancer (St. Louis, C. V. Mosby Co. 1958), p. 93.

14. Urban, J. A. What is the rationale for an extended radical procedure in early uses? JAMA 199: 742, 1967.

15. Fisher, B., Slack, N., Covanaugh, P. J., Gardner, B., Ravdin, R. G. Post- operative radiotherapy in the treatment of breast cancer. Results of the NSABP Clinical Trial. Ann. Surg. 172: 711, 1970.

16. Fletcher, G. H., Montague, E. D., White, C. E. Evaluation of irradiation of the peripheral lymphatics in conjunction with radical mastectomy for cancer of the breast. CA: 21: 791, 1968.

17. Butcher, H. R., Jr., Seaman, W. B., Eckert, C., and Saltzstein, S. An assessment of radical mastectomy and postoperative irradiation therapy in the treatment of mammary cancer. 17: 480, 1964.

18. Crile, G. Jr., Conservative treatment of advanced breast cancer. Am. J. of Surg. 126: 343, 1973.

19. McWhirter, R. Simple mastectomy and radiotherapy in the treatment of breast cancer. Brit. J. Radiol. 28: 128, 1955.

20. Roberts, M. Maureen, et al. Simple versus radical mastectomy. Lancet 1: 1073, 1973.

21. Fisher, B. Cooperative clinical trials in primary breast cancer: A critical appraisal. CA31: 1271, 1973.

22. Fisher, B. Breast cancer task force meeting, Washington, D.C. Sept. 30, 1974.

23. Ackerman, L., Butcher, H. R. Surgical pathology, C. V. Mosby Co. (St. Louis, Pp. 720-759) 1968.

24. Foote, F. W. and Stewart, F. W. A histological classificiation of carcinoma of the breast. Surg. 19: 74, 1946.

25. Gentile, J. M., and Flickinger, J. T. Isolation of tumor specific antigens from adenocarcinoma of the breast. Surg. Gyn and Obs. 135: 69, 1972.

26. Loisillier, F., Burtin, P., and Grabar, P. Isolement et caracterisation de l’auto-antigene responsable de la formation d’auto-anticorps chez les malades atteints de lesions mammaries. Ann. de L’lnstitut Pasteur 829, 1968.

27. Edynak, E. M., Lardis, M. P., Vrana, M. Antigenic changes in human breast neoplasia. CA;1457, 1971.

28. Edynak, E. M., Hirshaut, Y., Bernard, M., Trempe, G. Fluorescent anti- body studies of human breast cancer. J. N.C.I., 48: 1137, 1972.

29. Hellstrom, I., Hellstrom, K. E., Sjogren, H. O. and Warner, G. A. Demonst- ration of cell-mediated immunity to human neoplasms of various histologic types. Int. J. Ca. 7: 1, 1971.

30. Richters, A., Sherwin, R. P. The significance of autochronous interaction with human breast cancer cells in primary tissue cultures. CA 27: 274, 1971.

31. Hudson, M. J. K., Humphrey, L. J., Mantz, F. A. Correlation of circulating serum antibody to the histological findings in breast cancer. Southwestern Surgical Congress, May 1974.

32. Smith, R. T. Possibilities and problems of immunologic intervention in cancer. N. Eng. J. Med. 287: 439, 1972.

33. Hamlin, I. M. E. Possible host resistance in carcinoma of the breast: A histological study. Br. J. Ca. 23: 34, 1968.

34. Morton, D. L., Haskell, C. M., Pelch, Y. H., Sparks, F. C., Winters, W. D. Recent advances in oncology. Ann. Int. Med. 77: 431, 1972.

35. Black, M. M. Human breast cancer a model for cancer immunology. Israel J. Med. Sci. 9: 284, 1973.

36. Cheema, R. A. and Hersch, E M. Patient survival after chemotherapy and its relationship to in vitro lymphocyte blastogenesis. CA 28: 851, 1971.

37. Carter, S. K. Single and combination non-hormonal chemotherapy in breast cancer. CA 30: 1543, 1972.

38. Greenspan, E. M. Combination cytotoxic chemotherapy in advanced dis- seminated breast cancer. J. Mt. Sinai Hosp. 33: 1, 1966.

39. Cooper, R. G. Combination chemotherapy in hormone resistant breast cancer. Proc. Am. Assoc. Ca. Res. 10: 15, 1969.

40. Hoogstraten, B. and George, S. Adriamycin and combination chemotherapy in breast cancer. Proc. Am. Assoc. Ca. Res. 15: 279, 1974.

41. Hoge, A. F., Shaw, M. T., Bottomley, R. H., Hartsuck, J. M. Analysis of therapeutic regimens in advanced breast cancer. JAMA, in press.

42. Hoge, A. F., Hartsuck, J. M., Kollmorgen, G., and Schilling, J. A. Endoc- rine and immunologic studies of breast cancer, Amer. J. Surg. 126: 722, 1973.

43. Hersh, E. M., Whitecar, J. P., McCredie, K. B., et al. Chemotherapy and immunocompetence, immunosuppression and prognosis in acute leukemia. N. Eng. J. Med. 285: 121, 1971.

44. Harris, J., Bagai, R., Stewart, T. Immunocompetence and response to anti-tumor treatment. New Eng. J. Med. 286: 494, 1972.

825 N.E. 13th, Oklahoma City, Oklahoma 73104

	THE UNIVERSITY OF OKLAHOMA
	COLLEGE OF MEDICINE
WEEKLY AFTERNOON OF CONTINUING EDUCATION
	EVERY WEDNESDAY
	January 1st, 1975 through May 28th, 1975
	Developed by The Department of Medicine Office of Continuing Medical Education for Physicians University of Oklahoma Health Sciences Center
	Registration fee: $30.00 per semester
	SECOND SEMESTER SCHEDULE
TIME	CONFERENCE	LOCATION
12:00 to 1:00 P.M.	Medical Grand Rounds	East Lecture Hall Basic Science Building
1:30 to 2:30 P.M.	Pulmonary Disease Conference	C007 Everett Hospital
1:30 to 2:30 P.M.	Hematology-Oncology Conference	A 001 Everett Hospital
1:30 to 2:30 P.M.	Gastroenterology Conference	C002 Everett Hospital
2:45 to 3:45 P.M.	Pulmonary Problem Case Conference	C007 Everett Hospital
4:00 to 5:00 P.M.	Cardiology Conference	C007 Everett Hospital
4:00 to 5:00 P.M.	Infectious Disease Conference	C002 Everett Hospital
4:00 to 5:00 P.M.	Renal Conference	A27 V.A. Hospital
This program is acceptable for Category 1 credit toward the Physician’s Recognition Award of the American Medical Association and the American Academy of Family Practice on an hour for hour basis.

12

Oklahoma State Medical Association

Laboratory Practices In My cobacteriology:

Results Of A Survey Of Oklahoma Laboratories

DIXIE E. SNIDER, JR., MD R. LEROY CARPENTER, MD, MPH

The results of a survey of Oklahoma laboratories indicate that some laboratories need to change their procedures and policies regarding tuberculosis bacteriology work.

I. INTRODUCTION

The isolation and identification of Mycobac- terium tuberculosis in tissues and body fluids require special staining techniques, specific cultural conditions, and a niacin test. Even more specialized and sophisticated techniques are required to identify the various species of "atypical” mycobacteria.1 2 Consequently, the species identification of "atypical” mycobac- teria, as well as drug susceptibility testing, are usually done by only a few larger laboratories.

On the other hand, the practicing physician would like to have certain laboratory proce- dures readily available so that he may know as soon as possible if mycobacteria are present in a specimen. This knowledge may not only be im-

Journal / January 1975 / Volume 68

portant for treatment of the patient but also for the protection of the patient’s family and those caring for him. Because of these considerations and because fresh specimens are more likely to yield positive results, physicians often want a local laboratory to have the capability of iden- tifying mycobacteria, especially M. tuber- culosis.

In order to do this properly, the laboratory should be able to do acid-fast stains, set up cul- tures, and preferably, perform niacin tests. The latter test, if positive, nearly always identifies the organism as M. tuberculosis. It is important to differentiate disease caused by this organism from diseases caused by other mycobacteria, be- cause diseases caused by "atypical” organisms have not been shown to be communicable and, therefore, do not require the precautions and contact investigation necessary when a case of tuberculosis is discovered.

In order to determine the practices of Ok- lahoma laboratories regarding mycobacteriol- ogy, a survey of these laboratories was begun in October 1973.

II. METHODS

A questionnaire was developed which would emphasize the most important aspects of mycobacteriology (Figure 1). After consultation with laboratory workers, it was decided that the questionnaire should be brief (one page) and easily understandable in order to get a response

13

Survey / SNIDER, et al

RESULTS OF

MYCOBACTERIOLOGY QUESTIONNAIRE 2/18/74

Name of Laboratory (or Hospital, etc.)

Location

		Yes	No
1.	Does your laboratory stain for
	mycobacteria?	121	102
2.	Does your laboratory culture for
	mycobacteria?	82	141
OF	THE 82 LABORATORIES DOING	CUL-
TURES, THE FOLLOWING RESPONSES
WERE OBTAINED:
3.	Do you use the niacin test?	32	50
4.	Does your laboratory identify the
	various Runyon groups of
	mycobacteria and M. bovis ?	16	66
5.	Does your laboratory do biochemical
	tests to identify the different species
	of "atypical” mycobacteria?	15	67
6.	Does your laboratory confirm any of
	the above findings with any other
	laboratory?	72	10
	If so, what laboratory?
7.	Does your laboratory do drug
	susceptibility testing on
	mycobactieria?	4	78
	If so, which drugs?
8.	Do you do your mycobacteriology
	work under an isolation or
	safety hood?	30	52
9.	Is the vacuum on this hood checked
	frequently?	19	63
	If so, by whom?
10.	Do you report all new isolations of M.	tuber-

culosis to the state or county health depart- ment, or do you depend upon others (physician, nurse, medical records, etc.) to do this?

Report directly 43 Depend on others 39

(52)* (30)

Comments:

*Total if credit is given for laboratories refer- ring cultures to other laboratories that do report.

FIGURE 1

from as many laboratories as possible. The in- tent was to determine what types of procedures the laboratories were performing and no at- tempt was made in this questionnaire to deter- mine the methods used.

The names and addresses of all laboratories in Oklahoma known to the Laboratory Service, Oklahoma State Department of Health were obtained. The questionnaire, along with a cover letter signed by the Oklahoma State Commis-

sioner of Health explaining the purpose of the questionnaire, was mailed to each laboratory on the list. Four weeks later a second letter was sent to those not responding. This was repeated in another month if no response was received. If there still was no response, a letter and a copy of the questionnaire were sent to a public health nurse in the area. She was asked to contact the laboratory personally in an effort to obtain the desired information.

The laboratories at the Oklahoma State De- partment of Health and Oklahoma State Sanatorium were not included in this survey.

III. RESULTS

Of 228 laboratories to whom the question- naire was mailed, a response was obtained from 223 (97.8%). The responses to each question are shown in Figure 1. All 223 questionnaires were tabulated to obtain the responses shown for questions 1 and 2. The responses to questions 3 through 10 were tabulated only for those laboratories giving a "yes” response to question 2.

As can be seen, only 121 (54%) of the laboratories stain for mycobacteria. Thirty- nine (18%) do smears but do not culture. Eighty -two (37%) of the laboratories culture for mycobacteria. Sixteen (20%) of the 82 laboratories doing cultures identify "atypical” mycobacteria by Runyon group and fifteen identify the species.

All but ten laboratories (12.2%) doing cul- tures refer these cultures to some other laborat- ory for further identification and/or confirma- tion of previous test results. Forty-five of the seventy-two laboratories referring cultures use the Oklahoma State Department of Health Laboratory as their reference laboratory. A pri- vate laboratory in Oklahoma City was next in frequency with nine referring laboratories. Six referred cultures to out-of-state laboratories. Five laboratories in the Tulsa area referred cul- tures to the Tulsa City-County Health Depart- ment Laboratory. Other reference laboratories received referral cultures from one or two laboratories.

Only four laboratories in the state perform drug susceptibility testing on mycobacteria.

Of the 82 laboratories doing cultures, only 30 (36.6%) have an isolation or safety hood. Nine- teen of these hoods are checked frequently to determine whether the exhaust fan is working

14

Oklahoma State Medical Association

properly. (Two laboratories have hoods with UV light and no ventilation fans.)

Forty-three (52%) of the laboratories report positive results directly to the Oklahoma State Department of Health. When one considers that some laboratories may not report directly but refer cultures to laboratories that do, there are still apparently only 62.7% of laboratories that report findings through laboratory channels.

IV. COMMENTS

The response to the questionnaire was better than expected. Although it was necessary to make three mailings and a few visits, it is un- common to get a 97.8% response in any survey conducted primarily by mail. We are grateful to the laboratories in the state for their coopera- tion. We interpret this response to mean that the questionnaire itself was acceptable in terms of brevity and clarity.

It was somewhat surprising that only 54% of the laboratories reported that they stained specimens to identify mycobacteria. The reason for such a low percentage of laboratories per- forming this test is unclear. It may be because some persons have the erroneous impression that, unless the newer fluorochrome technique is used, the results are unreliable.

In recent years the use of the fluorochrome staining technique has become more popular. While this technique is more sensitive and timesaving, especially if thirty or more speci- mens are processed daily, the special equipment required makes it an impractical and un- economical technique for the small laboratory to perform.

The older Ziehl-Neelsen technique is rel- atively easy to perform, inexpensive, and of suf- ficient reliability to be used as an initial screen- ing test when tuberculosis is suspected.3 If posi- tive, a presumptive diagnosis can be made quickly, often saving the patient from further diagnostic tests and delayed or inappropriate treatment. We would encourage more laboratories, even small ones, to perform this test.

Although a smear done on a concentrated specimen which has been decontaminated, di- gested, and centrifuged has a higher yield of positive results, the direct smear still has clini- cal usefulness and can often be as good as a concentrated specimen, if material is carefully selected.4

In contrast to the above situation regarding staining of smears, more laboratories than ex-

pected (82) culture for mycobacteria. The reason for this is also unclear. It may be that many medical staffs and/or laboratory super- visors have encouraged laboratories to have this capability, even though cultures may be performed infrequently. Of interest in this re- gard is the fact that only 32 of the 82 laboratories doing cultures (39%) perform a niacin test. This is a relatively simple test and, as previously mentioned, if it is positive the organism nearly always is M. tuberculosis. If a laboratory can justify performing cultures for mycobacteria, it is reasonable to expect that laboratory to presumptively identify the or- ganisms as M. tuberculosis by doing a niacin test.

From the responses to questions 4 and 5, it will be seen that 16 laboratories identify the four Runyon groups and 15 laboratories do bio- chemical tests to identify the species. Most of these laboratories are larger reference labor- atories. Unless the species of mycobacteria growing in culture is identified, an erroneous diagnosis and inappropriate treatment may re- sult, since not all atypical organisms are patho- genic. Therefore all isolations of atypical mycobacteria should be referred for identifica- tion. The expense and expertise required for performing the necessary biochemical tests make it impractical for all but the larger ref- erence laboratories to perform them.

The response to question six indicates that all but 10 of the 82 laboratories performing cul- tures confirm their results with other laboratories. This is encouraging. However, two laboratories were found which did not do niacin or any other biochemical tests and which also did not confirm their findings with any other laboratory. These laboratories should either begin to refer their cultures or begin to do the procedures required to identify the species of mycobacteria if the physician receiving the re- sults is to make an accurate diagnosis.

Only four laboratories reported doing drug susceptibility studies. This is certainly a suffi- cient number for the state. Here again, the ex- pense and expertise required for these studies make it impractical for all but the larger ref- erence laboratories to perform them. Three laboratories performed susceptibility tests to streptomycin, para-aminosalicylic acid, isoniazid, and ethambutol; two to rifampin; and one each to viomycin and ethionamide. One laboratory failed to state which drug suscept- bility studies were done.

Oklahoma State Medical Association

15

Survey / SNIDER, et al

One explanation for the small number of laboratories doing niacin tests and other bio- chemical tests may be that only thirty laboratories reported having an isolation or safety hood. Laboratories without hoods may be reluctant to manipulate cultures or do niacin tests using cyanogen bromide. Apparently these laboratories are not reluctant to handle specimens and set up cultures. Tuberculosis is spread by the airborne route and unfortunately, many procedures in the laboratory can produce infectious aerosols even though cultures are not manipulated.7- 8 It would appear from previous statements9- 11 that workers handling myco- bacteria-containing specimens are at increased risk of developing active tuberculosis. There- fore, we would encourage all laboratories which regularly handle specimens for mycobac- teriology work to utilize the safety measures which have been previously published.12- 14

Of these thirty hoods, nineteen are checked frequently to determine whether the exhaust fan is functioning properly. Hoods should be checked every three months.5 The exhaust fan should have the capacity to draw a minimum of 50 to 75 lineal feet of air per minute across the entire front opening.6 Presumably nine hoods are not checked and may be ineffective.

In spite of the fact that reporting of tuber- culosis is required, only 43 of 82 laboratories doing cultures report positive findings directly to the Oklahoma State Department of Health. The Oklahoma Public Health Code (Art. 5, Sec. 1-503) states "(a) The State Board of Health shall promulgate rules and regulations estab- lishing a system of reporting cases of diseases diagnosed or detected by practicing physicians and/or clinical laboratories which come within the purview of this article . . If one considers

indirect reporting, there are still only 52 laboratories that report their findings through laboratory channels. The other laboratories in- dicated that they depend upon others, primarily physicians, to report positive findings. While this is understandable, it often leads to delayed reporting or failure to report a case of tuber- culosis.

Perhaps the reluctance to report findings di- rectly results from a fear of violating the physician-patient relationship and/or the feel- ing that the laboratory cannot make a diagnosis but can only report test results. Regarding the first consideration, the patient-physician rela-

16

tionship should not take precedence when the law specifies that a communicable disease be reported. In addition, the policy of the Tuber- culosis Division of the Oklahoma State De- partment of Health is to contact the private physician before contacting patients or their families. Secondly, the intent of the Oklahoma legislature was for laboratories to report posi- tive findings, otherwise the statement "cases of disease . . . detected by . . . clinical laboratories” would not have been included in the Public Health Code.

The Oklahoma State Department of Health needs more rapid and complete reporting be- cause it has the responsibility to (1) see that infectious cases are under treatment, (2) inves- tigate contacts of active cases, and (3) collect information about the occurrence and incidence of tuberculosis in our state. If a case is not re- ported, the patient may be lost to follow-up and not receive adequate treatment if he moves or fails to return to his private physician. This could result in the infection of more persons with M. tuberculosis. These individuals then become the reservoir from which more active cases will develop in the years ahead. Examina- tion of the contacts of active cases of tuber- culosis is done to find others who might have been infected and may have active disease. This

A 1969 graduate of the University of Louis- ville School of Medicine, Dixie E. Snider, Jr., MD, has been certified by the American Board of Internal Medicine. She is presently Chief, Research and Development Branch, Tuber- culosis Control Division, Bureau of State Ser- vices, Center for Disease Control in Atlanta. Other medical affiliations include the Ameri- can Thoracic Society. Doctor Snider was for- merly Tuberculosis Medical Officer, USPHS, assigned to the Oklahoma State Department of Health.

R. LeRoy Carpenter, MD, MPH, was graduated from the University of Kansas School of Medicine in 1956. He is Commis- sioner, Oklahoma State Department of Health and Adjunct Assistant Professor of Biostatistics and Epidemiology at the College of Health, University of Oklahoma Health Sciences Center. His medical memberships include the Association of State and Territorial Health Of- ficers, the Conference of State and Provincial Health Authorities of North America, the Ok- lahoma State Thoracic Society and the Ameri- can Association of Automotive Medicine.

Journal / January 1975 / Volume 68

contact investigation may be neglected if the case is not reported.

V. CONCLUSION

The results of this survey indicate that (1) more laboratories should be staining slides for mycobacteria, (2) fewer laboratories should at- tempt to culture mycobacteria, (3) laboratories that do cultures should perform niacin tests, (4) more laboratories need safety hoods, (5) safety hoods in existence should be checked more fre- quently, and (6) direct laboratory reporting to the Oklahoma State Department of Health needs to be improved.

We encourage persons responsible for estab- lishing laboratory policies and procedures to critically review their practices regarding mycobacteriology work. Some laboratories will need to change the types of procedures they perform and/or how they perform them. In this way the laboratory will assist the physician in making a more rapid and accurate diagnosis

and thus provide better treatment for the pa- tient.

REFERENCES

1. Kubica, G. P., and Dye, W. E.: Laboratory Methods for Clinical and Public Health Mycobacteriology. U.S. Dept, of Health, Education, and Wel- fare. PHS Publication No. 1547, 1967.

2. Vestal, A. L.: Proccedures for the Isolation and Identification of Mycobacteria. U.S. Department of Health, Education, and Welfare. DHEW No. (HSM) 73-8230, 1973.

3. Ibid.: p. 27.

4. Tarshis, M. S.: "Bacteriology of the Mycobacteria.” Diagnosis and Treat- ment, Pfuetze, K. H., and Radner, D. G., eds. Charles C. Thomas, Springfield, 111., 1966, p. 39.

5. Vestal, A. L.: Ibid., p. 5.

6. Ibid.: p. 4.

7. Ibid.: p. 1.

8. Tomlinson, A. J. H.; "Infected Air-Borne Particles Liberated on Opening Screw-capped Bottles.” Brit. Med. J. 2:15, 1957.

9. Reid, D. D.: "Incidence of Tuberculosis Among Workers in Medical Laboratories.” Brit. Med. J. 2:10, 1957.

10. Pike, R. M., Sulkin, S. E., and Schulze, M. L.: "Continuing Importance of Laboratory-Acquired Infections.”: Amer. J. Public Health. 55:190, 1965.

11. Long, E. R. "The Hazard of Acquiring Tuberculosis in the Laboratory.” Amerc. J. Public Health, 41:782, 1951.

12. Vestal, A. L.: Ibid. pp. 1-10.

13. Handbook of Tuberculosis Laboratory Methods, Veterans Admin- istration: Armed Forces Cooperative Study on the Chemotherapy of Tuber- culosis, 1962.

14. Wedum, A. G.: "Control of Laboratory Airborne Infection.” Bact. Rev. 25:210, 1961.

1Chief, Research and Development Branch, Tuberculosis Control Division, Bu- reau of State Services, Center for Disease Control, Atlanta, Georgia 30333. (At the time of this survey Dr. Snider was a Tuberculosis Medical Officer in the U.S. Public Health Service assigned to the Oklahoma State Department of Health.) Commissioner, Oklahoma State Department of Health.

Center for Disease Control, Atlanta, Georgia 30333

INTERNAL MEDICINE REVIEW COURSE

1975

East Lecture Hall, Basic Science Education Building University of Oklahoma College of Medicine, Oklahoma City, Oklahoma

Developed by

The Department of Medicine, University of Oklahoma Health Sciences Center

and

Office of Continuing Medical Education for Physicians Registration Fee; $15.00 per semester

Send Advance Registration to: Office of Continuing Medical Education for Physicians, University of Oklahoma Health Sciences Center, P. O. Box 26901, Oklahoma City, Oklahoma 73190

DATE TITLE — SPEAKER

January 22, Pulmonary Disease II — C. Dowell Patterson, MD January 29, Diabetes, Hypoglycemia and Calcium — James Males, MD

February 5, Metabolic and Respiratory — Robert D. Lindeman, MD; Acid Base Distrubances — Chris E. Kaufman, MD

February 12, Glomerulopathies Diagnosis and Management — Solomon Papper, MD; Anil K. Mandal, MD February 19, Urinary Tract Infection and Stones; Diagnosis and Management — Anthony Czerwinski, MD February 26, Infectious Disease I — Infectious Disease Section.

March 5, Infectious Disease II — Infectious Disease Section

March 12, Valvular Heart Disease — Eliot Schechter, MD

March 19, Gastroenterology I — Gastroenterology Section

March 26, Congenital Heart Disease In The Adult — Lofty L. Basta, MD

April 2, ASCVD and Cardiomyopathies — Stephen D. Shappell, MD

April 9, Gastroenterology II — Gastroenterology Section

April 16, Metabolic Disorders Presenting In The Adult — Sylvia Bottomley, MD

April 23, Pituitary Adrenalin and Endocrine Hypertension — David C. Kern, MD

April 30, Thyroids and Gonads — E. William Allen, MD

Journal / January 1975 / Volume 68

17

News From e Oklahoma State Department of Health

PKU REVISITED

Although phenylketonuria is a rare inborn error of metabolism, enough children have been successfully managed to be optimistic about the results. Therefore, we must improve our diag- nostic methods to avoid a tragic oversight. True to the maxim that more mistakes are made by not looking than not knowing, we should check every newborn infant. Using the Guthrie test as a screening procedure is not enough. As a screening test it has limitations which are magnified by drawing the specimen under 72 hours of age and in cases where the initial pro- tein intake may be in question because of dif-

ficult early feeding. One can expect false posi- tive tests in any procedure used for screening and, troublesome as it may be, a false positive is easier to explain than a false negative.

Please consider rechecking all infants with an initial Guthrie test of over 4 mg % im- mediately, not waiting until four to six weeks of age. Also, plan to recheck infants who were tested before 72 hours of age. Seriously consider rechecking babies who had trouble feeding or in breast fed babies with questionable intake. Some physicians are repeating the Guthrie test at the routine one month checkup.

The intelligence and behavior of an affected child seems to be optimal when limited dietary phenylalanine therapy was started under 21 days of age. The Oklahoma State Department of Health is ready to assist you in the early diag- nosis of this treatable disorder. Treatment cen- ters are available at Tulsa’s Children’s Medical Center, and in Oklahoma City through Children’s Memorial Hospital. □

COMMUNICABLE DISEASES IN OKLAHOMA FOR NOVEMBER, 1974

DISEASE	November 1974	November 1973	October 1974	Total To Date 1974 1973
Amebiasis	3	1	2	27	29
Brucellosis	2	—	2	11	5
Chickenpox	129	15	61	1006	1331
Encephalitis, Infectious	4	3	8	55	101
Gonorrhea (Use Form OBH-228)	970	752	1072	10385	9995
Hepatitis, A, B, Unspecified	117	64	62	950	1053
Leptospirosis	1	—	—	2	—
Malaria	—	—	3	6	3
Meningococcal Infections	2	1	1	18	34
Meningitis, Aseptic	5	2	3	63	103
Mumps	24	10	9	405	468
Rabies in Animals	13	5	16	155	155
Rheumatic Fever	—	2	1	12	16
Rocky Mountain Spotted Fever	6	—	4	66	76
Rubella	8	1	3	66	182
Rubella, Congenital Syndrome	—	—	—	1	—
Rubeola	—	5	2	29	61
Salmonellosis	18	15	34	255	263
Shigellosis Syphilis, Infectious	24	9	12	174	185
(Use Form ODH-228)	12	15	12	133	160
Tetanus	2		—	3	4
Tuberculosis, New Active	12	29	43	271	302
Tularemia		1	4	18	23
Typhoid Fever			—	2	2
Whooping Cough	3	—	—	19	21

For Consultation Call: (405) 271-4060

18

Oklahoma State Medical Association

news

Dues and Finances Dominate AMA House of Delegates Meeting

Extended debate, often heated, took place during the American Medical Association’s 28th Clinical Convention in Portland, Oregon, November 30th-December 4th. The dispute re- volved around the financial situation of the AMA.

The house was reminded that the AMA had operated at a deficit for four of the last five years, and that its cash reserves had been seri- ously depleted during that time. In addition, AMA finances in 1974 were adversely affected by inflationary pressures.

After almost six hours of comment and delib- ration on Tuesday afternoon and Wednesday morning, the delegates adopted a $60 special assessment as a stop-gap measure. The man- datory assessment, effective January 1st, will be billed from the AMA Washington office to all members, excluding students, interns and resi- dents.

The $60 assessment is expected to improve the immediate cash flow problems for the as- sociation and to help build up its depleted fi- nancial reserves.

The house rejected a $90 dues increase pro- posed by the AMA’s Board of Trustees. In doing so, however, they called for a special committee of the house to study the dues issue and report back at the 1975 Annual Meeting in Atlantic City. The committee will make a comprehen- sive study of the AMA’s financial priorities and capabilities. In the meantime, the house urged the board to restore in a "holding pattern” the structure of several councils and committees which it had previously eliminated, and to maintain present publication schedules for JAMA, all specialty journals and Prism.

In a related issue, the house approved adver- tising as a legitimate function in AMA publica- tions, and urged that the present full and unre- stricted advertising program in AMA publica- tions continue pending further study and a re- port at the June meeting.

Meeting a total of 16 hours and 40 minutes, one third of it devoted to the AMA finances

Journal / January 1975 / Volume 68

and related issues, the delegates acted on 77 reports and 68 resolutions for a total of 145 items of business. The following is a brief de- scription of some of the highlights of the meet- ing.

Harry Schwartz, PhD, visiting professor of Medical Economics at the Columbia University College of Physicians and Surgeons was se- lected to receive the AMA’s Laymens’ Citation for Distinguished Service. Doctor Schwartz is on leave from the Editorial Board of the New York Times and is the author of the Case for American Medicine.

Doctor Schwartz will be presented his award at the 1975 Annual Meeting in Atlantic City. Last year he was a guest speaker during Ok- lahoma Medical Summit, the combined annual meeting of the OSMA, Oklahoma Academy of Family Physicians and the Oklahoma City Clinical Society.

During a discussion of malpractice problems, the house adopted a recommendation calling for the board to give "priority attention” to provid- ing legal counsel and advise to AMA members and state societies in the event their profes- sional liability insurance is not renewed. The necessity for state associations to seek legisla- tive remedies for malpractice problems was emphasized.

A separation of the fall business meeting of the house and the scientific meetings will be permitted beginning in 1977. Under new by- laws changes the house will hold its fall meet- ing separately in cities recommended by the Board of Trustees and selected by the house, and the scientific session will hold regional meetings at other times during the years deemed necessary by the board and at cities selected by the board. This new format was de- vised to allow regional scientific programming. The scientific assemblies will continue to be held in conjunction with the annual meetings, however.

Strong programs of continuing medical edu- cation and peer review as alternatives to re-

19

news

licensure were called for by the house. Specific recommendations included all possible encour- agement for medical professional organizations to expand the continuing medical education programs. Well designed peer review programs would be endorsed as an important component of performance evaluation, the house stressed performance evaluation, rather than knowl- edge per se, as the best method of appraising competence in patient care.

A vote of confidence was given to the Board of Trustees by the delegates for its effort to de- velop new approaches to National Health In- surance while maintaining traditional AMA goals. The house adopted a board report con- taining basic guidelines for NHI deliberations. (These guidelines are outlined in another arti- cle in this issue of The Journal.)

A strong policy position against the use of human chorionic gonadotropin for use in weight reduction was taken. The house re- solved, "that the AMA warn our citizens about the potential danger of such weight control pro- grams.” Clinics utilizing chorionic gonadotro- pin have been established and widely adver- tised in various parts of the country, including Oklahoma City.

An AMA policy to encourage insurance coverage of the newborn from the moment of birth was reaffirmed by the delegates. They urged the Health Insurance Industry to offer coverage for obstetrical care and any compli- cations, and recommended that the insurance industry, as well as government, offer such coverage on the broadest possible basis.

State legislation to regulate the practice of acupuncture was supported by the delegates. A new policy says acupuncture should only be per- formed in research settings by a physician or under the direct supervision of a physician.

The house again objected to language in in- surance letters indicating that claims were "not medically necessary,” since this encourages pa- tients to decline to pay for services and is de- famatory to physicians.

The present 55-mile per hour speed limit was endorsed by the house while delegates urged the government to continue the reduced limit for at least a one-year period. It noted that traffic fatalities have declined 14.8% since the speed limit was imposed last year.

A proposal to replace the Council on Legisla- tion and many functions of the American Medi-

20

cal Political Action Board of Directors with a new Council on Public Affairs was soundly de- feated by the House of Delegates. Although it was proposed by the AMA’s Board of Trustees, many delegates felt that the AMPAC Board should remain separate from functions of the AMA. □

Washington Political Profile for 1975

There can be little doubt that the 1974 elections changed the political profile of the nation’s capital. Going into the election the United States Senate held 58 Democrats and 42 Republicans while the House of Represen- tatives had 248 Democrats and 187 Republi- cans.

Following the November elections it was clear that the Republicans had suffered numerous defeats, but had not given the Democrats the landslide victories that they anticipated. On November 5th, 34 Senate seats were contested, of which 20 were held by Democrats and 14 by Republicans. Of the 20 Democrats, three were unopposed. On election day, four seats formerly held by Re- publicans were captured by Democrats and one seat formerly held by a Democrat was captured by a Republican for a net gain of three Democratic seats.

In 1975 the United States Senate of the 94th Congress will hold 61 Democrats and 38 Republicans.

All members of the House of Representa- tives run every two years. In the 435 House races, 44 candidates were unopposed. On election day, 49 seats formerly held by Re- publicans were taken by the Democrats and six seats formerly held by Democrats were captured by Republicans. This gives the Democrats a net gain of 43 House seats so that House lineup for the 94th Congress will be 291 Democrats and 144 Republicans. (At the time of this writing one House seat in Louisiana is still being resolved.)

In state governor races, Democrats went into the elections with 31 governors’ chairs while the Republicans held 19. Following the elections, the Democrats held 31 chairs, the Republicans retained only 13, and one Inde- pendent was elected. This was a net gain of five Democratic governships. □

Oklahoma State Medical Association

BEVERLY HILLS HOSPITAL BEVERLY HILLS CLINIC

PSYCHIATRY INPATIENT - OUTPATIENT DEPARTMENT OF ADOLESCENT PSYCHIATRY

A Private 115 bed psychiatric hospital located in Oak Cliff on 18 acres amidst natural wooded sur- roundings. A multi-approach treatment center of neurologic and all psychiatric disorders. Treatment modalities include Somatic Therapy, Milieu Therapy, Chemotherapy, Individual and Group Therapy, Transactional Analysis, Gestalt, and Behavior Modification. Complete facilities for OT-RT under the division of trained personnel. An individually directed program based on full diagnostic evaluation and actual performance administered by a staff skilled in special education and problems of the adoles- cent and young adult.

PSYCHIATRY

Jackson H. Speegle, MD Fred H. Jordan, MD

John T. Holbrook, MD Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

Journal / January 1975 / Volume 68

21

neuos

Ford Announces Administration’s Health Insurance Plan

President Gerald Ford has indicated that the National Health Insurance Plan his ad- ministration will submit to the next Congress will be similar to former President Nixon’s Comprehensive Health Insurance Plan, known as CHIP. In a legislative message to the lame duck congress in late ’74, Ford made it clear he expected no action during that year and that he wanted Congress to wait to see his plan.

CHIP was based on manadatory coverage of workers by employers through the existing private health insurance system. While the original plan had very little congressional support, it was highly favored by the HEW leadership.

In the meantime, HEW Secretary Casper Weinberger has been meeting with the prin- ciple medical and health care providers, in- cluding the AMA, in an effort to arrive at some sort of consensus with respect to an NHI Bill.

The AMA has provided the secretary and other organizations with a 14 point set of principles that it believes essential to any na- tional health insurance plan. Approved by the AMA’s Board of Trustees, these NHI guidelines are as follows:

1) Minimum federal involvement in admin- istration of any national health insurance program . . .

2) State jurisdiction with respect to licen- sure and certification of professional health personnel and regulation of insurance . . .

3) Minimum federal dollars in financing of programs for comprehensive coverage at the least possible cost . . .

4) Funding through federal, state and pri- vate funds including employer-employee con- tributions for private health insurance and an individual tax credit as applied for full health care protection . . .

5) No added Social Security tax for financ- ing .. .

6) No administration by the Social Security Administration . . .

7) Cost sharing by participating individuals and families and a subsidy for the indigent scaled according to income . . .

8) Use of private insurance on risks and underwriting basis . . .

22

9) Comprehensive coverage, basic and catastrophic, for the entire population . . .

10) Pluralism in methods of health care de- livery . . .

11) Cost controls as appropriate . . .

12) Quality controls as appropriate . . .

13) Continuity of benefits . . .

14) Coordination of benefits. □

Tulsa Possible Site For AMA Regional Meeting

Tulsa has been selected by the AMA’sUouncil on Scientific Assembly as a potential site for a Regional Continuing Medical Education Meet- ing in 1976.

Regional meeting sites are chosen on the basis of physician-population, ease of trans- portation access, and availability of physicial facilities and course faculty. The council has tentatively selected the month of January, 1976, for a Tulsa presentation.

The regional meeting is presented on a Saturday-Sunday weekend to minimize the physician time away from his practice. Each meeting is composed of six to eight post- graduate courses on broadly related clinical topics.

It is possible for a physician to take two courses with a total of 12 hours of Category I Continuing Medical Education credit toward the AMA’s Physicians Recognition Award.

An all encompassing fee "package” is avail- able to cover room, food and registration. The fees are collected by the AMA which also bears the cost of planning and putting on the meeting.

The concept of the regional Continuing Edu- cation Meeting is part of an expanded program for which the Council on Scientific Assembly of the AMA is responsible. The council is the AMA’s principle programming arm in Contin- uing Medical Education, an outgrowth of its traditional responsibility for programming the scientific and education portions of the AMA Annual and Clinical Conventions.

During the Portland Clinical Convention the AMA’s House of Delegates moved for the sep- aration of the Fall Business Meeting of the house and the scientific meetings. This will begin in 1977. It is anticipated that the scien- tific meetings of the Clinical Convention will be replaced by the Regional Continuing Education Programs. The scientific assemblies will con- tinue to be held in conjunction with the annual meeting, however. □

Oklahoma State Medical Association

Medical Information Confidentiality Stressed

Confidentiality of medical information, in light of computer technology and vast govern- ment involvement in health delivery, is be- coming a national concern. The most recent voice heard was that of the American Medical Record Association during its annual meeting in San Francisco.

A position paper outlining the association’s stand on medical information was adopted by its House of Delegates. The paper, as originally published, is as follows:

"The American Medical Record Association throughout its history has recognized the patient’s right to privacy in relation to his med- ical record. While the patient does not have the property right to his record, he does have the protected right of information.

"The primary purpose of the medical record is to document the course of the patient’s health care and to provide a medium of communication among direct care professionals for current and future patient care. Unless the patient can feel assured that the highly sensitive and personal information he shares with health care profes- sionals will remain confidential, he may with- hold information critical to his treatment, thereby diminishing the quality of the care pro- vided him.

"Economic and social issues, together with technological advances, have resulted in an erosion sf the confidential relationship tradi- tionally existing between patient and health care professional. Substantiation of claims for payment has generated an ever increasing number of requests for information from pa- tient health records. At the same time, the tre- mendous growth of computerized health data, the development of huge data banks and the advancement in record linkage pose an enorm- ous threat to the privacy of medical informa- tion. The public is generally unaware of this threat or of the serious consequence of a loss of confidentiality in the health care system. Ade- quate measures to control medical privacy in the light of electronic information processing can and must be established.

"The American Medical Record Association recognizes the need for patient health informa- tion in providing a sound basis both for substan- tiating claims and for conducting medical care evaluation. Therefore, subject to applicable legal provisions, release of any individually

identifiable medical information for any pur- pose other than patient care must be done only with the expressed authorization of the patient or his legal agent.

"Further, AMRA recommends greater em- phasis on the patient’s right to privacy by health care institutions through the establish- ment of written policies for the release of infor- mation, together with active educational pro- grams for all staff personnel, to enforce these policies.

"With respect to the right of privacy, AMRA, urges the development and implementation of programs to: (1) protect the patient from inva- sion of privacy as a result of indiscriminate and unauthorized access to confidential health in- formation and (2) promote applicable usage of medical information once it is disseminated to authorized persons.” □

San Antonio To Host International Medical Assembly

Historic San Antonio will play host for the International Medical Assembly of Southwest Texas. The 39th Annual Meeting will be held in San Antonio’s Saint Anthony Hotel and the University of Texas Medical School, Thursday and Friday, February 27th and 28th.

This year’s program is dedicated to the American Academy of Family Physicians, with built in interest for the specialists. Nine outstanding guest speakers have been ob- tained along with panels composed of local experts from the University of Texas Medical School at San Antonio, Wilford Hall Medical Center, Brooke Army Medical Center and the Bexar County Medical Society.

At the conclusion of the two-day conven- tion, the annual extension trip will be to Acapulco and Mexico City. This trip has be- come an integral part of the postgraduate medical seminar and the number of physi- cians and their wives going on the trip has increased every year.

Distinguished speakers for the Medical As- sembly include an Oklahoman, David C. Kem, MD, an Oklahoma City internist.

Persons interested in receiving additional details should write Mr. Sid Cockrell, Jr., Executive Director, P.O. Box 12678, San An- tonio, Texas 78212. □

Journal / January 1975 / Volume 68

23

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance Springfield, Mass.

For additional details and application form, please contact

Phil Payne

Administrator

720 N.W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

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It depends, of course, on your age and annual earnings, but the amount can quite reasonably exceed $400,000.

The total value of all your possessions — property, savings, cars and personal belongings — is only a fraction of what you will probably earn during years of practice. And yet some of you have insured these things and left your earning power unprotected.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION . . . gives you individual coverage at low group rates.

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For Additional Information, call or write

Phil Payne, Jim Thaxton or Rodman A. Frates C. L FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695 OKLAHOMA CITY, OKLAHOMA 73118 Telephone 405 848-7661

24

Oklahoma State Medical Association

One-Third of Health Dollars Spent By Government

Of every health care dollar spent in this country, 33 cents is being provided by the federal government, according to a unique report made annually by the AMA’s Wash- ington office.

Actual dollar outlays in any given year may vary considerably from the appropri- ations provided by Congress, but the appro- priations figure used by the AMA is an accu- rate guideline of the nation’s year to year health spending.

During the fiscal year that ended last July, the federal government disbursed more than $32.7 billion for health, up $2.6 billion from the previous year, plus more than $12 billion for disability programs. Total spending from all sources on health was estimated at about $100 billion.

The federal tab for the current fiscal year, ending in July, 1975, is slated to register a sharp jump as new federal programs get going and increased overall health care costs are reflected.

As was to be expected, the HEW Depart- ment leads the list of government health spenders with $23.7 billion appropriated last fiscal year for its many health activities in- cluding Medicare and Medicaid. Next in line were defense and veterans administration, each spending over $3 billion.

Fourth and fifth slots are occupied by rel- atively recent federal activities, the Federal Employees Health Insurance Program and the Environmental Protection Agency, with $696 million and $528 million respectively.

Animal disease control, research, meat in- spection, and a few other lesser activities under the Department of Agriculture add up to $302 million per year. Even though it might be considered a health cost, the AMA did not count $7.8 billion for health related programs of food for school children, and rural housing, water and waste disposal ac- tivities.

Medicare is the single largest federal health plan moneywise though financed out of Social Security taxes. Technically, Medi- care remains an appropriation that must be approved by Congress each year. Last fiscal year Medicare spent $12.1 billion, a $2.5 bil- lion increase due to increased utilization, higher costs, and a new program for the dis-

abled, including kidney disease patients, which accounted for an additional $1.25 bil- lion.

Of the Medicare total, almost $3 billion was paid out for the supplemental insurance plan for outpatient benefits. Half of the pre- mium is paid for by the beneficiaries.

The federal government allotted $5.8 bil- lion to the states for the Medicaid Program for medically indigent people, an increase of almost $1 billion due to expansion of cate- gories eligible for such assistance. If federal, state and local funds are counted, Medicaid cost $10.5 billion. □

Medicare Deductible Up For 1975

The Department of Health, Education and Welfare has announced that commencing with the first of the new year the medical hospital deductible will jump to $92. The present deductible is $84.

HEW said that the $92 deductible is equi- valent to the average cost of one day of hos- pitalization. The increased payment was brought about by rising hospital costs, ac- cording to the department.

The Medicare law requires an annual re- view of hospital costs under Medicare and an adjustment of the portion of the bill for which a Medicare beneficiary is responsible, if the costs have risen substantially.

When the hospital deductible amount changes, the law requires comparable changes in the dollar amounts that a Medi- care beneficiary pays toward a hospital stay for more than 60 days, or an extended care facility stay of more than 20 days.

Now, if a Medicare beneficiary has a hospi- tal stay of more than 60 days, he will pay $23 a day for the 61st through the 90th day, up from the $21 per day charged in 1974. If he has a post-hospital stay of over 20 days in the extended care facility, he will pay $11.50 per day toward the cost of the 21st through the 100th day, up from the $10.50 per day charge in 1974.

If it becomes necessary for a beneficiary to dip into his "lifetime reserve” of hospital days, the extra 60 hospital days the bene- ficiary can use when he needs more than 90 days of hospital care in any given benefit period, the extra use will cost him $46 for each reserved day, instead of the present $42 per day. □

Journal / January 1975 / Volume 68

25

MEDiCENTER PSYCHIATRIC HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy ® Occupational Therapy

• Psychological Testing

® Psychiatric Social Worker Services

• Neurological Consultation

• Electro-Convulsive Therapy

• Clinical Laboratory

Offering complete private Psy- chiatric Services using the Therapeutic Community ap- proach in an open setting.

Fully Accredi&ted

60 Beds

Mrs. Billie Speck-Administrator

® X-ray ® Pharmacy ® Physical Therapy ® Medical Consultations

SPONSORED BY THE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE DISABILITY INCOME INSURANCE

Contact Association Counselors:

Phil Payne, Jim Thaxton ©r Rodman A. Frates

Administrators

720 NW 50th

PO Box 18593 405 848-7661 Oklahoma City 73118

26

Oklahoma State Medical Association

Fifty Years of Medical Practice

Doctor Coker has had the privilege of delivering many children in and around Durant. Among those whom he has watched grow to maturity are pictured above (1 to r) Betty (Harlin) Bowen, Kathryn (Harlin) Melson, Doctor Coker, J. D. Harlin, B. B. Newton, Georganna (Harlin) Black, behind her, Henry George Wells, Ben Wells, Dwayne Wells, Bob Wells and John Wells.

Battey B. Coker, MD, Durant, has had many experiences in his fifty years of practice in southeast Oklahoma. Doctor Coker arrived in Durant on March 15th, 1926, after a five-day train trip from California. He had originally planned to form a partnership with another Durant physician and equally share their in- come. However, upon learning that the largest income the other physician had received in any given month was $80, he decided to establish his own practice. At the time, Durant had 25 physicians and a population of 7,400 and Doctor Coker found his specialty, ophthalmology, was not very lucrative, so he entered general prac- tice.

He underwent many trying times such as making a house call in the middle of a cold, foggy, February night at Bee, Oklahoma. He could drive his car only as far as Nida, Okla- homa, and had to ride horseback to Bee. This was a two-hour ride. Arriving at the home, he found a patient with kidney stone colic and it was 3:00 a.m. before he was ready to return to Durant. However, he was told that everyone had gone to bed and there was no one to take him on horseback to his car in Nida. He was forced to spend the rest of the night in the patient’s home.

Another time he drove as far as he could and then walked a mile on a muddy road to aid a 78-year-old patient. It developed that her ap- pendix had ruptured. An operating table was

set up in the kitchen of the home and emergency surgery was performed. As Doctor Coker pointed out later ". . . to everyone’s surprise, the patient survived and lived for many years.”

In his early practice all obstetrical cases were delivered at home.

It was not unusual during a good cotton-crop year for Doctor Coker to collect unpaid bills dating back several years.

His practice was interrupted during World War II when he served as a Lieutenant (jg) in the Medical Corp of the US Navy.

In 1965, the physician closed his office and returned to school for postgraduate training in his specialty. Following two and one-half more years of practice, he retired. However, he said, "I found out house work was harder than prac- ticing . . .” so he accepted a position at South- eastern State College doing consulting exami- nations.

Doctor and Mrs. Coker have two daughters, six grandchildren and four great grand- children. He is a Life Member of the OSMA, a member of the American College of Surgeons and the Southern Medical Association. □

DEATH

ELIZABETH M. CHAMBERLIN, MD 1883-1905

A 91-year-old Bartlesville physi- cian, Elizabeth M. Chamberlin, MD, died December 10th, 1974. A native of Nebraska, Doctor Chamberlin was graduated from Creighton Univer- sity School of Medicine in 1905.

Her practice was established in Bart- lesville in 1917. In 1937, she became a charter member of the Diplomates of the American Board of Pathology.

Doctor Chamberlin was presented a Life Membership in the OSMA in 1951. □

MARK YOUR CALENDAR

NOW!

OKLAHOMA MEDICAL SUMMIT 75

April 23rd-26th, 1975 Lincoln Plaza Forum, Oklahoma City

27

Oklahoma State Medical Association

news

New “Doctor’s Office”

In The State Capitol

Each year the OSMA, in conjunction with the Oklahoma State Nurses Association, sponsors a Legislative Doctor and Nurse of the Day Pro- gram during the annual legislative sessions. While 1975 will be no exception, there is some- thing new. . .a new office for the doctor and nurse located on the third floor of the capitol.

When the program first started, approxi- mately 12 years ago, the "doctor of the day” did not have an office. He would simply come into the capitol building and tell the receptionist for the House of Representatives and the State Se- nate who he was and where he could be found during the day.

As an outgrowth of their appreciation, State Legislators began to insist that the doctor be given an office somewhere in the building. The first such office was a plywood, one room, "shack” constructed in one of the large open

BOOK

Functional Anatomy of the Newborn. By Edmond S. Crelin, PhD, 87 pp, Yale Uni- versity Press, New Haven, Connecticut, 1972. $8.00

The author enunciating the principle that "the newborn infant is not a miniature adult” was unable to find such description in the liter- ature and thus prepared his book for those who evaluate the neonate. This is a concise descrip- tion of the anatomical features of the newborn infant. It is divided into some 60 subject head- ings such as larynx, bronchi and alveoli, heart and eye, to name a few. There are no references. Three figures accompany the text. Physiologi- cal and some histologic aspects are loosely in- cluded in the anatomic descriptions, but are too superficial to be helpful in most cases. Organ weights with some ranges are given for most major organs. The author, a professor of anatomy, is an experienced writer with a con- cise, clear style. The book will be helpful in the education of students meeting the newborn for the first time, and for nurses. Harris D. Riley, Jr., MD

28

spaces on the fourth floor of the capitol building. Later the office was moved to a real office on the fourth floor of the capitol building; it has built in shelves and storage areas for the doctors paraphernalia. The main drawback with both of the early offices was that there were no water facilities in them.

The new office is being constructed in the southwest comer of the third floor of the capitol building in what had been a janitorial room. The room is being completely redone and parti- tioned into an examining area and waiting room. Special lighting and storage facilities are being installed for the doctor and nurse of the day. However, the most important single new item is the availability of water.

Physicians from throughout the state are asked to serve one day during each legislative session as the "doctor of the day.” The nurses association also has volunteers from through- out the state.

The doctors office is well stocked with phar- maceutical and first aid supplies donated by various manufacturers and companies. □

REVIEWS

Mental Retardation, by Louis B. Holmes, MD, 430 pp, MacMillin Company, New York, New York, 1972. $28.00

In recent years there has been dramatic ex- pansion of knowledge and elucidation of the pathogenetic mechanisms underlying a number of syndromes and disorders charac- terized by abnormal mental development. This particular book is the most complete and infor- mative of the recent publications in this field. More than 170 syndromes are described. In each instance, the discussion is brief and timely and includes a review of physical abnormalities, nervous system aspects, pathological findings, treatment and prognosis, differential diagnosis and genetic aspects. The various syndromes are well illustrated with a variety of different photographs.

Although expensive, the book should serve as a standard reference for physicians and others concerned with the problem of mental retarda- tion. Harris D. Riley, Jr., MD □

Journal / January 1975 / Volume 68

Miscellaneous Advertisements

EXCELLENT OPPORTUNITY for general practice in nice community near Lake Eufaula. Privileges in modern 44-bed hospital. Space available for three GP’s in clinic adjoining hos- pital that already has an abundant patient load. Can expect full-time practice in a short time, along with time off coverage. Guaranteed start- ing salary — very rapid chance of advancement — with capabilities of earning up to $50,000.00 yearly. Located in an ideal community from which the patients are drawn from an area of approximately 20,000 population. Ideally lo- cated on Highway 1-40 and IS-75 — an hour’s drive to Tulsa theaters and restaurants and only an hour and a half from downtown Okla- homa City. Only a few minutes drive to Lake Eufaula, Fountainhead Lodge being only 25 miles away. There is a new high school and a new grade school. A small town having all the advantages of a city. A wonderful place for rais- ing children. This is a marvelous opportunity for a family type practice with time off. Call Carlton E. Smith, MD, 918 652-3337, Hen- ryetta, Oklahoma, collect.

DUE TO THE RECENT RETIREMENT of one of our local general practitioners, and mov- ing of another physician, we have two office spaces for rent. Each consists of waiting room, two examining rooms and private office. For more information contact E. D. Greenberger, MD, Medical Arts Building, McAlester, Ok- lahoma. Phone 423-1432.

ONE, TWO OR THREE PHYSICIANS NEEDED. Would like to retire. Clinical facilities with lab and x-ray. Especially good for general practitioner, orthopedist, ophthal- mologist, pediatrician or could be easily con- verted to accommodate any field of medicine. Overflow parking space available. General surgery instruments, some orthopedic, few nose and throat and several miscellaneous in- struments and equipment. One-hundred bed hospital; new hospital to open in November, 1975 with 145 beds. Make $30,000 easily; could make $100,000. Good clientele. Oklahoma State University with over 19,000 enrollment as asset. Located between Tulsa and Oklahoma City with connecting four-lane highway under construction. Good hunting and fishing. Physi- cians interested in coming to a clean, educa- tional city with a population of 32,800, contact A. B. Smith, MD, 408 S. Main, Stillwater, Ok- lahoma 74074. Phone 405 372-5656 (office) or 405 372-6460 (home.)

NEWLY CONSTRUCTED, multi-specialty clinic in Lubbock, Texas has openings in areas of OB-GYN, Internal Medicine and Family Practice. New 120-bed hospital adjacent to clinic. Top salary leading to partnership. In- terested applicants send curriculum vitae to University Medical-Surgical Clinic, 6602 Quaker Avenue, Lubbock, Texas 79414. □

Second Annual

Hair Transplant Symposium and Workshop

February 14th-15th, 1975 Hot Springs, Arkansas

Co-sponsored by the American Academy of Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery, Inc.

Further information may be obtained from William G. Irwin, MD, The Stough Dermatology and Cutaneous Surgery Clinic, PA, Doctor’s Park, Hot Springs, Arkansas 71901.

Journal / January 1975 / Volume 68

29

64th

ANNUAL MEETING

INTERNATIONAL ACADEMY OF PATHOLOGY

March 4th— 8th, 1975 New Orleans, Louisiana Marriott Hotel

The annual Maude Abbott lecture entitled “Pathology and Preventive Medicine” will be delivered on Wednesday, March 5th, by Doctor John Higginson, Director, Interna- tional Agency for Research on Cancer, Lyon, France.

In addition there will be 80 scientific papers, six pathology specialty con- ferences and 48 short courses.

Additional information is available from Mrs. J. Preston, IAP Registrar, Armed Forces Institute of Pathology, Room 4090, Washington, D.C. 20306. Telephone 202 576-2969.

30

PRESCRIBING INFORMATION Antiminth (pyrantel pamoate) Oral Suspension

Actions. Antiminth (pyrantel pamo- ate) has demonstrated anthelmintic activity against Enterobius vermicu- laris (pinworm) and Ascaris lumbri- coides (roundworm). The anthelmin- tic action is probably due to the neuromuscular blocking property of the drug.

Antiminth is partially absorbed after an oral dose. Plasma levels of unchanged drug are low. Peak levels (0.05-0. 13/tg/ ml.) are reached in 1-3 hours. Quantities greater than 50% of administered drug are excreted in feces as the unchanged form, whereas only 7% or less of the dose is found in urine as the unchanged form of the drug and its metabolites. Indications. For the treatment of ascariasis (roundworm infection) and enterobiasis (pinworm infection). Warnings. Usage in Pregnancy: Re- production studies have been per- formed in animals and there was no evidence of propensity for harm to the fetus. The relevance to the hu- man is not known.

There is no experience in preg- nant women who have received this drug.

Precautions. Minor transient eleva* tions of SGOT have occurred in a small percentage of patients. There- fore, this drug should be used with caution in patients with pre-existing liver dysfunction.

Adverse Reactions. The most fre- quently encountered adverse reac- tions are related to the gastrointes- tinal system.

Gastrointestinal and hepatic reac- tions: anorexia, nausea, vomiting, gastralgia, abdominal cramps, diar- rhea and tenesmus, transient eleva- tion of SGOT

CNS reactions: headache, dizzi- ness, drowsiness, and insomnia. Skin reactions: rashes.

Dosage and Administration. Chil- dren and Adults: Antiminth Oral Suspension (50 mg. of pyrantel base/ ml.) should be administered in a single close of 1 1 mg. of pyrantel base per kg. of body weight (or 5 mg./ lb.); maximum total dose 1 gram. This corresponds to a simplified dosage regimen of 1 cc. of Antiminth per 10 lb. of body weight. (One teaspoonful = 5 cc.)

Antiminth (pyrantel pamoate) Oral Suspension may be adminis- tered without regard to ingestion of food or time of day, and purging is not necessary prior to, during, or after therapy. It may be taken with milk or fruit juices.

How Supplied. Antiminth is avail- able as a pleasant tasting caramel- flavored suspension which contains the equivalent of 50 mg. pyrantel base per ml., supplied in 60 cc. bot- tles and Unitcups™ of 5 cc. in pack- ages of 12.

ROGRIG

A division of Pfizer Pharmaceuticals

New York, New York 10017

auxiliary

1974 has been a very busy year for many auxiliary members, who took an active part in their areas in helping the candidates they felt best represented the views of physicians. How- ever, now that the election is over, much more work remains to be done on the legislation which is being written, studied and acted upon by the men we have sent to Washington and to Oklahoma City.

Our job now is to keep in contact with these men, be informed on what is taking place on the state and national level and take necessary ac- tion on a moment’s notice when needed to help influence their vote on certain bills, not because of selfish interest but in the interest of the fu- ture delivery of quality medicine and its effect on the lives of doctors, as well as the people of America.

To be ready to do this job we would like to have the "Legsline” at a better stage of de- velopment in Oklahoma. The LEGSLINE Alert System has been developed to ensure quick and effective communication between all Legs par- ticipants.

The system can operate on a letter writing basis for transmitting up-to-date information implementing any member of public affairs pro- jects or reporting results of completed projects. In the event of an emergency the alert can be done by phone. For optimum organization, there should be at least one LEGSLINE Alert Chairman for every ten auxiliary members in the state. There is no limit to the number of subchairmen but there should be as many as are needed. It cannot be emphasized enough how effective and important this organization can be

Oklahoma State Medical Association

but it will take your cooperation to get it started.

A must is knowing what all of the initials stand for — for example: PSRO — Profession- al Standards Review Organization. HMO — Health Maintenance Organization. NHI — Na- tional Health Insurance.

Mark your calendar: March 5th, 1975 rrA Day at the Legislature Special plans were made last fall for you to spend a day becoming ac- quainted with your State Legislature. In some areas it would be best to charter a bus, which would really be a lot of fun. Smaller areas could get together in car-loads and come. Just make sure you plan to attend — you won’t be sorry — it will truly be a day well spent.

Each year more and more laws are being written at both the national and state levels that concern health, health-care and the deliv- ery of health-care. If we don’t take an interest now, laws will be passed that may not have the doctors’ and patients’ best interest in mind.

When someone asks you to serve as a chair- man in your area to help us get our "LEGS” organized, say yes. The success of our effort rests completely in your hands. Don’t let us down.

Just one last word. If you have not yet joined AMPAC-OMPAC, do so today. This is your American Medical Political Action Committee and the Oklahoma Medical Political Action Committee. Through these organizations, friends of medicine are assisted when they run for office. We need your financial support and personal interest in these organizations. Re- spectfully Submitted, Shirley Forsythe, Legisla- tion Chairman D

xxxvii

Malpractice law suits are growing. According to a recent publication from the St. Paul Fire and Marine Insurance Company, "one of every ten US physicians insured (by that company) currently has a malpractice claim pending against him. The number of claims pending has more than doubled since 1969.” In that year only one out of every 23 of the company’s insureds had claims pending with an average reserve of only $6,705. As of September 30th, 1974, the average claim reserve was $12,534. The publication stated editorially, "the result is that the nation is dangerously close to having no malpractice insurance avail- able at any price. Private insurance carriers cannot indefinitely sustain current losses from malpractice underwriting. Physicians cannot sustain premiums of $10,000 to $12,000 per year and more without passing the cost along to the already hard pressed consumer.”

All regular AMA publications, except

JAMA, American Medical News, and Today’s Health, will now be on a subscription basis for members as well as non-members. The action was taken by the AMA’s Board of Trustees at its meeting in Portland, Oregon. The AMA pub- lishes ten specialty journals. In the past, each regular AMA member was entitled to one spe- cialty journal plus the above named publica- tions, free of charge.

Hawaii in the fall is being planned for some lucky Oklahoma physicians. The OSMA is sponsoring a nine-day tour to the AMA’s Con- vention in Honolulu November 28th-December 7th. The trip includes a two-day tour to Maui and six days in Honolulu for the AMA Meeting. Additional details will be announced as plans are completed.

An Oklahoma representative, James R. Jones, has been named to the newly expanded House Ways and Means Committee of the Unit- ed States House of Representatives. When Wil- bur Mills, the Arkansas Democrat, resigned his 17-year leadership of the committee, the Demo- cratic Caucus expanded the committee mem-

xxxviii

bership from 25 to 37. A1 Ullman, an Oregon Democrat, has been nominated to succeed Mills as Chairman. Jones is one of 12 new members named to join the 13 Democratic holdovers.

A priority mission of the newly expanded House Ways and Means Committee will apparently be to produce a National Health Insurance Plan. A1 Ullman stated that he was opposed to a So- cial Security financed National Health Insur- ance Plan and went on to say, "I don’t believe in payroll taxes, but we’d have to find some other financial mechanism. I think it would be a dis- aster to dip into general revenues.”

One victim of the AMA’s $60 assessment

was the unified membership voted last May by the Medical Society of New Jersey. During its Annual Meeting the New Jersey House of Dele- gates had voted in favor of compulsory AMA, state and county membership. At a special ses- sion of the house on December 8th, immediately after the AMA’s Portland meeting, the New Jersey delegates reversed their decision and voted down unified membership.

Volunteers to serve as Legislative 'doctor of the day” are being sought by the OSMA. Physicians interested in serving one day as the doctor for members of the Oklahoma House of Representatives and State Senate should con- tact the OSMA office in Oklahoma City. The Legislature meets Monday through Thursday of each week and will probably be in session until late May.

A bill to overhaul Oklahoma’s program of Aid to Families with Dependent Children

(AFDC) is being considered by the State Legis- lature. Authored by Terry Campbell, a Repre- sentative from Bethany, Oklahoma, the bill would require an AFDC applicant to produce an affidavit from the State Employment Sec- urity Commission that there was no work available paying the federal minimum wage which the applicant could perform and which met federal health and safety standards. The measure would also set up a community service program and would require any able bodied AFDC recipient to work 80 hours a month in public or social srvices unless he is in a man- power training program. Campbell said that the average Oklahoma recipient stays on the welfare rolls for more than 18 months. A similar law enacted in the state of West Virginia has cut the length of stay to six months. □

Oklahoma State Medical Association

The

February

1975

Vol. 68, No. 2

of th e Oklah oma State Medical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD Editor-in-Chief

HARRIS D. RILEY, Jr.,MD Editor

ROBERT G. TOMPKINS, MD Editor

ERNEST LACHMAN, MD Corresponding Editor Regents Professor Emeritus of Anatomical and Radiological Sciences, University of Oklahoma Health Sciences Center.

OFFICERS

JACK L. RICHARDSON, MD President

ROGER J. REID, MD Vice-President

HAVEN W. MANKIN, MD Secretary-Treasurer

STAFF

DON BLAIR BusinessManager

LOUISE MARTIN EditorialAssistant

THE JOURNAL is the official publica- tion of the Oklahoma State Medical Associa- tion, and is published monthly under the di- rection of the Board of Trustees, 601 N.W. Expressway, Oklahoma City, Okla. 73118. Publication office (printer) 222 East Eufaula St., Norman, Okla. 73069. Second-class postage paid at Oklahoma City, Okla- homa 73125.

SUBSCRIPTION TO THE JOUPNAL is included in membership fees. Other subscriptions are $6.50 per year or $1.00 per copy with each request subject to approval of the Editorial Board.

CONTENTS

editorial

Pruning Time ........ 31

President’s Page ........ 32

scientific

Management of the Acutely Burned Patient, Jack

Metcoff, MD and E. Ide Smith, MD ... 33

Extrahepatic Complications of Viral Hepatitis, Everett

R. Rhoades, MD and Lynn Copeland, BS . . 40

News from the Oklahoma State Department of

Health 49

news

Medical Summit Features Entertainment and Educa- tion ......... 50

Legislative Program Set For Doctors’ Wives . . 51

Balkan Adventure Calls Members of OSMA . . 53

Department of Medicine Open House Set at Health

Sciences Center ....... 54

Peer Review Foundation Publishes Hospital Guide- lines ......... 56

Society Named for Former Dean Bird ... 56

Legislative Reports Available to Members . . 58

“Disabled Physician’’ To Be Subject of Conference . 59

Tutor Funds Needed For Medical Students . . 59

Death ... 0 ...... 60

OSMA To Sponsor Hawaii Tour in Fall ... 60

Book List Available . . ..... 60

Book Review . . ...... 61

Miscellaneous Advertisements ..... 62

Index To Advertisers ....... xxx

Woman’s Auxiliary ....... xxxi

The Last Word ........ xxxii

(Cover Art by William . Cason )

POSTMASTERS: Send all change of address notices to 601 N.W. Expressway, Oklahoma City, Okla. 73118.

Ill

a basic need for life support

INII (dyphyiline)

Before,^ rise rlbihh, pleasereview complete prod- uct inform^iom a summary of which follows:

Indications; For rehebof acute • bronc h i dl msLfmch and for reversible bronchuspasm associated with

chronic bronchitis and emphysema.

■ . , -■*

Precautions: Exercise caution' with use in the presence of severe cardiac disease, renal or -he- patic malfunction, glaucoma, hyperthyroidism, peptic ulcer, ‘-and concomitant Yise of other xan- 1 thine-containing formulations or other CNS stim- ulating drugs.

Adverse Reactions: May cause nausea, headache cardiac palpitation and CNS stimulation. Post prandial administration may help to avoid gastri- discomfort.

How Supplied:

LUFYLLIN, 200 mg.. Tablets: NDC 19-R521-92 ‘bottle of 100'; NDC 19-R521-97. bottle of 1000. LUFYLLIN Elixir: NDC 19-R515-68, pint bottle NDC 19-R515-69, gallon bottle.

LUFYLLIN Injection: NDC 19-R537-T2, box of 2 x 2 ml. ampuls,

ft ?ditorial

PRUNING TIME

Planted as a seed of social revolution in America in the early 1930’s, the clamor for some form of tax-supported, federally-con- trolled health care program has now become a wild, unflowering vine. Its growth has gone beyond the limits of manageability. It has so many branches trailing off in so many direc- tions that it has overgrown all order and reason. In an effort to stimulate its growth and bring it to flower, a broad-scale attack was launched against the entire health care estab- lishment by media people and politicians about ten years ago. Their major criticisms were — and are — that health care was too expensive, too unavailable, too haphazard and too poor. Under the wise and watchful eyes of assorted bureaucrats, lawyers, elected and appointed government officials, and of honest, impartial, medically-expert, omnipotent journalists, all these deficiencies could be corrected. More care, of a higher quality, could be rendered to more people, more efficiently for less money.

Of course, this is hogwash. Any rational per- son who has an understanding of the complex problems involved in delivering health care — and who also understands the staggering in- efficiency of the bureaucratic process — knows it’s hogwash. Yet, on the eve of decision, no one has ever been able to convince the politically responsible people in this nation that it is, patently, hogwash.

We, as individual physicians, and our profes- sional organizatons, at every level, have failed to gather and present the evidence in a way that would convince most Americans that their health is being jeopardized by government de- cree.

Each of us needs to know the actual ad- ministrative costs of Medicare, Medicaid, V.A.

Journal / February 1975 / Volume 68

medical care, armed forces medical care and all other government-controlled, tax supported health care programs. Then, these costs should be compared with the administrative costs of private-agency care. Also, we need to know how effective these government-controlled health services are in maintaining health and preventing disease, injury, absenteeism, dis- ability and death.

Such information and data are available, and we should have a corps of experts, working full time, digging it out of the bureaucracy’s hide-away bookkeeping system.

Once obtained, the evidence — in hard, hon- est facts and figures — should be given to the people of this country, on a daily or weekly or monthly basis. Since the odds are heavily against the likelihood of the media voluntarily disseminating these reports, they should be publicized through spot announcements on radio, ads in newspapers, by billboard displays and, yes, even by handbills.

Such a direct approach to keeping the public honestly informed about the current cost- effectiveness of existing government-con- trolled health care programs would cut through the obfuscation designed by the bureaucrats and maintained by the media.

Perhaps, too, such an approach would cut some branches of that tangled vine which, in its wild and crazy growth, is threatening our freedom and our national solvency.

Certainly nothing could be more appropriate as we approach our nation’s bicentennial than to resist enslavement and bondage, and, through the medium of pamphlets, handbills and public notices, regain the stature of free- dom. MRJ

31

president's page

Confidentiality! Can there be any word more important to a patient?

Or the loss of which could be more hazardous? This is exactly what faces the public when PSRO is implemented. By the government’s own dec- laration, nationwide com- puterized print-outs are to be made of all en- tries in the charts of all patients. At the same time, the government contends that the information will be held confidential and pro- tected. No thinking person can possibly be- lieve this. Such taped information, passed from hospital to hospital and from govern- ment agency to government agency, must necessarily pass through the hands and be- fore the eyes of literally thousands of em- ployees from all strata of society having all varieties and degrees of responsibility and persuasion. A break in confidentiality can occur and will occur time and again, place after place. This was proven in the Watergate incidents. It was also proven in the theft of a million dollars worth of narcotics stored in the "security vault” of the New York Police Department. So anyone who assumes that the information can be protected from revelation is simply naive. Now what can be the result? Information in the hands of unethical or mercenary persons could result in blackmail, bribery, divorce, cancellation of insurance, loss of a job, loss of credit rating, public ridicule and unlimited litigation of all types. It should be remembered also that the com- puter cannot discern fact from fiction, so that all information, true or false, will be recorded on the tapes. Nefarious ones can have a cir- cus with information intercepted — and in- tercepted it will be, most assuredly. To my mind, this is one of the greatest dangers in the PSRO Program and every effort must be made to have computerization eliminated.

Actually, it is infringement of one’s consti- tutional rights.

In addition to the above, it will soon be- come apparent that a patient cannot safely, freely or honestly give a proper medical his- tory; to do so may place him, and his family, in jeopardy. Information can be transmitted and transported without the informed consent of the individual. Incriminating information that is false can be inserted, either by mis- take or by intent. Already there are commer- cial computer centers storing patients’ pro- files that are being sold or exchanged under pretext of developing statistics. Thus instant dossiers become available on almost anybody at anytime. It is then but a short step into the hands of private investigators and per- sonnel bureaus.

Whereas in the past the patients’ records had not been officially accessible without the patient’s approval, even to other physicians, the government is now about to mount a mas- sive invasion of patient privacy and of the con- fidentiality of the doctor-patient relationship.

There has never been a time in the history of American medicine in which unity and mu- tual understanding was needed more. Full communication is needed not only among ourselves, but dialogue must be had with our patients and the public in general. They must be made thoroughly informed concerning the serious drawbacks and disadvantages to them by governmental controls and the serious los- ses that can result from any decrease in the private, personal medical care they have al- ways had available in this time. History re- veals that once privileges have been lost to government, they can rarely be recovered; bureaucracy seldom relinquishes that which it has secured.

Meanwhile, we must provide the best med- ical care possible in the appropriate medical facility with proper consideration for the cost involved. When this is done, our motives and our efficiency will be unassailable.

32

Oklahoma State Medical Association

PEDIATRIC GRAND ROUNDS

scientific

Management of the Acutely Burned Patient

JACK METCOFF, MD E. IDE SMITH, MD

Doctor Metcoff advocates the replacement of acute fluid losses in the burned child with less water and less sodium based on measurements of the exudative losses and obligatory edema. Doctor Smith answers in support of the current "formulas”

used in burn resusitation.

Doctor Metcoff: We will talk today about fluid therapy for acute burns. The patient is a 6-year- 11-month old Negro boy. He was ad- mitted on the 19th of May with acute flame burns which were said to have occurred a few hours before admission. An estimated 64% of his body surface was involved. I will not go into details of his admission or surgical manage- ment because Doctor Ide Smith will do that in a few minutes. That first period of fluid therapy for severe burns (the initial 24-48 hours) has essentially four problems associated with it: (1) estimating the fluid needs of the patient, (2) caring for the burn surface per se,

From the Department of Pediatrics and Pediatric Surgery, The Children’s Memorial Hospital. University of Oklahoma Health Sciences Center and The Oklahoma Department of Institutions, Social, and Rehabilitative Services, Oklahoma City, Oklahoma

Journal / February 1975 / Volume 68

(3) preventing infection, and (4) developing psychological support for the patient. This first period of management requires considerable teamwork.

The second period begins after the first few days and extends into the second week. It is associated with five problems. Fluid therapy is no longer a problem. The outstanding, po- tential problems are infection, anemia, contin- ued care of the burn surface, psychological support for the patient, and the beginning of rehabilitation. Then, the final period after the burn, the third period, deals with the definitive treatment of the burn surface and its ultimate repair. Of course, these periods cannot be sharply demarcated. They blend into each other. After the initial acute phase, the major emphasis should be on psychological support for the child, rehabilitation of the severely burned patient, and concern about his nutri- tional status. Doctor Ide Smith will now com- ment about the initial surgical management.

Doctor Smith: The patient received his ini- tial therapy beginning with the Evans’ for- mula. He had minimal debridement and tetanus prophylaxis. He was given meperidine hydrochloride (Demerol) intravenously for pain, and the burn was treated topically, first with manfenide and then with silver sulfa- diazine.

Doctor Metcoff: Were there any major com- plications during the initial post-burn period?

33

Management / METCOFF, et al

Doctor Smith: None. I think one point I would like to stress is that philosophically I have looked at the three areas that you men- tioned as components of one problem: fluid therapy, psychological support, and prevention of infection. I think it is terribly important to conceive of these not as isolated, but as interre- lated problems which are a part of the one major problem.

Doctor Metcoff: I certainly agree that there is no differentiation between these phenomena. They are, indeed, as Doctor Smith has said, completely interrelated. They are presented as separate problems only for emphasis.

This child had a 64% body burn. The efforts of the surgical team were effective and life- saving. Sixty-four percent burns often are fatal, particularly in childhood. The fact that this child survived and did reasonably well should be emphasized. I propose to talk about a certain philosophy dealing with the fluid therapy part of the initial burn treatment.

I am going to present a point of view different from that often expressed by members of good surgical services.

I have tried to assess this child’s fluid therapy over the first 32 hours. He was a 6- year- 11-month old boy. He weighed 19.04 kg at the time of admission. He was 116 cm long, which gave him a surface area of Q.82. I do not know whether he was weighed prior to begin-

A 1944 graduate of Northwestern University Medical School, Jack Metcoff, MD, is pres- ently Professor of Pediatrics, Professor of Bio- chemistry and Molecular Biology at the Universi- ty of Oklahoma Health Sciences Center. He is a member of the American Society of Nephrol- ogy, the Society of Pediatric Nephrology, the American Society for Clinical Investigation, the American Society for Clinical Nutrition and the American Pediatric Society.

A 1948 graduate of Johns Hopkins Univer- sity School of Medicine, E. Ide Smith, MD, has been certified by the American Board of Surgery and specializes in pediatric surgery. He is Clinical Assistant Professor of Surgery and Pediatrics at the University of Oklahoma Health Sciences Center. He is a member of the American College of Surgeons, the American Academy of Pediatrics (Surgical Section), the American Pediatric Surgical Association (Founding Member) and the American Burn Association.

ning fluid therapy, that is, without arm board and leg boards and bandages, or whether he was weighed after these were applied. It would be desirable to get an initial weight before the patient is bandaged and hooked up to in- travenous infusion equipment, and another weight immediately after these are applied. The second weight is the baseline for repeated weighings. The first weight is the actual weight of the patient.

In the first 32 hours, his total fluid intake was 7,880 ml and he received about 1,100 mEq of sodium and about 149 gm of protein. His urinary output was 2,567 ml. He gained 2.5 kg during this 32-hour period. That weight gain represents edema. The estimated average loss- es during this period have been measured and reported previously.1 Based on those data, for his burn he should have received about 5,000 ml of fluid and about 100 mEq of sodium. He received approximately ten times more sodium than I suspect was necessary. His protein re- quirement, based on his expected exudative losses, should have been about 60 gm. He re- ceived 149 gm. I would have anticipated a smaller urine volume for him had he received the amount of fluid calculated as above, but he had a very large fluid intake. Fortunately, his kidneys were able to respond with a larger uri- nary output. Despite this, he gained 2.5 kg. This edema was the result of fluids leaking through injured capillaries. The "obligatory edema” under the burn surface area occurs promptly, within a few minutes to two hours after the burn. I would estimate that it should have amounted to only about 140 gm. Unless the patient receives too much fluid, further ac- cumulation of extracellular fluid, plasma, or intracellular fluid does not occur. According to recent studies, further subcutaneous edema re- sults from diffusion of excess parenteral fluids.

Where do these figures come from and what do these calculations mean? Figure 1 shows in- take and urinary output and weight gain over the 56-hour period of observation. The ob- served pattern is compared with our calculated estimates. The difference between observed and calculated fluid intake is about 2.5 liters per calculation. The expected urine volume on the same basis would be about 1.5 liters. The only edema would have been the result of the burn, which amounted to about 140 gm.

I would like to explain the physiological reasoning and the direct study observations which form the bases for the calculations re-

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Oklahoma State Medical Association

Figure 1: Estimated and observed intake and uri- nary output: case 1

ferred to. The exudative losses from the burn surface were originally interpolated from stud- ies of blister fluid from burned animals, or in some instances, of blister fluid from human pa- tients. Later, Doctor Artz and his associates of the Brooke Army Hospital applied absorbent dressings to the burned surface of human pa- tients, collected all of the exudative material in the dressings, and analyzed it. Their data for electrolyte values and protein losses in five pa- tients were the first reasonably accurate esti- mates of burn surface losses. We used exactly the same technique in children. By measuring the surface over which the collection was made, we could relate the losses to 100 sq cm of burn surface. The average skin exudate val- ues for these children in a 24-hour period would be a loss of about 15 ml of water, about 1 mEq of sodium, about 0.1 mEq of potassium, and about 1 mEq of chloride per 100 sq cm of burn surface. For the patient being discussed today, total surface area was 8,000 sq cm. Sixty-four percent or 5,120 sq cm was burned (Note: 10,000 sq cm = 1 sq m). Since 7.3 ml of water are lost per 100 sq cm, 7.3 ml/100 sq cm x 5,120 sq cm or 374 ml would be the exuda- tive water loss expected from his entire burned surface over a 12-hour period. Burn losses go down slightly in the subsequent 24-hour periods. His exudative water loss in the first eight-hour period was calculated to be in the neighborhood of 300 ml, and this would contain about 20 mEq of sodium.

Doctor Humphrey: What type of topical therapy were the four patients you studied re- ceiving?

Doctor Metcoff: Topical therapy was not used. The urinary output bears little rela-

Journal / February 1975 / Volume 68

tionship to the infusate volume during the first 24-hours after the burn. Irrespective of very large fluid infusions in the first 12 hours, it appears that urinary volume tends to be very much smaller. Urine volume gradually in- creases over the subsequent 12-hour periods, again somewhat independently of fluid intake. There is no direct relationship between urine volume and infusate volume. By 24 hours after the burn, there is an excretion of about 15%-20% of the therapeutic infusate. By 36 hours, this averages about 40% of the infusate; by two days, about 50% of the infusate volume can be excreted as urine.

Several burned children were observed here last year and the urinary volume as a propor- tion of the intake was calculated. These chil- dren received a modified Evans’ formula treatment. The urinary output by 48 hours was about 40%-50% of the infusate volume. By three days, it averaged between 50% and 60% of the infusate volume. During the initial period, almost irrespective of the intake, only a very small portion of the infusate is removed in the urine. Why doesn’t a large infusate volume "flush the kidneys?” It should if kidney func- tion is completely intact. Then as one increases the infusate volume, the functioning kidney can readily remove the excess fluid.

This is not actually the case in children with severe burns. The urine volume gradually in- creases over the first 24 hours. For example, on one child, urine output ultimately amounted to about 1 ml a minute per square meter of sur- face area. On the other hand, during the initial ten hours, she received 2 ml per minute of infu- sate, but because the urine volume remained low, she then received 3.5 ml per minute infu- sate over the next ten hours. Urine volume gradually rose. Measurements of renal func- tions (glomerular filtration rate and renal blood flow) during these periods gave evidence that renal function was impaired in the first 24 hours after the burn and then rapidly rose to normal levels. We have made similar observa- tions in about four or five different studies. Sometimes the takeoff point for improved renal function is about 20 hours, sometimes at about 28 hours, sometimes a little before 20 hours, but the general pattern is the same. Generally, renal functions are reduced, probably as a re- sult of a striking reduction in renal blood flow, during the initial hours following the burn. There is an equivalent decrease in the glomerular filtration rate. From the point of

35

Management / METCOFF, et al

view of the nephrologist, the lack of urine vol- ume is the result of a reasonably competent capacity for reabsorption of a small filtrate. Water reabsorption by the renal tubule con- tinues even though the urine volume is quite low. The glomerular filtration rate is also low. The low urine volume in the first 12 to 24 hours after the burn depends upon the reduc- tion of glomerular filtration which may be at- tributed to the decrease in renal blood flow. To attempt to increase urine volume at a time when renal blood flow and glomerular filtra- tion is reduced is fraught with danger, because it is quite likely that the kidney will not be able to respond to that extra load. As a result, the excess water will accumulate. That is edema. The massive edema of burned patients appears to be the result of the discrepancy be- tween the ability to remove the water in the urine, due to reduced renal function, and the large volumes of fluids which are infused.

As an example, observations were made on three children treated by three different types of fluid administration. One received an Evans’ formula which contained a large amount of water and salt. The cumulative water balance over a 48-hour period was about 1,400 gm, which represented a 25% increase in body weight. There was a huge positive balance of sodium, about 210 millimoles which was about equivalent of the retention of water. In con- trast, another patient received an amount of fluid based upon the estimated losses which had been measured in previous patients. The infusate volume and composition were calcu- lated to apply to the expected requirements. The net positive water balance was small, be- tween 4 to 5 ml, and remained reasonably sta- ble at 48 hours. The sodium balance remained at the baseline throughout and there was no edema in this child.

Calculations for fluid requirements (Table 1) were based on previous studies. I do not use surface area as a reference in these calcula- tions because I think all fluid therapy should be expressed in square meters, because when one is dealing with a burn, one is dealing with the problem of a surface loss. That surface is best expressed in square centimeters. Hence, in order to keep all the units the same, I adjust fluid therapy to square meters.

The urine volume in the first 12-hour period is generally low, amounting to about 110 ml

36

Table 1

Calculation of Fluid Requirements*

Exudative losses Obligatory edema Insensible water loss Urine

* first 12 hours.

7.3 ml/100 sq cm bum surface area 2.8 ml/100 sq cm burn surface area

450 ml per sq m body surface area 110 ml per sq m body surface area

per sq m provided there is not a very large excess of fluid given. If there is, urine volume may be double or triple this amount, but it can only increase to the extent that the kidney is capable of functioning. During the immediate post-burn period, the kidney cannot easily cope with excess fluid, so even though the urine volume may be increased by volume overload, it is almost never sufficient to prevent the ac- cumulation of water. The urine volume gradu- ally increases, and one would anticipate that the fluid requirements over the first 48 hours would increase. The reason for this is that al- though insensible water loss remains the same and exudative losses continue at about the same rate, the increased urine volume requires replacement. Hence, fluid therapy should in- crease during the first 48 hours. In contrast, usually a very large intake is provided in the first 12 hours and then is gradually reduced. It is that large initial intake which I believe ac- counts for the edema.

Exudative losses generally tend to be small. If the patient has surface application of an agent which prevents exudation, for example silver nitrate or sulfamylon, exudative loss- es will be lower. With silver nitrate, the ex- udative losses are about 50% less than without any surface covering. The losses with sulfa- mylon are probably greater than those with silver nitrate, but less than those without anv surface covering. Exudative losses are calcu- lated on the basis of 7.3 ml/100 sq cm of burn surface per 12-hour period. For a child with 60% burn, who has 1 sq m of total body sur- face, there would be 6,000 sq cm of burn sur- face: 6,000 sq cm x 7.3 ml/100 sq cm = 1,170 ml of exudative loss. It is quite a simple calcu- lation.

Edema is a little more complicated to cal- culate. On the basis of studies previously re- ported, obligatory edema will amount to about 3 ml/100 sq cm of burned area. Skin and sub- cutaneous tissues are about 75% water. In cases where the edema is so obvious you cannot only see it, but you can pit very deeply by

Oklahoma State Medical Association

pressure from your finger, the water content of the skin and subcutaneous tissue has increased by about 10%. That means that instead of 75% water, it is 85% water. With that as a figure for marked edema, I calculated the maximal amount of water edema that would accumulate in the burned area. That number turned out to be about 3 ml/100 sq cm of burned surface. The obligatory edema which occurs initially does not recur. The obligatory edema need be taken into consideration only once, and there- fore, is calculated for the first 12 hours only and not for subsequent fluid requirements. So in a child with a 60% burn, 110 ml is lost urine volume, insensible loss would require about 450 ml/per sq m of surface area, and exudative losses would be about 130 ml. The accumula- tion of edema fluid would be equivalent to 168 ml. All of these losses would total about 1,100 ml. This would satisfy the fluid requirements for 12 hours for a child with a body surface area of 1 sq m who has a 60% burn. The same kind of calculation is applied to the subsequent period to bring into consideration the increas- ing urine volume.

I have applied this type of calculation to the child under discussion this morning and esti- mated his losses for the first 12 hours and then adjusted those to the actual periods of ob- servation, which were eight hours, to coincide with nursing shifts. For exudative losses, at the rate of 7.3 ml/100 sq cm of burn surface with 5,120 sq cm of burn surface, 374 ml are required to cover losses for a 12-hour period. Obligatory edema would require 2.8 ml per 100 sq cm x 5,120 sq cm = 143 ml. Insensible water loss was estimated to be 365 ml, or 450 ml per sq m times a surface area of 0.8 sq m. My estimate of what his urine volume would have been had he received this amount of fluid therapy is that he would have had 88 ml of urine and 970 ml total losses for the 12 hours or 728 ml for eight hours. The calculated fluid would include a gain of 143 gm of obligatory edema fluid. Actually, he received 1,240 ml in- stead of 728 ml during that eight-hour period, his urinary output was 479 ml instead of 88 ml, and he gained about 0.8 kg of body weight.

The calculation of the electrolytes and pro- teins required was also based on the previously measured losses. Knowing what the surface loss will be and measuring the concentration and content of electrolytes and proteins in it and in the urine, it is possible to calculate the electrolyte and protein losses per square meter

Journal / February 1975 / Volume 68

of body size in a child for a given burn area. In the first 12 hours, such a child would lose about 53 Eq of sodium from the exudate and from the urine. In the next 12-hour period, losses would be similar. The potassium losses tend to be rather small. The protein losses are appreci- able, but not as large as are commonly thought. For this child, the protein losses amount to about 30 gm in the first 12 hours and then subsequently stay at about the same level. I estimated this child would have about a 60-61 gm protein loss in his first 52 hours of treatment. He received about three liters of plasma. If it contained 6% protein, he would have received about 180 gm of protein, an amount which was roughly two to three times his expected losses.

I have attempted to make some comparisons between different recommended fluid therapies. The calculated amounts of fluid based upon our actual observations in children for the initial 48 hours represent at least a 20% reduction from the amounts recommended by Evans.

The main problem with fluid therapy in the initial post-bum period derives from the con- ception that it is necessary to sustain a given arbitrary urine volume, eg, 1 ml/min. Fluid then is infused until the urine volume gradu- ally increases to the arbitrary, pre-determined level. This reasoning is based upon an incor- rect premise. There is nothing magic about maintaining a given urine volume during early fluid therapy after a severe burn. Urine volume reflects the kidney’s capability to re- move water. The provision of large quantities of fluid which exceed the capacity of the kidney to remove the excess is fraught with danger. Not only will edema occur, but there is a very real possibility of producing edema in organs such as the lungs and brain. During the second 24 hours after the burn, the children do tend to become hypotonic and edematous. If hypo- tonicity and edema are marked, the children may have seizures related to excessive water retention, dilution of the extracellular fluid, and possible edema of the central nervous sys- tem. I think this unfortunate sequence of events could be completely prevented by the appropriate administration of fluid.

To summarize, it seems to me that there is no rule of thumb that should be used in the treatment of severely burned children, or for that matter, in any form of parenteral fluid therapy. It is possible to use very simple

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Management / METCOFF, et al

arithmetic and calculate the needs of a particu- lar child. The calculation of fluid replacement and maintenance is based upon observed losses in similar situations. It takes only a matter of minutes to calculate requirements. To do so, you need to have the weight and the length of the child. The weight should be obtained before and after his arm boards, tape, and intraven- ous tubing are applied. These first weights are the essential baseline for reference. His length should be measured initially. Surface area then can be calculated. The estimate of burn surface area is done by using the burn nomo- grams which provide a reasonably good ap- proximation. Once the percentage of burned surface is estimated, the actual number of square centimeters of burned surface can be calculated. One square meter is equivalent to 10,000 sq cm. So a 60% burn surface in a child with a body surface area of 1 sq m, for ex- ample, is equivalent to 6,000 sq cm of burn area. If the exudative losses in 12 hours amount to about 7 ml N/100 sq cm of burn and the burn surface is 6,000 sq cm, then 7 ml/100 sq cm x 6,000 sq cm = 420 ml of potential exudative water loss from the burned surface, provided silver nitrate, sulfamyalon, or some other agent which may diminish exudative loss has not been used. Urine volume indicates the effectiveness of renal function. Renal function, in turn, is going to depend upon the adequacy of the renal blood flow. Even though one in- fused volume expanding agents such as plasma and albumin, it does not seem to appreciably change renal blood flow during the first 12 hours following an acute burn. Renal blood flow is sustained, but at a low level, and the plasma seems to be diverted to circulations other than the renal circulation. Urine volume will increase gradually as renal function in- creases. The quantity of urine excreted in the first 12 hours for a child with 1 sq m of surface area is usually in the neighborhood of 100 ml. In the second 12 hours, it is about double that. In the first 24 hours, therefore, one should an- ticipate about 300 ml of urine will be excreted per square meter of body surface. Insensible water loss is the result of respiratory and evap- orative skin losses. The evaporative skin loss from the non-burned surface continues as well as exudation from the burned area. If the body temperature goes up, the evaporative losses will increase. Generally, about 130 to 450 ml

per sq m of unburned body surface are lost in the 12-hour period.

Taken together, calculated allowances for exudative loss, insensible water loss, and urine volume permit accurate provision of sufficient parenteral fluid to satisfy fluid requirements, yet avoid fluid overload and excessive edema.

Doctor Smith: There are a couple of things that I feel have to be put into perspective. One is mortality and certainly everyone who deals with burns stands on the mortality which he had reported in cases for the world to see. There can be little argument that the mortal- ity from shock has been greatly diminished by a standardized approach to fluids. I would be very concerned if one were to try to get away from these formulas without having a better or an equivalent alternative. There is a difference between the problems which face an inves- tigator in a clinical research center with one burn and the problems which relate to the treatment of ten burns resulting from a school bus accident as they come in the emergency room. Much of the approach that is pertinent and lifesaving in one does not apply with the other.

The other point which I think is fairly criti- cal, and I think perhaps Doctor Metcoff may have passed over somewhat, is whether or not (and we do not know this quite frankly) the kidney is intrinsically troubled and altered by the burn or whether the kidney is normal. Is the fall in glomerular filtration rate a result of low plasma flow or low cardiac output, and is this the responsible party for the kidney dys- function? The old concept that at the time of an operation there is an obligatory kidney de- pression is probably under serious question. If one preloads an individual prior to an opera- tion to a point where there is no diminution in extracellular volume during the operation, the individual can come out of that operation with a kidney that functions if not normally, at least very close to normal. Recent experimental work on burn injury suggests that the critical 30 minutes to 60 minutes after the burn may be the most critical period for fluid shifts. If fluid needs of the individual are rapidly met, will the kidneys function normally? This is the critical question. There is no doubt that if one loads the burn victim with an unphysiological amount of fluid the cardiac output can be raised to normal far more rapidly than it can be otherwise. The question is, "Is the price which one pays to do this too high a price and

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Oklahoma State Medical Association

Table 2

Topical Therapy of Burns in Children : Neurological Complications2

Age	Agent*	Burn Surface Area (%)	Manifestation	Post-burn Day	Cause
8 mo	M	20	Seizure	2	Hypernatremia
4 yr	M	15	Coma	2	Electrolytic; hypokalemia
6 yr	F	40	Seizure-coma	83	Sepsis, urinary tract disease
6 yr	F	54	Coma	38	Unknown
1 yr	M	14	Seizure	2	Hypernatremia
2 yr	M	10	Seizure	Burn day	Previous seizures
3 yr	M	20	Seizure	5	Mental retardation with seizures
3 yr	F	25	Seizure	42	Unknown (?sepsis)
2 yr	F	24	Seizure	7	Unknown (hypertension)
5 yr	M	30	Coma	3	Hypernatremia, mental retardation

* M, marfenide; F, furazolium.

too harmful a price in terms of the overall economy of the individual?”

The critical organ area really is not the glomerulus, but the cells which have been in- jured in the burned area. What you really are concerned with is the maintenance of the peripheral circulation and nutrition of this area as well as all areas of the body during the critical phase. There is sludging of the capil- lary flow in the burned area. There is also an undeniable capillary lesion which leads to the leakage of protein for the first 12 to 24 hours. The damaged capillaries are going to leak water and electrolytes, but the question that still has to be asked is what constitutes the optimal situation for these cells in what is es- sentially an unphysiological injury? There is as great an interest in therapy with enormous quantities of sodium without water as there is in considerably less sodium and more water. The goal which we seek is the maintenance of optimal peripheral circulation in the burn area, and it may well take a very unphysiologi- cal solution in both senses of the word to achieve this. At the periphery of a burn are a number of cells which are on the borderline of death or of survival. I think it is the nutri- tion in this area which we are critically con- cerned with in terms of our maintenance of the circulation in the area of the burn.

Are there any questions or comments?

Doctor Krober : One suggestion was that sometimes the neurologic dysfunctions you see in the burn patient might be related to fluid overload. I am not sure of your reaction to that

hypothesis, or do you think that some other aspect is more important?

Doctor Smith: In our own experience, there has been more neurological dysfunction from hyperosmolarity caused by inadequate fluid than there has been from - hypoosmolarity. This was true in the 229 cases which we re- ported from Kansas City’s Children’s Mercy Hospital.

Doctor Humphrey: Ide, what about the renal clearance rates during fluid delivery?

Doctor Smith: They are rapidly decreased within a period I believe of two or three hours, Ben. These neurological complications are shown in Table 2. You will notice that of those occurring along with hypernatremia (sodium level of over 145/mg%), there was probably inadequate fluid therapy, or at least it is our assumption that this was true. There was a hypokalemia on the 15th post-burn day. These babies were generally not treated with lactated ringers; they were more often treated with maintenance fluids which, in the face of vom- iting, were inadequate. Our problems were due to iatrogenic inactivity more than to iatrogenic overactivity. □

References

1. Metcoff, J., Buchnan, H., Jacobson, M., Richter, H., Bloomenthal, E. D., and Zacharias, M., Losses and physiologic requirements for water and electrolytes after extensive burns in children. New Eng. Jour. Med. 265: 101-111, 1961.

2. Smith, E. I., and DeWeese, M.S., The topical therapy of burns in children. Arch. Surg. 98: 462-468, 1969.

P.O. Box 26901, Oklahoma City, Oklahoma 73190

Journal / February 1975 / Volume 68

39

Extrahepatic Complications of Viral Hepatitis

EVERETT R. RHOADES, MD LYNN COPELAND, BS

Extraheptic complications of hepatitis are not rare. Evidence is accumulating that immune complexes involving hepatitis antigen (HBAg) play a role in periarteritis , anemia, and ploy arthritis.

INTRODUCTION

Viral hepatitis is a common systemic dis- ease predominantly affecting the liver. There are two epidemiologically distinct but clini- cally similar forms: Infectious hepatitis (hepa- titis A) and serum hepatitis (hepatitis B), both of which are characterized by inflammation and necrosis of hepatic cells. It is now clear that these two forms are immunologically dis- tinct and are caused by different viruses, re- spectively A and B. Blumberg and co-workers first reported discovery of a circulating antigen in hepatitis which was designated "Australia antigen,” then "hepatitis-associated-antigen” (HAA). More current usage suggests that the symbol "HBAg” will replace the earlier terms. HBAg appears to represent at least a portion of

40

the infective virus particle and has become a common marker of hepatitis B in that it can be demonstrated in 50 to 98 per cent of patients infected with hepatitis B. Recent investigation suggests that HBAg may contain two or more immunologically separate types. The implica- tion of this observation is not yet clear but raises the possibility that several viruses may cause hepatitis. Several particles in plasma are intimately associated with HBAg. Dane in 1970 described a particle of approximately 43 nm which carried HBAg. This has been desig- nated the Dane particle.1

Hepatitis produces a spectrum of manifesta- tions ranging from symptomatic infection to fulminant disease leading to death in a few days. The course of infectious hepatitis has been well described many times and need not be reviewed here. After the onset of jaundice, the clinical course of hepatitis A and hepatitis B are quite similar except that the latter tends to be more severe and hepatic complications such as chronic aggressive hepatitis are more common. In general, viral hepatitis has a good prognosis with a mortality rate of 0.04 to 0.08 per cent among formerly healthy individuals. However, if the disease progresses to chronic aggressive hepatitis or acute fulminant hepati- tis, hepatic failure may result in death. The outcome for patients in hepatic failure is greatly influenced by associated complications which include: hemorrhagic diathesis, second-

Oklahoma State Medical Association

ary infection (such as pneumonia or sep- ticemia), hypoglycemia, hypokalemia, acid- base disturbances, cardiovascular distur- bances, fluid accumulation, renal failure and respiratory failure. These complications occur because of impaired function of hepatocytes and other liver cells which have been damaged by the inflammatory process.

Another group of complications is sometimes seen in hepatitis which is not so directly re- lated to impaired function of liver cells. It is the purpose of this paper to discuss some of the common extra-hepatic complications of hepati- tis reported in recent publications.

EXTRA-HEPATIC MANIFESTATIONS OF VIRAL HEPATITIS

Polyarteritis Nodosa

The association of liver derangements and polyarteritis nodosa was described in 1954 by Mowrey and Lundberg.2 They reviewed 200 literature cases of polyarteritis and 230 au- topsy protocols from the Armed Forces Insti- tute of Pathology. They were interested in hepatic complications of polyarteritis and many of the cases they reported were not as- sociated with infectious hepatitis. On the con- trary most of the changes were hepatic compli- cations caused by arteritis such as rupture of an artery or occlusion with hepatic infarction. The first association between polyarteritis no- dosa and HBAg was described in 1970 by Gocke and coworkers.3 In a study of 11 patients with biopsy-proven polyarteritis nodosa, four had concomitant HBAg in serum. Each case presented with fever of obscure origin accom- panied by polyarthalgia, myalgia, rash and ur- ticaria. Evidence of mild hepatic damage was present but hepatic dysfunction was not the primary problem. Further studies showed: (1) The antigen was not found in 49 patients with systemic lupus erythematosis, rheumatoid arthritis, or other "connective tissue dis- orders.” (2) HBAg was not found in 153 pa- tients tested randomly; and finally in a pros- pective study of post-transfusion hepatitis, HBAg was present in only one percent. Thus, al- though not all cases of polyarteritis nodosa were associated with HBAg, its presence in four of eleven patients was much higher than could be accounted for by chance. Three of the four pa- tients also had circulating immune complexes consisting of HBAg plus immunoglobulin and one patient was found to have deposition of

Journal / February 1975 / Volume 68

HBAg, IGM and complement in blood vessel walls. These observations raise the possibility that some cases of polyarteritis arise as an immunologic complication of hepatitis B.

Further studies have linked necrotizing an- giitis with HBAg. Koff et al4 suggested that necrotizing angiitis associated with methamphetamine abuse may in reality be due to hepatitis B. These authors suggest that testing for HBAg may be warranted in patients with necrotizing angiitis regardless of whether or not a history of methamphetamine abuse can be obtained.

Cardiac Manifestations

Adler and Lyon5 in 1947 found a 7% incidence of abnormal cardiac signs and symp- toms in a group of patients with icteric viral hepatitis. Angina, palpitations, tachycardia, arrhythmias and dyspnea were observed along with electrocardiographic abnormalities which included P-wave, T-wave, and S-T segment changes.

A retrospective study of thirty consecutive autopsies of patients who died with acute viral hepatitis showed clinical evidence of cardiac disease manifested by prolonged hypotension, progressive cardiomegaly, pulmonary edema and sudden death.6 EKG abnormalities in- cluded left axis deviation, T-wave abnormali- ties, and arrhythmias. Pathologic findings re- vealed widespread petechial hemorrhage, in- filtration with lymphocytes, fatty degenera- tion, flabby dilated ventricles and edema of the

Everett R. Rhoades, MD, received his medical degree from the University of Oklahoma College of Medicine in 1956, where he is presently Chief, Infectious Disease Section. He is a Diplomate of the American Board of Internal Medicine. Among his medical affiliations are the Ameri- can Federation for Clinical Research, the American Society for Microbiology, the Ameri- can Thoracic Society and the Infectious Disease Society of America. He was President of the Asso- ciation of American Indian Physicians in 1972.

Lynn R. Copeland attended Phillips Univer- sity where lie received his BS degree in biology in 1971. He is a fourth-year medical student at the University of Oklahoma College of Medicine.

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Hepatitis / RHOADES, et al

subendocardial connective tissue. Petechial hemorrhage was the most common abnormal- ity and frequently involved the epicardial and subendocardial surfaces of the heart as well as the interventricular septum. Lymphocytic in- filtration of the myocardium in fatal cases has been attributed to a direct viral effect.7 Lucke8 found that fatality was most commonly linked to hemorrhage into the interventricular septum.

Cardiac manifestations have been further

delineated in a case report by Kontaxis et al 9 of a nine-year-old girl with complete heart block following infectious hepatitis. The pa- tient presented with syncopal attacks. She had been in good health until one month previously when she had become jaundiced because of infectious hepatitis.

Elevated serum bilirubin is thought by some to be important in explaining these cardiac ab- normalities. Wakin and coworkers have shown that injected bile salts cause tachycardia, asys- tole, severe hypotension, heart failure and death in animals.10 At present cardiac abnor- malities are not obviously more common in one or the other type of hepatitis.

Anemia

Conrad and coworkers found contrary to prior opinion that anemia occurred frequently in hepatitis patients although it nearly always corrected spontaneously during con- valescence.11 This anemia was associated with increased hemolysis. It has been suggested that the hemolysis might be associated with antigen-antibody reactions on red cell surfaces.

The association of viral hepatitis and aplas- tic anemia was first described by Lorenz and

TABLE 1

ENTITY DATE

Polyarteritis nodosa with association of viral hepatitis 1954

Polyarteritis nodosa in association with HAA 1970 Necrotizing angiitis with Hepatitis B 1973

Cardiac involvement in viral hepatitis 1947

Complete heart block in infectious hepatitis 1971

Urticaria in viral hepatitis 1972 Arthritis in viral hepatitis 1843 Thrombophlebitis 1971

Quaiser in 1955. 12 It may occur one week to several months after the onset of acute viral hepatitis. The incidence seems to be higher in males, especially under age 20 years. There may be pancytopenia. In either case, the prog- nosis is very grave.

It has been suggested that hepatitis virus might induce chromosomal damage in the hematopoetic system with subsequent stem cell failure. In some cases liver failure might result in decreased detoxification of drugs with resultant harmful effects.12 Deller and cowork- ers suggested that the virus could induce an autoimmune reaction with resultant bone marrow failure.13 This latter possibility is perhaps supported by the occasional response to corticosteroid therapy.

Bodenbender14 reported a 12-year-old girl who developed aplastic anemia nine months after apparent recovery from viral hepatitis. Her clinical course was complicated by menor- rhagia and lack of bone marrow remission in spite of multiple transfusions and corticos- teroid therapy. She died with bilateral hemor- rhagic pneumonia and gastric hemorrhage.

Arthritis

Arthralgias and arthritis associated with hepatitis have been observed for many years.15 The arthritis usually involves multiple joints and produces effusions characterized by sev- eral hundred to several thousands of cells which are almost all mononuclear.

The joint involvement is symmetrical and may involve the peripheral small joints as well as the weight bearing joints. Occasionally the distribution resembles that of rheumatoid arthritis. Rheumatoid factor, however, is ab- sent.

Interestingly, the arthritis occurs during the prodromal periods, resolving spontaneously with the advent of jaundice. It frequently is accompanied by skin rash and may precede clinical hepatitis by as long as one month.

Onion and coworkers found that the arthritis was accompanied by a fall in serum comple- ment and the appearance of HBAg in serum. As jaundice appeared complement returned to normal and HBAg disappeared as antibody to HBAg appeared.16 These investigators also demonstrated HBAg in synovial fluid and Sug- gested that the arthritis might be the result of circulating antigen-antibody complexes. Per- manent joint changes have not been described.

INVESTIGATOR

Lundberg

Gocke

Koff

Adler and Lyon Kortaxis

Lorenz & Quaiser

Graves

Green

42

Oklahoma State Medical Association

OTHER EXTRA-HEPATIC MANIFESTATIONS OF

ACUTE VIRAL HEPATITIS

Urticaria associated with viral hepatitis may develop in either the prodromal or icteric phase of the disease.17 Other dermatologic signs include maculo-papular or erythematous lesions, purpura, and scarlatiniform rashes. It is not surprising that the mechanism for these has been thought to be allergic in nature. It has been suggested that an antigen is released from the liver as a result of the viral inflamma- tion with resultant adsorption of antigen-anti- body complex onto mast cells causing subse- quent histamine release and urticaria.18

Glomerulitis and thrombophlebitis have also been associated with viral hepatitis. Thrombo- phlebitis recently reported in a previously healthy young male who subsequently de- veloped jaundice and positive HBAg suggests that viral hepatitis be considered in patients with unexplained thrombophlebitis.19

CONCLUSION

Advancing knowledge and techniques have permitted more precise diagnosis of viral hepa- titis. Not only is it now possible to differentiate hepatitis A and hepatitis B by relatively pre- cise and reproducible laboratory studies but this advance has increased our understanding of hepatic complications such as progressive hepatitis. A number of interesting non-hepatic complications have been described and should be watched for. Although the mechanisms for many of these complications have not been elucidated, there is increasing evidence that antigen-antibody complexes may be responsi- ble. Indeed, Millman and coworkers have demonstrated circulating complexes of HBAg and antibody in hepatitis.20 The occurrence of such "collagen disorders” as polyarteritis nodo- sa as a possible complication of hepatitis strengthens this hypothesis. It is not beyond

possibility that the actual hepatocyte damage might in reality occur as a result of these im- munologic phenomena rather than from multiplication of viral particles.

Addendum:

Since submission of the manuscript a paper further clarifying nomenclature for hepatitis B antigen has appeared. The recognized desig- nation for HGAg is now HBsAg to indicate that the antigen is a surface antigen on the Dave particle (see Jour. Infect. Dis. 130:92, 1974.) □

REFERENCES

1. Dane, D.S., Cameron, C.H. and Biggs, M. Virus-like particles in serum of patients with Australia antigen associated hepatitis. Lancet 1:695-698, 1970.

2. Mowrey, F.H., Lundberg, E.A.: Clinical Manifestations of essential polyangiitis (periarteritis nodosa) with emphasis on hepatic manifestations. Ann. Intern. Med. 40:1145-1164, 1954.

3. Gocke, David J., Morgan, C., Lockshin, M., Hsu, K., Bombardien, S. and Christian, C.L. Association between polyarteritis and Australian antigen. Lancet 2:1149-1153, 1970.

4. Koff, Raymond S., Wedrich, Warren C., Robbins, Alan H. Necrotizing Angiitis in a Methamphetamine User with Hepatitis B-Angiographic Diag- nosis, Five month follow-up results and localization of bleeding site. NEJM 288:946-947, 1973.

5. Adler, E. and Lyon, E. Cardiac disorders associated with infectious hepatitis. Cardiologia 11:111-116, 1947.

6. Bell, Hubert. Cardiac manifestations of viral hepatitis. JAMA 218:387-391, 18 October, 1971.

7. Wood, D.A.: Pathologic aspects of acute epidemic hepatitis, with spe- cial reference to early stages. Arch. Path. 41:345-375, 1946.

8. Lucke, B. The pathology of fatal epidemic hepatitis. Amer. J. Path. 20:471-594, 1944.

9. Kontaxis, A.N., et. al. Complete heart block in a child following infec- tious hepatitis. J. Cardiovascular Surgery 12:501-502, Dec. 1971.

10. Wakin, K.G., Essex, H E., Man-, F.C.: The effects of whole bile and bile salts on the inervated and denervated heart. Amer. Heart Journ. 20:486-491, 1940.

11. Conrad, M.C., Schwartz, F.D., and Young A. A. Infectious hepatitis — a generalized disease. Am. Jr. Med. 37:789-801, 1964.

12. Lorenz, E., Quaiser, K.: Panmyelopathic nach hepatitis epidemica. Wien Med Wschr 105:19-22, 1955.

13. Deller, J.J. Jr., Cirksena, W.J., Marcarclli, J.: Fatal pancytopenia associated with viral hepatitis. NEJM 266:297-299, 1962.

14. Bodenbender, Reinhardt, H. Hepatitis and aplastic anemia. Amer. J. of Disease in Children 122:440-441, Nov. 1971.

15. Graves, R.J.: A system of clinical medicine, p. 564, Dublin, 1843.

16. Onion, D.K., Crumpacker, C.S., and Gilliland, B.C., Arthritis of hepa- titis associated with Australia Antigen. Ann. Int. Med. 75:29-33, 1971.

17. Lockshin, N.A. and Hurley, H. Urticaria as a sign of viral hepatitis. Arch. Derm. 105:570-571, April 1972.

18. Cowdrey, S.C. and Reynolds, J.S.: Acute urticaria in infectious mononucleosis. Ann. Allergy 27:182-190, 1969.

19. Green, Armin and Novak, Louis. Thrombophlebitic prodrome in hepa- titis. NEJM 285:1322, 2 Dec. ’71.

20. Millman, I., London, W.T., Sutnick, A. et al. Australia antigen anti- body complexes. Native (London) 226:83-84, 1970.

Veterans Administration Hospital

921 N.E. 13th Street, Oklahoma, City, Oklahoma

73104

Remember these Dates

April 23rd-26th, 1975 OKLAHOMA MEDICAL SUMMIT ’75

Lincoln Plaza Forum — Oklahoma City

A combined meeting of the Oklahoma State Medical Association, the Oklahoma City Clinical Society and the Oklahoma Academy of Family Physicians.

PLAN TO ATTEND

Journal / February 1975 / Volume 68

43

THE UNIVERSITY OF OKLAHOMA COLLEGE OF MEDICINE

WEEKLY AFTERNOON OF CONTINUING EDUCATION

EVERY WEDNESDAY January 1st, 1975 through May 28th, 1975

Developed by

The Department of Medicine Office of Continuing Medical Education for Physicians University of Oklahoma Health Sciences Center

Registration fee: $30.00 per semester

SECOND SEMESTER SCHEDULE

TIME— CONFERENCE— LOCATION

12:00 to 1 :00 P.M. — Medical Grand Rounds — East Lecture Hall — Basic Science Building

1:30 to 2:30 P.M. — Pulmonary Disease Confer- ence — C007 Everett Hospital

1:30 to 2:30 P.M. — Hematology-Oncology Confer- ence — A001 Everett Hospital

1:30 to 2:30 P.M. — Gastroenterology Conference — C002 Everett Hospital

2:45 to 3:45 P.M. — Pulmonary Problem Case Con- ference — C007 Everett Hospital

4:00 to 5:00 P.M. — Cardiology Conference — C007 Everett Hospital

4:00 to 5:00 P.M. — Infectious Disease Conference — C002 Everett Hospital

4:00 to 5:00 P.M. — Renal Conference — A27 V.A. Hospital

This program is acceptable for Category I credit to- ward the Physician’s Recognition Award of the American Medical Association and the American Academy of Family Practice on an hour for hour basis.

IMPORTANT INFORMATION: This is s

ule V substance by Federal law; diphei HCI is chemically related to meperi o case of overdosage or individual hypei ity, reactions similar to those after me; or morphine overdosage may occur; in is similar to that for meperidine or /jk intoxication (prolonged and careful * ing). Respiratory depression may recur of an initial response to Nalline® (nak HCI) or may be evidenced as late as ■: after ingestion. LOMOTIL IS NOT AN, UOUS DRUG AND DOSAGE RECOtoi TIONS SHOULD BE STRICTLY ADHEt ESPECIALLY IN CHILDREN. THIS k TION SHOULD BE KEPT OUT OF RE CHILDREN.

Indications: Lomotil is effective as adjum apy in the management of diarrhea.

Contraindications: In children less than 2 j to the decreased safety margin in you groups, and in patients who are jaundiced sensitive to diphenoxylate HCI or atropine

Warnings: Use with caution in young chi i cause of variable response, and with exti tion in patients with cirrhosis and other hepatic disease or abnormal liver fund because of possible hepatic coma. Diph HCI may potentiate the action of barbitur; quilizers and alcohol. In theory, the cone with monoamine oxidase inhibitors could p hypertensive crisis.

Usage in pregnancy: Weigh the potentia against possible risks before using dur nancy, lactation or in women of childbe; Diphenoxylate HCI and atropine are secre breast milk of nursing mothers.

Precautions: Addiction (dependency) tod late HCI is theoretically possible at highd; not exceed recommended dosages. Admit \ caution to patients receiving addicting , known to be addiction prone or having ai drug abuse. The subtherapeutic amount old added to discourage deliberate overdosat observe contraindications, warnings and pi. for atropine; use with caution in childrens; of atropinism may occur even with the reco dosage.

Adverse reactions: Atropine effects inclue1 of skin and mucous membranes, flushing a retention. Other side effects with Lomol nausea, sedation, vomiting, swelling of abdominal discomfort, respiratory depress ness of the extremities, headache, dizzine; sion, malaise, drowsiness, coma, lethargy restlessness, euphoria, pruritus, angi * edema, giant urticaria and paralytic ileus

Dosage and administration: Lomotil is cl, cated in children less than 2 years old. Lomotil liquid for children 2 to 12 year; ages 2 to 5 years, 4 ml. (2 mg.) t.i.d.; 5 to ml. (2 mg.) q.i.d.; 8 to 12 years, 4 ml, times daily; adults, two tablets (5 mg.) t.i tablets (5 mg.) q.i.d. or two regular te; (10 ml., 5 mg.) q.i.d. Maintenance dosage low as one fourth of the initial dosage. M ward dosage adjustment as soon as initial are controlled.

Overdosage: Keep the medication out ol of children since accidental overdosage! severe, even fatal, respiratory depression overdosage include flushing, lethargy or potonic reflexes, nystagmus, pinpoint puf cardia and respiratory depression which 12 to 30 hours after overdose. Evacuates lavage, establish a patent airway and, wf sary, assist respiration mechanically. Use ! antagonist in severe respiratory depress! vatlon should extend over at least 48 hour j

Dosage forms: Tablets, 2.5 mg. of dip HCI with 0.025 mg. of atropine sulfate, mg. of diphenoxylate HCI and 0.025 mg,' sulfate per 5 ml. A plastic dropper calibi crements of Vi ml. (total capacity, 2 m panies each 2-oz. bottle of Lomotil liquid

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to:

G. D. Searle & Co.

Medical Department, Box 5110,

Chicago, Illinois 60680

SEARLE

44

Oklahoma State Medical Association

News From The Oklahoma State Department of Health

OUTPATIENT CARE FOR TUBERCULOSIS

The prevention and control of tuberculosis in the United States has undergone significant change in the last ten years. In the following statement Doctor Richard M. Burke discusses changing thoughts on the communicability of tuberculosis, and the effects thereof upon cur- rent prevention and control recommendations.

"The Madras, India tuberculosis treatment studies (1959) demonstrated that the results were the same whether the patient was treated in a hospital or at home. Further, the incidence of household TB infection was the same in both groups.1 By 1965 it was generally agreed that isolation was outmoded and the risk of infecting others after effective TB chemotherapy begun is negligible.

"Today there continue to be many TB patients packed off to hospitals solely because of the con- tagion factor. The danger of the patient trans- mitting infection is sharply reduced after a few weeks on chemotherapy. At the same time the household associates and other close contacts are placed on TB preventive treatment.2 Hospitalization or some type of institutional care of the patient is sometimes needed but it is usually for associated non-tuberculosis condi- tions and not tuberculosis.3

"Our local health departments have the necessary diagnostic, treatment and consulta- tion services available to handle TB outpatient care.” □

1. Andrews, R.H., Devodatta, S. Fox, et al., Prevalence of Tuberculosis among close family contacts of tuberculosis patients in South India and influence of segregation of the patient on early attack rate, WHO 23:463-510, 1960.

2. Tuberculosis Care: When and Where? Reichman, L.B., Ann. Int. Med , 80:402, 1974.

3. Guidelines for prevention of TB Transmission in Hospitals: Public Health Service Center for Disease Control, Atlanta, Georgia, Sept. 1974.

COMMUNICABLE DISEASES IN OKLAHOMA FOR DECEMBER, 1974

DISEASE	December 1974	December 1973	November 1974	Total To Date 1974 1973
Amebiasis	2	2	3	29	31
Brucellosis	2	1	2	13	6
Chickenpox	161	14	129	1167	1348
Encephalitis, Infectious	3	—	4	58	101
Gonorrhea (Use Form ODH-228)	1109	641	970	11494	10636
Hepatitis, A, B, Unspecified	49	87	117	999	1140
Leptospirosis	—	—	1	2
Malaria	—	—	—	6	3
Meningococcal Infections	1	3	2	19	37
Meningitis, Aseptic	2	4	5	65	107
Mumps	12	44	24	417	512
Rabies in Animals	10	13	13	165	168
Rheumatic Fever	—	—	—	12	16
Rocky Mountain Spotted Fever	4	1	6	70	77
Rubella	-	4	8	66	186
Rubella, Congenital Syndrome	-	—	—	1	—
Rubeola	1	1	—	30	62
Salmonellosis	13	28	18	268	290
Shigellosis	17	18	24	191	204
Syphilis, Infectious (Use Form ODH-228)	19	14	12	152	174
Tetanus	—	—	2	3	4
Tuberculosis, New Active	12	49	18	283	350
Tularemia	—	—		18	23
Typhoid Fever	—	—	—	2	2
Whooping Cough	1	2	3	20	23

Journal / February 1975 / Volume 68

49

fiews

Medical Summit Features Entertainment and Education

Preliminary plans for Oklahoma Medical Summit ’75, the combined annual meeting of the OSMA, Oklahoma City Clinical Society and Oklahoma Academy of Family Physicians, will offer physicians the best in scientific medi- cal programming and entertainment.

Nearly 60 hours of continued medical educa- tion for physicians will be available. All lec- tures and demonstrations are credited by the American Medical Association and the Ameri- can Academy of Family Physicians. In addi- tion, nearly 100 scientific and pharmaceutical exhibits will be available for viewing.

Oklahoma Medical Summit ’75 will be held Thursday through Saturday, April 24th-26th, in Oklahoma City’s Lincoln Plaza Hotel. All scientific sections, exhibits and business meet- ings will be in the new Lincoln Plaza Forum Building.

Although registration will not begin until early Thursday morning, the first official func- tion will take place Wednesday evening. The Early Bird Party is designed to get Summit ’75 off to a festive start. The party will begin with a cocktail reception in the Congress Room of the Lincoln Forum Building. It will then ad- journ for dinner and a play in Oklahoma City’s new Lincoln Plaza Playhouse Dinner Theater. The star for the evening’s play will be either Mickey Rooney or Van Johnson, with the exact name of the play and the star to be announced later. The playhouse has been reserved in its entirety for persons attending Summit ’75.

Thursday morning’s scientific program will begin with a section on immunology being sponsored by the Oklahoma Society of Internal Medicine and The American College of Physi- cians. At the same time the Oklahoma Academy of Family Physicians will conduct their annual business meeting for members.

The Oklahoma Section of the American Col- lege of Obstetricians and Gynecologists is sponsoring a half-day program Thursday morning.

50

The first of the Summit noon luncheons will be held Thursday. Luncheon speaker will be Herbert L. Holden, MD, President of the American Academy of Family Physicians.

The afternoon will be devoted to a section on allergy sponsored by the Oklahoma Allergy Society, and a symposium on the management of burns being sponsored by the Oklahoma Surgical Association.

Sheldon B. Koronas, MD, Professor of Pediatrics at the University of Tennessee Col- lege of Medicine, will be the guest speaker at a section on pediatrics.

Thursday evening’s social function will be a double-header. For the men and those wives who wish to attend, there will be a Keg and Oyster Party featuring delightful delicacies from the briney deep and cooling brew. How- ever, for those with a more refined pallet, im- mediately next door will be a Wine and Cheese Tasting Party. All registrants are invited to attend both functions.

On Friday there will be a full day sym- posium on cancer sponsored by the State and County Chapters of the American Cancer Soci- ety. Preliminary plans call for the Friday morning session to concentrate on surgical in- tervention in cancer, while the afternoon will take up radiological and chemical intervention in cancer.

A special Superstar Session will be held Fri- day morning, featuring two outstanding speakers. The first is Phil Thorek, MD, one of the most sought after physician speakers in the United States today. The second speaker on the program will be the new provost of the Ok- lahoma University Health Sciences Center, William G. Thurman, MD, formerly Dean of the Tulane University School of Medicine.

Two other half-day sessions will be sched- uled Friday morning, one by the Oklahoma Society of Pathology, and another by the Ok- lahoma Branch of the American Psychiatric Association.

The luncheon speaker for Friday noon will Oklahoma State Medical Association

be Phil Thorek, MD, Director of Medical Edu- cation for the American Hospital of Chicago.

The Oklahoma City Academy of Ophthal- mology and Otolaryngology is sponsoring a full day of scientific program for its members. The morning will be devoted to ENT problems, and the afternoon to ophthalmology.

New concepts in the management of miocar- dial infarction will be the subject of a half-day program Friday afternoon sponsored by the Oklahoma Heart Association.

Friday evening will offer an opportunity for all physicians to honor the outgoing and in- coming presidents of the three sponsoring or- ganizations for Oklahoma Medical Summit: The OSMA, Oklahoma Academy of Family Physicians, and Oklahoma City Clinical Soci- ety. The Presidential Inaugural Dinner-Dance will begin with a cocktail reception in the Con- gress Room at 6:00 p.m. followed by dinner in the Lincoln Plaza Playhouse at 7:00 p.m. (The play will not be offered on this evening.)

A gourmet menu has been arranged and the "official ceremonies” of the evening will be brief. At 8:30 p.m. dance music will be fur- nished by the Forrest Wasson Orchestra.

Saturday morning will start with a half-day session on hyperlipodemia sponsored by the Oklahoma Medical Research Foundation. At the same time half-day programs will also be offered for urology, anesthesiology, and, of in- terest to all physicians, a half-day program planned by the Oklahoma Arthritis Founda- tion.

Saturday’s luncheon speaker will be Mal- colm C. Todd, MD, President of the American Medical Association.

A special program on the socioeconomical as- pects of medicine is planned for Saturday af- ternoon. Guest speakers will include officials, both elected and appointed, of the United States Government. Henry Simmons, MD, cur- rently the Director of the Professional Stan- dards Review Office of HEW will be one of the guest speakers.

Oklahoma Medical Summit ’75 has arranged for a public speaking training program to be conducted on Thursday and Friday, April 24th and 25th, by the Smith, Kline and French Speaker’s Training Team.

Attendance at the Speaker’s Training Pro- gram is limited to 40 persons. Registration will be taken on a first come first served basis.

Physician-participants in the program will learn the principles of effective speech compos-

ition and delivery, manuscript speaking, ex- temporaneous speaking, the use of visual aids, and how to conduct question and answer ses- sions. The seminar is two full days in length and follows a workshop format featuring alter- nate lecture and small group practice sessions.

All materials will be furnished. Although there is no registration fee, advance reg- istration is required and limited.

General registration for the entire meeting will be located in the lobby of the Lincoln Plaza Forum Building at 4545 Lincoln Boulevard in Oklahoma City. It will be open from 7:30 a.m. until 5:00 p.m. each day. Admission to all sci- entific sections, exhibits, and business meet- ings is by badge only, available in the reg- istration area. □

Legislative Program Set For Doctors’ Wives

A Legislative Orientation Program for Doc- tors’ Wives is being sponsored by the OSMA’s Legislative Committee. David Bickham, As- sociate Executive Director of the OSMA, is or- ganizing the one-day program for March 5th.

All physicians’ wives are invited to attend the orientation. It will begin at 9:00 a.m. on that date in the Supreme Court Chambers lo- cated on the second floor of the State Capitol Building.

The tentative program includes welcoming remarks by Governor David Boren. The governor’s talk will be followed by an explana- tion of the legislative process and a description of how Oklahoma laws are made.

A panel will be available to discuss legisla- tion. It will include Representatives Hannah Atkins and David Craighead and Senators Er- nest Martin and Lee Cate.

An opportunity to attend a public hearing on some bill of medical interest will be made available at about 11:00 a.m. in the morning. Lunch will be served at 12 noon in the Faculty House. Luncheon speaker will be Thomas Lynn, MD, Acting Dean of the O. U. College of Medicine.

The afternoon will be devoted to scheduled tours of the Oklahoma University Health Sci- ences Center.

All physicians’ wives are invited to attend the meeting. Additional information will be sent to physicians’ homes as soon as the pro- gram is finalized. □

Journal / February 1975 / Volume 68

51

Oklahoma State Medical Association

BALKAN ADVENTURE

Bucharest- Istanbul -Dubrovnik

Oklahoma City, July 19, 1975 JOIN US FOR A VACATION SPECTACULAR

Bucharest with its monumental French facades, casual sidewalk cafes and surrounding unspoiled forests . . . Istanbul with its slender minarets of 17th century mosques and medieval bazaars . . . Dubrov- nik, a Dalmation summer resort set against the blue Adriatic

PRICE *1128

A CAREFREE, DO-AS-YOU- PLEASE

TWO WEEK HOLIDAY WITH

EXCLUSIVE FEATURES INCLUDING:

• Direct flights via World Airways chartered jet

• Deluxe hotels

• American breakfasts; gourmet dinners at a selection of the finest restaurants

• Generous 70 pounds luggage

• Optional sightseeing tours

• Expedited Customs formalities

• Tips and Transfers

SEND TO OKLAHOMA STATE MEDICAL ASSOCIATION 601 N.W. Expressway Oklahoma City, Oklahoma 73118

1 Enclosed is my check for $ ($100 per person) as deposit.

1 Names Address

State

Another Non-Regimented INTRAV Deluxe Adventure

Ebbs

Balkan Adventure Calls Members of OSMA

An exclusive two-week charter holiday to Eastern Europe and the Balkans is awaiting OSMA physician-members. Cities to be visited include Bucharest, Romania; Istanbul, Turkey; Dubrovnik, Yugoslavia; with a side trip avail- able to Kiev, Russia.

Departure from Oklahoma City is scheduled for July 19th, and the cost, which includes di- rect flights via chartered jets, accommodations at the very finest hotels, full American break- fasts and gourmet dinners at a choice of the finest restaurants, is only $1,128.

Arrangements for the trip have been made by INTRAV, a company that has spent years developing deluxe personalized vacations at charter cost savings. INTRAV has sponsored a number of trips for the OSMA and has received the highest praise by persons on the various trips.

Both the OSMA and INTRAV point out that the Balkan Adventure is not a tour, it is a non-regimented holiday designed to give the traveler a maximum amount of free time in each city.

Even though the trip is non-regimented, a travel director and five hosts are available to assist travelers in each city. Optional sight- seeing tours are available each day for those persons wishing to go on them.

The adventure begins when travelers board a chartered World Airways DC-8 jet in Okla- homa City on July 19th. The jet features stretch-out extra comfort seating, first-class meals, complimentary champagne and cock- tails, and direct no-change flight to Bucharest.

Bucharest is Romania’s 500-year-old capitol. Its broad, tree-lined boulevards, city lakes and well kept parks charm the most traveled vis- itor. There is always a feeling of anticipation just knowing you are behind the Iron Curtain, yet the place is friendly and easy going.

This part of Europe was the source of many superstitions. One of the best known of which is the vampire. Don’t miss the brooding castle of Count Dracula in the nearby countryside of Transylvania.

Although Bucharest is a major center for opera, ballet and symphony, visitors will also find an ample supply of night life, from elegant clubs to cafe’s with gypsy violins and lively dancing.

An optional side trip to Kiev, Russia, is available from Bucharest.

Journal / February 1975 / Volume 68

An excursion into the lush countryside of Bucharest, Romania, passing small neat houses and the brooding cas- tle of Count Dracula (above), is one of many memorable experiences members of the OSMA will have on their ex- clusive two-week Balkan Adventure departing in July.

Second stop on the trip is Istanbul, due to its frenzy, a remarkable contrast to placid Bucharest. Golden domes and minarets dot the horizon. This is a city of intrigue. Here is the fabled Blue Mosque of Sultan Ahmed and Sancta Sophia built by Constantine in 325 A. D.

Topkapi Museum in Istanbul features a priceless collection of jewels, ceramics and re- ligious relics. In the Grand Bazaar shops bulge with trinkets and treasures. Copper and brass lamps, kettles and pitchers, Bursa silks, leath- ers, and Oriental rugs create a flowing sensa- tion of colors and contrasts.

Night clubs feature belly dancers and Tur- kish folk dancing. The national dish, shish- kabob, should be tried with a glass of good Turkish beer. Optional side trips are available to Izmar and the ancient ruins of Ephesus.

Last stop on the trip is the calm and ancient walled city of Dubrovnik, Yugoslavia, perched on a rocky peninsula overlooking the Adriatic Sea. Residents of the city take great pride in their churches, monestaries, art galleries, museums and hundreds of apartment houses that are physical reminiscences of the medieval past.

For an unusual dining experience, how about dinner in a Benedictine Abbey on a nearby island?

Shoppers in Dubrovnik will find wonderful

53

news

buys in pigskin luggage, filigree jewelry, em- broidered blouses and dyed wool rugs.

Yugoslavians are friendly, gregarious people who enjoy life in this historic and dazzling sea- side resort area. It will be a perfect climax to your Balkan adventure.

For further information or to make reserva- tions for the trip, please contact the Oklahoma State Medical Association at 601 Northwest Expressway, Oklahoma City, Oklahoma 73118, today. Space is strictly limited. □

Department of Medicine Open House Set at Health Sciences Center

Tours of its facilities and a talk by a nationally-known rheumatologist will be high- lights Thursday, February 27th, when the De- partment of Medicine at the University of Ok- lahoma Health Sciences Center holds a day- long open house.

Included in the day’s activities will be the William K. Ishmael Lectureship honoring the local physician, a reception and dinner that night in his honor, tours of the Department of

Medicine facilities and dedication of the department’s newly opened library.

Governor Boren has been asked to speak briefly at the dinner along with newly named HSC provost Doctor William G. Thurman, currently dean of the Tulane College of Medi- cine, New Orleans, Louisiana.

Most of the program for the 7:30 p.m. dinner at the Skirvin Hotel will be vignettes by friends and colleagues of Doctor Ishmael. A reception will be held at 6:30 p.m. and both the reception and dinner are by invitation only.

The open house will begin at 10 a.m. and tours will be formed continuously in the Everett Building lobby until 3 p.m. Dedication