The Diarrhea of Travelers—Incidence in Foreign Students in the United States

To ascertain whether foreign visitors to the United States experience the diarrhea of travelers, 215 foreign students matriculating at the University of California, Los Angeles, were interviewed. The attack rate of diarrhea was 14.0 per cent during the first month after arrival in the United States. In a comparison group of 238 U.S. students, the attack rate of diarrhea in one month was 8.4 per cent. The difference in attack rate was not statistically significant.The diarrheal episodes reported by the foreign students were less abrupt in onset, less severe and of longer duration than the usual diarrhea of travelers. The typical severe explosive diarrhea of short duration usually described as “diarrhea of travelers” was not encountered among the foreign students in this study.The occurrence of diarrhea was not associated with the age, sex or race of the students, with the location of eating places, with the geographic area from which the foreign students came or with any characteristics of the trip to the United States. In the group of U.S. students there was an increased incidence of diarrhea among students who came from outside California to Los Angeles.     

Physicians' Use of Relative Value Studies,Report of Bureau of Research and Planning

Data tabulated from the Study of the Characteristics of Physicians in California, conducted by the C.M.A. Bureau of Research and Planning, show that over 70 per cent of all physicians in active private practice utilize the Relative Value Studies, with over 41 per cent stating that they use it “all or most of the time.” Use figures range from almost 78 per cent of physicians who participate in some form of prepayment program to under 53 per cent of physicians who do not participate in any such program.Eighty per cent of all physicians in private practice who use the RVS expressed general satisfaction, with 11.8 per cent dissatisfied and 8.2 per cent stating no opinion as to their satisfaction. Of the 80 per cent who expressed satisfaction, two out of three use the RVS all or most of the time.     

CARCINOMA OF THE CERVIX

Studies by eminent surgeons to reevaluate the place of radical operations in the treatment of carcinoma of the cervix—now that extensive procedures have become less hazardous—apparently have led to confusion in some minds as to choice between surgical and radiation therapy. Pending outcome of the studies, general employment of surgical treatment is unwarranted. Radiation is the treatment of choice in most cases, particularly if the lesion is in an early stage, although radical operation is indicated in certain rare early cases in which delivery of an effective dose of radiation to involved areas is technically difficult. Elsewise it appears at present that operation should be used only in cases of stages III or IV carcinoma—in which results by either means of treatment are poor.One hundred and seven patients were treated with a combination of x-ray and radium irradiation. X-ray was used first to reduce the hazard of implanting the radium. The “five-year arrest” rates were as follows: For 22 patients with stage I lesion, 70 per cent; for 31 with stage II, 55.7 per cent; 33 with stage III, 39.7 per cent; 21 with stage IV, 0. Eighteen patients with diagnosis of carcinoma of the cervix who had had subtotal hysterectomy were treated. The stage of the disease could not be determined. In this group the five-year arrest rate was 52 per cent.     

MANAGEMENT OF CARCINOMA OF THE UTERINE CERVIX

The long, occult phase of pre-invasive carcinoma of the uterine cervix provides the clinician with his greatest opportunity in the actual prophylaxis of invasive cancer. By the use of four-quadrant biopsies and Papanicolaou smears, the authors increased by almost 20 times the frequency of diagnosis of preinvasive carcinoma of the uterine cervix.Radiation therapy of invasive carcinoma in 147 patients produced five-year “cure” in 84 per cent of stage I cases, 65 per cent of stage II cases. The over-all rate for stages I to IV, inclusive, was 51 per cent.Surgical management of this form of cancer, with preservation of the urinary tract, is an inadequate operation as judged by the extirpative standards observed in operations for cancer at other major anatomical sites.Improvements in technique of irradiation, more accurate measurements of depth dosage at critical sites, and more uniform dosage throughout the parametrial areas, have decreased the incidence of major complications of irradiation.Radical panhysterectomy and pelvic node dissection should be reserved for patients proved to have radioresistant lesions.The application of routine block dissection of pelvic nodes for Stage I and Stage II lesions, clinically controlled by irradiation, is of doubtful theoretic, and no evident practical value.Subject to future evaluation, pelvic eviscerative procedures seem to offer some salvage in cases of recurrent (occasionally primary) advanced lesions in rigidly selected patients.     

END RESULTS IN PAROTID TUMORS

Management of parotid tumors can be based on a clinical classification of these lesions as being either “encapsulated” or infiltrating.The Warthin tumor (papillary cystadenolymphomatosum) is a benign encapsulated tumor, often occurring multicentrically or bilaterally especially in the lower pole area of the parotid. It is characterized clinically by its softness and fluctuation in size and a high incidence in elderly men.The so-called “capsule” of well demarcated mixed and mucoepidermoid tumors is represented by a condensation of host fibrous stroma, in the interstices of which tumor cells may be present.The “encapsulated” tumors should be excised with a “shell” of uninvolved parotid tissue. To do this safely, the facial nerve should first be isolated.Total parotidectomy is necessary only if the size of the tumor, the multiplicity of recurrences, or the infiltrating nature of the tumor are such that complete eradication of the primary site must be done.Radical neck dissection is never performed electively except in the small group of nonencapsulated infiltrating primary lesions.In a series of cases of previously untreated parotid tumors treated by the method outlined, the local parotid recurrence rate was less than 1 per cent.     

SALIVARY GLAND TUMORS

In a review of a series of 248 salivary gland tumors, seen over a 28-year period, all pathologic material was brought up to date by reclassification according to more recent criteria and nomenclature. In parotid tumors, a probable lowered recurrence rate and a definite decrease in incidence of permanent facial nerve paralysis was found in the more recent cases in which the “Y” incision was used, with identification of the seventh nerve as it leaves the stylomastoid foramen. The five-year recurrence rate for primary mixed tumor was 8.3 per cent, and in recurrent cases it was found to be 18.1 per cent.Of 44 patients with malignant salivary gland tumors in all sites who were observed for five years or more, 32 or 72.7 per cent survived five years.     

DIVERTICULITIS OF THE COLON—Surgical Treatment

Appropriate surgical treatment of diverticulitis of the colon can result in a highly satisfactory proportion of permanent cures, with an operative mortality of 2 to 5 per cent.Colostomy is a valuable emergency procedure for the control of severe infection or the relief of obstruction but is not a satisfactory definitive treatment for the cure of diverticulitis. Definitive surgical treatment requires resection of the involved segment of colon.Three indications for surgical intervention in “uncomplicated” diverticulitis are: (1) continued or repeated attacks, (2) persistent deformity as seen by x-ray examination, and (3) persistent blood in the stools.Although a three-stage operation is usually considered a safer procedure, one-stage resections may be safely and satisfactorily employed in many instances.     

SCREENING TESTS FOR DIABETES DETECTION—Combined with a Chest X-Ray Survey

A program was carried out to test the value and feasibility of performing blood sugar screening tests in conjunction with a community-wide chest x-ray survey. A simple, rapid and inexpensive blood sugar screening test requiring only about two drops of blood from the finger tip was used. Among 14,681 persons who stated that they did not have diabetes, 191 or 1.3 per cent had “positive” results in screening tests. The number of persons referred to their physicians for diagnostic study because of the possibility of diabetes was reduced from 191 to 127 by means of a more specific secondary screening test.Diagnostic information with regard to 102 of the 127 persons referred to their physicians was supplied by the physicians. In 58 (0.40 per cent of the 14,681 participants) the diagnosis was diabetes—newly discovered as a result of referral by the survey.Some of the persons referred to their physicians because of suspicion of diabetes, while not then diabetic, might be considered prediabetic. The appearance of diabetes in this group during the year following the survey was therefore investigated. Glucose tolerance tests were performed for 32 of the diabetes suspects whose diagnosis immediately following the survey was either “not diabetic” or unknown. In 15 cases the glucose tolerance curves were indicative of diabetes, in seven cases questionable and in ten cases normal.The 58 persons diagnosed immediately after the survey plus the 15 found to have “diabetic” glucose tolerance curves a year later made a total of 73 newly discovered diabetics. This is a discovery rate of 0.50 per cent among the 14,681 participants in the survey.The success of this combined diabetes detection and chest x-ray survey suggests that other screening procedures should be studied to determine the desirability of adding them to similar community-wide case-finding programs.     

MALIGNANT TUMORS OF CHILDHOOD

In the past 20 years, cancer in the age group, 0-14 years has become the second leading cause of death by disease. At some ages, notably between 5 and 14, it may be the leading cause of death by disease.Leukemia is the most frequent form of cancer in childhood, and tumors of the brain are in second place.An attempt should be made to categorize more accurately tumors stated in reports as “miscellaneous,” since in the reports analyzed herein, 15.8 per cent of all malignant lesions were so classified.     

Detection of cancer of the lung; results of a chest x-ray survey in Los Angeles

In a mass survey by x-ray minifilm in Los Angeles County, apparently suspicion of cancer of the lung was reported in more than 90 per cent of cases in which the condition existed. Of the patients who were appropriate for resection with intent to cure, 35.8 per cent had "three-year cures." This high cure rate indicates that if the condition is detected early by the survey method and "curative" operation is done, cure rate for lung cancer may be much higher than is usually thought.     

HYPOTHYROIDISM IN MEN IN INDUSTRY—A Preliminary Report on Chemical Evidence

Of 2,807 specimens from blood donors and men in industry, 340 or 12 per cent had serum protein-bound iodine values of 4.0 micrograms or less per 100 cc.In a selected group of 610 “white collar” workers, 52 or 8.5 per cent had similar low values.Careful reexamination of a sample of the latter group indicated that at least 75 per cent of them had hypothyroidism needing treatment.Further analysis of the factors producing hypothyroidism and the validation of the incidence found is warranted. If the incidence observed in this study is confirmed, these findings indicate that 6 per cent to 9 per cent, or more than a million middle aged American men have hypothyroidism.     

Flowering in bougainvillea: a function of assimilate supply and nutrient diversion

Reproductive development, whether expressed as first node to flower or numbers of inflorescences developing, is promoted in direct relationship to leaf area and in inverse relationship to the numbers of axillary branches developing. Per cent soluble solids in the reproductive shoots vary with reproductive development. Cytokinin treatments promote inflorescence development and per cent soluble solids, further supporting a nutritional hypothesis in the control of flowering in Bougainvillea “San Diego Red.” Gibberellin treatments inhibit reproductive development completely without significant lowering of per cent soluble solids, which is counter to expectations for a nutritional hypothesis. A closer examination of the reproductive axes, the tissues in which morphogenetic change occurs, must be made for the gibberellin-treated tissues.     

ANALYSIS OF ABSENTEEISM IN INDUSTRY

There are many nonmedical factors that contribute to employee absenteeism in industry. An employee''s total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.The role of a private physician in determining and certifying the true state of a patient''s health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners.     

Characterization of the Rapidly Labeled Hybridizable RNA Synthesized in L5178Y Mouse Leukemic Cells: Hybridization Lifetime Studies

An attempt is made to characterize the rapidly labeled hybridizable RNA of L5178Y mouse leukemic cells which has been shown to have similar base sequences when synthesized in two different stages of the cell cycle. The size of rapidly labeled RNA molecules was heterogeneous. For labeling times of 20 min or less, the per cent of hybridization was maximal. With longer labeling times, the per cent of hybridization decreased as radioactivity appeared in long-lived species of low hybridization efficiency; the radioactivity profile resembled the optical density profile in sucrose gradients. The lifetime of newly synthesized hybridizable RNA was studied by pulse labeling exponentially growing cells and then “chasing” with nonradioactive uridine. The per cent of hybridization was studied as a function of chase time. Three RNA groups, which comprised different proportions of rapidly labeled hybridizable RNA, were distinguished. The short-lived group had a half-life of 10 min, much less than the values reported in the literature for messenger RNA of mammalian cells. The half-life of 1-1½ hr observed for a medium-lived group more closely corresponds to that of messenger RNA. A long-lived group had a half-life of approximately 20 hr. Specific activity measurements during chase indicate the presence of a “pool” of labeled uridine derivatives. The uridine of this pool appears to be nonexchangeable with but dilutable by exogenous uridine. A nontoxic concentration of actinomycin D was added to the chase media in an attempt to block the “pool effect”. A rapidly degradable RNA was demonstrable both by specific activity and per cent of hybridization measurements.     

Earlier Diagnosis of Cervical Cancer—An Analysis of Reports to the California Tumor Registry from 1942 to 1963

The mortality rate for cervical cancer in California declined during the period 1950-64. Indirect evidence shows that the incidence is also declining, but it is difficult to assess this decline because of the effect of the increasing use of cytologic examination on incidence rates for cervical cancer.Cervical cancer, in the 57 hospitals reporting to the California Tumor Registry, is being diagnosed at an earlier stage than in previous years. The proportion of cases diagnosed with the lesion still in the in situ stage rose from zero in 1942 to 56 per cent in 1963, and invasive cervical cancer, as a proportion of all invasive cancer in women, decreased from 15 per cent to 9 per cent. There is wide variation among hospitals in the proportion of cervical cancer cases that are in situ at time of diagnosis.     

POSTMATURITY SYNDROME—The Obstetrician's Role in Management

The obstetric problem of going past the date of expected confinement has no medical significance, provided the fetus in its demands does not outgrow placental capability. The problem of relative placental insufficiency, however, is a serious one with a total fetal wastage in the neighborhood of 15 per cent.Antepartum indications of such placental insufficiency have not yet been well documented. However, a decrease in the fundal measurements and particularly where associated with an otherwise unexplained loss of maternal weight has proved an ominous sign.In a study of application of reported criteria for determining when a patient is “at term” by vaginal cytologic methods, the results were approximately 75 per cent accurate. Cytologic studies when coupled with other physical findings may be of assistance in determining in which cases labor should be induced and in which the fetuses should be accorded the special attention that is demanded by the chronic state of low grade anoxia.     

Voluntary Health Insurance Coverage in California, 1952 to 1963—Report of the Bureau of Research and Planning

More than seven out of every ten of an estimated civilian population of 17.3 million people in California were covered under some form of voluntary health insurance at the close of 1963.Between 1952 and 1963, the number of Californians covered for hospital expenses increased from 5.7 million to 12.3 million; for surgical expenses from 5.4 million to 11.6 million; and for regular medical expenses from 3.0 million to 10.1 million.The percentage covered by health insurance also rose significantly: for hospitalization, from 51.3 to 71.0 per cent; for surgical, from 48.2 to 67.1 per cent; and for regular medical from 27.2 to 57.9 per cent. The rate of increase in hospitalization coverage was slightly higher in California than in the total U.S.; however, the per cent of persons covered remains lower. For surgical coverage, both the rate of increase and the per cent covered are lower in California. For regular medical, growth rates in California and in the U.S. were similar, however the over-all per cent covered is significantly higher in California.Major medical coverage, which has shown the fastest growth rate, covered only 0.4 per cent of the U.S. population in 1952 and 17.1 per cent by the end of 1963. Comparable figures for California are not available.     

REITER PROTEIN COMPLEMENT FIXATION TEST—A Preliminary Comparison of the TPI Test with the Complement Fixation Test Employing a Soluble Protein Antigen Derived from the Reiter Strain

A comparative study of the specificity of the Reiter protein complement fixation (RPCF) test and the Treponema pallidum immobilization (TPI) test on 180 sera showed that the results in 178 instances or 98.9 per cent were in agreement.The sensitivity of the RPCF test, when compared to the TPI test, on 189 sera from patients known to have syphilis was in agreement in 182 or 96.3 per cent, assuming a correlation exists between positive TPI and both the “reactive” or “weakly reactive” RPCF test results.As to reproducibility of results, the RPCF test results agreed in 84 of the 87 sera tested (95.4 per cent). The sera were tested at least three times on different days.Anticomplementary reactions were observed in three of 91 normal sera.     

Leading causes of childhood death

The over-all rates of death in childhood decreased five to ten fold during the first half of the century, with the greatest drop occurring in deaths due to infections. The death rate due to accidents has shown a relatively slight decrease; hence, accidents are now the leading cause of childhood death, and in California account for 32 per cent of the deaths in the group 1 to 15 years of age. In California, and among certain insured groups of children, cancer is the leading or second leading cause of death due to disease. There is indication that the incidence of leukemia is increasing in early childhood and in the older age groups.Accidents, the leading cause of childhood death, do not happen; they are caused, and so can be prevented. The medical profession should concern itself much more actively in the field of accident prevention.     

HEMOGLOBIN: NORMAL VALUES

Hematologists are not in agreement as to the “normal” amount of hemoglobin in the blood, nor is there agreement as to what amount of hemoglobin can be considered “a hemoglobin value of 100 per cent.” Different hospitals base reports of hemoglobin on different standards, which obviously can be misleading.By biometric study of the great mass of data on hemoglobin content that has become available as a result of the blood procurement program, it should be possible to determine what “normal” values are and to provide a basis for uniformity in reporting.