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                                                                                                                                        Anew
                                                                                  drug              development                           from

                                                              The             Dow                 Chemical                     Company

                                                             300 mg. capsules




            RI                                                                                                           N
             for use with other antituberculous        drugs in the
            initial treatment   and retreatment     of patients with
                            Pulmonary   Tuberculosis
               This   new   antibiotic,       now      available       for      use in the            United       States,
               was discovered,        developed         and patented              by a European               subsidiary
               of The   Dow      Chemical         Company           (Lepetit,          S.p.A.      of Milan,         Italy).


                                          =   #{149}
                                                 !-!          THE    DOW        CHEMICAL          COMPANY
                                 _j                                          Rx Pharmaceuticals
                                                                               INDIANAPOLIS


                                                                                                            (See facing page for full product   descriptioa
                                                                                          Rifad in#{174}
 DESCRIPTION:              Rifadin         (rifampin)      is a semisynthetic                        antibiotic            prothrombmn           times     be performed        until the dose of the anticoagu-
 derivative       of rifamycin            B. Specifically,       Rifadin   is the                  hydrazone,              lant required         has been established.
 3-(4-methylpiperazinyliminomethyl)                         rifamycin    SV.                                                       Urine,    feces, saliva,      sputum,      sweat   and tears may be colored
                                                                                                                           red-orange          by rifampin         and   its metabolites.           Individuals        to be
ACTIONS:             Rifadin       inhibits        DNA-dependent                RNA polymerase                ac-
                                                                                                                           treated      should       be made      aware     of these     possibilities          in order  to
tivity     in susceptible              cells.     Specifically,         it interacts        with    bacterial
                                                                                                                           prevent      undue       anxiety.
RNA polymerase,                   but does           not inhibit          the mammalian              enzyme.
This     is the mechanism                     of action          by which          rifampin        exerts      its         ADVERSE         REACTIONS:               Gastrointestinal             disturbances            such as heart-
therapeutic            effect.     Rifadin        cross      resistance        has only        been    shown               burn,     epigastric         distress,       anorexia,          nausea,       vomiting,         gas, cramps
with other          rifamycins.                                                                                            and      diarrhea          have       been        noted        in some            patients.        Headache,
        Peak blood              levels      in normal           adults      vary widely          from     mdi-             drowsiness,            fatigue,        ataxia,        dizziness,        inability         to concentrate,
vidual       to individual.             Peak       levels      occur       between         2 and 4 hours                   mental       confusion,           visual     disturbances,            muscular           weakness,         fever,
following          the oral administration                    of a 600 mg. dose. The average                               pains in the extremities                  and generalized               numbness            have also been
peak value            is 7 mcg./ml;             however,         the peak level may vary from                              noted.       Pruritus,        urticaria,         skin     rashes,      eosinophilia,            sore     mouth
4 to 32 mcg./ml.                                                                                                           and sore tongue              have occasionally                been encountered.
        In normal             subjects        the T’h (biological                half-life)       of Rifadin                       Thrombocytopenia,                      transient          leukopenia              and       decreased
in blood         is approximately                three     hours.      Elimination          occurs     mainly              hemoglobin            have been observed.                    Thrombocytopenia                  has occurred
through        the bile and, to a much                     lesser extent,         the urine.                               when       Rifadin        and ethambutol                  were     administered              concomitantly
                                                                                                                           according         to an intermittent                  dose schedule             twice       weekly,      and in
 INDICATIONS:            Pulmonary        tuberculosis.         In the initial      treatment
                                                                                                                           high doses.           Elevation        in BUN and serum                    uric acid have been                  re-
 and     in retreatment           of patients        with      pulmonary       tuberculosis,
                                                                                                                           ported.
 Rifadin     must be used in conjunction                  with    at least one other         anti-
                                                                                                                                   Transient          abnormalities               in liver       function          tests     (elevations
 tuberculous       drug.     Frequently       used      regimens       have been       the fol-
                                                                                                                           of serum         bilirubin,          BSP, alkaline            phosphatase              and serum           trans-
 lowing:
                                                                                                                           aminases)        have been observed.
                 isoniazid      and Rifadin
                 ethambutol         and Rifadin                                                                             DOSAGE     AND      ADMINISTRATION:                                    It is recommended                    that
                 isoniazid,      ethambutol       and Rifadin                                                              Rifadin  be administered      once   daily,                          either   one hour    before,               or
                                                                                                                           two hours after a meal.
Neissena     meningitidis              carriers.  Rifadin              is indicated          for     the treat-
ment     of asymptomatic                 carriers   of N.              meningitidis           to     eliminate             Pulmonary           tuberculosis:
meningococci       from            the nasopharynx.                                                                            Adults:        600 mg. (two 300 mg. capsules)               in a single        daily admin-
       Rifadin        is not indicated             for the treatment               of meningococcal                                istration.
infection.                                                                                                                     Children:         10-20 mg./kg.        not to exceed      600 mg/day.
       To avoid       the indiscriminate               use of Rifadin,         diagnostic       labora-                            In the treatment            of pulmonary       tuberculosis,         Rifadin     must be
tory procedures,            including          serotyping        and susceptibility             testing,                   used in conjunction               with   at least one other        antituberculous         agent.
should      be performed           to establish          the carrier      state and the correct                            In general,          therapy      should     be continued         until    bacterial     conver-
treatment.         In order      to preserve           the usefulness           of Rifadin        in the                   sion and maximal              improvement        have occurred.
treatment         of asymptomatic               meningococcal             carriers,     it is recom-
 mended       that the drug be reserved                    for situations        in which      the risk                    Meningococcal              carriers:    It is recommended         that   Rifadin    be ad-
of meningococcal             meningitis         is high.                                                                   ministered           once daily      for four consecutive       days in the following
       Both in the treatment                of tuberculosis           and in the treatment               of                doses:
meningococcal            carriers,      small      numbers         of resistant       cells,   present                        Adults:         600 mg. (two 300 mg. capsules)            in a single     daily admin-
within     large populations             of susceptible           cells, can rapidly         become                                istration.
the predominating              type. Since rapid              emergence          of resistance        can                     Children:          10-20 mg./kg.       not to exceed   600 mg./day.
occur,      culture     and      susceptibility           tests    should       be performed             in                       Data is not available            for determination      of dosage      for children
the event of persistent             positive       cultures.                                                               under       5.

CONTRAINDICATIONS:                         A history            of      previous       hypersensitivity                    Susceptibility     testing:     Pulmonary          tuberculosis.                 Rifampin           suscepti-
reaction  to any of the              rifamycins.                                                                           bility   powders      are available       for both direct                    and indirect           methods
                                                                                                                           of determining         the susceptibility           of strains               of mycobacteria.               The
WARNINGS:                Rifampmn          has been shown                 to produce           liver dysfunc-
                                                                                                                           MIC’s      of susceptible      clinical      isolates     when                determined             in 7H10
tion.     There        have been             fatalities        associated          with    jaundice      in pa-
                                                                                                                           or other       non egg-containing             media      have               ranged     from          0.1 to 2
tients     with      liver disease            or receiving           rifampin         concomitantly         with
                                                                                                                           mcg./ml.
other      hepatoxic           agents.       Since an increased                 risk may exist for mdi-
viduals       with        liver      disease,          benefits       must       be weighed          carefully             Meningococcal            carriers:        Susceptibility           discs containing               5 mcg. of
against       the risk of further                    liver    damage.          Periodic       liver  function              rifampin       are available         for susceptibility             testing      of N. meningitidis.
monitoring            is mandatory.                                                                                                Quantitative         methods            that      require        measurement                of zone
        The possibility              of rapid emergence                   of resistant        meningococci                 diameters         give the most precise                  estimates         of antibiotic           suscepti-
restricts      the use of Rifadin                   to short-term           treatment         of the asymp-
                                                                                                                           bility.   One such procedure*                   has been          recommended                for use with
tomatic        carrier        state.     Rifadin         is not to be used for the treatment                               discs    for testing       susceptibility            to rifampin.           Interpretations             corre-
of meningococcal                  disease.                                                                                 late zone       diameters        from       the disc test with              MIC       (minimal         inhibi-
Usage      in Pregnancy:         The effect        of combinations           of              Rifadin    with               tory concentration)             values       for rifampin.          A range of MIC’s                from 0.1
other    antituberculous            drugs    on the human             fetus    is             not known.                   to 1 mcg./ml.           has been          found       in vitro for susceptible                    strains      of
An increase           in congenital       malformations,           primarily                  spina   bifida               N. meningitidis.           With       this procedure,               a report        from       the labora-
and cleft        palate,   has been        reported        in the offspring                     of rodents                 tory of “resistant”            indicates         that the organism                is not likely          to be
given    oral doses of 150-250              mg./kg./day       of rifampin                    during    preg-               eradicated         from   the nasopharynx                of asymptomatic                carriers.
nancy.
                                                                                                                           HOW     SUPPLIED:              In maroon     and scarlet     capsules                      equivalent         to
       The     possible      teratogenic         potential       in women                      capable     of
                                                                                                                           300 mg. rifampin.              Bottles  of 30 (NDC     183-508-30),                       60 (NDC          183-
bearing      children     should       be carefully      weighed       against                the benefits
                                                                                                                           508-60)  and 100            (NDC 183-508-2).
of therapy.
                                                                                                                           *Bauer,      A. W., Kirby,           W. M. M., Sherris,                I. C., and Turck,            M. Anti-
PRECAUTIONS:            Rifampin          has been                    observed     to increase         the
requirements      for anticoagulant             drugs                of the coumarin        type.     The                   biotic     susceptibility          testing      by a standardized               single     disk method.
effect   was not observed          until     the fifth               day following     the initiation                       Am. 1. Clin. Path. 45:493-496,                     1966.
of treatment.    The decrease            in prothrombin                     time lasts five to seven
days on the average.         The cause of this                         phenomenon       is unknown.                                                THE     DOW       CHEMICAL             COMPANY
In patients   receiving      anticoagulants,           it             is recommended        that daily                                            Rx Pharmaceuticals            Indianapolis,        Ind.   46206    U.S.A.



                                                                                      When         writing        please   mention         CHEST                                                                                            7
                                     VOLUME           60       /     NUMBER           5    f     NOVEMBER,                   1971




                                    CHEST


           editorials
           421          The        Esophagogastric                                Sphincter
                        Arthur      M. Olsen,         Rochester,            Minnesota

           422          Coordination       of College    and Hospital                                                        Respiratory
                        Therapy      Educational     Programs
                        William       F. Miller,       Dallas



           clinical               Investigations

           424          Prolonged                Bed Rest in the Treatment                                                   of
                        Ischemic                Cardiomyopathy
                        G. E. Burch        and      C. D. McDonald,                  New        Orleans

           431          Coronary                Embolism                    in Patients                      with         Mitral            Valve          Prosthesis
                        Alberto       Benchimol.and                 Jose Sandoval,              Phoenix

           437          Clinical           Evaluation  of Persons   Positive                                                   to Stabilized
CONTENTS                Tuberculi           n but Negative   to Nonstabilized                                                     Tuberculin
                        Michael       B. Zack,        Lynn         L. Fulkerson        and        Emanuel           Stein,     Staten        Island

           441          Chalasia,               Peptic   Esophagitis                             and Hiatal   Hernia;    A Common
                        Syndrome                 in Patients   with                            Central Nervous     System   Disease
                        Thomas        W.   Holmes,           Jr.,     Eldridge,       California

           446          Angiographic                   Method     for Volume                                     Estimation                     of
                        Right and                  Left Ventricles
                        Rene      A. Arcilla;       Peeng           Tsai;   Otto     Thilenius;           and     Klaus       Ranniger,              Chicago

           455          Pneumomediastinum         in Diabetic     Ketoacidosis;
                        Comments      on Mechanism,      Incidence     and Management
                        Donald       E. Girard;        Victor          Carlson;       Ethan          A. Nafelson;            and      Herbert          L. Fred,   Houston

           460          Acoustic,   Mechanical                                    and Electrical   Alternans
                        in Hemopericardium                                        of Occult   Leukemic     Origin
                        F. X. Costeas;          G. Poulias;             N. Louvros;            and     D. Sotirakis,              Athens,       Greece

           464          Chemodectoma                               of the           Aortic             Body
                        Suthi     Surakiatchanukul,                  Edward         Goodsitt           and      John      Storer,       Cleveland
 Compared to aminophylline,          the bronchodilatorCholedyl                                                                                                     (oxtriphylline):
 V produces     less gastric irritation
    is more soluble and stable in gastric acid
 #{149}
    is better absorbed from the G.l. tract
 #{149}
    produces
 #{149}                             minimal                 tolerance                    over Iongterm                              use
 consider the stomach
 when you treat emphysema
                                                                                          p#{174}




(oxtri phyl line)
bronchodilator




 CHOLEDYL#{174} (oxtriphylline)        TABLETS       and ELIXIR.     Each yellow        coated   tablet contains   200 mg oxtriphylline;           each red coated          tablet contains       100 mg
 oxtriphylline.      Each teaspoonful     of the elixir contains     100 mg oxtriphylline;         alcohol  20%. IndicatIons:       Choledyl        (oxtriphylline)      is indicated       for relief   of
 bronchospasm           in bronchitis,  bronchial      asthma,   asthmatic      bronchitis,     pulmonary    emphysema,        and similar      chronic      obstructive     lung disease.       Precau-
tlons:      Concurrent     use of other     xanthine-containing        preparations         may lead to adverse     reactions,     particularly       CNS stimulation          in children.     Adverse
ReactIons:       Gastric   distress   and, occasionally,       palpitation      and CNS stimulation              have been        reported.      Dosage:     Average      adult dosage:
Tablets-200       mg, 4 times a day; Elixir-two        teaspoonfuls,       4 times a day. SupplIed:            200 mg tablets       in bottles     of 100 and 1000;      100 mg tablets            W   C
in bottles    of 100. Elixir, bottles   of 16 ft oz (1 pint) 474 ml and 128 ft oz (1 gallon).                    Full information       is available     on request.
CHSGP.1ISBW                                                                                                             WA    R N S R - CU        S LC  OTT     Morris   Plains,   New Jersey      07950

10                                                                   When      writing     please    mention      CHEST
selective therapeutic  action
        with Bronkosol
the Beta2 Inhalant Solution
     for use with hand      nebulizers,
          aerosolization,     IPPB




                                              A




                                          /
                      Airway clearance with
             relative freedom from adverse effects
Isoetharine: the unique Beta2                                                                                  COMPOSITION:     Dilabron
                                                                                                               HCI) 1.0%; phenylephrine
                                                                                                                                                                             (brand of isoetharine
                                                                                                                                                                            HCI 0.025%;
                                                                                                               thenyldiamine        HCI 0.10% ; in an aqueous-glycerine
Bronchodilator  is available in                                                                                solution
                                                                                                               chloride,
                                                                                                                           containing
                                                                                                                             sodium
                                                                                                                                            saccharin
                                                                                                                                        citrate,   sodium
                                                                                                                                                          sodium
                                                                                                                                                              bisulfite
                                                                                                                                                                        with sodium
                                                                                                                                                                            0.3%;



BronkosoF
                                                                                                               methylparaben          0.025%     and propylparaben
                                                                                                               0.014%      as preservatives.
                                                                                                               CONTRAINDICATION:                                   Hypersensitivity                    to
isoetharine                    I phenylephrine       I thenyldiamine                                           any component.
                                                                                                               PRECAUTIONS:       Although        Bronkosol     is relatively
                                                                                                               free of toxic side effects,       too frequent      use may
The new classification               of Beta receptors               of the cardiovascular                     cause tachycardia,      palpitation,      nausea,     headache,
and pulmonary            systems      differentiates        two      types, termed        Beta 1               changes    in blood pressure,        anxiety,   tension,
and Beta2.         Briefly,     an agent that acts on                Betai      receptors                          restlessness,            insomnia,               tremor,            weakness,
stimulates       the cardiac         muscle,       increasing          the rate and force of                   dizziness   and excitement         as is the case with other
contractions;         whereas        an agent that acts               on Beta2       receptors                 sympathomimetic          amines.    Bronkosol     should
                                                                                                               not be administered         along with epinephrine         or
dilates     and relaxes          bronchi      and certain           arterioles.
                                                                                                               other sympathomimetic            amines    as such drugs are
    lsoproterenol           acts on both Betai            and       Beta2 receptors.                           direct cardiac     stimulants     and may cause
    Isoetharine        is different.    “It’s a much more selective    Beta2                                   excessive    tachycardia.       They may, however,        be
stimulator.”1        It exerts     only a minor part of its action  on                                         alternated    if desired.     Dosage    must be carefully
Betai     receptors.                                                                                           adjusted   in patients      with hyperthyroidism,        acute
                                                                                                                   coronary          disease,            cardiac            asthma,           limited          cardiac
                                                                                                                   reserve        and in individuals                    sensitive             to
                                                                                                                   sympathomimetic        amines,     since                             overdosage                  may
                                                                                                                   result in tachycardia,     palpitation,                               nausea,
                                                                                                                   headache           or epinephrine-Iike                          side effects.

                                                                                                                    Method     of                  Usual                                                Usual
                                                                                                                    AdmInIstratIon                 Dose                      Rang.                      DIlutIon
        Epinephrine                                                                                                                                4                         3.7

        gaagha                                   .                                      Q2                          Hand      Nebulizer            inhalations               inhalations                Undiluted
                                                                                                                                                                                                        1:3 with
                                                                                                                    Oxygen                                                                              saline   or
         Norepinephrine                                                                                             Aerosolization*                1/2   ml                  1/4.1/2   ml               other diluent
        selective-alpha
                                                                                                                                                                                                        1:3 with
         Isoproterenol                           :                                                                                                                                                      saline   or
                                                                                                                    IPPBt                          /2    ml                  #{188}-iml                 other diluent
        dual-beta1,beta2                                               -


                                                                                                                   *Administration          with         oxygen      flow        adjusted         to    4 to    6 Iiters/
        Isoetharine
                                                                                                                     minute       over a period      of 15 to 20 minutes.          May be adminis-
        preferential            beta2,
                                                                                                                     tered     simultaneously       with    other   therapeutic       agents     such    as
        lesser      affinity       for   beta1                                                                       antibiotics        or wetting  agents.
                                                                                                                   tUsually        an inspiratory      flow rate of 15 liters/minute             at a cy-
*Based        on studies        2,3.                                                                                 cling      pressure      of 15 cm H30        is recommended.            It may be
                                                                                                                     necessary,         according    to patient    and type of IPPB apparatus,
                                                                                                                     to adjust       flow rate to 6 to 30 liters/minute;            cycling     pressure
.       relaxes                bronchospasm              promptly                                                    to 10 to 15 cm H30;           and further      dilution    according      to needs
                                                                                                                    of the patient.
.       relieves               congestion                                                                          SUPPLIED:              10 ml. dropper                    bottles.
C       improves                 ventilation-perfusion                     balance                                 REFERENCES:
                                                                                                                   1. Petty, T.: (ACP Panel)           Emerg.       Med. 3:116, June,        1971.
                                                                                                                   2. Lands,     A. M., Arnold,       A., McAuliff,       J. P., Luduena,       F. P.,
 Experience                              in Practice                                                               and Brown,
                                                                                                                   3. Lands,
                                                                                                                                    T. 0. , Jr. : Nature
                                                                                                                                A. M., Luduena,
                                                                                                                                                              214:597-598,
                                                                                                                                                         F. P., Grant,
                                                                                                                                                                                   May, 1967.
                                                                                                                                                                             J. I., and Ananenko,       E.:
In nine clinical     reports     on patients   given isoetharine       with                                        J. Pharmacol.       Exptl.    Therap.,      99:45-56,      Jan., 1950. 4. Levine,
                                                                                                                   E. R.: Dis. Chest,        49:610-624,      June,     1966. 5. Chervinsky,        P.,
phenylephrine        and thenyldiamine,4-12         adverse   effects     were                                     and Herstoff,      A.: J. Asthma        Res., 4:610-624,          Mar., 1967.
reported      to be absent45’#{176} or insignificant.6-9”12           In four                                      6. Shubin,     H. : J. Germantown           Hosp.,     6:57-64,     Oct., 1964.
                                                                                                                   7. Miller,   J.: Ann. Allergy,        25:520-527,        Sept., 1967. 8. Spielman,
of the studies     in which      results  were tabulated    on the usual                                           A. D.: Current       Therap.     Res., 3:235-242,         June,     1961. 9. Baker,
4 or 5 point scale,       a total of 81 % of the patients        experienced                                       A. G. : Ann. Allergy,        22:180-186,       Apr., 1964. 10. Goldfarb,          A. A.,
                                                                                                                   and Romanoff,         A. : Ann. Allergy,        20:307-314,       May, 1962.
good to excellent        bronchodilation      and improvement          of                                          11. Unger,      D. L., and Unger,         L.: Dis. Chest.        51:153,  Feb., 1967.
pulmonary                         12
                                                                                                                   12. Siegel,       C.: Lancet,         82:461-464,          Nov.,       1962.


                                                                                                                      Bronkosol#{174}
aTa1’iFT#{149}             BREON      LABORATORIES                INC.
..II1        iku           90 ParkAvenue,  NewYork,         N.Y. 10016                                      The Beta2                                      Inhalant                                Solution


                                                                    When      writing   please   mention   CHEST                                                                                                            13
PREPARATIONOF MANUSCRIPTS                                                                                                CHEST

     Manuscripts            should        be submitted                 to   ent to readers  outside     your field, even if                           ment the conclusions.                     A longer            strip of a
the Editor-in-Chief,                 Alfred       Soffer,       M.D.,       you seem to explain     too much to your col-                             particularly     illustrative              lead may be used
4nerican           College         of Chest           Physicians.           leagues.         AVOi(l    specialized        laboratory          jar-    for arrhythmias.           For          ECG         figures,         as In-
 112 East Chestnut                  Street,       Chicago,         Illi-    gon and abbreviations,                but use technical                   deed       for all other                 illustrations,               there
rtpis 60611.           An original           on 8#{189}”x 11”               terms      as necessary,         defining       those       likely        should        be no dates            or other            informatfqn
 heavy      duty        white      bond       paper         and one         to be known           only in your field. Readers                          on the illustration             itself.
 4uplicate       copy should be provided.                                   will skip a paper          they do not understand.                             All illustrations          must be numbered                          pd
      All copy         must     be double             spaced,         in-       Provide     enough        details      of method           and        cited in the text. Legends                       should          bepyo-
 cluding      references,         legends,        and footnotes.            equipment        so that     another        worker       can re-          vided for each illustration,                     listed on a #{232}p-
:   ach of these seents                    of the manuscript                peat your work, but omit minute                       and com-            arate       sheet     of paper.              Each          illustralj,n
 hou1d       begin       on a new page:                 title page;         prehensive         details      which        are generally                should         have     the following                  lightjy         pn-
 synopsis;       references;          legends;        tables.      The      known       or which can be covered                by citation            cilleci on the back or typed on a gumd
 title page         should       include         the institution            of another      paper.                                                    label affixed to the back of the figure:                                 fig-
 at which         the work           was performed,                  the        Use the active voice more often than the                              tire number,          title of manuscript,                      narnqof
 academic          title     of each         author,         and       an   passive,       which        usually        requires          more         senior       author     and arrow             indicating           t#{243}f o
 address        for reprint            requests.          Subheads          words and often obscures                  the agent of ac-                figure.       No paper         clips should                be in #{226}on-
 should      be used          to provide           guidance           for   tion. Use first person,               not third;         do not           tact with the illustrations;                    the illustratjpns
 the reader;         this format         can be flexible,           but     use    first person        plural      when        singular        is     should        be placed         in a separate                  enveppe
 the subheads               would         ordinarily          include        appropriate.                                                              to be mailed          with the text.
 such topics as: Introduction,                     Methods          and                                                                                    Composite          figures         and figures               labeled
 Materials,       Case Reports,             Discussion.                                                                                                 A, B, C, D, etc., cannot                        be repro4wed
                                                                            references
                                                                                                                                                       adequately          without          loss of detail.                Thus,
                                                                                 These       should      be cited consecutively                 in     each segment           must he considered                      as a sep-
synopsis
                                                                            the       text      as superscript            numerals           and       arate illustration.           An acceptable                 amount          of
     Each major article         will be preceded        by                  listed       on a separate            sheet      in numerical              documentary             (lata      is approximately                    . one


 a synopsis       which     will also be translated                         order.        Each      reference       should       contain,        in    illustration       for each four pages                       of menu-
 into foreign       languages       for inclusion    in a                   order,        the following:           author       (last name,            script.
 special    section      in Chest.      Following      are                   initials);       title of article          (lower       case,     no           A letter of permission                   must acconpany
 guidelines     for composition        of the synopsis:                      quotation           marks);      source,      volume,        inclu-       all photographs            when there is a possibility
                                                                             sive page            numbers,       year of publication;                  of identification.
 1)      It should      not exceed   150 words   (case                       abbreviation           of journal      names should            con-
          reports    and manuscripts    of five pages                        form to the Index Medicus.                     Following         are
          or less-50      words).                                            examples          of references:                                         color             illustrations

 2)      Begin         with       a statement         of purpose       of   1 Doe            JC,     Public  JQ:        Coronary          insuf-           The Journal     encourages     the inusion
          the study,             unless    this     is embodied        in        ficiency.         Chest 56:20-22,          1969                      of full color illustrations     and will pay part
          the title.                                                        2 Comroe         JH: The Lung:   Clinical Physi-                          of the expense     of reproduction      and ‘print-
                                                                                 ology    and Pulmonary    Function   Tests.
                                                                                                                                                      ing. The cost for the author’s          share may
 3)       Clearly   support      the subject    discussed
                                                                                 Chicago,     Year Book, 1962, p 281                                  be     obtained         from       the    editorial        oes.
          by new facts,       expressed      in the past
          tense, not the present.       Use the present                     3 Luisada     AA: Bedside        diagnosis     of ar-
          tense for generalizations.                                             rhythmias,   in Advances        in Cardiopul-                        fables
                                                                                 monary  Diseases    (Vol III). ed by Banyai
 4)      Give numbers           when possible.      “Five     of
                                                                                 AL, Gordon       BL, Chicago,      Year Book,                            Tables      should    be self-explanatqry              and
         eight      patients”      is better   than      “62.5
                                                                                 1966                                                                 should       supplement,         not     duplicate,         the
         per cent.”          Some    mention    of dosages
                                                                                                                                                      text. Tables        must be numbered                opnsecu-
          is desirable.                                                        Personal  communications        should   not                           tively     and each must          have a title.          Each
 5) Metric               units     and    the     Centigrade       scale    be included   in the list of references,    hut
                                                                                                                                                      table    should       be typed       double-spaced           on
                                                                            may be cited    in the text in parentheses.                               a separate        sheet.  Tables       consisting      of not
          are preferred.
 8) Do not                    say, “The      findings      are pre-                                                                                   more than 6 to 12 columns                 are acceptable.
    sented”                    or “The     treatment         is dis-        illustrations
          cussed.”             Use the direct      approach.    For
          example,              “In our study         of (so many
                                                                                   In     preparing            original        drawings         or     manuscript                    editing
                                                                             graphs,        use black         india      ink. Typewritten
          patients)              having (disease),       we found
                                                                             or freehand             lettering         is not acceptable.                   Manuscripts          are received          witi    the un-
          that,       etc.
                                                                             All lettering          must be clone professionally.                      derstanding           they       have      not been           sub-
 7) The synopsis         comprises     material     pre-                     Do not send original                   art work, x-ray films              mitted        to other       journals                     m
                                                                                                                                                                                                  or n#{248}ws edia.
    sented    before      the main      body    of the                       or ECC tracings.               Glossy print photographs                   Chest       is not responsible            in theevent           any
     communication          and should       not be a                        are preferred;             good black and white                con-       manuscript           is lost. Manuscripts                become
     simple   duplication        of the conclusions.                         trast     is essential.                                                   the      permanent           property         of Chest          and
                                                                                   Electrocardiograms                are notoriously         dif-      may not be published                   elsewhere         without
                                                                             ficult to reproduce                adequately.        The paper           written        permission         from the author              and
    writing              the       paper                                                                                                               journal.          All accepted            manuscripts            are
                                                                             smudges          easily and great             care must be ex-
    Present                  the news      of your      finding    or         ercised      in preparing            a glossy print. Unless               subject        to manuscript            editing.       Reprints
 a statement                    of the problem    first, support-             an arrhythmia              is to be illustrated,           one or         should        be ordered            at the        time     galley
 ing details                   and arguments        second.     The           two complexes                should        be photographed                proofs       are seen.        An order         form     for this
    significance               of your work should       be appar-           using only those leads necessary                         to docu-          purpose          is incorporated             ip the       proof.




    14
Products made
with he
individual
patieitt
in mind.




Research and
development
make them                                                                                                                                  II’


that way.

How do wg know what your                 result, we’ve made those products
patient nees.  Simple, Mnaghan           to conform    with the patient’s          department            did to improve          on
has been tking    to the people          needs. As an example,      let’s take     a simple disposable               plastic
who use ow products     and, as a        a look at what our R&D                    face mask.

inlet has a frue 360 degree                                                           ‘   no metal clips on strap to
swivel for lministration                                                                  injure skin and eyes with
oxygen frQpi either side of                                                               “slingshot” effect
bed; won’t crimp hose                                                                     beaded strap for easier
rodesigne    mask shape                                                                   removal       especially       in
comfortaby                                                                            emergency
anyone’s     npse                                                                 no       slippage of beaded strap
molded     ch,ekbones                                                                ‘clean      room” prepackaged
patient coifort    with     minimal                                                   with oxygen tubing attached;
air leakage                                                                           tubing far exceeds     industry
softer, more                                                                          standards.
vinyl conforms    to the     shape                                                    air goes directly to patient’s
of the face                                                                           nose because     nose inlets
strap is mpre pliable       and                                                       angled at 34 degrees
softer, nocutting    into     ear                                                    ‘exhaust vent holes on both
webs with prolonged          use                                                      sides with one always open
                                                                                      for added safety
    Sound jke we went to a lot           about your patients.    And that                           I   monaghan
of trouble just for a mask? We           same care goes into the design                                 A Division     of
did. It’s Monaghan’s   way of            and production    of all the                                   Sando:- Wander,     Inc
                                                                                                        SX Alcott     St.
saying “We Care”-about      you,         products   in our total respiratory                            Inver.     Colorado   802W
                                         care systems.
                                      When   writing   please   mention   CHEST                                                       15
The link between           the life-giving
instrument      and the patient.                OverlOOlinkiof
Monaghan        offers over 150
LifeLine1M links in conductive                  the LifeLine...
and non-conductive             neoprene,
silicone, and disposable             plastic.
    All of our disposables            are
“clean room” packaged,                and


                                                                                                                                                              7
many are available           in both adult
and pediatric       sizes. What’s
more, our disposable             LifeLine
comes in systems already
adapted     to all brands of
competitive       equipment.
    Over 100 disposable            products
provide you with a full line of
accessories      for all types of
respiratory     care. Monaghan’s
high quality products            insure
patient safety and comfort.
There’s no chance for cross-
                                                JPPB Therapy       Systems      and Components           Collection     and Retard      Valve    Manifold!
infection    and no need for costly,            COMPLETE          SYSTEMS-                               Nebulizer        Hose Assembly.
                                                                                                                       #{149}                     Nebulizer
time-consuming          sterilization.          Monaghan/Bennett           or Bird compatible              Manifold
                                                                                                         #{149}            s’kuthpiece
                                                                                                                         #{149}                Corrugated
                                                                                                                                            #{149}
                                                  Standard
                                                #{149}          System #{149} Collection
                                                                            Gas               and        Flextube       Support
                                                                                                                      #{149}                  Floor Stand
                                                                                                                                     Arm #{149}
You save time and money while                   Retard    Valve    System #{149}COMPONENTS                 “On
                                                                                                         #{149} Guard”      Alarm
protecting     your patients.                     Standard
                                                #{149}          Manifold/Nebulizer        Gas
                                                                                       #{149}


16                                                     When     writing      please   mention    CHEST
                                                                                         ,,v’               ‘,




                                          __
                                                                                                                   I

                               Oxygen Therapy         Systems    and Components                 OXYGEN         THERAPY           SYSTEM-Low
                               OXYGEN          MASK     SYSTEMS-Adult                           Concentration         OXYGEN
                                                                                                                   #{149}             THERAPY
                               Under-The-Chin,        Adult Over-The-Chin,                      SYSTEM        COMPONENTS                Nasal Catheters
                                                                                                                                     #{149}
                               Pediatric   Over-The-Chin           High Concentra-
                                                                #{149}                            Airways/Guedel
                                                                                                #{149}                       Oxygen Masks #{149}
                                                                                                                          #{149}                 Nasal
                               tion, n-Rebreathing          #{149} Concennation,
                                                              High                              Cannula #{149}Oxygen      Tubing
                                                   Madium     Concentration.




                               AerosolHwiiclficadon/Nebithzadon                                  ostomy    Mask                  Oxygen
                                                                                                                     Flextube #{149}
                                                                                                                   #{149}                       Masks-
                               Systemsand Components         HUMIDIFIER!                         Aerosol    Tracheostomy      Adaptors
                               NEBUUZERS          Also Available
                                               #{149}             th    Heater
                                  APPUCATION
                               #{149}                  SYSTEMS           Face
                                                                      #{149}    Tents.
                               Tracheostomy        Masks wfHose          Aerosol
                                                                      #{149}
                               Masks w/Hose           COMPONENTS
                                                   #{149}                      Trache-
                                                                            #{149}




monughun                                                                                        On-Stream        Drug Vials #{149}Manifold       Air
                                                                                                                                              #{149}
                               Systems and Components             APPUCATION                                 Tracheostomy
                                                                                                Filters #{149}                              Trache-
                                                                                                                                 Masks #{149}
A Thvision of
                               SYSTEMS-Adult              and Pediatric     Face
                                                                         #{149}                 ostomy      Adaptors        Oxygen
                                                                                                                         #{149}       Masks
Sandoz-Wander,      Inc.
                                          Tracheostomy
                               Tents #{149}                   Masks wfHose                         Flextubes
                                                                                                #{149}
51Xi Akott     St.
                                  Aerosol
                               #{149}        Masks w/Hose          COMPONENTS
                                                                #{149}
Denver,    Colorado    80204
                               #{149}           Mouthpiece
                                             #{149}            Drug Vials.

                               When      writing   please   mention    CHEST                                                                              17
An Invitation



                                                             Fourth Annual                                   Fall Scientific                    Assembly
                                                                                               (38th           Annual    Meeting)


                                                               American                      College                  of Chest Physicians
                                                                                       Denver,            October       22-26,          1972




CALL         FOR       ABSTRACTS                                                                                         will     be       in      the      same             area         as the            lecture          rooms.
The        Program                Committee                     invites            submission                   of       Please         request            scientific              exhibit           application                 forms
abstracts          (circulation,                   respiration,                thoracic-cardio-                          from       the        Chairman,                Scientific                Exhibit          Committee,
vascular          surgery, and related                                systems)           for presen-                     American                 College          of        Chest               Physicians,              112         East
tation          at the 1972   Annual                                  Meeting            in Denver,                      Chestnut            Street,         Chicago,                Illinois         60611.            Exhibitors
October            22-26.           Membership                        in the       College             is not            need       not         be members                   of the           College.              DEADLINE:
a prerequisite                   to participation                       in the        program.                In-        APRIL          15, 1972.
vestigators           from              outside         the      United            States         are wel-
come,           provided     abstracts                    and presentations                            are       in      FILM       PROGRAM
English.           The   Scientific                     Program    Committee                                 will        The      Motion            Picture         Committee                       for     the        Fourth         An-
communicate        their                          decisions      to                all applicants                        nual Fall Scientific                     Assembly                 welcomes                 submission
within   six weeks   after                         the deadline,                   April 15, 1972.                       of scientific  motion                      pictures                for their             review.     Sev-
Presentations                    will      be        limited           to     10      minutes            with           eral      sessions               have      been             scheduled                 for        presenta-
2 minutes             for discussion.     Abstracts   accepted                                                for        tion     of      films      and         discussion                  periods.             Please            write
publication             will be published       in CHEST.                                                                the Chairman,                    Motion             Picture             Committee,                112        East
1.    Abstracts             should              be      approximately                    200          words             Chestnut                Street,         Chicago,                 Illinois         60611,           for       film
      in length           and           typed         double           spaced.           Please          pro-            applications.
      vide       an original                and        three          carbon           copies.
2.    Include    the title                 of the            paper,          names   of authors
                                                                                                                        CECILE            LEHMAN                 MAYER               RESEARCH                     AWARD
      and institutions                     where             work           was performed.                              PAPERS
3.    Provide             full          address              where             correspondence
                                                                                                                        The       Cecile            Lehman               Mayer               Research                  Award           for
      should         be directed.
                                                                                                                         basic         research            is open            to     physicians                   of     residency
4.    Identify        individual                   who         will         present         the       paper.
                                                                                                                        or fellowship                     status   or         under            age 35. The sum of
5.    Mail       abstract           to:     Roger            S. Mitchell,              M.D.,          Chair-
                                                                                                                        $1,000    will             be       awarded             the          investigator present-
      man, Scientific   Program        Committee,    American
                                                                                                                         ing     the       best          paper          on      pulmonary                     diseases,               and
      College  of Chest    Physicians,      112 East Chestnut
                                                                                                                        $1,000   will be awarded    the investigator                                                   presenting
      Street,        Chicago,                     Illinois            60611.           DEADLINE:
                                                                                                                         the best paper on cardiovascular        disease.                                                Abstracts
      APRIL         15,          1972.
                                                                                                                         in triplicate              (250         words)             of     unpublished                     material
CALL         FOR      SCIENTIFIC                      EXHIBITS                                                          should            be       submitted                  by         April        15,         1972         to      the
The     American                 College             of Chest           Physicians             will      pre-           Chairman,                 Research              Forum,               American                  College              of
sent scientific   exhibits                          as a major   feature                              of the            Chest           Physicians,       112                 East         Chestnut                Street,           Chi-
Annual   Fall Scientific                          Assembly.   The exhibit                              space            cago,          Illinois    60611.




18
                                              ‘ti1                                                         home...

                                              care problems.
                                               provisions       for an external                intensive    care use. Offers
                                               compressed          gas source offering         variable oxygen mixture             and
                                               an easy means of delivering                an   humidification         control.
                                               oxygen enriched           atmosphere                1%,I51o A heavy-duty          hospital!
                                               when needed. Lightweight                 and    home-care       IPPB unit that can
                                               low cost, the M515 does not                     be gas or compressor            driven.
                                               require costly upkeep making it                 Economical,        reliable, simple
                                               ideal for at-home          use. And its         to operate.
                                               quiet operation          permits use in             M5O5 Avery low cost,
                                               any environment.                                versatile    IPPB that can be
                                                   Using Monaghan            disposables       mounted       nearly anywhere.          Flow
                                               with the M515 adds to its                       rate pressure       and nebulizer        can
                                               convenience          and safety. The            be varied by front panel controls.
             iii offers a variety      of      instrument        is easy to clean, and             The M701 “On Guard” Alarm
           for the treatment         of the    all accessories        may be stored             System sounds an immediate
        variety of today’s                     inside the case. For home use,                   warning when any malfuntion
                  care problems.       Our     the M515 is the IPPB of choice.                 occurs in the IPPB systems Use
            IPPB is the M515, a                    Other Monaghan            IPPB’s...          it to insure continuing          safe,
versatile,      home-care       unit that          M520 A versatile,           gas-driven,     effective     therapy.
includes       a self-contained                assistor-controller         especially               Monaghan.       The company          to
compressor.         There are also             suited for postsurgical           and            look to for innovations           in IPPB
                                                                                                therapy for today and tomorrow.




                                                               monaghan
                                                               A Lvision      of
                                                               Sandoz-Wander,       Inc.
                                                               5(X) Alcott    St.
                                                               Denver,     Colorado    80204
                                                                                                                                              19
COLLEGE                         NE’\IVS                                                         9:30    a.m.       Respiratory           Mechanics

                                                                                                                   Jere       Mead,      M.D.

                                                                                              10:00a.m.            Arterial      Blood         Techniques         and
Postgraduate          Course:                                                                                      Methods   of Sampling
Respiratory         Function        and Therapy                                                                    Joseph  F. Tomashefski,                   M.D.
Dates:                                                                                        1 0:30    a.m.       Coffee       Break
January       27-29,       1972                                                               10:45a.m.            Radioactive            Methods

Sponsors:                                                                                                          Leonard A. Swanson,           M.D.
American     College    of Chest Physicians                      and                          i i :1 5 a.m.        Pulmonary     Ventilation      Measurements
The Hospital      of the Good Samaritan                        Medical       Center,                               Hurley    L. Motley,     M.D.
Los Angeles
                                                                                              1 1 :45   a.m.       Diffusion           Capacity      Measurements
Location:                                                                                                          Bertrand           J. Shapiro,     M.D.
The Hospital           of the Good           Samaritan         Medical       Center,
Los Angeles,           California                                                             12:15     p.m.       Lunch-Hospital                 Auditorium
Course      Directors:                                                                        Afternoon         Session:       Alterations          of Pulmonary         Function
Hurley      L. Motley,   M.D.                                                                 in Disease
Joseph       F. Tomashefski,             M.D.
                                                                                              Chairman:         Joseph        F. Tomashefski,              M.D.
Course Description:
This three-day            program           on respiratory            function       and        1:45    p.m.      Obstructive  Abnormalities
therapy       is directed        to the practicing             internist        and the                           Hylan A. Bickerman,       M.D.
physician        with special            interest      and clinical           needs in
the area of circulation                    and respiration.              The course            2:15     p.m.       Restrictive Abnormalities
will emphasize           clinical      pulmonary          physiology          in health                            Hurley L. Motley,   M.D.
and disease.           Major        consideration           will be placed             on
the techniques            of pulmonary             function        testing       and on        2:45     p.m.      Respiratory           Mechanics      in
the determination               and evaluation              of function           abnor-                          Obstructive           and Restrictive             Disease
mality.      Practical        application          in patient          management                                 Jere Mead,            M.D.
will   be stressed.
                                                                                               3:15p.m.           Coffee        Break
The subject          matter       to be covered           in the program             can
be grouped          in five sessions:                                                          3:30     p.m.      Alveolar       Hypoventilation
 1. Pulmonary          function         testing                                                                   Joseph        F. Boyle, M.D.
2. Alterations         of pulmonary              function       in disease
                                                                                               4:00     p.m.      Alveolar Hyperventilation
3. Physiologic          therapy                                                                                   Joseph F. Tomashefski,                     M.D.
4. New developments                   in respiratory          function         and
     therapy                                                                                   4:30     p.m.      V/Q Abnormalities
5. Practical          application            with     case       presentation            in                       Oscar J. Balchum,                 M.D.
     pulmonary         emphysema,               pulmonary           fibrosis,      bron-
     chitis,     acute       respiratory          acidosis,        and bronchial
     asthma.
                                                                                              FRIDAY,          JANUARY          28,      1972
The case presentations          will              include    the history    and
physical   find ings, laboratory                  findi ngs, roentgenologic
findings,  complete      pulmonary                  function   measurements                   Morning      Session:         What’s       New
and treatment      procedures.
                                                                                              Chairman:         John      K. Shirey,       M.D.
Enrollment:         Maximum            200
                                                                                               9:00     a.m.      In Emphysema
Tuition:   (including    luncheons)                                                                               Joseph    F. Tomashefski,                  M.D.
ACCP     members:     $100                                                                     9:20     a.m.      In Microatelectasis
Non-members:        $125                                                                                          Hurley   L. Motley,   M.D.
Residents:     $50
                                                                                               9:40     a.m.      In Air Pollution
Hotel Accommodations:                                                                                             Oscar J. Balchum,                 M.D.
Information     concerning     occupancy                    will    be sent      to ap-
plicants    upon registration.                                                                10:00a.m.           In Aerosols
                                                                                                                  Hylan A. Bickerman,                   M.D.

THURSDAY,              JANUARY           27,     1972                                         10:20a.m.           Coffee        Break

 8:00      a.m.      Registration                                                             10:40     a.m.      In Asthma
                                                                                                                  Alexander            Kahn,     M.D.
Morning Session:              Pulmonary         Function           Testing
Chairman: Hurley              L. Motley,        M.D.                                          11:00     a.m.      In Hyperbaric    Medicine
                                                                                                                  Edwin R. Levine,    M.D.
 9:00      a.m.      Spirometry          and     Lung     Volume
                     Measurements                                                             11:20     a.m.      In Pulmonary    Function                  Equipment
                     Roman        L.   Yanda,      M.D.                                                           Karlman   Wasserman,                  M.D.
                                             Detecting    impairments
                                             of the lung...
                                             Pulmonary      function equipment
                                             flow rate, 2) vital capacity                           which measures           maximum       flow
                                             (PVC), 3) volume expelled       in                     rate of forced expiration           of both
                                             one second (FEV ), and 4)                              children     and adults. Also avail-
                                             minute   breathing  capacity                           able are the standard          and low
                                             (MBC). All these tests require                         range models of the Wright
                                             only a few minutes to perform.                         Peak Flow Meter.
                                                The M402 provides      a flow and                       Monaghan        diagnostic     equip-
                                             volume             output     for printout        on   ment        another
                                                                                                                .   .   .    part of our
                                             either       strip charts          of X-Y              continuing      dedication      to total
                                             recorders.            The     readout     meter        respiratory      care. Assuring       you
                                             can be adjusted   to be compatible                     that Monaghan           is the company
                                             with high accuracy     diagnostic                      to come to for the most modern,
                                             equipment,              as well as for                 dependable        equipment       in the
Because diagnosis is as important            barometric              pressure  variations.          respiratory      care field.
as therapy    in respiratory       care,     Its lightweight,   compact    design
Monaghan       is introducing       a new    and ease of use makes the M402
screening
Pulmonary
             unit-the
                Function
                            M402
                             Analyzer.
                                             ideally suited for mass screening
                                             of lung impairments      in office,                    I                           monaghan
                                                                                                                                A Division     of
The Analyzer       measures       four       clinics, and hospitals.                                                            Sandoz-Winder.      Inc.
valuable   parameters       of                   You can also utilize our M403                          .
                                                                                                            .   .
                                                                                                                            .   5X)Akott
                                                                                                                                Denver,
                                                                                                                                               St.
                                                                                                                                           Colorado    80294
pulmonary      function:      1) peak        Electronic     Peak Flow Indicator

                                            When      writing     please   mention   CHEST                                                                     21
 College             News        continued
 11:40a.m.                   In Patient         Monitoring
                                                                                                                     7:30    p.m.        Dinner
                             Max      H. Weil,       M.D.
                                                                                                                     8:30    p.m.        The American        College of
12:00         noon           Lunch-Hospital                   AuditOrium                                                                 Chest Physicians         1980
                                                                                                                                         Albert    H. Andrews,     Jr., M.D.
Afternoon             Session:            Physiologic          Therapy                                                                   President     Elect, American       College                  of
                                                                                                                                         Chest Physicians
Chairman:              Joseph            F. Tomashefski,              M.D.

     1 :45 p.m.              Oxygen         Therapy                                                             SATURDAY,                JANUARY          29,      1972
                             Hylan       A. Bickerman,               M.D.                                       Morning          Session:         Practical       Applications             with
     2:15     p.m.           Mechanical            Assistance            (IPPB)                                 Case Presentations
                             Edwin        R. Levine,          M.D.                                              Chairman:           Hurley        L. Motley,       M.D.
     2:45     p.m.           Rehabilitation in Chronk                        Pulmonary                               8:00    a.m.        Pulmonary       Emphysema
                             Disease                                                                                                     William     B. Joy, M.D.
                             Roman L. Yanda, M.D.                                                                                        Discussant:      Joseph  F. Tomashefski,                      M.D.
     3:1 5 p.m.              Coffee       Break                                                                      8:45    a.m.        Pulmonary         Fibrosis
                                                                                                                                         Alexander        Kahn, M.D.
     3:30     p.m.         Bronchodilators,     Wetting     Agents,
                                                                                                                                         Discussant:        Edwin R. Levine,                 M.D.
                           Expectorants     and Antibiotics
                           John K. Shirey,     M.D.                                                                  9:30    a.m.        Bronchitis
                                                                                                                                         John K. Shirey,   M.D.
     4:00     p.m.           Bronchopulmonary                   Cleansing
                                                                                                                                         Discussant:   Edwin R. Levine,                      M.D.
                             Karlman    Wasserman,                 M.b.
                                                                                                                10:15        a.m.        Coffee      Break
     4:30     p.m.         Complications      of Long                  Term
                           Mechanical      Ventilation                                                          10:30a.m.                Acute Respiratory       Acidosis
                           William    B. Joy, M.D.                                                                                       William     B. Joy, M.D.
                                                                                                                                         Discussant:      Joseph F. Tomashefski,                       M.D.
                      LOS          ANGELES            HILTON             HOTEL
                                                                                                                11:15a.m.                Bronchial   Asthma
     6:30     p.m.           Cocktail  Reception                Courtesy          of                                                     John K. Shirey,     M.D.
                             Riber Laboratories                                                                                          Discussant:    Hylan A. Bickerman,                         M.D.




                                                                            APPLICATION               FOR         ENROLLMENT

            Postgraduate
       Respiratory
                                     course:
                              Function       and
                                                        NAME             -
                                                        ADDRESS_______________________                                         -______________________
                 Therapy
         Hospital of the Good                           CITY/STATE                                                                                                    ZIP_________
      Samaritan    Medical Center                       TYPE          OF PRACTICE
        Los Angeles, California
                                                        Please      reserve _____ tickets                for the Dinner  (January  28, 7:30 P.M.)                    at $7.50        ea.
            January        27-29,        1972                    Tuition:  ACCP members,                   $100; non-members,     $125; residents,                    $50

Remittance             for     tuition      should      accompany             enrollment       application.           Make      checks     payable       to the     American          College       of Chest
Physicians.            Forward           to: American          College       of Chest      Physicians,        112 East Chestnut               Street,     Chicago,        Illinois     60611.       Refund,
excluding            $10     registration         fee, will     be made        for cancellations          received      prior    to January        17,   1972.

Accreditation:  The continuing     education  program        for physicians,                                   sponsored         by the American     College           of Chest Physicians,               has
been accredited    by the Council     on Medical      Education       of the                                  American          Medical Association,      and          is acceptable    for            credit
toward the American    Medical    Association    Physician’s      Recognition                                   Award.

HOWARD               S. VAN ORDSTRAND,                         M.D.                     ALFRED        SOFFER,           M.D.                             BRADFORD      W. CLAXTON,                    M.Ed.
Chairman,            Postgraduate Medical                                               Executive      Director                                          Director of Continuing
Education            Committee                                                                                                                           Education




22
    In ultrasonic       nebulization,  if the                                                     Nebulizer       and the M690
    particles     aren’t small enough,                                                            Ultrasonic       Anesthesia           Humid-
    they won’t reach the desired                                                                  ifier. The M650 very effectively
    sites of action.      That’s an                                                               administers        drugs by on-stream
    important       point.                                                                        or direct application.              Its
        That’s why we closely              control                                                penetrating        particles       are in the
    the manufacture            of the                                                             same size range as the M67Os.
    Monaghan          M670 Ultrasonic                                                             The M690 adds moisture                     to
    Humidifier.        It has a uniform                                                           anesthesia       systems       to help lessen
I   output    of particles        1 to 8                                                          lung irritation        and general
    microns       in size with 43.9%                                                              dehydration         during       prolonged
    smaller     than 3 microns          at a                                                      surgery. And the M690’s small
    minimum         delivery     of 3 cc. per                                                     size makes it welcome                 in even
    minute.     This supplies         a stable,      the crystal.     And the M670 can be         the smallest        of operating          suites.
:   reliable     volume      of fog under            used with IPPB instruments             for   Both the M650 and M690 are
I   total control,       making      the M670        in-line humidification.         You can      UL approved.           and all accesswies
    quite suitable     for prolonged                 get the complete         system   from       are available        for them.
    tent or mask therapy.         And the            Monaghan         from instrument       to        Monaghan          ultrascnic        equip-
    unit automatically       shuts off               all accessories.                             ment delivers         the benefits          where
    when the water is depleted                           In addition      to the M670, we         they’re     needed.
    providing    extra protection      for           make the M650 Ultrasonic




                                les...




                     monaghan
                      A Division     of
                      Sando:-Wande,;      Inc.
                      5(XJ Alcott St.
                      Denver.    Colorado   80204
                                                                                              MONDAY,          FEBRUARY              28
 COLLEGE                             NEWS
                                                                                              Acute     Lung     Disease

Postgraduate                 Course:
                                                                                               7:00     a.m.        Introduction  and Orientation
Modern      Concepts              in Acute and            Chronic                                                   Ernest K. Cotton, M.D.
Cardiorespiratory                 Care-Newborn,              Adult
                                                                                               7:30     a.m.        Shock       in the      Newborn
Dates:
                                                                                                                    George       Gregory,      M.D.
February            28   -   March        2, 1972
                                                                                               8:30     a.m.        Asthma
Sponsors:                                                                                                           Alexander        Spock,      M.D.
American            College       of Chest        Physicians
Pediatric           Pulmonary             Department,
University        of Colorado     Medical    Center                    and                     9:30     a.m.        Discussion
National        Cystic   Fibrosis   Foundation
                                                                                               4:30     p.m.        Guest lecturers     available    for questions
Location:                                                                                                           Individual  audio-visual      aids available
The Inn at Thunderhead
Steamboat  Springs,   Colorado                                                                 4:30     p.m.        Resuscitation   in the Respiratory              Distress
                                                                                                                    Syndrome
Course        Directors:                                                                                            George Gregory,    M.D.
Ernest       K. Cotton,           M.D.,      Margo      Pinney,       P.H.N.
                                                                                               5:30     p.m.        Assisted Ventilation in Asthma
Course        Description:                                                                                          David N. Myers, M.D.
This    four-day       postgraduate           course      is being presented
in a resort area to create                   a relaxed       and informal          at-         8:00     p.m.        Meet the Faculty Social             Hour
mosphere.         Its purpose           is to provide         physicians        with                                Courtesy,   The Monaghan             Company,
up-to-date       information          on pulmonary          problems        in new-                                 Division  of Sandoz-Wander,             Inc.
born children           and adults.           Specifically,        the program                                      Ski Movie
will   present       updated         diagnostic         and therapeutic            in-
formation        in such problems                 as RDS, reactive           airway
disease       and chronic            obstructive         problems.       Didactic
lectures,      slides,      movies        and practical         sessions        with          TUESDAY,         FEBRUARY               29
actual equipment              will be used to present              the material.
Specific      subjects       to be covered           by the faculty       include:            Chronic     Lung       Disease
shock in the newborn,                 individual       audiovisual       aids, as-
sisted ventilation          in asthma,         cystic fibrosis       and chronic
obstructive         airway        disease        in children         and adults,               7:00     am.      Cystic Fibrosis and Chronic                Obstructive
congenital           lung      disease,       oxygen     transport,          blood   gases,                      Airway    in Children
resuscitation,  intensive    care, hospital    and home care,                                                    Alexander    Spock,   M.D.
as well as inhalation     therapy    and related   equipment.
Time has been allotted      for small group work and prac-
                                                                                               8:00     a.m.     Chronic  Obstructive   Airway in Adults
tice sessions.
                                                                                                                 Thomas   L. Petty, M.D. and
Enrollment:                                                                                                      Louise  M. Nett, R.N., A.R.I.T.
Maximum:             100
                                                                                               4:30     p.m.        Questions:    Adult Problems
Tuition:                                                                                                            Thomas     L. Petty, M.D. and
                                                                                                                    Louise   M. Nett, R.N., A.R.I.T.
ACCP members:      $100
Non-members:     $125
Residents:   $50                                                                               5:30     p.m.        Infections      and Lung Disease
                                                                                                                    Kenneth        McIntosh, M.D.
Hotel       Accommodations:
A block    of rooms      has                  been reserved     at the Inn at
Thunderhead,       Steamboat                     Springs, Colorado.   See ap-                 WEDNESDAY,               MARCH          1
plication    form.
                                                                                              Other     Pediatric       Lung Problems

SCHEDULE                 OF     INSTRUCTION
                                                                                               7:00     a.m.        Foreign       Body

                                                                                                                    Ernest       K. Cotton,      M.D.
SUNDAY,              FEBRUARY               27
                                                                                               7:30     a.m.        Croup
  4:00       p.m.        Registration                                                                               Ernest       K. Cotton,      M.D.




24
We don’t sell you                                                                                you
The Monaghan                                 and he’ll have his service engi-
                                             neer partner back to you within
                                                                                          believe that service is at least
                                                                                          as important  as sales.
Sales/Service                     Ibain      hours. He’s fully equipped              to
    We at Monaghan            aren’t just    handle any problem            because of
interested in selling         you our        his extensive      factory     training
products.     We also     want    to be      program.      He’s equipped          with
sure those     products       are always     test instruments       ari replacement
working      for you and your                parts to facilitate      on-site repairs.
patients.    That’s   why our service        If, by chance, your instrument
engineer     is an integral      part   of   must be removed,           he will loan
our field force even though you              you a replacement           until yours is
probably      won’t need him often.          repaired.     It’s as simple as that.                     monaghan
                                                                                                       A Division     of
   If one of your instruments                    Monaghan       will field 21 such                     Sandoz-Wander,       Inc.
malfunctions,      simply place a call       sales/service      teams across the                       5(X) Alcott    St.
                                                                                                       Denrer,     Colorado    80204
to your Monaghan         representative,     United States because             we
                                             When   writing   please   mention   CHEST                                                 25
                                                      Capastat#{174}uIfate (eom                                                                                                                            sulfate)
                                                    Ampoules                                   equiva’ent                         to 1 Gm. capreomycin                                                       activity
            a new product                                                                           with important                                                                               considerations


                     Not      for      Pediatric                  Use                                 Whop                is it contraindicated?                                                  travenous     doses      of capreomycin.        This
                                                                                                                                                                                                  action    was    enhanced        by ether     anes-
                                                                                                    Caprdomycin                          is     contraindicated                             in
                                 Warnings                                                                                                                                                         thesia    (as has     been    reported    for neo-
                                                                                                    those         patients              who         are      hypersensitive
                                                                                                                                                                                                  mycin)               and          was             antagonized                            by
  The        use of capreamycin                                    in patients                      to it.
                                                                                                                                                                                                  neostigmine.
  with        renal insufficiency                                 or preexist-                                                                                                                       Caution               should              be      exercised                    in     the
  ing        auditory                  impairment                       must          be
                                                                                                                Note              the         precautions
                                                                                                                                                                                                  administration                    of antibiotics,                           including
  undertaken                    with          great             caution,           and              Audiorpetric                    measurements                             and          as-
                                                                                                                                                                                                  capreomycin,                     to any             patient                 who         has
  the        risk       of      additional                      eighth-nerve                        sessment               of vestibular                  function              should
                                                                                                                                                                                                  demonstrated                      some              form               of     allergy,
  impairment                     or         renal          injury          should                   be      performed               prior         to initiation                 of ther-
                                                                                                                                                                                                  particularly                 to drugs.
  be        weighed              against                 the       benefits               to        apy      with          capreomycin           and                    at     regular
  be      derived    from                      therapy.                                             interval6             during      treatment.                                                               It has              these                  adverse
        Refer     to animal                        pharmacology                                       Regular               tests of renal    function                          should                                           reactions
  section         for   additional           informa-                                               be ma                 throughout      the period                           of treat-          Nephrotoxicity-In                                  36     percent                 of 722
  tion.                                                                                             ment,          nd           reduced             dosage              should            be      patients           treated         with capreomycin,       ele-
      Since      other    parenteral         antituber-                                             employed                    in patients       with                  known               or    vation           of the          BUN above       20 mg/lOU
  culous      agents     (streptomycin,           viomy-                                            suspectd                   renal   impairment.                                                ml. and             of       the NPN     above                               35 mg./
  cm)       also       have          similar          and                                                 Renal          Injury,           with        tubular               necrosis,            100 ml.            has        been observed.                                In many
  sometimes                   irreversible       toxic   effects,                                   elevatiQp              of      the        blood          urea            nitrogen             instances,               there          was             also           depression
  particularly                   on eighth-cranial-nerve                                            (BUN)            r         nonprotein                 nitrogen                 (NPN),         of P.S.P.          excretion                 and         abnormal                   urine
  and        renal         function,                simultaneous                     ad-            and        abpormal                   urinary            sediment,                   has      sediment.              In      10 percent                      of this            series,
  ministration                      of these                 agents                with             been   noted.    Renal                             function      studies                      the BUN elevation                             exceeded                       30 mg./
  capreomycin                        is not              recommended.                               should   be made     both                          before   capreomy-                         100 ml. or the NPN                             exceeded                      50 mg./
  Use with      nonantituberculous            drugs                                                 cm therapy    is started                            and on a weekly                            100 ml.
  (polymyxin,        colistin        sulfate,   gen-                                                basis        4uring  treatment.                             Slight      eleva-                    Toxic         nephritis       was       reported       in one
  tamicin,    kanamycin,           and neomycin)                                                    tion       of the BUN or NPN                               has     been      ob-              patient           with      tuberculosis            and     portal
  having              ototoxic               or      nephrotoxic                     po-            served               in a significant                           number       of               cirrhosis           who       was      treated        with    cap-
  tential         should       be                   undertaken                     only             patients              receiving    prolonged                        therapy.                  reomycin              (1 Gm.)                and       aminosalicylic
  with        great      caution.                                                                   The appearance      of casts,    red cells,   and                                             acid    daily          for one               month.        This patient
      Usagein     Pregnancy-The             safety                                                  white  cells in the urine     has been      noted                                             developed                renal                insufficiency           and
  of the use of capreomycin              in preg-                                                   in a high               percentage                    of these   cases.                       oliguria             and     died.      Autopsy          showed
  nancy       has not been      determined.                                                         Elevation              of the BUN                     above    30 mg./                        subsiding              acute     tubular       necrosis.
        Pediatric                   Usage-Safety                              of the                100        ml.        or      any          other         evidence                      of            Ototoxicity-Subclinical                                              auditory
  use        of capreomycin                              in      infants           and              decreasjg                   renal         function           with         or with-            loss       was         noted            in        approximately                              11
  children             has            not         been           established.                       out a rie      in BUN                      levels   calls                for care-            percent  of patients                               undergoing                       treat-
                                                                                                    ful evaluation      of                     the patient,                   and   the           ment with capreomycin.                                   This               has     been
                                                                                                    dosage        should      be reduced                           or the drug                    a 5 to 10-decibel               loss     in the 4,000                                        to
            When                is it indicated?                                                    completely            withdrawn.                            The      clinical                 8,000-CPS          range.       Clinically         apparent
Capreomycin,                          which     is                 to be        used                significance           of abnormal                             urine       sedi-              hearing       loss     occurred         in 3 percent                                         of
concomitantly                         with  other                   appropriate                     ment      and     slight     elevation                        in the BUN                      722     subjects.            Some          audiometric
antituberculous                        agents,                 is indicated                    in   (or total     NPN)                   observed                during              long-        changes    were                   reversible.                    Other   cases
pulmonary                    infections                  caused            by        cap-           term    capreomycin                              therapy                 has        not       with permanent                      loss were                    not progres-
reomycin-susceptible                                  strains           of Myco-                    been          established.                                                                    sive      following              withdrawal                     of capreomy-
bacterium                    tuberculosis                       when       the        pri-             The peripheral                       neuromuscular            block-                       cm.
mary      agents                (isoniazid,                    aminosalicylic                       ing action     that                   has    been     attributed        to                          Tinnitus           and        vertigo              have               occurred.
acid,        and       streptomycin)                           have        been            in-      other         pojypeptide                     antibiotics                 (colistin                 Liver-Serial                   tests          of         liver          function
effective            or cannot                 be        used         because               of      sulfate,          polymyxin       A sulfate,    paromo-                                       have      demonstrated                      a decrease                         in BSP
toxicity           or the           presence                   of resistant               tu-       mycin,           and    viomycin)    and     the amino-                                       excretion       without                  change      in                     SGOT    or
bercle     bacilli.                                                                                 glycoside         antibiotics       (streptomycin,                                            SGPT     in the                 presence                   of preexisting
    Susceptibility                     studies                 should         be     per-           dihydrostreptomycin,               neomycin,                                      and         liver disease.                 Abnormal                    results   in liver
formed   to determine                                    the       presence                    of   kanamycin)             has    been      studied                                  with         function           tests     have              occurred     in                    many
a capreomycin-susceptible                                               strain                 of   capreomycin.                    A partial              neuromuscular                          persons              receiving                  capreomycin                                 in
M.      tuberculosis.                                                                               block         wgs          demonstrated                  after           large        in-     combination                  with       other            antituberculous

 26
    agents
    changes


    normalities
    riodic
                 in
    of capreomycin
                      which
                                  hepatic


                                  is not
                     determinations
                                      also


                                         in producing
                                                     are
                                               function.


                                                     clear;
                                                              of
                                                                 known



                                                                      however,
                                                                      liver
                                                                                 The
                                                                                    to cause


                                                                                these


                                                                                     function
                                                                                              role
                                                                                               ab-
                                                                                                  pe-
                                                                                                            trations
                                                                                                            lowest
                                                                                                            egg protein
                                                                                                            from
                                                                                                            method
                                                                                                                     in liquid
                                                                                                                                     for
                                                                                                                                 media


                                                                                                                         1 to 5 mcg./ml.
                                                                                                                              is used.
                                                                                                                                         that
                                                                                                                            (7H10 or Dubos)
                                                                                                                                                  M.         tuberculosis




                                                                                                                                                       Comparable
                                                                                                                                                                  when                the
                                                                                                                                                                                          are
                                                                                                                                                                                          and
                                                                                                                                                                                                   free of
                                                                                                                                                                                                     range
                                                                                                                                                                                                 indirect
                                                                                                                                                                                           inhibitory
                                                                                                                                                                                                            are
                                                                                                                                                                                                                               by deep
                                                                                                                                                                                                                               large


                                                                                                                                                                                                                               creased
                                                                                                                                                                                                                                          intramuscular
                                                                                                                                                                                                                                       muscle
                                                                                                                                                                                                                               injections
                                                                                                                                                                                                                                             Capastat


                                                                                                                                                                                                                                                   mass,
                                                                                                                                                                                                                                                               may
                                                                                                                                                                                                                                                             pain
                                                                                                                                                                                                                                                                         Sulfate




                                                                                                                                                                                                                                                                           and
                                                                                                                                                                                                                                                                                be        associated
                                                                                                                                                                                                                                                                                          the
                                                                                                                                                                                                                                                                                                should
                                                                                                                                                                                                                                                                                                    injection
                                                                                                                                                                                                                                                                                                 since
                                                                                                                                                                                                                                                                                                                   be
                                                                                                                                                                                                                                                                                                                     into
                                                                                                                                                                                                                                                                                                             superficial


                                                                                                                                                                                                                                                                                                     development
                                                                                                                                                                                                                                                                                                                         with
                                                                                                                                                                                                                                                                                                                                   given



                                                                                                                                                                                                                                                                                                                                           in-
                                                                                                                                                                                                                                                                                                                                            of
                                                                                                                                                                                                                                                                                                                                              a
                                                                                                                                                                                                                                                                                                                                                           I
    are       recommended.
          Blood-Leukocytosis
    nia have                been      observed.
                                                                    and
                                                                       The
                                                                                    leukope-
                                                                                    majority
                                                                                                            concentrations
                                                                                                            7HlO
                                                                                                            bility
                                                                                                                          agar
                                                                                                                           testing.
                                                                                                                                           is used
                                                                                                                                                  When
                                                                                                                                                         are
                                                                                                                                                                for
                                                                                                                                                                       obtained
                                                                                                                                                                         direct
                                                                                                                                                                      indirect
                                                                                                                                                                                            suscepti-
                                                                                                                                                                                            suscepti-
                                                                                                                                                                                                      when                         sterile


                                                                                                                                                                                                                                   tered
                                                                                                                                                                                                                                               abscesses.
                                                                                                                                                                                                                                        Capreomycin
                                                                                                                                                                                                                                                     in combination
                                                                                                                                                                                                                                                                                     is         always
                                                                                                                                                                                                                                                                                                 with at
                                                                                                                                                                                                                                                                                                                       adminis-
                                                                                                                                                                                                                                                                                                                   least  one
                                                                                                                                                                                                                                                                                                                                                           4
    of patients                 treated       have                      had          eosino-                bility         tests         are       performed                         on     standard                               other              antituberculous                             agent            to which
    philia
    receiving
                       exceeding
                            daily            injections
                                                           5 percent
                                                                      of capreomy-
                                                                                       while                tube
                                                                                                            tible
                                                                                                                          slants
                                                                                                                          strains  are
                                                                                                                                            with
                                                                                                                                          inhibited
                                                                                                                                                         7H1 0 media,
                                                                                                                                                                                      by 10 to 25
                                                                                                                                                                                                 suscep-                           the
                                                                                                                                                                                                                                   is susceptible.
                                                                                                                                                                                                                                                  patient’s                strain
                                                                                                                                                                                                                                                                            The
                                                                                                                                                                                                                                                                                            of
                                                                                                                                                                                                                                                                                          usual
                                                                                                                                                                                                                                                                                                     tubercie
                                                                                                                                                                                                                                                                                                         dose           is 1 Gm.
                                                                                                                                                                                                                                                                                                                                bacilli
                                                                                                                                                                                                                                                                                                                                                           4!
    cm.       This          has         subsided                   with         reduction                   mcg.         / ml. Egg-containing                                        media,  such                                  daily              (not          to       exceed      20                mg./Kg.                      per
    of      the       capreomycin                          dosage               to     2 or             3   as       L#{246}wenstein-Jensen                             or   ATS,                 require                          day)              given               intramuscularly                        for                60     to
    Gm.      weekly.                                                                                        concentrations                         of 25 to 50 mcg./ml.                                            to              120             days,            followed                    by         1 Gm.                   intra-
        Pain    and                induration         at                the      injection                  inhibit     susceptible                     strains.                                                                   muscularly                        two         or three                times           weekly.
    sites    have                 been       observed.                         Excessive                           Cross-Resistan                         ce-Frequent                                   #{227}ross- (Note-Therapy                                                           for        tuberculosis
    bleeding                at the            injection               site      has          been           resistance                 occurs                  between                    capreomy-                                should      be                   maintained                      for eighteen                          to
    reported.                Sterile            abscesses                     have           been           cm and                 viomycin.                    Varying                   degrees                  of              twenty-four                       months.                    If facilities   for                     ad-
    noted.                                                                                                  cross-resistance                           between               capreomycin                                           ministering                           injectable                  medication                         are
        Hypersensitivity-Urticaria                                                            and           and          kanamycin                        and           neomycin                        have                       not available,                            a change                  to appropriate
    maculopapular                             skin         rashes             associated                    been          reported.                No cross-resistance                                       has                   oral            therapy                is indicated                     upon              the        pa-
    in       some           cases              with           febrile           reactions                   been           observed                 between        capreomycin                                                     tient’s              release                from         the        hospital.)
    have            been            reported                when              capreomy-                     and          isoniazid,                ammnosalicylic                               acid,         cy-
    cm   and      other      antituberculous                                               drugs            cioserine,                 streptomycin,                             ethionamide,                                                     Animal                       pharmacology
    were    given       concomitantly.                                                                      or       ethambutol.                                                                                                   In addition                      to renal               and         eighth-cranial-
                                                                                                                                                                                                                                   nerve      toxicity       demonstrated      in animal
                       How               does               it act?                                              Dosage                     and              administration                                                        toxicology          studies,      two dogs    have    de-
    Human                   PharmacologyCapastat#{174}                                                      Capastat#{174}    Sulfate       (capreomycin          sul-                                                             veloped         cataracts        while   on doses       of ‘
    Sulfate               (capreomycin           sulfate,                            Lilly)           is    fate,     Lilly)  should       be dissolved         in 2                                                               62 mg./Kg.                            and          100         mg./Kg.                    for
    not absorbed       in significant          quantities                                                   ml.     of Sodium         Chloride        Injection      or                                                            longed      periods.
    from    the  gastro-mntestinal            tract       and                                               Sterile     Water    for Injection.      Two to three                                                                      In teratology                                 studies,                 a    low
    must   be administered          parenterally.            In                                             minutes              should            be allowed                        for complete                                  dence                of ‘ ‘wavy                     ribs’ ‘ was                 ,

    two           studies           of ten           patients                each,           peak           solution.              For         administration                             of a 1-Gm.                               litters            of female                    rats treated
    serum             concentrations                           following                   1 Gm.            dose,          the entire   contents    of the ampoule                                                                 doses                of     capreomycin                            of      50                          ,; J.
    of capreomycin                            given              intramuscularly                            should            be given.    For doses     of less than                                                              ad              higher.
    were      achieved                       one        to two                hours           after          1 Gm.,          the      following                  dilution                 table             may
    administration,                          and        average                 peak            1ev-        be       used.                                                                                                                                     How                  supplied
    els reached                     were             28 and   32 mcg./ml.                                                             DILUTION                         TABLE                                                       apastat#{174}                     Sulfate
    respectively                    (range,            20 to 47 mcg./ml.).
                                                                                                                                                                                                                                                                                                                                   i,
                                                                                                                                                                                                                                   fate, Lilly),                    equivalent
    Low serum                  concentrations         were                            present                   Diluent                            Volume of
                                                                                                               Added to                             Capastat                          Concentration*                               mycin                   activity,                                                     ,   ruibor-
    at twenty-four                 hours.     However,                               1 Gm. of                                                                                                                                      stoppered
                                                                                                            1-Gm. Ampoule                      Sulfate Solution                           (Approx.)
    capreomycin                         daily           for thirty                   days   or
    more    produced                       no         significant                   accumu-                        2.15 ml.                            2.85 ml.                       350       mg.     per       ml.                                                                                    ‘h            #{149}   [051971]
                                                                                                                   2.63 ml.                            3.33      ml.                  300       mg.     per       ml.
    lation            in     subjects    with     normal  renal                                                                                                                                                                                                                                                                                        ,
                                                                                                                   3.3 ml.                             4.0       ml.                  250       mg.     per       ml.
    function.               Two patients      with marked      re-                                                 4.3       ml.                       5.0       ml.                  200       mg.     per       ml.
                                                                                                                                                                                                                                                                                                                                                  .1
    duction      of renal                    function    had                 high          serum
                                                                                                            *Stated in terms of mg. of capreomycin activity.
    concentrations                           twenty-four                     hours            after
    administration                           of the           drug.           When            a        1-         The         solution                  may             acquire                   a         pale
    Gm.            dose        of       capreomycin                           was          given            straw   color                   and      darken                with    time,    but
    intramuscularly                            to normal                      volunteers,                   this is not                    associated                   with    loss     of po-
    52 percent                    was          excreted                 in      the urine                   tency           or the development           of        #{149}
                                                                                                                                                                                                                            . ..         .

    within             twelve       hours.                                                                  After          reconstitution,     solutions      of v                                                            ,,             ,,


        Paper              chromatographic                                    studies    in-                astat          Sulfate       may be stored      4
    dicated              that    capreomycin                                 is excreted                    eight          hours             at     room
                                                                                                            up       to fourteen                  days          under                                                   ,
    essentially                   unaltered.                  Urine           concentra-                                                                                         .


    tions           averaged                  1 .68        mg./ml.               (average
    urine           volume,                  228       ml.)        during              the        six
    hours            following                a 1 -Gm.              dose.
           Microbiology-Capreomycin                                                      is ac-
    tive        against       human                                strains              of M.
    tuberculosis.
       The       susceptibility                             of      strains             of        M.
                                                                                                                                     -,.           ,ulfate
    tuberculosis                        in     vitro                                with                                         information          on this drug                                      a
                                                                                                                                 request       from     the ).
    mediaand                                                                                  -
                                                                                                                          _._,‘sion,        Eli Lilly      and
    eral,    the            minimum                                                                              Janapo1is,           Indiana       46206.




,
 College         News           continued

     8:00    a.m.          Congenital             Lung         Disease                                                 8:00        a.m.        Blood      Gases
                           William           Parry,      M.D.                                                                                 William         H. Parry,       M.D.
                           Question            Period                                                                                         Resuscitation
                                                                                                                                              David N. Myers, M.D.
     4:30    p.m.          Lung or Heart Disease?                                                                                             Intensive     Care
                           James J. Nora, M.D.                                                                                                Mary Sue Jack, B.S.N.
                                                                                                                                              Chronic    and Home Care
     5:30    p.m.          Oxygen Transport                                                                                                   Margo Pinney, P.H.N.
                           Gerd Cropp,  M.D.,                    Ph.D.                                                                        Inhalation    Therapy     and
                                                                                                                                              Related    Equipment
                                                                                                                                              Janet Kerkman,        R.N., A.R.I.T.
THURSDAY,                  MARCH              2
                                                                                                                     1 0:00        a.m.       Workshop   and practice                      sessions
Practical           Aspects          of Management                                                                                            (small groups)




                                                                            APPLICATION                   FOR         ENROLLMENT

Postgraduate
Modern
                  Course:
           Concepts    in Acute
                                                          NAME                        .
and Chronic     Cardiorespiratory                         ADDRESS                      .                                       .

Care-Newborn,       Adult                                 CITY/STATE                                                                                                          ZIP________________
February        28    -   March       2, 1972             TYPE           OF PRACTICE
The Inn at Thunderhead
Steamboat            Springs,         Colorado           Tuition:          ACCP      members,        $100;      non-members,              $125;      residents,      $50.
Remittance            for tuition            should      accompany                enrollment        application.        Make        checks          payable       to the American            College    of Chest
Physicians.        Forward     to: American    College of Chest Physicians,                                       112 East Chestnut     Street,    Chicago,                     Illinois      60611.         Refund,
excluding        $10 registration     fee, will be made for cancellations                                       received  prior to February     18, 1972.

Accreditation:             The continuing               education           program        for physicians,          sponsored         by the American              College     of Chest Physicians,               has
been accredited    by the Council     on Medical      Education    of the                                          American         Medical         Association,       and     is acceptable           for     credit
toward the American     Medical   Association    Physician’s    Recognition                                          Award.

HOWARD              S. VAN           ORDSTRAND,                  M.D.                           ALFRED          SOFFER,            M.D.                           BRADFORD     W. CLAXTON,      MEd.
Chairman                                                                                        Executive        Director                                         Director of Continuing Education
Postgraduate              Medical          Education           Committee



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28
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                                                                                                          :

                                        For     many          of your patients             with    mild       rent   to treatment          (although   the   usu-
                                        to moderately               severe       hypertension,                al precautions           concern-
                                        you     may choose      to go                 to      diuretic        ing thiazide         I rauwolfias,                    I
                                        with    rauwolfia  therapy.                                           of course,         will   apply).
                                             Enduronyl,  with     its 24-hour                        ac-
                                        tion and scored-tablet         flexibility,                    is     EnduronyI                    Tablets
                                        just that much     easier     for your                       pa-      methyclothiazide 5 mg. with deserpidine 0.25 mg.
                                        tient to take.
                                              The      product       is well     tolerated,         and       Enduronylx                   Forte
                                        side        effects      usually       are   not a deter-             methyclothiazide     5 mg. with deserpidine 0.5 mg.

See   following   page for Brief Summary.                                                                                                                    107322
Brief Summary
E N DU RONYL                                                       and
                                                       (Enduron#{174} Harmonyl)
Methyclothiazide and Deserpidine, Abbott
Description-ENDURONYL            is an orally-administered    combination of Enduron                                  taking digitalis. Sensitivity to digitalis is increased with reduced serum potassium
(methyclothuazide) and Harmonyl#{174}    (deserpidine). Methyclothiazide is a potent oral                             and signs of digitalis intoxication may be produced by formerly tolerated doses of digi-
diuretic-antihypertensive    of the benzothiadiazine (thiazide) class. Deserpidine is a                               talis. Hypochloremic alkalosis may occur following intensive or prolonged thiazide
purified rauwolfia alkaloid which produces antihypertensive and tranquilizing ef-                                     therapy. Replacement of chloride may be indicated in such cases.
fects. The combined antihypertensive actions of methyclothiazide and deserpidine                                         Thiazides may decrease serum P.B.I. levels without signs of thyroid disturbance.
result in a total clinical antihypertensive effect which is greater than can ordinarily
be achieved by either drug given individually.                                                                           Deserpidine should be used cautiously in patients who have a history of peptic
                                                                                                                      ulcer because the drug may cause a rise in free and total hydrochloric acid and an
Actions-The      predominant effects of Enduron (methyclothiazide) are diuresis, natriu-                              increase in volume of gastric secretion.
resis, and chloruresis. The excretion of sodium and chloride is greatly enhanced;
potassium excretion is low. Although urinary excretion of bicarbonate is increased                                       The drug should be withdrawn or dosage reduced during the two weeks prior to
slightly, there is usually no significant change in urinary pH. The diuretic and saluretic                            elective surgery. An unexpected degree of hypotension and bradycardia has been
effects are produced by inhibition of renal tubular reabsorption. These effects reach a                               reported during anesthesia in patients under treatment with rauwolfia alkaloids.
peak in about six hours and persist for 24 hours foIIowin administration of a single                                     When emergency surgical procedures are necessary, parenteral administration of
oral dose. In non-edematous patients the ‘peak” (maximum effective) natriuretic                                       vagal blocking agents to prevent or reverse hypotension and/or bradycardia may be
single dose of Enduron is 10 mg., whereas the “peak” kaliuretic dose is 5 mg. Thus,                                   considered.
doubling a single daily dose of 5 mg. results in an increase of sodium output without                                    In epileptic patients therapy may necessitate dosage adjustment of anticonvulsant
significantly      increasing      potassium      excretion.                                                          medication. Rauwolfia alkaloids lower the convulsive threshold and shorten seizure
   Enduron also has antihypertensive properties and has been shown to enhance the                                     latency. When patients on deserpidine receive electroshock tjierapy, use lower milliam-
response to other antihypertensive drugs. The mechanism by which the benzothiadia-                                    perage and shorten the duration of stimulus initially, since more prolonged and se-
zines, including methyclothiazide, produce a reduction of elevated blood pressure has                                 vere convulsions as well as apnea have been reported with previously well tolerated
not been definitely established. Sodium depletion, however, would appear to be of                                     stimulation. Shock therapy within 7 days after giving the drug is hazardous.
primary importance.                                                                                                      As with all rauwolfia preparations, severe mental depression has appeared in a
   Enduron is readily absorbed from the gastrointestinal tract and it is excreted un-                                 small percentage of patients. Usually, the patient had a pre-existing, incipient, en
changed by the kidneys.                                                                                               dogenous depression which was unmasked or accentuated by the deserpidine. This
   The pharmacologic actions of Harmonyl (deserpidine) are essentially the same as                                    true depression should be differentiated from the transient lethargy, physical fatigue, or
those of other active rauwolfia alkaloids. The antihypertensive effect is attributed to a                             change in mood that may occur during initiation of therapy. When the drug is dis-
reduction of peripheral vasoconstriction resulting from a central action on the vasomotor                             continued, depression usually disappears, but active treatment, including hospitaliza-
mechanism. This effect is often accompanied by bradycardia. The tranquilizing proper-                                 hon for shock therapy is sometimes required. Watch for symptoms of depression,
ties of the drug also may be beneficial in the treatment of hypertension, especially                                  particularly in patients whose histories are questionable. Alert responsible members of
when anxiety and emotional factors are present                                                                        the family to the problem.
   Harmonyl is adequately absorbed from the gastrointestinal tract, but exhibits a flat                               Adverse Reactions-Blood           dyscrasias, including thrombocytopenia with purpura,
dose-response curve. Also several days to several weeks may elapse before the full                                    agranulocytosis, and aplastic anemia, have been reported with thiazide drugs, and
effects of the drug become manifest At least halfofan orally administered dose appears                                this possibility should be kept in mind.
in the urine; the fate of the remainder is unknown.                                                                      Thiazides            have been reported,             on rare occasions,           to have elevated           serum calcium
lndications-ENDURONYL           (methyclothiazide and deserpidine) is indicated in the                                to hypercalcemic levels. The serum calcium levels have returned to normal when the
treatment of mild to moderately severe hypertension. In many cases ENDURONYL                                          medication has been stopped. This phenomenon may be related to the ability of the
alone produces an adequate reduction of blood pressure. In resistant or unusually                                     thiazide       diuretics      to lower the amount              of calcium        excreted      in the urine.
severe cases ENDURONYL also may be supplemented by more potent antihypertensive                                          Elevations of blood urea nitrogen, serum uric acid, and blood sugar have occurred
agents. When administered with ENDURONYL, more potent agents can be given at                                          with the use of thiazide drugs. Symptomatic gout may be induced.
reduced dosage to minimize undesirable side effects.                                                                     Other side effects that may accompany thiazide therapy include anorexia, nausea,
Contraindicatlons-ENDURONYL            (methyclothiazide and deserpidine) is contraindi-                              vomiting, diarrhea, headache, dizziness, paresthesias, weakness, skin rash, and
cated in patients with a known sensitivity to methyclothiazide and/or other thiazide                                  photosensitivity ; jaundice and pancreatitis also have been reported.
diuretics. It should not be used in patients with severe renal disease (except nephrosis)                                Although not established as an adverse effect of methyclothiazide, it has been
or complete renal shutdown. Thiazide diuretics should not be used in the presence of                                  reported that thiazide diuretics may produce a cutaneous vasculitis in elderly patients.
severe liver disease and/or impending hepatic coma. Hepatic coma has been reported
as a consequence of hypokalemia in patients receiving thiazide diuretics. Because of its                                 Side effects encountered with deserpidine are qualitatively similar to those reported
deserpidine content ENDURONYL is contraindicated in patients with severe mental                                       for reserpine, but the incidence of these untoward effects, particularly lethargy and
depression and suicidal tendencies, active peptic ulcer or ulcerative colitis.                                        depression, is lower. Side effects may include nasal stuffiness, abdominal cramps
                                                                                                                      and/or diarrhea, nausea, headache, weight gain, reduction of libido and potency,
Warninas-The       possibility of sensitivity reactions should be considered in patients                              aggravation             of peptic ulcer, epistaxis,           and skin eruption.
with a history of allergy or bronchial asthma.
                                                                                                                         Other side effects are excessive drowsiness, fatigue, weakness, dizziness, anorexia,
   There have been several reports, published and unpublished, concerninq non-specific                                and nightmares, which may be early signs of mental depression. The drug should be
small bowel lesions consisting of stenosis with or without ulceration, associated with the                            discontinued at the first sign of mental depression. In some patients severe mental
administration of enteric-coated thiazides with potassium salts. These lesions may                                    depression may lead to suicidal attempts. Any antihypertensive agent, including
occur with enteric-coated            potassium      tablets alone or when they are used with nonenteric               ENDURONYL, which can cause significant hypotension may precipitate angina in
coated thiazides, or certain other oral diuretics.                                                                    patients with arteriosclerosis who are prone to angina pectoris.
   These small bowel lesions have caused obstruction, hemorrhage and perforation.                                       Asthma may occur in susceptible persons. Although not established as side effects of
Surgery was frequently required and deaths have occurred.                                                             deserpidine, the following rare allergic reactions have been reported with related
   Available information tends to implicate enteric-coated potassium salts although                                   compounds: thrombocytopenia and purpura, and a syndrome manifested by dull
lesions of this type also occur spontaneously. Therefore, coated potassium-containing                                 sensorium, deafness, uveitis, glaucoma, and optic atrophy.
formulations should be administered only when adequate dietari supplementation is                                       Electrolyte imbalance and excessive salivation have been reported                                        during deserpidine
not practical, and should be discontinued immediately if abdominal pain, distention,                                  therapy, as with other rauwolfias.
nausea, vomiting or gastrointestinal bleeding occur.
                                                                                                                         A reversible typical Parkinson’s syndrome with large doses of rauwolfia alkaloids
   ENDURONYL(methyclothiazideand        deserpidine)does notcontain added potassium.                                  has occurred rarely.
Use in Pregnancy: ENDURONYL should be used with caution in pregnant women                                                 When adverse reactions occur, they are usually reversible and disappear when the
and nursing mothers since thiazides and rauwolfia alkaloids cross the placental                                       drug is discontinued.
barrier and appear in cord blood and in breast milk. The use of thiazides may result
in fetal    or neonatal         jaundice,    bone marrow          depression   and thrombocytopenia,          aI-      Dosage and Administration-ENDURONYL             (methyclothiazide and deserpidine) is
tered carbohydrate metabolism in newborn infants of mothers showing decreased                                         administered orally. Two tablet strengths (ENDURONYL and Enduronyl Forte), each
glucose tolerance, and possible other adverse reactions which have occurred in the                                    grooved, are provided to permit considerable latitude in meeting the dosage require-
adult Increased respiratory secretions, nasal congestion, cyanosis and anorexia                                        ments of individual patients.* Therapy should be instituted with the lower strength
may occur in infants born to rauwolfia-alkaloid treated mothers. When this prepara-                                   tablet, ENDURONYL (methyclothiazide 5 mg., deserpidine 0.25 mg.). Mild to moderate
tion is used in       women       of childbearing       age, the potential     benefits   of the drug should           hypertension may respond satisfactorily to a dosage of one lower strength tablet once
be weighed against the possible hazards to the fetus.                                                                  a day. This should be considered as the usual starting dosage, even in patients with
                                                                                                                       severe hypertension. Dosage may be increased to one and one-half ENDURONYL
Precautions-Thiazide    therapy should be used with caution in patients with severely                                  tablets or to one Enduronyl Forte (methyclothiazide 5 mg., deserpidine 0.5 mg.) tab-
impaired renal function because of the possibility of cumulative effects. Caution is                                   let once a day, depending upon the response to the initial dosage.
also necessary        in patients     with impaired       hepatic function     or progressive     liver disease.
                                                                                                                          Usually a period of ten days to two weeks of therapy is required to determine the
   It has been observed that thiazide drugs may reduce arterial responsiveness to                                     full effects of a given dosage. In all cases an effort should be made to determine the
levarterenol (nor-epinephrine). Accordingly, the dosage of vasopressor agents may                                     lowest effective dosage for each patient Dosage as low as one-half lower strength
need to be modified in surgical patients who have been receiving thiazide therapy.                                    tablet, once a day, may suffice in mild cases, whereas up to a maximum dosage of two
   Thiazide drugs may increase the responsiveness to tubocurarine.                                                    forte strength tablets, once a day, may be necessary to control some patients with
   The antihypertensive effect of the drug may be enhanced in the sympathectomized                                    moderate           to severe         hypertension.          There      is no contraindication               to combining    the
patient                                                                                                               administration of ENDURONYL with other antihypertensive agents.
   All patients should be observed for clinical sigos of fluid or electrolyte imbalance,                                When other antihypertensive agents are to be added to the regimen, this should be
including       hyponatremia        (“low-salt”      syndrome).      These include    thirst,   dryness    of the     accomplished gradually. Ganlionic blocking agents should be given at only half the
mouth, lethargy, and drowsiness.                                                                                      usual dose since their effect is potentiated by pretreatment with ENDURONYL.
  Hypokalemia may occur during therapy with methyclothiazide. In such cases supple.
mental potassium may be indicated. Potassium depletion can be hazardous in patients                                   ‘in addition each component is separately avajiabiens                    #{163}nduron(methyciothiazide)and Harmonyi
                                                                                                                      (deserpidine)forthooe         pati.ntz   whorquirefurtherindividuaiizationofdosage.                          1o7



30                                                                               When       writing       please    mention          CHEST
                                                                                           ,.     k                        Godart-Statham             overseas        is backed           by
                                                                                                  .-   -‘   .      :       nationwide         Statham         seice     over      here.
                                                                                                                   .2...         To find     out more     about       Godart-Statham
                                                                                                                           “‘4uct$,          write or call Statham     today.
                                                                                                                                   ,--     ‘nstruments,    Inc., Medical
                                                                                                                                                        tam E’ I., Oxnard,
                                                                                                                                                                            - -       11.


   ..,%-,.        ‘,    ,

with a 0.1 second     response           And            On the spot.                                                             The facts     will   leave     you breathless.
whether   your application     is pulmonary             And automatically.
function    testing or continuous     gas analy-         In addition,      Godart-Statham        makes                       -             ______I_
sis, there’s just nothing     else like it.          just about      every   other    kind of respiratory
    Then there’s the Capnograph,          designed   and gas analysis         system      you can think          of.         uIu-IIIj
to measure         dynamic   changes     in          From Nitrogen         Analyzers.      To Respiratory
respiratory      CO2. Like the Rapox,       it’s     Care Systems.
extremely     fast and simple. And no other             And    best   of all, everything        made        by
     While      effectively
relieving      bronchospasm
          in bronchitis-
         no need to
    upset the stomach.
                         Compared      to aminophylline,               Tablet : 200 mg oxtriphylline
                                                                       and 100 mg glyceryl              guaiacolate.
                         the bronchodilator      in Brondecon:         Elixir (5 ml tsp):
                                                                       100 mg oxtriphylline              and 50 mg
                    0 produces           less gastric                  glyceryl guaiacolate.
                      irritation                                      Indications:           Brondecon       is an
                                                                       adjunct       in the management             of
                    0 is more         soluble     and     stable       bronchitis,        bronchial      asthma,
                                                                      asthmatic        bronchitis,       pulmonary
                         in gastric      acid                          emphysema,            and similar chronic
                                                                       obstructive        lung disease.
                    0 is better        absorbed         from           It is indicated         when both
                         the G.I. tract.                               relaxation       of bronchospasm            and
                                                                      expectorant          action are desirable.

             BrondecoO                                                Precautions
                                                                      other xanthine

                                                                       particularly
                                                                                           : Concurrent
                                                                                                preparations
                                                                      may lead to adverse reactions,
                                                                                            CNS stimulation
                                                                                                               use of



                                                                      in children.
              oxtriphylline        and glyceryl         guaiacolate   Adverse        Reactions:        Gastric
                                                                      distress      and, occasionally,
                        Bronchodilator/                                palpitation
                                                                       have been reported.
                                                                                          and CNS stimulation

                                                                      Dosage:        Tablets-over          12 years
                        Expectorant                                   of age : one tablet, 4 times a day.
                                                                       Elixir-over          12 years of age:
                                                                      two teaspoonfuls,            4 times a day;
                                                                       from    2 to 12 years:
                                                                       one teaspoonful           per 60 lb body
                                                                       weight, 4 times a day.
                                                                      Supplied:         Brondecon         Tablets:
                                                                       bottles of 100. Brondecon                Elixir:
                                                                      237 ml (8 fi oz), 474 ml
                                                                      (16 fi oz) bottles. Full information
                                                                      is available        on request.

                                                                      WARNER.CHILCOTT
                                                                      Division, Warner.Lambert                   Company
                                                                      Morris Plains,   New Jersey                07950
                                                                         CHEST
L‘ML
                                                                        VOLUME                    60          I      NUMBER                     5    I       NOVEMBER,                             1971

EDITORIALS

                                                                                                                                                    esophagogastric                              sphincter               in neonates                    and infants.
The          Esophagogasfric                                                 Sphincter
                                                                                                                                                    Hypotonicity                       of         the lower                sphincter                  apparently     is
                                                                                                                                                    common      in the newborn      infant                                            and            almost           invari-
I         this
        page          issue, Dr.  Thomas attention
                     441 ) has called           W.                                     Holmes,the
                                                                                         to                   frequency( see
                                                                                                                        1                           ably is present   in the premature                                               in7                 Of        interest,
                                                                                                                                                    too, is the                 fact that the sphincteric                                        zone           is located
of esophageal        lesions                          in patients   who    have    spastic
                                                                                                                                                    above   the                  hiatus  of the  diaphragm                                           in          70 to 80
paralysis     or cerebral                           palsy.   He has quoted      the work
of Abrahams      and              2 who     were    the first to call                                                                               percent            of        newborn                    infants.6               As      the         child          grows,
attention   to this interesting        association,     at least      in                                                                            the       tone         of       the          lower           sphincter                increases                and         the
the English    literature.     Abrahams         and Burkitt      were                                                                               sphincter               assumes                 its     normal             position              straddling                the

unable          to explain        the frequency       of hiatal   hernia    or                                                                      hiatus           of the            diaphragm.                       Although                 chalasia              occurs
refiux        without      hiatal    hernia   in patients     with cerebral                                                                         commonly                     in        early           infancy,              the         disorder                 usually
palsy,           but           they           suggested                        that          extensor                   spasm,                      corrects              itself           as     the child                grows             and    the               defense
                                                                                                                                                    mechanisms                        at        the cardia                 become               normal.                  Occa-
incoordination                         of      deglutition                       accompanied                            by      air
swallowing,         and                     kyphoscoliosis                            are     possible  factors                                     sionally           cardioesophageal         relaxation,      described     ra-
which     predispose                         to incompetence                                of the esophago-                                        diologically             by Robins      and Jankelson8        and later    by
                                                                                                                                                    Neuhauser               and Berenberg,9        will persist.     The conse-
gastric          sphincter.                  Holmes                    has      speculated                    that          “cha-
                                                                                                                                                    quences            of persistent                        chalasia             may        be pulmonary,                        as
lasia”   of the lower    sphincter                                           is the primary       disorder
and    that    it is the    result                                          of vagal     hypertonicity.                                             manifested                      by           repeated                 episodes                    of      aspiration

Actually,                the        anatomic and  physiologic      basis                                                        for                                                 1 0     or the           principal              effect           may         be      in the
primary              incompetence          of the cardiac     sphincter                                                           in                esophagus                 because                      of      the         devastating           effect                       of
children             and adults      is yet to be determined.                                                                                       frequent              regurgitation                         of acid         gastric    content.’
      The        literature       on the anatomy        and physiology                                                              of                    Recently,                a fascinating                       chapter            has        been        added            to
the     gastroesophageal           junction                                          is extensive.        The                                       our knowledge                        of the control                          of the closing                       mecha-
reasons       for incompetence           and                                      reflux   in association                                           nisms  at the                     esophagogastric                            junction.   The                      studies
with     hiatal      hernia    are     rather                                        well                                             3
                                                                                                                                                    of      Giles         and                    oc2                     and        of     Castell              and          Har-
Displacement                       of the            esophagogastric                               sphincter                  into                  us3            have            suggested                    that       the           tone          of    the         lower
the         thorax             often           has            a        significant                effect             on         the                 sphincter               may            be      regulated               by the            hormone                  gastrin.
closing           mechanism                        of the              esophagogastric                         sphincter.                           Significant                    increases                    in      sphincter                    pressure                have

Recurring                 episodes                  of        reflux            esophagitis                       may         pro-                  been         demonstrated                         after             injection               of pentagastrin.
                                                                                                                                                    The        production                       of gastric             secretions               is now known                        to
duce      cicatrization,                           with                 both        shortening          of                      the
esophagus            and                     stricture                   at      the     esophagogastric                                            be subject                      largely                to hormonal                      control,      and   the
                     4    Permanent         damage       to the                                              sphincteric                            ingestion               of        either              acid  or alkali                   will     also exert     a
mechanism                  is an inevitable      consequence.                                                                                       profound                effect      on the production                                       of                       1 4     Of
      Primary              incompetence                                or      chalasia              of       the           lower                   correlative                interest     is the observation                                      that   ingested
sphincter                is less            well         understood,                        but      has          been          the                 acid will               decrease       the tone    of the                                   esophagogastric

subject   of intensive     study.                                             Information          regarding                                        sphincter                and,               conversely,                  that          administration                           of
this phenomenon        has been                                              derived      primarily        from                                     antacid           preparations                          will        result           in a strengthening
manometric                     studies             of the               esophagus                 and         its sphinc-                           of       the      physiologic                         barrier at the esophagogastric
                                                                                                                                                                        1 5 Thus,                  it would    appear       that orally admin-
ters.       The          application                     of        manometric                      techniques                       in
infants           and          children              has           been         of      particular                  interest.                       istered            antacids                    not    only   neutralize       acid   gastric
The         reader             is referred                        to     the         studies            of        Gryboski                          secretions,                 but         also        play         a role         in preventing                      gastric
and         associates#{176}              and Strawczynski         and     associates,6                                                             refiux.          The           influence                of chemical                   factors           on        sphinc-
who         have studied                    the pressure   characteristics          of the                                                          teric          competence                          is illustrated                    further            by         the       in-


                                                                                                                                          421
430                                                                                                                                                                                                                                              BURCH                      AND               McDONALD

of       clinical                improvement,                                  but           no          reduction                     in        heart         an       attempt                    to      carry                    the          load          of work                    imposed                     upon
size.           Three                  died               in      hospital                  and              two             died           shortly           the heart.                       Unfortunately,                                         arteriosclerosis                        is a diffuse
after            discharge.                           Experience                           with                this           small    group                  disease,                       so that         even                                    the      living                     sarcomeres        in
indicates                      that                I)ttients                 with             ischemic                         cardiomvo-                     general                     receive                       an               inadequate                           supply                   of          blood,
)athiy            achieve                      symptomatic                                l)eiiefit              from               prolonged                 certainly                      too         little              to meet                   the          demands                      of an active
1)ed           rest,           but            enhanced                         survival                   is unlikely                        unless           person.
clinical                improvement                                  is accompanied                                    by          a decrease
                                                                                                                                                                                                                                   REFERENcES
iii cardiac                    size.
       Postmortem                              studies                revealed                    those               changes                usual-             1 Burch                   GE,           (:iles               TD,           Colcolough                    UL         : Ischemic                     cardio-

ly encountered                                       in        cardiomyopathv,                                         including                   car-                 myopathy.                   Amer                Heart                 J 79:291,              1970
                                                                                                                                                                2 Case                  Records                   of           the            Massachusetts                         General                  Hospital:
diac           dilatation,                         endocardial                        thickening,                            and       myocar-
                                                                                                                                                                  New                Eng J Med 283:1392,                                               1970
dial           degeneration                                    and         fibrosis.                    In        addition,                      there          3       Bnrch          CE, Walsh ii, Black                                              \VC:          Value           of      prolonged                    bed
was            widespread                                 coronary                    arteriosclerosis                                 and            lo-               rest       in        management                             of cardiomegaly.                           JA\IA               183:81,               1963
calized                  regions                         of       myocardial                             fibrosis                   consistent                  4       Burch             CE,           DePasquale                             NP:          Hot        Climates,                 Man           and          His
rith             old             niyocardial                               infarction.                           Three                 patients                         Heart.               Springfield,                         Illinois,           Charles            C Thomas,                          1962
                                                                                                                                                                5       Burch             (;E,          DePasquale                             NP,       Hvnian               A, et        al:       Influence                   of
died             suddenly,                               presumably                           from                 arrhythmia                            or
                                                                                                                                                                        tropical               weather                   Ofl cardiac                        output,            work            and           power               of
acute            myocardial                               infarction.                      Five              patients                 died          fol-                right           and        left       ventricles                        of     man          resting           in      hospital.               AMA
lowing                  courses                      of         progressive                             worsening                      of         con-                  Arch            mt       \Ied         104:553,                         1959
gestive                heart                 failure,                one         complicated                                 by      pneumo-                    6 Burch                      CE,            DePasquale’                               NP:            Heart                Muscle                 Dise’ase

nia       and           one            rith               a pulmonary                          embolus.                        Ventricular
                                                                                                                                                                        ( Monograph                        ) . Disease-a-Month,                                     Chicago,                Yearbook                   Mcd-
                                                                                                                                                                        ical       Publishers,                        1968
arrhivthmias                                and                marked                     sensitivity                         to       digitalis
                                                                                                                                                                7       Burch                CE,           McDonald                             CD,      Walsh      JJ: The                                  effect              of
were            commonly                            encountered.                                                                                                        prolonged                   bed               rest          on        postpartal      cardiomyopathy.                                         Amer
       These                  studies                     support                    the            need                 to         recognize                           Heart            J    81 : 186,                1971
ischemia                    as a cause                          of the           classic                 clinical                  manifesta-                   8 McDonald                              CD,             Burch                 CE,           Walsh            JJ:      Alcoholic                    cardio-
                                                                                                                                                                        myopathy                    managed                           with            prolonged                    bed         rest.          Ann               Int
tions            of       cardiomyopathy.                                        To            accept                    the         entity              of
                                                                                                                                                                        ( in press)
                                                                                                                                                                        Med
ischemic                      cardiomyopathy                                         is       of          assistance                        to      the
                                                                                                                                                                9 McDonald       CD,                                  Burch               CE,          \Valsh           JJ    : Prolonged                     bed          rest
clinician                 in that                   he immediately                                 realizes                   its extreme-                        in the treatment                                           of      idiopathic                   cardiomyopathy.                              Amer                   J
ly      grave                 prognosis,                          resistance                       to          therapy             and     the                          Med         (in          press)
value             of          resting                    the         heart            even                if      it      requires                  the       10 Burch                       CE,          Ray                CT,              Cronvich                JA:           The          George                Fahr
                                                                                                                                                                        Lecture.                 Certain                     mechanical                      peculiarities                    of       the         human
1)ttieiit                to           live            the      life              of an     invalid.      1 2                                If     the
                                                                                                                                                                        cardiac               I)111iP            in          normal              and         diseased               states.            Circulation
diagnosis                       is       not            realized                   too late,      patients                                       with
                                                                                                                                                                  5:504,     1952
ischemic                      cardiomyopathy                                     can           live             several               years              at   1 1 Burch     GE, DePasquale    NP: On resting   the                                                                               human               heart.
l)e(l      rest.              However,                          when            the          myocardial                             pathology                     ( Annotation    ) Amer Heart J 71 :422, 1966
is      extensive,                          life         is      short          even               with                bed          rest.         The         12        Burch             CE,           DePasquale                             NP:          There           is such            an       entity             as         a

mvocardial                            cell           is        non-mitotic                         so           that           dead              myo-                   cardiac               invalid.                Amer               Heart          J    78:426,               1969

cytes            are           never                  replaced                    and              the           surviving                       ones,
                                                                                                                                                              Reprint              requests:                Dr. Burch,                           Department         of Medicine,                                   Tulane
even           ‘hien                 iii      poor             health,              can           only            hypertrophy                            in   University                School              of Medicine,                            New     Orleans     70112




                                                                                              Fellowship                                         in Pulmonary                             Diseases
               The          Lung               Station                (Tufts)                at Boston                    City         Hospital               and         research                  opportunities.                                    Further                 information                        and
        will         have              an          opening               for        one           first-year                   Postdoctoral                   application                        forms                may                be      obtained                    from          Maurice                    S.
        Fellow                commencmg                              January                 1, 1972.                    American                  citi-      Segal,              M.D.,             Professor                            of Medicine                          (Tufts)                and           Di-
        zeus           only           will          be         considered.                    Approved                        multiple-dis-                   rector,              Lung                 Station                      (Tufts)                 Boston                City            Hospital,
        ciplme                training                   in     pulmonary                      diseases                  with          teaching               818         Harrison                      Avenue,                          Boston,              Massachusetts                             02118.




                                                                                                                                                                         CHEST,                         VOL.                      60,           NO.           5,        NOVEMBER                                    1971
        I




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Film, a premium           speed film offered             at a non-premium           price. This
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    treatmenrof
 a major
ublic heakh
 pro em
                               from CIBA

    Rimactane#{174}
                                 (rifampin)
     a new oral antibiotic
for pulmonary    tubercu1osis
  In clinical studies:   ...the combination      of
     rifampin-isoniazid,    both given orally,
 is as effective as the best regimen     available
         now and considerably     less toxic.”1
                      Rimactane                  is generally          well   tolerated.
       However,              adverse          effects       can     occur.Before            prescribing,
          please      read        carefully             Contraindications,                 Warnings,
       Precautions,            and Adverse        Reactions    sections                        contained
                              in full prescribing      information.
          *F       uce in conjunction                   with      other an!ituberculous                drugs.

                   REFERENCE
                   1. Rifampin    in Initial Treatment  of Pulmonary  Tuberculosis,
                   A United States Public Health Service Tuberculosis       Therapy           Trial:
                   On file, Medical    Division,  CIBA Pharmaceutical  Company,
                   Summit,      N.J.
                                        Rimactaile                           (rifampin)                   is a semisynthetic                    antibiotic                  derivative
                                             of rifamycin                        B. Specifically,                        Rimactane                 is the      hydrazone,
   3-(4-.methylpiperazinyliminomethyl)                                                                                 rifamycin             SV.         It is unrelated      chemically
                                                       to any    previous                 antituberculai                           antibiotic             in clinical    use.

                    The eflE#{232}ctiveness of Riiiiactane         (in conbiiiatioii        with OI1C or iiioi’e
          aFltitUl)CFCU1OU5       drugs)    is iiidicated       by the Uiiited       States    Public     Health Service
                           colltiOlle(I    clinical     studiesm    in 400 tuberculosis          patients
                                                         with    bll(xllerately                      or      far    advaiicecl               tubercular                    disease.*

                         demonstrated                                                                demonstrated                                                     demonstrated
                         by        sputum                                                            by     roentgenographic                                          by cavity
                         conversion                                                                  improvement                                                      closure
                         percent positive                                                            percent of patients with moderate                                percent of patients with cavities
                         cultures by period                                                          or marked roentgenographic     im-                               closed or smaller by period and
                         and regimen                                                                 provement   by period and regimen                                regimen
               1OC                                                                             ()(




          C
          5)
                7’                                                                        C
                                                                                          5)                                                                a)   75


                                                                                                                   /
          U                                                                                    75                            ;;‘
                                             k.
                                                                                          a)   50                                                                Sc

                                                  \\
                                                                                          I    25           /                                                    25
                                                                                                                                                                            I

                     0                                   10       15
                                                                       ,.-

                                                                       ::
                                                                                   20            0                          mo          15          20            0
                                                                                                                                                                       I                             12          16
                                                        Weeks                                                             Weeks                                                        Weeks
                                were treated
                     #{149}Patients                             randomly  with one of three                     antituberculous
                         regimens            over a period        of 20 weeks.
                         Regimens
-133                          patients received rifampin-isoniazid.
----                     131            received
                                  patients        rifampin-isoniazid-ethambutol.
                         (Results with this regimen were equivalent           to those with rifampin-isoniazid.)
.-.-.-.                  136 patients   received the standard        regimen:    streptomycin-isoniazid-ethambutol.



                                             Oral     therapy      with Rimactane                                                   Moreover,                the     earlier sputum
                               and           isoniazid       avoids the inconven-                                                   conversion                   in the Rimactane                         reg-
                               ience of parenteral                                  administration                                  imens          (see      sputum               conversion
                                    simplifies
                               #{149}
                                  . .              hospital                           care and                                      chart       above)                may       shorten        the
                               follow-up       outpatient                             management.                                   hospital             stay.

                                                                                                                                    Please turn pageJ#{224}rprescribing
                                                                                                                                    inJ#{252}rmation.
Rimactane#{174}                                                                       cleft palate, has been reported in the offspring
                                                                                      of rodents given oral doses of 150-250 mgI
                                                                                      kg/day of rifampin during pregnancy.
                                                                                                                                                                                 Children: 10 to 20 mg/kg,
                                                                                                                                                                          600 mg/day.
                                                                                                                                                                                 In the treatment
                                                                                                                                                                                                                  not to exceed

                                                                                                                                                                                                       of pulmonary     tubercu-
               (rifampin)                                                                     The possible teratogenic potential    in                                    losis, Rimactane       must be used in conjunction
                                                                                      women capable of bearing children        should be                                  with at least one other antituberculous           agent.
 INDICATIONS                                                                          carefully   weighed against the benefits of                                         In general, therapy should be continued             until
Pulmonary Tuberculosis                                                                therapy.                                                                            bacterial    conversion     and maximal improve-
         In the initial treatment        and in the re-treat                                                                                                              ment have occurred.
                                                                                      PRECAUTIONS
 ment of pulmonary           tuberculosis,      Rimactane                                   Rimactane                has been observed                to increase         Meningococcal      Carriers
 must be used in conjunction               with at least one                          the requirements                for anticoagulant               drugs of                   It is recommended        that Rimactane      be
other antituberculous           drug.                                                 the coumarin              type. The effect was not observed                         administered once daily for four consecutive
        Frequently       used regimens         have been the                          until the fifth day following          the initiation    of                         days in the following       doses:
following:                                                                            treatment.     The decrease in prothrombin               time                              Adults: 600 mg (two 300-mg Capsules) in
        isoniazid     and Rimactane                                                   lasts 5 to 7 days on the average. The cause of                                      a single         daily     administration.
        ethambutol        and Rimactane                                               this phenomenon           is unknown.        In patients                                        Children:       10 to 20 mg/kg,           not to exceed
        isoniazid,     ethambutol      and Rimactane                                   receiving    anticoagulants,       it is recommended                               600 mg/day.
Neisseria        Meningitidis           Carriers                                      that daily prothrombin          times be performed                                        Data is not available for determination                               of
      Rimactane                is indicated  for the treatment                        until the dose of the anticoagulant              required has                       dosage for children    under 5.
of asymptomatic                 carriers of N. meningitidis    to                     been established.                                                                   Susceptibility Testing
eliminate        meningococci                  from      the   nasopharynx.                   Urine, feces, saliva sputum, sweat, and                                               Pulmonary      Tuberculosis:      Rifampin     sus-
           Rimactane           is not indicated            for the treat              tears may be colored red-orange               by Rimactane                          ceptibility      powders      are available     for both
ment       of meningococcal              infection.                                   and its metabolites.        Individuals     to be treated                           direct      and indirect     methods      of determining
        To avoid the indiscriminate            use of                                 should be made aware of these possibilities                   in                    the susceptibility         of strains   of mycobacteria.
 Rimactane,      diagnostic     laboratory      procedures,                           order to prevent undue anxiety.                                                     The MIC’s of susceptible                 clinical      isolates      when
 including    serotyping     and susceptibility          testing,                                                                                                         determined            in 7H 10 or other          non-egg-contain-
 should be performed         to establish the carrier                                 ADVERSE          REACTIONS                                                          ing media           have ranged   from          0.1 to 2 mc/ml.
state and the correct treatment.              In order to                                       Gastrointestinal             disturbances             such as                         Meningococcal         Carriers: Susceptibility
 preserve the usefulness          of Rimactane         in the                         heartburn,            epigastric       distress,      anorexia,         nau-        discs containing               5 mcg rifampin    are available
treatment     of asymptomatic          meningococcal                                  sea, vomiting,             gas, cramps,            and diarrhea          have       for susceptibility             testing  of N. meninitidis.
carriers,   it is recommended           that the drug be                              been noted in some patients.           Headache,       drowsi.                            Quantitative              methods    that require             mea-
 reserved for situations        in which the risk of                                  ness, fatigue, ataxia, dizziness,          inability to con-                        surement    of zone diameters     give the most
 meningococcal        meningitis      is high.                                        centrate,    mental confusion,       visual disturb-                                precise estimates   of antibiotic    susceptibility.
        Both in the treatment         of tuberculosis         and                     ances, muscular       weakness,      fever, pains in                                One such procedure1     has been recommended
in the treatment       of meningococcal           carriers,                           extremities,    and generalized        numbness        have                         for use with discs for testing susceptibility        to
small numbers of resistant cells, present within                                      also been noted. Pruritus,        urticaria,      skin                              rifampin.          Interpretations        correlate          zone   diam-
 large populations       of susceptible       cells, can                              rashes, eosinophilia,     sore mouth, and sore                                      eters from              the disc test with      MIC (minimal
rapidly become the predominating                  type. Since                         tongue have occasionally         been encountered.                                  inhibitory          concentration)        values       for    rifampin.
rapid emergence         of resistance       can occur,                                       Thrombocytopenia,        transient      leukopenia,                          A rangeofMlC’sfrom         0.1 to 1 mcg/ml       has
culture and susceptibility          tests should be                                   and decreased       hemoglobin        have been                                      been found in vitro for susceptible     strains    of
performed          in the       event     of persistent             positive          observed. Thrombocytopenia             has occurred                                  N. meningitidis.  With this procedure,      a report
cultures.                                                                             when rifampin      and ethambutol         were admin-                               from the laboratory     of “resistant”  indicates
                                                                                      istered      concomitantly              according   to an inter-                    that the organism     is not likely to be eradicated
CONTRAINDICATIONS                                                                     mittent       dose schedule             twice weekly    and in high
           A history     of previous             hypersensitivity              re-                                                                                        from the nasopharynx         of asymptomatic
                                                                                      doses. Elevation in BUN and serum                               uric acid           carriers.
action       to any     of the      rifamycins.                                       have been reported.
                                                                                                Transient         abnormalities            in liver     function          HOW         SUPPLIED
WARNINGS
       Rifampin   has been shown to produce liver                                     tests (elevations  of serum bilirubin,  BSP,                                                    Capsules,      300 mg (opaque scarlet                   and
                                                                                      alkaline phosphatase,     and serum transami-                                       caramel);           bottles of 100 and 500.
dysfunction.    There have been fatalities      asso-
ciated with jaundice    in patients with liver                                        nases) have been observed.                                                          REFERENCE
disease or receiving   rifampin    concomitantly                                      DOSAGE         AND       ADMINISTRATION                                             1. Bauer,          A. W., Kirby, W. M. M., Sherris, J. C.,
with other hepatoxic    agents. Since an increased                                              It is recommended                 that Rimactane             be           and Turck,           M. Antibiotic susceptibility  testing
risk     may    exist    for     individuals            with   liver    disease,      administered             once      daily,   either      one     hour    before      by a standardized               single   disk   method.
benefits must            be weighed carefully  against                          the   or two hours after a meal.                                                          Am. J. Clin. Path. 45: 493-496,                     1966.
risk of further          liver damage. Periodic liver                                 Pulmonary       Tuberculosis                                                        CIBA        Pharmaceutical           Company
function       monitoring            is mandatory.
                                                                                             Adults:    600 mg (two                300-mg        Capsules)           in   Division of CIBA-GEIGY Corporation
       The possibility   of rapid emergence         of                                a single    daily administration.                                                   Summit, New Jersey 07901
resistant meningococci        restricts the use of
Rimactane    to short-term      treatment    of the
asymptomatic      carrier state. Rimactane        is not
to be used for the treatment         of meningococcal
disease.
Usage       in Pregnancy
      The effect of combinations     of Rimactane
                                                                                                               fmm                CIBA
with other antituberculous     drugs on the human


                                                                                       Rimactane#{174}
fetus is not known. An increase in congenital
malformations,              primarily           spina      bifida      and



                                                                                        (rifampin)
                                                                              Advancing      the treatment of
                                                                             a major pullic health problem.




                                                                                                                                                                                                           CIBA
w                                                  looJato                                                             qflollhS
                 Operate
                 performance
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                                          Then       you’ll
                                          and reliability.
                                              to take       one
                                                                    be convinced
                                                                         If YOU never
                                                                       apart     like    this.
                                                                                                 of its

                                                                                                                 ,‘fllo4jtlar
                 youll    be impressed   by the quality and
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                 available         are combined                with      our 50 years
                 experience              in manufacturing                  pulmonary
                 function         testing       equipment:               a combinatIon
                 which
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                               guarantees
                                            This
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                 you’re        using      the very          best.


                 Perform the following    maneuvers        with an
                 assurance of excellence      in pulmonary
                 function testing instrumentation:

                         FVC                                      Inspiratory            Capacity
                         P/Cl                                     ERV
                         FVC1%                                    Calculated             VC
                         MMF                                      FRC
                         Peak Flow                                TLC
                         MVV                                      RV
                         Respiratory    Rate                      RV/TLC
                         Ventil. L/Min.                           Single Breath DLCO,
                         Tidal Volume                                mean of 1 to 4 tests
                         02 Uptake, V02

                                                                                                             .
                                                                                                            . - - - -.-          //




    //_#{149}_




                   We at Collins            know that more accurate
                   procedures             and greater instrumentation
                   efficiency            mean      better       patient          care.    Write
                   now for our brochure                       of Office          and Clinical
                   Modular          Lung        Analyzers.


                   WARREN                                E. COLLINS,                                      INC.
                   Dept.                 3L          ,   220                   Wood                   Road,               Braintree,   Mass.   02184
advantages
that make all other aerosols
seem obsolete

                                                                                                     Contralndlctlons:                           Known     hypersensitivity      to
Duohaler            is breath-actuated,                   assuring       deliVery      of            either   agent    constitutes                 a contraindication       to the
                                                                                                     use of this drug. Isoproterenol                                  preparations               are
medication            atthe        very    first     instant    in the     breathing        Cycle.   generally  contraindicated    in      patients                              with   pre-
                                                                                                     existing  cardiac arrhythmias     associated                               with tachy-
It provides          dependability            and predictability  that                               cardia   because  the cardiac     stimulant                              effect      of the
                                                                                                     drug may aggravate       such disorders.
parallels      the     principle          of IPPB breath-actuated      delivery.                     WarnIngs:              Excessive            use of an adrenergic                       aero-
                                                                                                     sol should       be discouraged,         as it may lose its effec-
                                                                                                     tiveness.      Occasional       patients    have been       reported
                                                                                                     to develop        severe     paradoxical       airway    resistance
                                                                                                     with repeated,          excessive       use of isoproterenol         in-
                                                                                                     halation      preparations.      The cause of this refractory
Duohaler            requires         no coordination-         breath                                 state     is unknown.       It is advisable       that in such in-
                                                                                                     stances      the use of this preparation          be discontinued
actuation        synchronizes                 release of medication  and                             immediately       and alternative    therapy      instituted.
                                                                                                     since in the reported       cases the patients        did not
delivery      for the greatest                therapeutic effect from a single                       respond     to other forms of therapy
                                                                                                     was withdrawn.               Deaths
                                                                                                                                                 until the drug
                                                                                                                                            have been reported                           follow-
                                                                                                     ing excessive             use of isoproterenol  inhalation                          prepa-
in halation In halation
                .                         triggers        release    of medication,                  rations      and  the exact cause is unknown.                                      Cardiac
                                                                                                     arrest      was noted in several instances.
which enters lungs                   during          first 4% of inhalation           and is         Prcautlons:                 lsoproterenol               should       not be admin-
                                                                                                     istered       with       epinephrine,               since         both   drugs   are
carried      to bronchioles                 by the       remaining         96%     of the            direct     cardiac   stimulants                   and their          combined      ef-
                                                                                                     fects     may produce      serious                 arrhythmias.             If desired.
inhaled       airstream.                                                                             these      drugs        may be alternated,                  provided          an inter-
                                                                                                     val of at least          four     hours         has elapsed.
                                                                                                          Although            there has been no evidence  of terato-
                                                                                                     genic effects            with these drugs. use of any drug in
                                                                                                     pregnancy,           lactation,           or in women             of child-bearing
                                                                                                     age requires             that the potential   benefit of the drug
Duohaler      automatically                                                                          be weighed               against  its possible      hazard  to the
                                                                                                     mother       and       child.
delivers    a single dose of medication.       It must be reset                                               Duohaler        should           be used         with      caution          in pa-
                                                                                                     tients       with       cardiovascular                  disorders               including
before it can be used again, thus discouraging            overuse.                                   coronary  insufficiency.     diabetes,   or hyperthyroid-
                                                                                                      sm, and in persons      sensitive   to sympathomimetic
This mechanical       delay allows medication      to take                                           amines.
                                                                                                     Advsrs#{149} Rctlons:                           Overdosage               with       isopro-
effect,  and diminishes     the need for additional     doses.                                       terenol
                                                                                                     ulousness,
                                                                                                                can       produce
                                                                                                                          flushing,
                                                                                                                                             palpitation,
                                                                                                                                               anginal-type
                                                                                                                                                                 tachycardia.
                                                                                                                                                                       pain,
                                                                                                                                                                                           trem-
                                                                                                                                                                                        nausea,
                                                                                                     dizziness,     weakness     and sweating.       while overdos-
                                                                                                     age with phenylephrine           can induce      cardiac     irreg-
                                                                                                     ularities, central nervous system disturbances                  and
                                                                                                     reflex bradycardia.
                                                                                                           The individual    patient’s sensitivity     to either drug
                                                                                                     would      dictate   the overdosage          signs.     However,
                                                                                                     there is reason       to believe    the overdosage         effects
                                                                                                     of either       drug       are     antagonized              by the         other       drug
The new standard                    of safety, efficacy              and     control                 in the mixture.
                                                                                                     Dosag#{149}and AdmInistratIon:                              The recommended
                                                                                                     dose for the relief of dyspnea                           in the acute episode
                                                                                                     is 1 to 2 inhaiations.                  Start    with    one      inhalation.          If no
                                                                                                     relief     is evident           after     2 to 5 minutes,                a second            in-
                                                                                                     halation    may be taken.    For daily maintenance,                                         use
                                                                                                     1 to 2 inhalations  4 to 6 times daily or as directed                                         by
                                                                                                     the physician.
                                                                                                           No more than two inhalations            should    be taken
                                                                                                     at any one time. nor more than 8 inhalations                   per
                                                                                                     hour, unless advised by the physician.
                                                                                                     How Supplied:          initial  Rx - Duohaler        7.5 ml. (300
                                                                                                     inhalations)   NDC -742-21:         Refill - Duohaler        Refill
(isoproterenol     hydrochloride                         0.16 mg.                                    7.5 ml.(300 inhalations)       NDC 89-742-11.
                                                                                                     CautIon:     Federal law prohibits        dispensing     without
  and phenylephrine       bitartrate                     0.24 mg.)
                                                                                                     prescription.
                                                                                                     Rikir
                                                                                                     NORTHAIDGE.
                                                                                                                     Laboratorlei,Inc.
                                                                                                                                     CALIFORNmA                91324
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                                                                                                                                         vital
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502-I)                                                                               When      writing   please   mention            CHEST
                         Prediction                      of Pacemak.r                                       fallur                    by telephone




                                              ‘Pthk&,!
                                                     Them,
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                                                      THEY                   DO                                     WEDO
                                                      Sell you equipment                                            Supply            & maintain            all equipment
                                                                                                                     Supply           toll-free         phone     lines for patients
                                                                                                                     Supply  24 hour-7                      days a week service
                                                                                                                     Supply  full staff                 of trained technicians
                                   YOU               MUST                    DO                                      Supply complete                      insurance     protection
                                                                                                                     Take responsibility                     for all insurer relationships
               Initial investment        of receiving       equipment
          Initial investment          of transmitting        equipment                                               All billing made                   directly         to third          party
                 Service and maintenance                of equipment
                                         Set up laboratory           space                                          YOU                      MUST                         DO
                       Hire and specially          train technicians
                                                                                                                     Send           us prescription
            Install special         phone lines (Toll Free if you
                                                 want to be like us)                                                 YOU                     GET
                Set up 24 hour, 7 day a week emergency
                                                                   service                                           Information               on impending                     battery             failure   plus
                            Purchase       additional      liability    and                                          pulse correlation
                                           malpractice        insurance                                              Complete                analysis           by qualified
                       Set up billing relationship             with third                                            Cardiologist:
                                                        party insurers                                                  . Rate in milliseconds
                       Bill.patient      and third party insurers                                                       . Graph    of rate change
                                                                                                                        .          Pacer-Pulse                 capture        recording
                                                                                                                        .          Determination                  on whether
                                                      YOU              GET                                                         Pacemaker                  is actually
                                Information         on impending             battery                                               capturing           heart
                                                                   failure      only                                 Instant          notification              of emergency                    situation



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                                                                                                                                      Department
                                                                                                                                                                DATACORP.,
                                                                                                                                                                   CD 2-E
                                                                                                                                                                                                    INC.

                                                                                                                                      1 705 Walnut                 Street
                                                                                                                                      Philadelphia,                 Pa. 19103
                                                                                                              i:     Please           send      me     full     information         on the            Pacemaker

                                                                                                                     Evaluation              System.

                                                                                                             0       Please           have     your      representative             call.

                                                                                                              NAME
                                                                                                                                                                      (please     printl
                                                                                                             ADDRESS                                                                            __________




                                                                                                             cii__________________________                                       STATE                               ZIP



                                                        When       writing       please          nmention          CHEST                                                                                                   502-E
         HEPA           can HELP                     protect                                                                    another
         your          ventilator                    patients!

        Bennett’s       newest     main-flow       and nebulizer        bacteria       filters   assure a
        nearly      sterile    gas delivered        to your patient         when       used with       IPPB
        therapy       or respiration        units. These bacteria          filters    also reduce        the
        possibility       of cross.infection        or re-infection       by preventing           bacteria
        from entering        the ventilator       via the patient      tube system.           A most im-
        portant      use is with       the patient      whose       upper      respiratory      tract has
        been by.passed.

        Both are ultra.high          efficiency particulate     air (HEPA) filters.                          Because
        of their low-pressure        drop, machine     function    is not affected.

        Each filter is tested        for its particulate          retention         efficiency.           Minimum
        efficiency   is 99.97%         retention    of 0.3        micron      or larger             and      99.99%
        efficient  on bacteria       1 to 5 micron.

        The filters are housed in a high               impact plastic, ultrasonically  welded,
        for durobility  and appearance.                Both filters  will withstand   repeated
        autoclaving.      Under     normal     conditions,    they should last at least 5,000
        hours.

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        Bennett representative          or dealer.


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502-F                                                              When       writing      please         nmention     CHEST
New      accuracy         and thoroughness            in your diagnosis        brush            simply        and      easily         with       one-hand               operation.
of diseases         of the chest is routine.            Olympus      Bron-     Olympus                 designed,             developed                 and      manufactures
chofiberscope            lets you observe          and record on color         every         element           in the        Olympus                Bronchofiberscope.
transparencies,             areas not possible          to diagnose      be-   That’s            why        Olympus             can       provide              you      the      assur-
fore without           surgery       or with radiology       alone. Only       ance         of the       fastest        service          and         repair          arrangement
five millimeters            in diameter,       the Bronchofiberscope           in     our        industry-repair                       service           is performed                     by
may be inserted               safely into the sub-sub-segmental                factory            trained            technicians                in      an       electronically
bronchi-with              a minimum            of patient    discomfort.       equipped                laboratory.              Mail         this       coupon    for more
Control       of the distal end assures               even easier inser-       complete                information                about          the      Olympus     Bron-
tion and greater               scope in your examination               over    chofiberscope                   (BF-5B)                 and     how            it can      help        you
primitive         rigid      bronchoscopes.          Cell samples        are   to fast,           easier,          accurate           diagnosis-with                      a photo-
collected,         under        direct     view, by the cytological            graphic            and       biopsy          record        to back             your       decisions.
An Olympus          Bronchofiber-
scope    Inserted     Into the sub
segments       of the upper       lobe
of the left lung biopsying
3cm x 3cm cancer.
                                       a
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                                                                                        Olympus Corporation                             of America
                                                                                        Medical             Instrument           Division               Dept.  B 1
                                                                                        2 Nevada              Dr., New          Hyde Pk.,               N. Y. 11040
                                                                                        Please send detailed                         Information          about the Olym-
OLYMPUS                                 BF-5B                                           pus Bronchoflberscope                           (BF-5B),         my specialty Is

b ronchofi                           berscope
-new reach, new speed, minimum patient                                                 Name

discomfort, more efficient diagnosis.                                                  Address
          Bronkometer
with                        tor
       solves the problem
         without creating
             a new one



                   .p..
                             Bronchodilation with
                                           Prompt
     .        relative freedom from adverse effects
Isoetharine: the unique Beta2
                                                                                                                                               COMPOSITION:                              (
                                                                                                                                                                            Dilabron#{174}brand of isoetharine
Bronchodilator is available in                                                                                                                 methanesulfonate)
                                                                                                                                               0.125%;            thenyldiamine
                                                                                                                                                                               0.6% ; phenylephrine     HCI
                                                                                                                                                                                     HCI 0.05% with saccharin,


Bronkometer
                                                                                                                                               menthol,           and fluorochlorohydrocarbons                                 as
                                                                                                                                               gaseous            propellants.            Preserved           with      ascorbic            acid
                                                                                                                                               0.1 % and alcohol  30% . Each ml of solution
                                                                                                                                               supplies at the mouthpiece   20 metered    doses
     isoetharine                      1 phenylephrine                I thenyldiamine                                                           of 350 mcg Isoetharine  methanesulfonate
                                                                                                                                               (0.6%), 70 mcg phenylephrine     HCI (0.125%)                                                  and
                                                                                                                                               30 mcg         thenyldiamine                  HCI         (0.05%).
   The new classification          of Beta receptors         of the cardiovascular
and pulmonary        systems       differentiates      two types, termed          Betai                                                        CONTRAINDICATION:                             Hypersensitivity                  to any
                                                                                                                                               component.
and Beta2. These terms apply to both the receptors                        and the
sympathomimetic          ‘amines which activate           them. An agent that acts                                                             PRECAUTIONS:          Although       Bronkometer        is relatively
on Betai    receptors      stimulates        the cardiac     muscle,    increasing                                                             free of toxic side effects,        too frequent      use may
the rate and force of contractions.                 An agent that acts on Beta2                                                                cause tachycardia.        palpitation.       nausea. headache,
                                                                                                                                               changes in blood pressure.             anxiety,   tension,
receptors    dilates    and relaxes         bronchi    and arterioles.
                                                                                                                                               restlessness,     insomnia.      tremor, weakness,
           lsoproterenol                  acts      on both        Betai      and     Beta         2 receptors.                                dizziness     and excitement        as is the case with other
   Isoetharine   is different. It exerts                                    the major          part of its action                 on           sympathomimetic     amines.                          Bronkometer                should
Beta2 receptors,     only a minor part                                      on Betai          receptors.                                       not be administered   along                          with     epinephrine               or
                                                                                                                                               other       sympathomimetic                    amines          as such          drugs         are
                                                                                                                                               direct      cardiac           stimulants            and     may       cause      excessive
                                     Principal             Pharmacologic              Activities:::                                            tachycardia.             They       may, however,                 be alternated
                                                                                                                                               if desired.           Dosage         must       be carefully              adjusted             in
                                                                                                                                               patients   with hyperthyroidism,           hypertension,                                 acute
                                                                                                                                               coronary    disease.    cardiac      asthma,     limited
                                                                                                                                               cardiac   reserve and n individuals            sensitive                               to
                                                                                                                                               sympathomimetic         amines,      since overdosing                                   may


    -
         Epinephrine                                                                                                                           result in tachycardia,       palpitation,     nausea,
         general-alpha,                                                                                                                        headache      or epinephrine-like         side effects.
         beta1 . beta2
                                                                                                                                               RECOMMENDED                        DOSAGE:          The average   dose is
         Norepinephrine                                                                                                                        one or two inhalations.                      Occasionally    more may be
         selective-alpha
                                                                                                                                               required.           It is important.            however,              to wait    one
         Isoproterenol                                                                                                                         full minute after the initial one or two inhalations                                                in
         dual-beta1,beta2                                                                                                                      order to be certain       that another  is necessary.
                                                                                                                                               In most cases, inhalations         need not be repeated
         isoetharine
                                                                                                                                               more often than every four hours, although             more
         preferential            beta 2,
                                                                                                                                               frequent   administration       may be necessary      in
         lesser     affinity       for beta1
                                                                                                                                               severe cases.
    *Based        on laboratory          studies    1,2.
                                                                                                                                               HOW SUPPLIED:                     Bronkometer     tpr 10 ml Refill with
                                                                                                                                               Actuator (Code                  No. 1 184): Bronkometer     tpr 10 ml
                                                                                                                                               Refill      only      (Code       No.      1183):         Bronkometer               10 ml Vial
.        provides                      prompt                long-lasting                  bronchodilation                                     with Oral Nebulizer                     (Code No. 1 193); Bronkometer
.        enjoys                 relative              freedom               from          adverse                  effects                     20 ml Vial with Oral                    Nebulizer for desk or bedside
                                                                                                                                               (Code No. 1182).
                                                                                                                                               REFERENCES:
                                                                                                                                               1. Lands,     A. M.. Arnold.        A.. McAuliff,      J. P.. Luduena.       F. P..
Experience                                  in Practice                                                                                        and Brown.
                                                                                                                                               A. M., Luduena.
                                                                                                                                                                 T. 0.. Jr. : Nature,
                                                                                                                                                                        F. P., Grant.
                                                                                                                                                                                            214597-598,
                                                                                                                                                                                           J. I.. and Ananko,
                                                                                                                                                                                                              May. 1967. 2. Lands,
                                                                                                                                                                                                                        E.:
In nine                   clinical        reports           on patients           given       isoetharine                 with                 J. Pharmacol.         Exptl.    Therap     . 99:45-56.     Jan . 1950 3 Levine.
                                                                                                                                               E. R. : Dis. Chest. 49:610-624,              June, 1966. 4. Chervinsky,          P.,
phenylephrine                            and thenyldiamine,3-’1                       adverse                effects                           and Herstoff,        R : J. Asthma       Res., 4610.624.         Mar.. 1967.
were   reported                          to be absent349                  or insignificant.5-810”                                              5. Shubin,      H.: J. Germantown             Hosp.,   6:57-64,    Oct., 1964.
                                                                                                                                               6. Miller,   J. : Ann. Allergy,        25:520-527,       Sept . 1967. 7. Spielman,
In four of the                         studies  in which                results   were tabulated                          on the               A. 0. : Current     Therap.     Res., 3:235-242.       June. 1961 . 8 Baker. A G.
                                                                                                                                               Ann. Allergy,       22:180-186,       Apr., 1964. 9. Goldfarb,          A. A , and
usual 4 or 5 point scale, a total                                          of 81 % of the patients                                             Romanoff,       A. : Ann. Allergy,        20:307-314.       May, 1962. 10. Unger.
experienced   good to excellent                                            bronchodilation   and                                               0. L.. and Unger,          L.: Dis. Chest. 51:153,          Feb.. 1967. 11. Siegel,
                                                                                                                                               c. : Lancet,     82:461-464,       Nov.. 1962.
improvement                            of pulmonary                function.789               11




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                                                                                      \Vhen        writing       please      mention   CHEST                                                                                                .5O(-C
to find                        Ste rneed (INTRADERMAL        MULTIPLE           PUNCTURE
                                                                                                     Id
                                                                                                    DEVICE)



the”hidderf’            can screen 450 per hour
TB cases                 at only pennies per test
                             with max. control of
                         \\   all variables (:)



                                         Unlike other techniques,
                              STERNEEDLE          finally        provides             the    accuracy
                          :    of a careful,        skiIlfuIIydone           Mantoux        in
                                  a rapid, simple,         low cost screening           pro-
                                 cedure. STERNEEDLE            avoids     the variables
                               of depth and deposit               related to the use
                                of crude Old Tuberculin,                with its heavy
                                  viscosity,      and the frequent               pain-re-
                                   sponse to the long-tine              penetration         of
                                    the other      multiple        puncture      tests...
                                     and even the reconstituted               PPD of the
                                     Mantoux.       STERNEEDLE           alone uses a
                                      highly   purified,        concentrated           PPD
                                      (Connaught)          with automated,             con-
                                  trolled    penetration.        It also avoids van-
                              ables in reading-response                    lasts several
                              days longer,        needs no measurement                    and
                              can     even    be reported              by an adult                with          the

1                             use of simple,
                              (available
                                               illustrated
                                          on request).
                              From the originator
                                                              response

                                                                       a
                                                                         cards

                                                        of PARASAL#{174} mino-
                              salicylic acid and other agents. Literature

                              available       on request.
               ‘h   f

                         c7
                          r.-                                      Division

                                                        Ormont        Drug      & Chemical               Co.,     Inc.
                              South Dean Street, Englewood, New Jersey 07631
                              IN    CANADA:
                              Winley-Morris    co. , Ltd. , 2795    Bates     Road,    Montreal      26, P. 0.

                                                                                       Patent #3,208,452
 516                                                                                                                                                                                                                                                                          AROESTY                                  AND                  COHEN

                                                                                                                     I,.. e;:/
                                                                                                                                                                                                                                                       DiscussioN

                                                                                                                                                                                      Increased                           utilization                         of          plastic                  iuitrax’enous                           catheters
                                                                                                                                                                              has         heeui             accompauiiecl                                    lw           a variety                         of      adverse                     effects.
                                                                                                                                                                              Arli()ng               the             reported                     complications                                     are           iuifec.tiot,s,:(.i                        per-
                                                                                                                                                                              foration                 of             the           heart,’                   throml)osi.s,”7                                    and           emi)oliziltion
                                                                                                                                                                              of       the         entire                  catheter                     or         of         a      catheter                      fragment.’”                              The
                                                                                                                                                                              latter           complication,                                    eml)oliZation                                 of       a catheter                        fragment,
                                 ‘                                                                                                                                            usually                occurs                    l)ec-ause                 of             transectioui                         of        the          catheter                       b’
                                                                                                                                                                              the        unprotected                                 point             of the                     introducing                          needle                   and           c-au
                                                                                                                                                                              be        prevented                              iy          firmly                  anchou-ing                           the            catheter                      to        the
                                                                                                                                                                              arm        . 0
                                                                                                                                                                                      \Vhen                introduced                                  from                   the            antecul)ital                            position,                          a
                                                                                                                                                                              central               venous                      pressure                      catheter                        angulates                        at        the          shoul-
                                                                                                                                                                              der.        Catheter                         angulation                          or         venospasm                              may           present            suffi-
                                                                                                                                                                              cient            resistance                           to     traction                      to         result             in catheter                          fracture.
                                                                                                                                                                              This           complication                                  c’au         l)e         1)re’eumted                      by             firmly               wrapping
                                                                                                                                                                              the        exposed                       portion                    of tile                 CVP                 catheter                     to the               arm.               In
                                                                                                                                                                              addition,                    it        is     recommended                                           that         the           hands                  of         the         con-

                                                                                                                                                                              fused                1)atients                        l)e         restrained.                              If        a        catheter                       fragment
                                                                                                                                                                              embolizes                         to        an         ac’cessil)le                        location,                      it may                   be         removed
                                                                                                                                                                              i)\’ snare               teclniciue.

                                     .,.....                                                            ..

                                                                                                                                                                                                                                                    REFERENCES

                                                                                                                                                                                   1 \Iassunii                       RA,            Ross          A\I          : Atraurnatic’,                              non-surgical                             technic
                                                                                                                                                                                       for         reniovai                    of         l)roken                  catheters                       from            cardiac                  chamber.
 :
                                                                                                                                    1                                                  New           Eng              J Med                277:         195-196,                         1967
                                                                                                                                                                               2       Ross          AM              : Polyethelene                                emhoii                : How                   many              more?               Chest
l”i;un:             2. Chest       x-ray      flInt deunonstrating                                                         the        l)osition          of the                        57:307-309,                             1970
central             Veuiouus    iressture         catheter          after                                           it     had          been          forcibly
                                                                                                                                                                                3      Dru:.kin                  \IS,               Siegel              PD : Bacterial                                  contamination                                 of       in-
fractuured.              Arrovs         note-     tlt’     proximal                                                and        (!iStl!           ends.        The
                                                                                                                                                                                       dwelling                        )olyethylene                                 catheters.                          JAMA                    185:966-968,
photograph                      has            i)’(’1           retouched                    for      c’laritx’.
                                                                                                                                                                                       1963
                                                                                                                                                                               4       Hassali                  JE,             Rountree-                      P\I            :      Staphylococcus                                     SeI)ticc-mia.
l)t-(’aumu-            unarke-dlv                       confused                     and           t’as found                      hol(ling              a balf-
                                                                                                                                                                                       Lancet               1:213-217,                            1959
length            of      time original                              CVP            cath(-ter                 in    her       hand.             The          (liStal
                                                                                                                                                                               5       Brown                CA,                 Kent              A:          Perforation                              of        right              ventricle’                 by
tip        of the         catheter                      tas           irregular               an(l           tal)ered            aS       if it had             l)een
                                                                                                                                                                                       polyethylene                             catheter.                    Southern                     MJ 49 :466-467,                                   1956
i)tull(’(l        tI)art  ( Fig    1 ) . There    t’as a large h(-nlab)ul(a            over   the
                                                                                                                                                                               6       Knutson                        H,            Steinberg                       K :             Pulmonary                             (‘ll1i)Oli5ull                   after
(()5(,            of time’ left l)aSili(’   vein.    A chest    x-ray     filumi shoved       the
                                                                                                                                                                                       catheter                 i)reak.                  Nord           Med              62:         1491,             1959
(listal         i)ortioul  of timt’ CVP cathete-r         in the     Icft suubclavian       vein
                                                                                                                                                                               7       \lonc’rief                    JA:            Femoral                   catheters.                       Ann               Siurg          147:           166-172,
t’xteualing                   to the            right            atriuunm             ( Fig          2 )
                                                                                                                                                                                       19.58
      The         1)atieumt               \%.aLs taken                       to      the       cardiac               cathe’te-rization                       laho-
                                                                                                                                                                               8 Turner                         DD,             Sonimers                       SC:                Accidental                        passage                    of         poly-
ratorv           t’llc-re’           an          incision                   tvas       um,ale           over                      It-ft     l)aSilic            vein.
                                                                                                                                                                                       etllylene                     catheter                   ft-on               a      cubitil                  vein             to        rigilt            atriuni:
A (louui)led-over                                230            cumm flexible                      gui(le- wire                     was         1)oSitioned
tvitlmin          the           lLun’-n                 of       a (:ri’                   KiLt        catheter                  froul          \Vhich            tile                 Fatal          case.               New             Eng          J Med                  251 :744-745,           1954
                                                                                                                                                                               9       Vellman                         KF,                Reinhard                        A,     Salazar          EP:      Polyethylene
tape-re(l              til)      I(iL(I           i)’t’n              cut.           fhc’          catheter                 was           filled   with a
solutiot               of l1(’)itu’iu                    Lul(l         saline,             afl(l      vas          a(l’t’ail(’e(.l           to the CVP
                                                                                                                                                                                       catheter                 em1o1iuii.                        Re-view                     of the   literature        and      report                                           of
                                                                                                                                                                                       a case              vith                associated                      fatal                tricuspid                    and          systemic’                    can-
c’atht-tt-r            fragune’nt.                      Uul(ler              fluoroscopic                      guidance,                  the       distal         tip
                                                                                                                                                                                       didiosis.                Circulation                         37 :380-392,                              1968
of       tla-   C\’P           catheter                       t’as      snare(l1               and           reuiu)ved.
                                                                                                                                                                              10       Fehig           PA :                Prevention                          of          intravenous                             loss         of         catheters.
      Serial            cre-atine                   pliospilokinase,                                 serumun             gliutanlic                oxaiacetic
trauisaui          mast-,             lactic                  dehydrogenase                            (leterun             iuiations              and       serial
                                                                                                                                                                                       New           Eng              J Med                276:         1263-1269,                             1967

elec’trocardiograuus                                     c’onfiruued                   the         initial          diagnosis                of an           acute
uuyocardial                    infarction.                           TIe’          Sui)se(lue-nt                   hospital               course           of     the        Reprint    requests:       Dr.                                       Staflord                  Cohen,                      Beth              Israel            Hospital,
1)ttit’Itt        was           uune-vt-ntful.                                                                                                                               330 Brookline        Avenue,                                          Boston                  02215




                                                                                                        Ninth Annual                                                    Cardiology                      Seminar
              The              Ninth        Annual      Carcliology                                                 Seminar,                  sponsored                      L. Schiebler;      Demetrio         Sodi-Pallares;                                                                         arid Milford      C.
          l)V  the             Rogers         Heart    Foundation,                                                   will          be       held     at the                  \Vyman.       The seminar         is directed                                                                     by      Dr. Henry     J. L.
          Princess               1-lotel, Acapulco,            Mexico,                                               December                    2-5. The                    Marriott.      For   information,          please                                                                      write    the   Rogers
          fac’uultv             ‘ill      iulclude     Drs.      Cerard                                                  Church;                    Ross             D.       Heart             Foundation,                                 St.         Anthony’s                             Hospital,                      St.         Peters-
           Fletcher;                 Frank      LaCamera;          Joseph                                                 K. Perloff;                    Cerold               burg,            Florida                     33705.




                                                                                                                                                                                        CHEST,                              VOL.                  60,               NO.                  5, NOVEMBER                                                  1971

				
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