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Afterload reduction with sodium nitroprusside was performed in a patient with idiopathic lactic acidosis in whom sodium bicarbonate therapy had precipitated pulmonary edema. The drug reduced mean pulmonary-artery wedge pressure from 28 to 12 mm Hg, accompanied by a modest rise in left ventricular stroke work index from 33 to 43 g-m per square meter. Concomitantly, there was dramatic resolution of the metabolic acidemia, the arterial pH rising from 7.19 to 7.61, arterial carbon dioxide tension from 13 to 26 mm Hg, and bicarbonate content from 6 to 28 mEq per liter, and the anion gap falling from 32 to 11 mEq per liter. Metabolic improvement occurred despite a fall in cardiac output from 5.5 to 4.8 liters per minute. These findings support the concept that regional vasoconstriction plays a part in idiopathic lactic acidosis, and suggests that vasodilators may be an effective form of therapy for this almost uniformly fatal disorder. (N Engl J Med 293:468–471, 1975)

Elevations of blood levels in glycolytic metabolic factors such as pyruvate, lactate and LDH activity were demonstrated in patients with malignant neoplastic diseases. In leukemic patients treated with anti-tumor agents, on one hand, cases in which clinical improvement was observed were accompanied with normalization of serum LDH activity. On the other hand cases in which clinical aggravation was observed were accompanied with abnormal elvations of LDH activity. The majority of carcinoma cases, in which normalization of serum LDH activity due to anti-tumor agent was encountered, were also characterized with normalization of bl000d levels of pyruvate, lactate and α-ketoglutarate. On the other hand, carcinoma cases in which re-elevation of serum LDH activity followed the treatment were characterized with elevation of blood levels of the above glycolytic metabolites. In cases with malignant neoplastic disease in which decreases of serum LDH activities were observed, the isozyme pattern also may show a tendency to be normalized. But in cases whose LDH activities increased the isozyme patterns indicated a tendency of aggravation of the malignant pattern. The above observation was verified by animal experiments in which Yoshida sarcoma was transplanted to rats. Elevated LDH activities of serum, ascitic fluid and tumor cells in tumor-bearing rats were decreased after treatment with Mitomycin C. The LDH isozyme patterns of serum, ascitic fluid and of tumor cells were characterized with an increase of LD4 and a decrease of LD5. Treatment of these rats with Mitomycin C resulted in a tendency of normalization of LDH isozyme patterns. It is therefore concluded that changes of serum LDH level following treatment with anti-tumor agents reflect metabolic improvement or aggravation. The determination of serum LDH activity, therefore, may serve as an indicator of the effectiveness of the anti-tumor treatment.

Summary By administering ATP to the mother during delivery fetal hypoxia was relieved in respect of both metabolic and gaseous exchange. However, there was no difference between doses of 20 and 40 mg. ATP. The metabolic improvement of the fetus during delivery was also reflected by the more favourable condition of the infants at birth.

Analysis of Data on Proptosis (74 Patients) The average period of serial observations is 11 years, the shortest 2, and the longest 20. Changes of 1 mm. are disregarded in using the Luedde or other "ruler" types of exophthalmometers. 1. During the uniform improvement in metabolic status and in appearance of the eyes that occurred during preoperative treatment, increase of proptosis was found as often as decrease. 2. Decrease occurred in only 10% of patients between preoperative measurements and those made during four months postoperatively. No correlation was found with the rapidity or quantity of metabolic improvement. 3. Decrease in 16% and increase in 71% of patients occurred between the early period of observation and the final. Patients less than 30 years of age were most apt to show improvement. 4. Range of final measurements in 59 instances revealed bilateral proptosis of 18 mm. or less in 15% and of

Seven patients with small-intestinal diverticulosis were studied by means of intestinal absorptive tests, biopsies, and bacterial cultures of small-intestinal aspirates. Aerobic bacterial cultures were obtained in all patients, while anaerobic cultures with a modified Hungate roll-tube technic were performed in 3. Three of the patients manifested steatorrhea and were studied over prolonged periods of time. The bacterial flora varied over a wide quantitative range, with highest total counts in excess of 109 colony-forming units per milliliter found in the 2 patients with the most severe malabsorption. Despite multiple diverticulosis, 1 patient without steatorrhea had no recoverable aerobic or anaerobic bacterial flora. E. coli predominated among the recovered aerobic organisms in this series, but A. aerogenes and various streptococci also were encountered repeatedly. Patients treated with antibiotics directed at the aerobic flora showed prompt improvement in absorption, and reduction in bacterial counts. Repeated short courses of antibiotics were needed to treat early bacteriologic and clinical relapses. After several such courses, all 3 patients treated maintained their clinical and metabolic improvement for periods of close observation ranging from 2 to 15 months without additional antibiotic treatment, and the clinical remissions were accompanied by gradual reductions in total bacterial counts to “borderline normal” limits. Of the 3 patients, 1 has now been followed for 5 years without relapse. It is apparent that the mere presence of diverticulosis does not lead necessarily to malabsorption. Malabsorption of fat, Vitamin B12, and other nutrients was found only in patients with excessive bacterial flora, emphasizing the crucial role bacteria play in the pathogenesis of malabsorption in diverticulosis of the small intestine.