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The purpose of this review is to address what is known, speculated, and hypothesized regarding the issue of hydration and concussions. Based on the question, “What impact does hydration have on the relative risk for suffering concussive injuries along with long-term ramifications that have been associated with concussive (and repeated subconcussive) traumas to the cerebral cortex?,” a search of available literature was performed through June 2019. Deducing from the available literature, we can stipulate that changes in hydration within the cerebral cortex increase the likelihood for disruption of neurofilament proteins, dysregulation of membrane dynamics of the neurons and exacerbate inflammation responses following head trauma. As such, it can be speculated that differences in incidence rates may be attributed to difference in tissue fluid based on athlete demographics, level of whole-body water balance, and degree of tissue dehydration more than selection of sport. Moreover, tissue hydration in combination with other inflammation factors provides the scaffolding for the development of long-term issues (e.g. chronic traumatic encephalopathy) associated with repetitive head trauma in athletes.

Exercise goals that tend to focus on weight loss have varying degrees of long-term success, leading to the phenomenon commonly referenced as yo-yo dieting. The aim of the investigation is to examine the impact of periodized training focused on specific performance goals on long-term weight loss and improvement in fitness for individuals who are overfat with long-term history of yo-yoing. 12 family-related overfat volunteers, 28 ± 5 year and average history of overfatness 8 ± 12 year, completed 108-week periodized training program, broken into 9–12 week mesocycles combining progressive and undulating periodization of exercise choice and training volume for specific improvements in performance measures. Diet was energy density standardized to Cal/d of 90–95% BMR and macronutrient standardized to have a protein intake of 2.2 g/kg BM and carbohydrates intake of 50–100 g/d. There was an average reduction of 35 ± 3% in total body mass and 72 ± 9% fat mass, with a gain of 9 ± 8% in fat-free mass across the length of the study. This was accompanied by 56 ± 3% increase in aerobic fitness and 52 ± 14% reduction in resting heart rate, and strength and endurance gains of 148 ± 65% (squat), 130 ± 10% (dead lift), 110 ± 33% (leg press), 88 ± 27% (lateral pull-downs), 102 ± 36% (bench press), and 720 ± 260% (1-min push-up) and 271 ± 44% (1-min sit-up). Periodized exercise focusing on performance changes, and not weight loss, may provide the stimulus necessary for long-term behavioral modification that is necessary for long-term changes to body composition, where the performance goals may induce a reward response and encourage continuation of exercise for longer durations than had previously attained.

This review examined the general level of effectiveness that can be drawn from a systematic review of the literature for dietary supplements based on the following three premises: 1) ability to elicit body compositional changes; 2) ability to elicit changes in musculoskeletal performance; and 3) ability to elicit improvements in cardiovascular health and endurance. Based on the culmination of review of available studies, to date there is limited support to many of the purported benefits that have been ascribed to a host of dietary supplements.

This investigation assessed differences between the response of men and women with knee osteoarthritis to superficial heat, cold, or contrast therapy applied with a water-circulating system or a standard heating pad, and rest. We further analyzed data from a previous study to better understand the influence of gender on the response to treatment based on Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales and a visual analog pain scale (VAS). Using a within-subject, randomized order design, 34 patients received each treatment in 1-week blocks. A KOOS questionnaire and VAS were completed at baseline and twice each week. Women were more likely to report clinically meaningful improvement in pain and symptoms on the KOOS with the use of heat, cold, and a heating pad. There were no significant differences in response to treatment between men and women for the function-daily living and quality of life subscales or percent pain reduction on the VAS. Men and women reported improved quality of life with intervention. Women are more likely to report clinically meaningful improvement in pain and symptoms associated with knee OA following the use of superficial heat, cold, or a heating pad than men.

Introduction A large body of evidence has established a pattern of altered functioning in the immune system, autonomic nervous system and hypothalamic pituitary adrenal axis in chronic fatigue syndrome. However, the relationship between components within and between these systems is unclear. In this paper we investigated the underlying network structure of the autonomic system in patients and controls, and a larger network comprising all three systems in patients alone. Methods In a sample of patients and controls we took several measures of autonomic nervous system output during 10 minutes of supine rest covering tests of blood pressure variability, heart rate variability and cardiac output. Awakening salivary cortisol was measured on each of two days with participants receiving 0.5mg dexamethasone during the afternoon of the first day. Basal plasma cytokine levels and the in vitro cytokine response to dexamethasone were also measured. Symptom outcome measures used were the fatigue impact scale and cognitive failures questionnaire. Mutual information criteria were used to construct networks describing the dependency amongst variables. Data from 42 patients and 9 controls were used in constructing autonomic networks, and 15 patients in constructing the combined network. Results The autonomic network in patients showed a more uneven distribution of information, with two distinct modules emerging dominated by systolic blood pressure during active stand and end diastolic volume and stroke volume respectively. The combined network revealed strong links between elements of each of the three regulatory systems, characterised by three higher modules the centres of which were systolic blood pressure during active stand, stroke volume and ejection fraction respectively. Conclusions CFS is a complex condition affecting physiological systems. It is important that novel analytical techniques are used to understand the abnormalities that lead to CFS. The underlying network structure of the autonomic system is significantly different to that of controls, with a small number of individual nodes being highly influential. The combined network suggests links across regulatory systems which shows how alterations in single nodes might spread throughout the network to produce alterations in other, even distant, nodes. Replication in a larger cohort is warranted.

The purpose of this study is to perform a match comparison of 3 different exercise programs: traditional continuous endurance training (ET); mixed-intensity interval ET (MI-ET); and circuit-interval resistance training (CRT) programs, to determine which of the 3 programs provides greater benefit of exercise in individuals who are overweight. This benefit of training is measured in Caloric expenditure per minute of exercise (kcalxmin), along with acute cardiovascular responses (average and maximal heart rate [HR], bxmin) and time of training spent within a favorable HR training zone for the exerciser. Thirteen (13) individuals, 7 men and 6 women, average of 35 +/- 2.3 years of age, who are overweight, average body weight of 79.8 +/- 5.1 kg with a body mass index of 35 +/- 1, were recruited from a local fitness center and were then randomly assigned to an order to complete 1 session of each of the 3 modes of exercise. There was no difference between program groups (MI-ET, CRT, and ET programs) for average HR response, p0.05; however, the individuals while performing the MI-ET program spent a greater percent of training time within a favorable training zone than the CRT or ET programs (p0.01). Additionally, the MI-ET and CRT programs produced greater Caloric expenditure (kcalxmin) than the ET program (p0.01) with no statistical difference between the MI-ET and CRT programs (p0.05). Although the CRT produces the greatest overall Caloric expenditure, the MI-ET program produces measures that provided a significantly greater benefit of exercise for the 3 programs of interest.

Background Chronic fatigue syndrome is a common condition characterized by severe fatigue with post-exertional malaise, impaired cognitive ability, poor sleep quality, muscle pain, multi-joint pain, tender lymph nodes, sore throat or headache. Its defining symptom, fatigue is common to several diseases. Areas of agreement Research has established a broad picture of impairment across autonomic, endocrine and inflammatory systems though progress seems to have reached an impasse. Areas of controversy The absence of a clear consensus view of the pathophysiology of fatigue suggests the need to switch from a focus on abnormalities in one system to an experimental and clinical approach which integrates findings across multiple systems and their constituent parts and to consider multiple environmental factors. Growing points We discuss this with reference to three key factors, non-determinism, non-reductionism and self-organization and suggest that an approach based on these principles may afford a coherent explanatory framework for much of the observed phenomena in fatigue and offers promising avenues for future research. Areas timely for developing research By adopting this approach, the field can examine issues regarding aetiopathogenesis and treatment, with relevance for future research and clinical practice.

Michael F Joseph1, Craig R Denegar1, Elaine Horn1, Bradley MacDougall1, Michael Rahl1, Jessica Sheehan1, Thomas Trojian2, Jeffery M Anderson1, James E Clark1, William J Kraemer11Department of Kinesiology, 2Department of Sports Medicine, University of Connecticut, Storrs, CT, USAAbstract: Lower extremity mechanics during landing have been linked to traumatic and nontraumatic knee injuries, particularly in women’s athletics. The effects of efforts to mitigate these risks have not been fully elucidated. We previously reported that a 5° medial wedge reduced ankle eversion and knee valgus. In the present report we further investigated the effect of a 5° medial wedge inserted in the shoes of female athletes on frontal plane hip motion, as well as ankle, knee, hip, and trunk saggital plane motion during a jump landing task. Kinematic data were obtained from 10 intercollegiate female athletes during jump landings from a 31 cm platform with and without a 5° medial wedge. Hip adduction was reduced 1.98° (95% CI 0.97–2.99°) by the medial wedge but saggital plane motions were unaffected. A 5° medial wedge reduces frontal plane motion and takes the knee away from a position associated with anterior cruciate ligament injury and patellofemoral pain syndrome. Although frontal plane motion was not captured it is unlikely to have increased in a bilateral landing task. Thus, it is likely that greater muscle forces were generated in these highly trained athletes to dissipate ground reaction forces when a medial wedge was in place. Additional investigation in younger and lesser trained athletes is warranted to assess the impact of orthotic devices on knee joint mechanics.Keywords: jump landing, foot orthotic, lower extremity kinematics, knee biomechanics, knee injury

Fifty-three primary uncemented custom-molded Identifit (Depuy, Warsaw, IN) hip arthroplasties were evaluated prospectively at a mean follow-up period of 30 months. The custom technique provided the capability to reproduce the unique femoral offset, version, and height in each hip and to achieve high percentages of femoral canal fill. Surgical time for unilateral cases was a mean 153 minutes. Clinical results, however, were disappointing. Nine hips (17%) required stem revision for persistent thigh pain and limping. Of the remaining 44 hips, the mean Harris hip score was 83, and 20% experienced moderate to severe thigh pain and 50% had a limp. Radiographically, 65% of the stems had subsided and 27% had migrated into valgus. Survivorship analysis predicted an 80% stem survival rate at 43 months. A precise fit and fill of the femoral canal is not in itself sufficient for femoral implant stability in total hip arthroplasty surgery.

Over the last half century there has been an epidemic of diminished health status induced by what seems as a concurrent rise in a population of individuals that are overfat. During the past few decades, the use of exercise has become a staple in the prevention and treatment options for the retarding the development of health issues pertaining to individuals who are overweight, overfatness or experience obesity. However, there are few studies and reviews look at the global issues surrounding the metabolic and hormone consequences of overfatness and the interaction of exercise with adiposity in humans developing the health status for the individual. This review offers an insight into our current understanding of health issues pertaining to metabolic and hormonal disruption related to overfatness and the treatment effect that exercise, especially resistance exercise, can have on impacting the health status, and overall well-being, for individuals who are overfat, regardless of body compositional changes leading toward a lessening of diseased state, and eventually a return to a normal health status for the individual.

Osteoarthritis (OA) of the knee is a common and progressive condition. Michael et al1 reported that 6% of adults suffer from clinically significant knee OA with the prevalence increasing with each decade of life. Lawrence et al2 provided a summary of population based studies which revealed estimates of symptomatic and radiographically confirmed knee OA as high as 16.7%3 for those 45 years and older, with women more affected than men.2 OA results in pain and recurrent swelling and is associated with progressive functional limitations and disability.2 Multiple treatment options are available for patients with OA of the knee including the use of superficial heat or cold, transcutaneous electrical nerve stimulation (TENS), oral medications, injection of hyaluronic acid or a corticosteroid, or ultimately knee joint replacement surgery.4–6 Unfortunately, knee OA is a progressive disease and not all patients are good candidates for all interventions. Moreover, there are risks and side effects associated with medications and surgery that are not associated with some remedies, such as superficial heat or cold applications.6,7 Furthermore, not all treatment options meet with the same results, supporting individualized patient management approaches. The benefits of others such as injections of hyaluronic acid or a corticosteroid do not last indefinitely and must be repeated.8,9 The use of lower risk, lower cost interventions that are effective in helping patients manage chronic conditions including knee OA, warrant further examination and attention when discussing treatment options or recommending a plan of care. The periodic application of superficial heat or cold is a relatively safe and low cost treatment that can be recommended in isolation or in combination with other treatments for patients with knee OA.10 Contrast therapy involving intervals of heat and cold application within a treatment session offers yet another option in the management of many different musculoskeletal conditions, including knee OA. Few studies are available to demonstrate if either superficial heat, cold, or contrast therapies are of greater benefit.11 Despite limited understanding of the response to heat, cold, or contrast modalities in the management of knee OA, the application of superficial heat or cold is very common, often self-initiated, and is considered a component of a “first-line” intervention in the management of knee pain in older adults.4,12 Porcheret et al12 reported that of 201 older patients with knee pain surveyed, 84% reported applying superficial heat or cold, and most reported this treatment as a self-initiated intervention. Additionally, Cetin et al4 reported that the use of superficial heat or cold in conjunction with diathermy, TENS or ultrasound led to varying levels of symptom relief and functional improvements in patients with knee OA. Health care providers are often asked whether heat or cold is better, and how these modalities should be used outside of clinical settings for treatment of knee OA.11 Unfortunately, as previously noted, there are no clear answers or recommendations for patients to follow, hence anecdotal recommendations are often based on personal experiences, patient preferences, and previously established clinical training and education.10–15 Studying the response to thermal modalities is complicated by the fact that it is not possible to blind subjects or providers to the intervention. Moreover, clinical observations show many patients have experiences with heat and cold applications and express preferences based on these experiences. The first purpose of this Phase I study (subjects were randomized to order but not to a particular treatment with primary focus on treatment preference) was to investigate the preferences of patients with knee OA using a single device that is able to provide multiple treatment options with an identical method of application. Other factors may also need to be considered in recommending treatments. Impairments of the hand and loss of mobility in the lower extremities may impede an individual’s ability to self-apply superficial heat and cold around a peripheral joint. For example, securing an ice pack can be difficult for some patients. Furthermore, wrapping an electric heating pad in place poses risk of burns, especially if peripheral sensation or circulation is compromised. Several commercially available warm and cold-water circulating units offer a means of surrounding a joint with a garment through which temperature controlled water circulates. These garments are wrapped around the joint and held in place with Velcro™ closures. These garments may offer a safer and more convenient means of applying cold or heat. The second purpose of this investigation was to assess the preferences of patients toward a given treatment option provided by a wrap-around system when compared to use of a standard electric heating pad. A preferred treatment may or may not yield a better outcome. The third purpose of this investigation was to assess self-reports of patients with level II or greater OA16 for pain, symptoms, function in daily living (FDL) and recreation, and quality of life (QOL), following 5 days of twice daily superficial heat, cold or contrast therapy applied with a wrap-around water circulating device, twice daily use of a standard heating pad, or twice daily rest for 20 minutes.

Growth hormone (hGH) presents pleiotropic effects in many tissues encompassing a diverse range of physiological actions. Its complexity as a family of hormones with different isoforms and different somatotroph molecular functions continues to challenge the status quo of our understanding of its release, function, and signaling. Owing to the fact that the majority of the literature has viewed hGH from the perspective of the primary 22 kD monomer, further investigation is needed as to the influence and biological activity of other aggregate and splice variant isoforms that are released into circulation. Its role over the life span and with supplementation yields equivocal results with more study needed. Testing for the use of hGH has progressed, and the first positive test was recently documented. Understanding of pituitary function and physiology will remain complex until the use of a broader range of analytical techniques, including assays, becomes mainstream.

The purpose of this study is to examine improvements in cardiorespiratory fitness (VO(2)) after the use of a mixed-intensity interval endurance-training (MI-ET) program in female soccer players, to validate the MI-ET program as an appropriate training regimen to improve cardiorespiratory fitness (VO(2)) in soccer players. 32 female soccer players (average 18.66 +/- 0.31 years) were recruited from a group of currently conditioning local U-19 and college soccer teams and randomly assigned to participate in an 8-week periodized training program that involved either the MI-ET program or the continuation of a current endurance-training (ET) program. Analysis of variance indicates no differences in VO(2) values within the group of athletes before participating in the exercise program. After the 8 weeks of training, the MI-ET group of athletes had significantly greater average VO(2) values (62.13 +/- 0.96 ml O2.kg.min vs. 57.27 +/- 1.59 ml O2.kg.min), p = 0.015, along with a greater group average of change in VO(2) (12.44 +/- 0.92 ml O2.kg.min vs. 7.72 +/- 0.99 ml O2.kg.min), p < 0.001. The MI-ET program is shown to be a valid means to improve aerobic fitness as indicated by the MI-ET group exhibiting significantly greater VO(2) measures after training.

The first reported case of bilateral renal hemangiopericytoma ispresented. The 19 previous renal hemangiopericytomas that have been reported in the world literature are reviewed. This lesion has afflicted patients ranging in age from sixteen to sixty-eight years (mean 41 years) with an equal sex distribution. Mortality from hemangiopericytoma of the kidney has been 50 percent, and the primary mode of therapy remains surgical.

Publisher Summary Disposal of liquids into underground formations through injection wells was started in 1930 by the U. S. petroleum industry, which as a common practice, disposed of produced brine in this manner. Underground injection is the disposal of liquid waste material into isolated geologic strata, placing the wastes in portions of the earth's crust that are free from the usual effects of the hydrologic cycle. Enactment of the Safe Drinking Water Act (SDWA) in 1974 ratified the Environmental Protection Agency's (EPA's) underground injection policy position and required the Agency to promulgate minimum injection well requirements of state programs to prevent endangerment of underground sources of drinking water (USDWs). In 1984, the Hazardous and Solid Waste Amendments (HSWA) prohibited land disposal of hazardous waste, including underground injection, unless the EPA could determine that the disposal would not adversely affect human health and the environment. Since 1980, with the implementation of the underground injection control (UIC) program of the SDWA, no cases of USDW contamination have occurred, due to stringent siting, construction, operation, and testing requirements for Class I hazardous and nonhazardous wells.

Nash MS, Jacobs PL, Woods JM, Clark JE, Pray TA, Pumarejo AE. A comparison of 2 circuit exercise training techniques for eliciting matched metabolic responses in persons with paraplegia. Arch Phys Med Rehabil 2002;83:201-9. Objective: To test whether acute metabolic (VO 2 ), chronotropic (heart rate), and perceptual (rating of perceived exertion; RPE) responses to exercise by persons with paraplegia differ when the exercise is on a multistation isoinertial exercise system (MultiGym) or on a customized system of Thera-Band® resistance bands (ElasticGym). Design: Within-subjects comparison of 2 treatments. Setting: Academic medical center. Participants: Sixteen men and 1 woman with complete paraplegia (T4-L1), as defined by the American Spinal Injury Association. Interventions: A circuit resistance training (CRT) program for persons with paraplegia was adapted to both a MultiGym and a customized ElasticGym. Exercises used for training and testing used 6 resistance maneuvers at 50% of the 1-repetition maximum (1-RM), with interposed rapid arm spinning. Subjects were habituated to both conditions for 2 weeks before testing on randomized nonconsecutive days. Main Outcome Measures: VO 2 (L/min) was measured by portable spirometry, heart rate (beats/min) by a chest strap monitor, and RPE by the Borg Scale of Perceived Exertion (6-20). Results: No significant effects of test condition on average VO 2 or heart rate were observed, with differences between conditions reflecting only.08L/min and 6.4 beats/min, respectively. Average RPE was significantly higher in testing under the ElasticGym condition ( P Conclusions: CRT on a customized ElasticGym system elicited acute metabolic and chronotropic responses that did not differ from responses to exercise on a MultiGym, though RPE was greater with the ElasticGym. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Traffic congestion has historically been regarded as a problem confined to major metropolitan areas. Over the years, the traffic problems that existed in densely developed urban areas began creeping into the suburbs as the work force migrated away from the traditional center city work pattern. Modem business operates at a feverish pace and is more mobile in nature, automobile technology advances have allowed more people to drive, and the commuting public has caused traffic congestion problems to appear even in small towns. Simply adding pavement to mitigate the traffic problems is neither adequate nor feasible. The Intelligent Transportation Systems (ITS) initiative was invoked by congress in 1991 to advance our traffic control systems by fostering development of Advanced Traffic Management Systems (ATMS). These technologies are designed to help move the motoring public more efficiently over the existing transportation system. Computer simulation has proved to be a vital adjunct to traditional traffic engineering analysis methods in hlly understanding the dynamics of traffic movement and control operations,. These simulation tools are critical in the development and evaluation of these new ideas, algorithms, and traffic control systems. This paper presents three case studies illustrating the importance and positive impacts of

The development of a computer simulation model to approximate the interactions of those traffic elements present at a signalized intersection is presented. The simulation model is designed as a tool for the engineer or analyst to predict the behavior of a signalized intersection under different operational conditions. GASP IV is the simulation language used in this study. This language is FORTRAN based and can be easily implemented on the computing systems of different manufacturers. By varying different parameters (logo, geometrics, movement percentages, traffic signal information, volumes, phasing, etc.) while holding others constant, the impact of design changes were studied. Both exclusive and no exclusive left-turn phase signal operation were investigated and the simulation output indicates reasonable results. The engineer could use this simulation model in the integral part of making traffic operation decisions.

There are number of means of methods to alter body composition, and metabolic issues, available for the adult who is overfat. The following is a systematic review and meta-analysis focused on comparing changes from treatment program for adults who are overfat based on analysis of aggregated effect size (ES) of inducing changes. So as to determine the relative effectiveness of such protocols and intervention plans of choice. This tiered meta-analysis of 66-population based studies, and 162-studywise groups, a clear pattern of ES being established across and within treatments. First, hypocaloric balance is necessary for changing body composition, but the effectiveness for establishing imbalance does not equate with the effectiveness for body compositional changes, or any biomarkers associated with metabolic issues. With analysis showing that there is a necessity to include exercise in combination with diet effectively elicit changes in body composition and biomarkers of metabolic issues. More importantly, the combination, resistance training (RT) was more effective than endurance training (ET) or combination of RT and ET, particularly when progressive training volume of 2-to-3 sets for 6-to-10 reps at an intensity of ≥75% 1RM, utilizing whole body and free-weight exercises, at altering body compositional measures (ES of 0.47, 0.30, and 0.40 for loss of BM, FM, and retention of FFM respectively) and reducing total cholesterol (ES = 0.85), triglycerides (ES = 0.86) and low-density lipoproteins (ES = 0.60). Additionally RT was more effective at reducing fasting insulin levels (ES = 3.5) than ET or ET and RT. Even though generally lower ES than RT, the inclusion of ET was more effective when performed at high intensity (e.g. ≥70% VO2max or HRmax for 30-minutes 3-4x’s/wk), or in an interval training style than when utilizing the relatively common prescribed method of low-to-moderate (e.g., 50-70% VO2max or HRmax for at least equal time) steady state method, ES of 0.35, 0.39, and 0.13 for BM, FM, and FFM respectively. Thus indicating that focus of treatment should be on producing a large metabolic stress (as induced by RT or high levels of ET) rather than an energetic imbalance for adults who are overfat.

Erythrokinetic studies on two anephric and asplenic patients are described. The patients were nephrectomized in preparation for renal homotransplantation and maintained on hemodialysis for six and eight months. Results of these studies indicate that despite absence of kidneys and spleen, and intrinsic base line erythropoietic activity remains, with a relatively constant and persistent reticulocyte production and radioiron turnover. Autonomy of this erythropoietic activity was apparent by lack of responsiveness to induced anemia and polycythemia. In the second patient a reticulocytosis and increased iron turnover occurred five months postnephrectomy. This was accompanied by significant plasma titers of erythropoietin-like substance. A renin-like enzyme was also found in the plasma of both patients. These observations suggest the existence of an autonomous base line erythropoietic activity of bone marrow and a possible functional relationship between inappropriate secretion of extrarenal "erythropoietin" and extrarenal "renin."

Excerpt To the editor: The paper by Bernardo Rodriguez-Iturbe and his associates (1) has been of considerable interest to us. Being aware of consistent reports linking infectious mononucleosis to t...

Excerpt Segments of ileum or jejunum were isolated from the remaining bowel and one or both ends exteriorized in 19 chronically uremic patients. The etiology of their uremia varied widely, and all ...

To the Editor.— In the report entitled, "Renal Allotransplantation for Bilateral Renal Tumors," (210:1721, 1969), Case 2, known to have tuberous sclerosis, had what appears to have been benign mesenchymomas (hamartomatous angiomyolipoma) in both kidneys necessitating the removal of one. In a similar case (Arch Intern Med120:70-80, 1967), a patient having benign mesenchymomas bilaterally without evidence of tuberous sclerosis underwent a right nephrectomy in 1962 and a left nephrectomy in 1965, necessitating the implantation of an arteriovenous shunt and maintenance extracorporeal hemodialysis. A renal homotransplantation from a fraternal twin (by Dr. David Hume) in 1966 was successful. This should lend further strength to Dr. Jochimsen's projection of eventual successful transplantation in his patient when the patient's condition eventually warranted removal of the remaining kidney.

THREE recent reviews1,2,3have stressed the unilaterality of benign mesenchymomas of the kidney (hamartomatous angiomyolipoma) except in those patients with tuberous sclerosis. The sudden onset of shock is reported by Price and Mostofi3in two of 30 patients and is even more of a rarity in the sporadic cases reported in the English language literature.1-31The following report demonstrates both that this lesion can be bilateral and that severe spontaneous retroperitoneal hemorrhage can rapidly develop. Report of a Case A 42-year-old white woman (JMCH 217456) with no evidence of tuberous sclerosis was in good health until June 22, 1962, when severe right flank, abdominal and back pain developed and she was admitted to Delaware County Memorial Hospital. Despite no obvious external blood loss hypovolemic shock developed necessitating blood replacement. Abdominal x-ray film showed absence of the right psoas shadow, and an intravenous pyelogram revealed no calyceal deformity