Altered aortic protease and antiprotease activity in patients with ruptured abdominal aortic aneurysms

Aortic elastase, antiprotease (a-1-antitrypsin) and total protein were assayed in 37 patients who underwent an operation on the abdominal aorta for ruptured abdominal aortic aneurysms (AAA), an elective procedure for AAA or aortofemoral bypass for occlusive disease. Aortic elastase modified by local antiprotease activity (elastase/a-1-antitrypsin) was significantly higher in patients with a ruptured AAA compared with patients with an elective AAA or occlusive aortic disease: 241 nanograms per milligram of tissue in AAA-rupture versus 57 nanograms per milligram of tissue in AAA-elective versus 32 nanograms per milligram of tissue for occlusive (p less than 0.003). Patients with a ruptured AAA had the highest elastase activity (354 nanograms per milligram of tissue) and the lowest a-1-antitrypsin (1.07 nanograms per milligram of tissue) compared with patients with an elective AAA and occlusion (p less than 0.05). These data suggest that the homeostatic balance between elastase and antiprotease may be significantly altered in the aortic wall at the time of aneurysm rupture. Increased elastase unchecked by low antiprotease results in increased elastin breakdown which may be the inciting event for rupture of a compromised, thin aortic aneurysm wall.     

Outcome of subsequent pregnancies following antibiotic therapy after primary or multiple spontaneous abortions

The course of the subsequent pregnancy and the maternal and fetal complications were evaluated in 254 couples who were seen in an infertility clinic after primary or multiple spontaneous abortions. The 100 couples who were treated with antibiotics after pregnancy loss showed a significantly better chance of achieving a subsequent pregnancy. The outcome of pregnancy was significantly better in the antibiotic treated group and the rate of spontaneous abortion recurrence was significantly lower (10 versus 38 per cent). The number of maternal complications was significantly less in the treated group--premature rupture of membranes, three (4 per cent) versus 30 (46 per cent), and postpartum fever, three (4 per cent) versus 23 (35 per cent), respectively. The untreated group experienced a significantly lower percentage of vaginal delivery (56 versus 69 per cent) (p less than 0.001). In the antibiotic treated group, there were significantly lower rates of fetal complications, including fetal distress, meconium, respiratory distress syndrome, neonatal infection and hyperbilirubinemia. The mean birth weight of infants in the antibiotic treated group was significantly higher (3,529 versus 3,090 grams; p less than 0.001). Prematurity and postdatism were significantly less frequent in the antibiotic treated group, and the corresponding Apgar scores were significantly better. We, thus, postulate that certain spontaneous abortions may be caused by bacteria present in the genital tract at the time of conception. These bacteria may have an adverse effect on the course of pregnancy and result in increased maternal and fetal complications.     

Two year prospective analysis of the Oxford experience with surgical treatment of abdominal aortic aneurysm

During the two years from 1 November 1985 to 31 October 1987, 177 patients were admitted to a hospital in Oxford with the diagnosis of abdominal aortic aneurysm (AAA). The aneurysm had ruptured in 88 patients, of whom 75 underwent emergent surgical treatment, yielding an operative mortality rate of 36 per cent. Of the 13 patients who did not have surgical treatment, two died before transfer to the operating room; in the other 11 patients, a deliberate decision was made not to undertake surgical treatment--in ten patients, the reason was an age of 85 years or more and in one patient, severe debilitating Parkinson's disease. Emergent operations were done upon another 15 patients--11 who had acute aneurysm and four in whom symptoms were not caused by an aneurysm. Emergent operations for ruptured or acute aneurysms represented 55 per cent of all operations for AAA. This high proportion and large number of emergent operations is in marked contrast with the experience of comparable specialist vascular surgical units in the United States. The 24-fold difference in mortality rates between surgical procedures performed electively and for ruptured aneurysm suggests that a considerable impact on over-all mortality could be achieved by a substantial increase in referral of patients     

Biopsy of the breast for mammographically detected lesions

We prospectively studied 718 women who underwent biopsy of the breast for suspicious, mammographically detected mammary lesions in an attempt to identify key clinical risk factors, as well as roentgenographic characteristics associated with the appearance of early carcinoma of the breast. Patients with a benign outcome had an average age of 55 years versus 63 years for patients with carcinoma of the breast. Seventy-six per cent of these patients had no previous history of mammary problems, 20 per cent had a positive family history for carcinoma of the breast, 58 per cent were premenopausal and 21 per cent had used birth control pills. Except for age (p less than 0.001), the distribution of clinical risk factors was equal among patients with benign or malignant outcomes. Suspicious mammographic findings included mass lesions (53 per cent), calcifications (36 per cent) and the association of both (11 per cent). The predominant Wolfe pattern on mammography was P1 (36 per cent). No relationship was observed between Wolfe pattern and malignant conditions. In this group of patients, mammography was poorly specific; however, the positive predictive value increased with age and is related to the age-specific prevalence of carcinoma of the breast. Eight hundred and twenty-five lesions were removed. Twenty-five per cent (n = 203) of the specimens taken at biopsy contained carcinoma. Stellate mass lesions were highly suggestive of a malignant growth (p less than 0.0001). No relationship between the size of the suspicious mammographic mass and the malignant lesion was observed. A marked correlation (chi-square test with Yate's correction) was observed between malignant tumor and lesions with a linear or branching pattern, more than 15 calcifications, or small sized calcifications. The presence of a mass with calcifications was associated with carcinoma in 34 per cent. The incidence of invasive carcinoma was much higher for mass lesions (81 per cent) than for suspicious calcifications (56 per cent) (p less than 0.0001).     

Initial experiences with the determination of neopterin in the urine of females with genital and breast tumors

The quantitative analysis of urinary neopterin was carried out ahead of the operation by means of high performance liquid chromatography (HPLC). The sample included 98 women with genital or breast neoplasias. Significant differences have been found between the patients with benign or preinvasive neoplasias as well as women with malignancies (p less than 0.001) as compared to a control group of healthy females. The neopterin levels of the malignant tumors were definitely higher than those of the benign tumors (p less than 0.01). As far as genital tract cancer ist concerned, the neopterin levels found were in 51.5 per cent of the cases above the estimated limit with a specificity of 95.1 per cent in healthy patients and 79.5 per cent within the group of nonmalignant gynecologic lesions. The neopterin levels established in patients with genital tract malignancies appear to be related with the stage of the development of the disease (i.e. levels and positive rate are significantly higher in stages III and IV as compared to stages I and II; p less than 0.01). Tests of women with breast cancer showed the smallest number of raised neopterin levels. The average level of the last mentioned cases didn't differ greatly from the levels of the benign breast tumors. Tests of the patients with cancer after treatment showed in 68.8 per cent of all cases neopterin levels corresponding to the clinical findings. However, cases of smaller recurrent tumors may be accompanied by normal neopterin levels as well.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis-related groups and the salvagable trauma patient in the intensive care unit

We reviewed 59 patients with trauma treated in the surgical intensive care unit (SICU) in 1983 comparing hospital charges with payments calculated from diagnosis-related groups (DRG). There were 37 male and 22 female patients with a mean age of 38.3 years. The mechanism of injury was blunt trauma in 42 and penetrating injury in 17 patients. The mean injury severity score (ISS) was 30.7 +/- 13.8 (mean plus or minus standard deviation). The duration of SICU care was 5.4 +/- 6.1 days. Over-all, 18 patients died. For the entire group, payment based upon a DRG system would have resulted in an over-all loss of $1,468,094.00 or $24,883.00 dollars per patient. Calculated DRG payments would have accounted for only 32.3 per cent of the total hospital charges. Calculated losses for 41 survivors would have been $1,098,431.00 dollars. Length of stay had a significant relationship to the calculated DRG payment (r = 0.69, p less than 0.001) but account for only 48 per cent of the variance. DRG only accounted for 26 per cent of the variance in charges despite a statistically significant relationship (r = 0.51, p less than 0.001). No statistically significant relationship was found between ISS and hospital charge by linear regression (r = 0.20, p greater than 0.01) or between ISS and DRG payment (r = 0.14, p less than 0.4). DRG as presently formulated would only pay one-third of total hospital charges for patients with trauma requiring SICU care. Present DRG payment schedules reflect neither the elements of care currently expended nor the modifiers necessary to adjust for acuity and severity. The ISS score would not be a useful modifier to correct DRG payment in this high cost group.     

Risk for postoperative congestive heart failure

To identify predictors of postoperative congestive heart failure (CHF), a high-risk population, mainly hypertensive and diabetic patients undergoing elective general operations, was studied. Of the 254 patients, 6 per cent had postoperative CHF. Among patients with preoperative cardiac disease (that is, previous myocardial infarction, valvular disease or CHF), 17 per cent had postoperative CHF; in contrast with less than 1 per cent of those without cardiac disease (p less than 0.001). Patients with diabetes were also at high risk (12 versus 2 per cent, p less than 0.005), particularly those with cardiac disease. Patients who had equal to or greater than 40 millimeters of mercury increases or decreases intraoperatively in mean arterial pressure in relation to preoperative baseline had increased postoperative failure rates (p less than 0.02). Of note, postoperative failure rates were highest among patients with less than 500 milliliters per hour of net intake (input and output) (p less than 0.03). Risk for postoperative CHF was restricted to patients with preoperative symptomatic cardiac disease and was especially high if patients also had diabetes. Intraoperative fluctuations in mean arterial pressure increased the probability of postoperative failure, while the intraoperative administration of higher net volumes of fluid was associated with decreased risk.     

Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community

The hospital records for patients treated for ruptured abdominal aortic aneurysms in southern West Virginia during a recent five year period were reviewed. The over-all mortality rate was 62 per cent. Patients with intraperitoneal rupture had a higher mortality rate (97 per cent) than patients with retroperitoneal rupture (25 per cent). Patients at increased risk were more than 80 years of age, presented with syncope, experienced a short duration of symptoms before seeking medical attention, had preoperative systolic blood pressure levels of less than 90 millimeters of mercury and had a preoperative hemoglobin level of less than 8. Other factors associated with death were a delay in beginning surgical treatment, a larger total blood loss and amount of blood transfused. The results of multivariate analysis demonstrated that preoperative blood pressure, preoperative hemoglobin, presence of syncope and the amount of blood loss were, in large part, reflections of the type of rupture and had only slight independent relationship to mortality. The most effective method of preventing fatal outcome is elective resection of the aneurysms before rupture occurs.     

Analysis of surgical complications after 397 hepatic transplantations

The results of 397 consecutive orthotopic hepatic transplantations in 333 recipients were reviewed. One or more surgical complications developed in 172 of 323 patients (55 per cent), excluding ten intraoperative deaths. The six month mortality rate among the patients with surgical complications (55 of 172; 32 per cent) was statistically higher than that among patients without such complications (16 of 151; 11 per cent) (p less than 0.001; chi-square, 58.36). Surgical complications included exploratory laparotomy for bleeding or infection in 74 (22 per cent), reconstruction of the bile duct for biliary obstruction or leakage in 55 (17 per cent), external biliary drainage for biliary leakage in four (1 per cent), tracheostomy in 80 (24 per cent), thoracotomy in 12 (4 per cent) and splenectomy in seven (2 per cent). The incidence of biliary obstruction (16 per cent mortality rate) and leakage (48 per cent mortality rate) was 18 per cent (34 of 193) and 2 per cent (four of 193) each after choledochocholedochostomy, which was 3 per cent (five of 187) and 9 per cent (17 of 187) each after choledochojejunostomy. Biliary obstruction (16 per cent mortality rate) was more common after choledochocholedochostomy (p less than 0.005; chi-square, 23.01), whereas the incidence of more serious biliary leakage (48 per cent mortality rate) was higher after choledochojejunostomy (p less than 0.005; chi-square, 8.97). It is concluded that orthotopic hepatic transplantation remains an unforgiving extensive surgical procedure, in which choledochocholedochostomy remains the first-choice reconstruction of the biliary tract because of its lower mortality.     

Choledochoduodenostomy, transduodenal sphincteroplasty and sphincterotomy for calculi of the common bile duct

The clinical features, indications and operative results in a consecutive series of 246 patients who underwent choledochoduodenostomy (CDD) and transduodenal sphincterotomy or sphincteroplasty (TDS) over a period of ten years (1972 to 1981) were reviewed. The over-all mortality for CDD was ten of 190 patients (5.3 per cent) and three of 56 patients for TDS (5.4 per cent). The over-all major morbidity rate for these procedures was 11.6 per cent for CDD and 21.4 per cent for TDS. This was not a statistically significant difference, but there were more elderly patients (more than 65 years old) in the CDD group (60.5 per cent) than in the TDS group (21.4 per cent) (p less than 0.001). The major morbidity rate associated with elective operations was 10.7 per cent for CDD and 20.0 per cent for TDS which is significant (p less than 0.05). Long term follow-up study (one to 12 years and mean of four and one-half years) revealed six patients in the CDD group with sump syndrome or cholangitis, or both, (3.3 per cent) and three patients in the TDS group had cholangitis develop (5.7 per cent). Over-all, the results compared favorably with the published results of endoscopic sphincterotomy. We conclude that CDD is the operation of choice when a permanent biliary drainage procedure is indicated and TDS should be reserved for instances of ampullary gallstone impaction.     

Emergency surgical treatment for nonvariceal bleeding of the upper part of the gastrointestinal tract

Endoscopic and biochemical data were collected prospectively from 1,530 patients admitted with nonvariceal bleeding of the upper part of the gastrointestinal tract between September 1985 and June 1989. Therapeutic endoscopy was done for 93 patients who underwent emergency surgical treatment for bleeding, subsequently required in 29 patients with seven postoperative fatalities. In contrast, 31 (15.7 per cent) of 198 patients (mortality rate of 9.6 per cent at 30 days) died in the hospital who had undergone emergency operation in whom therapeutic endoscopy had not been performed; data for this latter group is now presented. At admission, a greater likelihood of emergency operation was associated with a systolic blood pressure of 100 millimeters of mercury and endoscopic stigmatas of recent hemorrhage (ESRH) (p less than 0.001). Rebleeding rates for the presence of fresh blood, active spurting and oozing hemorrhage or visible vessel in an ulcer base were 26.5, 28.9 and 35.9 per cent, respectively. Endoscopic stigmatas were thus associated with an increased risk of bleeding (p less than 0.0001) and rebleeding led to a sixfold increase in the mortality rate. Congestive cardiac failure, chronic obstructive airway disease, chronic renal failure and a history of previous malignant disease were each associated with postoperative mortality rates of more than 50 per cent. An increased risk of mortality after emergency operation was related to age (p less than 0.0001), preoperative (p less than 0.002) and total (p less than 0.0001) blood transfusion requirement. Immediate operation after resuscitation and endoscopy was required in 87 patients; 11 deaths (hospital mortality rate of 12.7 per cent and 9.2 per cent at 30 days) occurred in this group compared with 20 fatalities (18.0 per cent) documented in 111 patients (9.9 per cent at 30 days) who underwent surgical treatment for rebleeding. We conclude that age, concomitant medical illness and preoperative and total transfusion requirements are each related to outcome after emergency operations. Such urgent intervention is best avoided if at all possible in patients with severe concomitant medical illness.     

Prolactin responsiveness to TRH in amenorrheic women with and without galactorrhea.

Sixty women were given intravenous injection of 200 microgram TRH to assess its diagnostic potential as a stimulus to PRL release. Following the administration of TRH, there was a prompt increase in serum PRL to 614.6%, to 296%, to 282.1%, and 34% in normal women, amenorrheic patients, non tumoral galactorrheic cases, and patients with pituitary tumors respectively. The TRH response above baseline of PRL levels was statistically significant in all groups, but the women with pituitary tumors which showed a blunted response. The per cent of increment of PRL levels after TRH was similar in amenorrheic women regardless the presence or not of galactorrhea; this increase was significantly greater than in patients with pituitary tumors (p less than 0.01). The per cent of increment above baseline of PRL was significantly greater in menstruating women than in amenorrheic patients (p less than 0.001). In basis of present data: 1) there is a diminished PRL secretion after TRH in amenorrheic women regardless the presence of galactorrhea or hyperprolactinemia; 2) a blunted response to TRH in hyperprolactinemic women may be indicative of a pituitary tumor.     

Morbidity and recurrence rates after surgical treatment of malignant melanoma by scalpel versus CO2 laser beam

A retrospective study was carried out on 219 patients who underwent surgical treatment of a malignant melanoma. A scalpel was used in 96 patients in group 1 and CO2 laser beam was used in 123 patients in group 2. The average length of hospitalization for group 2 was longer (16.3 versus 12.8 days for group 1). This was due to failure of the skin graft; 32.5 per cent in group 2 versus 15.6 per cent in group 1 (p = 0.005). The accumulative rate of recurrence for both groups was almost the same although there were significant differences according to the various parameters. Male patients in group 2 had a significantly higher rate of recurrence as compared with female patients in the same group (p less than 0.001) and male patients in group 1 (p = 0.002). In both groups, there was a significantly higher rate of recurrence for ulcerated primary lesions and those lesions more than 1.6 millimeters thick (p = 0.05). Patients in group 2, with lesions more than 3 millimeters in thickness, had a higher rate of recurrence than those in group 1 (54.6 versus 40.6 per cent). In both groups, patients who underwent elective regional dissection of lymph nodes had a lower rate of recurrence (19.4 per cent) than those patients who did not undergo dissection (53.6 per cent) (p = 0.001). It is suggested that thermal damage to the blood and lymph vessels incurred during laser excision may be more extensive than has been reported. These damaged walls may cause the higher rate of distal metastases of malignant melanoma from a primary lesion more than 1.6 millimeters in thickness; primarily in male patients.     

Fatal hemorrhage from legal abortion in the United States

Deaths from hemorrhage associated with legal induced abortion should not occur. Yet hemorrhage was the third most frequent cause of death from legal abortion in the United States between 1972 and 1979. This study was undertaken to document the scope of the problem, to identify risk factors for fatal hemorrhage and to recommend ways of preventing these deaths. Deaths were identified through the CDC's nationwide surveillance of deaths from abortions; information on numbers and characteristics of women having legal abortions was obtained from CDC and the Alan Guttmacher Institute. Twenty-four women died from hemorrhage after legal abortion in the United States from 1972 to 1979, for a death-to-case rate of 0.3 deaths per 100,000 abortions (95 per cent confidence interval 0.2 to 0.5). Women who died from hemorrhage were significantly older than those who died from other causes (27.6 versus 24.4 years; p less than 0.05). Documented uterine perforation or rupture was far more frequent among women who died from hemorrhage than those who died from other causes (71 versus 8 per cent; p less than 0.001). Women who sustained uterine perforation or rupture were over 1,000 times more likely to die from hemorrhage than those who did not. Deaths from hemorrhage can be eliminated by preventing uterine trauma during abortion and by rapidly diagnosing and treating hemorrhage if it occurs.     

Gastroduodenal ulcer perforation in the patient with cirrhosis.

This retrospective study was done to stress the particular features of perforation of the gastroduodenal ulcer in patients with cirrhosis. From 1979 to 1987, 135 patients were operated upon for perforation of the gastroduodenal ulcer: clinical, biologic and roentgenographic data of 22 patients with cirrhosis were compared with 112 patients without cirrhosis. In the 22 patients with cirrhosis, three gastrectomies and 19 simple closures with omental patch were performed. Clinical ascites was present in 16 of 22 patients with cirrhosis. Acute abdominal pain and leukocytosis were less frequent in patients with cirrhosis (p less than 0.05), whereas associated bleeding in the upper part of the gastrointestinal (GI) tract was more frequent (p less than 0.05). In patients with cirrhosis, abnormal plasma creatinine level and associated upper GI bleeding were more frequent in patients with ascites (p less than 0.05); on the other hand, acute abdominal pain and rebound tenderness were less frequent (p less than 0.05). The incidence of pneumoperitoneum was higher in patients with cirrhosis. Surgical treatment was significantly delayed in patients with cirrhosis and ascites. Ulcers were larger in patients with cirrhosis and ascites than without (p less than 0.001). Over-all morbidity and mortality rates in patients with cirrhosis were 77.3 and 50.0 per cent, respectively. Mortality and morbidity were significantly higher in patients with ascites than without (62.5 versus 16.6 and 100 versus zero per cent, respectively), in patients with prothrombin times of less than 50 per cent and with plasma creatinine levels more than 110 micromolars.     

The effect of cigarette smoking on the long term success rates of aortofemoral and femoropopliteal reconstructions

Cigarette smoking is a recognized causative factor in the genesis of arterial insufficiency, but the precise effect of nonsmoking on the success of the operation is not well documented. Three hundred and twenty-six patients who underwent aortobifemoral bypass (209) or femoropopliteal bypass (117) between 1969 and 1978 were observed to determine whether or not the discontinuation of cigarette smoking affected the long term results of these grafts. Patients were divided into three groups: group 1 smoked preoperatively and postoperatively; group 2 smoked preoperatively but not postoperatively, and group 3 did not smoke at all. The five year cumulative success rates for aortobifemoral bypass in the groups were: 42 per cent for group 1 (130 patients); 77 per cent for group 2 (67 patients), and 71 per cent for group 3 (12 patients) (p less than 0.001). In the femoropopliteal group, the variation with regard to the known patency rates of autogenous and prosthetic grafts made the results more difficult to assess. For all grafts the five year cumulative success rates were: 38 per cent of group 1 (57 patients); 33 per cent for group 2 (40 patients), and 70 per cent for group 3 (20 patients) (p less than 0.001). Subdivision of groups 1 and 2 into autogenous and synthetic grafts gave identical success rates of 54 per cent for long saphenous vein grafts (66). Prosthetic grafts were successful at five years in 19 per cent of the patients in group 1 (16 patients) and 43 per cent in group 2 (15 patients). These results were not significant. These results clearly favor the postoperative nonsmoker over the smoker in the aortofemoral group but the distinction in the femoropopliteal group is less clear, although there is a similar trend.     

The role of preoperative radionuclide ventriculography in defining outcome after revascularization of the extremity

Revascularization of the extremity was performed upon 110 patients after preoperative radionuclide ventriculography (RNVG). Mean ejection fraction (EF) was 50 +/- 13 per cent. Ventricular wall motion abnormalities were present in 46 per cent. Revascularization included inflow procedures, such as aortofemoral (n = 25) or extraanatomic bypass (axillofemoral or femorofemoral, n = 11); infrainguinal reconstruction, including femoropopliteal or distal bypass (n = 43), and other procedures to improve perfusion of the limb or correct complications after previous vascular reconstruction upon the extremity (n = 31). Perioperative (30 days) mortality rate was 0.9 per cent and 97.0 per cent of the patients were discharged alive from the hospital. Myocardial infarction (MI) occurred in 3.6 per cent, new ventricular arrhythmia in 1.8 per cent and congestive heart failure in 6.4 per cent of the patients during the perioperative period. During follow-up study (607 +/- 363 days), 7.3 per cent required major amputation, ipsilateral to reconstruction, 5.5 per cent required surgical or angiographic revision for hemodynamic failure of the reconstruction prior to thrombosis and 12.7 per cent thrombosed part or all of the reconstruction. Revascularization failure did not appear to be related to the level of cardiac function. Those with normal (greater than 50 per cent) EF had greater over-all survival by life table analysis than those with EF less than or equal to 50 per cent (p = 0.0006, Mantel-Cox test). Ventricular wall motion abnormalities were associated with reduced over-all survival (p = 0.008, Mantel-Cox test). The presence of angina or previous MI, singularly or in combination, did not have an adverse effect on over-all survival, whereas diabetes (p = 0.0058, Mantel-Cox test) and cigarette smoking (p = 0.0137, Breslow test) were associated with significantly diminished over-all survival. Preoperative RNVG can identify subgroups at a survival disadvantage after revascularization of the extremity in a population in which the presence of angina or previous MI does not predict survival.     

The influence of abnormal glucose tolerance (hyperglycaemia and hypoglycaemia) on pregnancy outcome when oestriol excretion is subnormal.

Subnormal urinary oestriol excretion was present in 611 (13.9 per cent) of 4403 consecutive patients in whom a glucose tolerance test had been performed and urinary oestriol excretion measured during the third trimester of pregnancy. Hypoglycaemia (less than 5th centile) had a significant association with subnormal oestriol excretion. The perinatal mortality rate was significantly higher in the presence of abnormal glucose tolerance when oestriol excretion was low. Normoglycaemia was associated with a perinatal mortality rate of 1.7 per cent when oestriol excretion was persistently low, whereas in the presence of hyperglycaemia (greater than 95th centile) the perinatal mortality rate was 12.5 per cent (P less than 0.01) and when there was hypoglycaemia the rate was 14.8 per cent (P less than 0.001). Small-fordates babies occurred in 46.3 per cent of pregnancies complicated by hypoglycaemia and persistently subnormal urinary oestriol excretion. The advantage of routine urinary oestriol assay and glucose tolerance testing in pregnancy is emphasized.     

A comparison of hospital costs and morbidity between octogenarians and other patients undergoing general surgical operations

The hospital costs and clinical results of 304 patients who were more than 80 years old and who underwent general surgical procedures were evaluated. The over-all mortality rate was 14 per cent; 19.9 per cent occurred in patients admitted under emergency conditions as compared with 8.9 per cent that occurred in patients undergoing elective procedures (p less than 0.001). Seventy-nine per cent of the patients were discharged and 7 per cent required care in a skilled nursing facility. Survival rates were as good or better than standard life table survival rates for 80 year old patients. Costs were higher in those who were admitted under emergent conditions or who died in the hospital. Deaths were a result of complications of the primary disease rather than associated disease in most groups. Neither costs nor length of stay could accurately predict survival of individual patients. We concluded that health resources should be directed at treating problems, such as cholelithiasis, hernia or carcinoma, early before complications develop.     

The value of CA 125 determination in the serum of patients with ovarian cancer

The circulating ovarian cancer associated antigen CA 125 was determined in serum of 63 patients with ovarian malignancies by radioimmunometric solid phase assay using the monoclonal antibody OC 125 as catcher and tracer. The results of 41 patients with 43 active tumour situations were compared with the CA 125 serum levels of 27 patients without recurrence after therapy of ovarian cancer and 49 benign ovarian tumours. Significant differences exist between these three groups (p less than 0.001) with elevated values (greater than 35 U/ml) in 84 per cent in ovarian carcinoma, 22 per cent in benign tumours and nought per cent in woman without recurrence in follow-up. The pre-operative sensitivity in ovarian cancer is 93 per cent (in epithelial carcinoma 96 per cent) with a distinct dependence of the CA 125 serum levels on the stage of the disease (stage III and IV versus stage I and II; p less than 0.01). A positive correlation of CA 125 values to clinical status was found in 82 per cent in follow-up. Increasing values of CA 125 can detect the recurrence any months earlier than the clinical examination. Decreasing serum levels in chemotherapy don't reflect the objective tumour remission in every case. Because of elevated values in benign and inflammatory adnexal tumours and the relative low sensitivity in borderline cases (three of seven patients greater than 35 U/ml) the CA 125 assay seems not be suitable for a screening method. However it is a substantial amplification in control of therapeutic success and an early detection of recurrence of ovarian cancer disease.