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To the Editor. —I agree with Dr Pollack and his colleagues' 1 major finding that variations in mortality rates in pediatric intensive care units (ICUs) may be partially explained by variables such as presence of a pediatric intensivist and teaching hospital status. However, I do not agree with the authors' post hoc analysis, which suggests that care by pediatric residents is associated with increased mortality. The authors fail to point out alternative explanations for their analysis, and their data are not entirely consistent with their conclusions. The authors found that teaching hospital status was significantly associated with increased mortality rates, even after adjusting for case mix severity. It is not surprising that the presence of pediatric residents was also a predictor of mortality since they are highly correlated variables (teaching hospitals are the primary sites for training pediatric residents). The authors' statistical model found that the presence of pediatric residents

• An unusual case of small cell carcinoma of the ethmoid sinuses is reported in which electron microscopy confirmed the presence of dense-core granules. The relationship to Pearse's "neuroendocrine programmed" cells is cited. With increasing numbers of different extrapulmonary primary sites for this tumor now being identified, it is believed that these sites must be investigated in any case of suspected small cell carcinoma that cannot be readily attributed to the lung. (Arch Otolaryngol1983;109:341-343)

In Reply.— Dr Silvers raises the question of whether black patients with melanoma, after controlling for the location of the melanoma lesion to volar and subungual primary sites, have a worse prognosis than their white counterparts. This question is indirectly answered in Table 2 of the article; we initially controlled for histology of the acral lentiginous type of lesion and subsequently constructed actuarial survival curves for the white and black populations. Acral lentiginous lesions are almost exclusively limited to the volar or subungual surfaces of patients with melanoma. In our black population, 22 patients had acral lentiginous histology, with 86% of these lesions present on palmar, plantar, or subungual locations. The remaining lesions were mucosal primary lesions that weretainedalso classified as acral lentiginous. The Figure shows median survival of 33.7 months in blacks and 110.7 months in whites with acral lentiginous melanomas. The P value for the difference in

For the physician who works at bedside or clinic with cancer patients, knowledge of lymphatic spread of tumors is based on the great anatomic work by Rouviere published in the early years of this century. In 1972, Haagensen's text on the lymphatics in cancer became the useful clinical counterpart of that approach, showing by surgical dissection and the meticulous pathological studies of Dr Robert Grinnell on cleared specimens, routes of lymphatic spread for a variety of cancers, particularly gastrointestinal. Now we have a new book on metastasis to the lymphatic system that combines chapters on basic pathophysiology of metastasis within the lymphatic system with diagnostic considerations and general therapeutic aspects in the first 40% of the text. The remainder considers metastasis within the lymphatic system from different primary sites. Individual chapters are written by clinical and laboratory experts at each particular organ or site and, while somewhat uneven, convey a

• Between 1968 and 1985, we treated 20 children for fibromatosis (also called desmoid tumor and aggressive fibromatosis). The primary sites included head and neck (seven patients), extremity (seven patients), and trunk (six patients). Lesions ranged from 3 to 18 cm in diameter. The tumors were smaller than 5 cm in 13 patients, and in seven patients they were larger than 5 cm. A total resection was not feasible in any of the patients with lesions larger than 5 cm. Ten of the 11 patients treated with wide local resection, in whom the margins were clearly negative or close, remained free of disease for six to 16 years. Nine patients required additional treatment with radiotherapy (nine patients) and chemotherapy (five patients). Two died of local disease progression. In the remaining seven children, the disease was controlled. We describe our strategies for managing this disease in a pediatric population. ( Arch Surg 1987;122:1296-1298)

Santayana wrote, "Those who cannot remember the past are condemned to repeat it." According to the editor of this book, which has 82 contributors it was "written to review the accomplishments of the Clinical Cooperative Groups during the past 25 years." Most of these 82 contributors, not only "remember the past," but they were active participants in the development of the clinical cooperative groups. As many of today's participants in the ongoing clinical cooperative studies in cancer have entered the field too recently to "remember the past," this publication should be required reading for them. There are chapters for each of the more important primary sites of cancer, and separate chapters for the contributions of various disciplines. Of special interest are chapters on the relationships between the cooperative groups and basic research in cancer and cancer education. The relationships and conflicts between the groups, the National Cancer Institute, the cancer

There exist few reports concerning cancer presenting in forensic autopsies. This study of 1,300 consecutive forensic autopsies yielded 22 cases of single cancers (1.7%) of multiple primary sites and histologic types. The forensic autopsy affords unique opportunity to study not only diagnosed and treated trauma, disease, and cancer, but the natural evolution of untreated cancer as well. Clinically occult cancer is not uncommon and may eventually present clinically or at autopsy in unusual fashion. Advanced cancer may, sometimes on initial presentation, be responsible for sudden, unexpected death. Persons with cancer, even in an advanced state, uncommonly commit suicide. Conversely, those committing suicide ostensibly because of known cancer infrequently prove to have cancer at autopsy. Through these autopsy studies, the forensic pathologist gains information invaluable for statistical, clinical, and medicolegal purposes, truly fulfilling his role of "community pathologist." ( JAMA 237:786-788, 1977)

Fifty patients with cellulitis were evaluated prospectively using cultures of aspirates from the advancing edge of cellulitis, skin biopsy specimens, and blood. Potential microbial pathogens were isolated in 13 patients. Biopsy specimen cultures were positive in ten patients, while aspirate and blood cultures were positive in five and two, respectively. Aspirate, biopsy, or blood cultures were more often positive in patients with apparent primary lesions than in patients without such lesions. Apparent primary sites of infection were identified and cultured in 24 patients. beta-Hemolytic streptococci were isolated from 17 primary lesions, and coagulase-positive staphylococci were present in 13. Both organisms were isolated from ten primary lesions. Among patients with positive aspirate, biopsy, and/or blood cultures, the same pathogens were also isolated from primary sites in ten of ten patients. Clinical features, including temperature, white blood cell count, and erythrocyte sedimentation rate, were not predictive of positive aspirate, biopsy, or blood cultures. These cultures provided no microbiologic information that was not obtainable from culture of primary lesions.

• Cutaneous carcinomas often arise in patients with severe epidermolysis bullosa (or other cutaneous ulcers) at multiple primary sites. Chronic tissue stress thus appears to promote carcinogenesis in preexisting somatic mutants in a stem cell population. Altered contractile properties of fibroblasts cultured from skin with epidermolysis bullosa may result from an altered interaction of these cells with their surrounding, chronically stressed, connective tissue matrix. (Arch Dermatol1988;124:737-741)

A Survey The purpose of this survey was to ascertain, if possible, our mortality rate in the varied 5-year periods, the duration of illness in those living and those dead, the main complications in the different decades, the primary sites within the stomach, the evaluation of lymph-node involvement, the operations, etc. To be sure, our series is not a large one, and it cannot be compared with those in the clinics such as the ones in Minnesota, New York, Boston, and other cities, but a knowledge of what is happening in the Albany Medical Center Hospital seemed to be worthwhile. This series comprises all cases of patients with carcinoma of the stomach who have been admitted to the Albany Medical Center Hospital during the years 1935-1958, inclusive. The total number of cases was 462–361 operative and 77 nonoperative, not including those discovered at autopsy. In approaching this subject for review