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Background: To meet the health care challenges and increasing population health demands of today and the future, the Missouri Center for Nursing developed the Culture of Health Initiative Project (CHIP). Method: Phase one surveys examined 33 nurse leaders' responses to the population health knowledge and training needs of nurses in their organizations. In phase two, 71 nurse leaders' and practicing nurses' responses from the Population Health Nursing Skills Survey provided insight into the education needs of Missouri nurses. Results: Findings identified a lack of available education and resources related to nursing, limited knowledge of concepts among nursing leaders, and a need for flexibility in the format and content to educate nurses in all types of nursing practice. Conclusion: Professional development practitioners must collaborate with nurses and nurse leaders, in all settings, to meet the learning needs necessary for Culture of Health competence. [ J Contin Educ Nurs . 2020;51(12):568–573.]

In Staphylococcus aureus, the two-component system SaeRS is responsible for regulating various virulence factors essential for the success of this pathogen. SaeRS can be stimulated by neutrophil-derived products but has also recently been shown to be inactivated by the presence of free fatty acids. A mechanism for how fatty acids negatively impacts SaeRS has not been described. We found that unsaturated fatty acids, as well as fatty acids not commonly found in Staphylococcal membranes, prevent the activation of SaeRS at a lower concentration than their saturated counterparts. These fatty acids can negatively impact SaeRS without altering the respiratory capacity of the bacterium. To uncover a potential mechanism for how fatty acids impact SaeRS function/activity, we utilized a naturally occurring point mutation found in S. aureus as well as chimeric SaeS proteins. Using these tools, we identified that the native transmembrane domains of SaeS dictate the transcriptional response to fatty acids in S. aureus. Our data support a model where free fatty acids alter the activity of the two-component system SaeRS directly through the sensor kinase SaeS and is dependent on the transmembrane domains of the protein.

SummaryBackgroundThe world is at the cusp of experiencing local/regional hot-spots and spikes of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19 disease. We aimed to formulate an applicable epidemiological model to accurately predict and forecast the impact of local resurgence and outbreaks to guide the local healthcare demand and capacity, policy making, and public health decisions.MethodsThe model utilised the aggregated daily COVID-19 situation reports (including counts of daily admissions, discharges, and occupancy) from the local NHS hospitals and Covid-19 related weekly deaths in hospitals and other settings in Sussex (population 1-7M), Southeast England. These datasets corresponded to the first wave of COVID-19 infections from 24 March-15 June 2020. The counts of death registrations and regional population estimates were obtained from the Office of National Statistics. A novel epidemiological predictive and forecasting model was then derived based on the local/regional surveillance data. Through a rigorous inverse parameter inference approach, the model parameters were estimated by fitting the model to the data in an optimal sense and then subsequently validated to make predictions subject to 95% confidence.FindingsThe inferred parameters were physically reasonable and matched up to the widely used parameter values derived from the national datasets. Unlike other predictive models, which are restricted to a couple of days, our model can predict local hospital admissions, discharges (including deaths) and occupancy for the next 10, 20, and 30 days at the local level.InterpretationWe have demonstrated that by using local/regional data, our predictive and forecasting model can be utilised to guide the local healthcare demand and capacity, policy making, and public health decisions to mitigate the impact of COVID-19 on the local population. Understanding how future COVID-19 spikes/waves could possibly affect the regional populations empowers us to ensure the timely commissioning and organisation of services. Primary care and community services can be guided by the projected number of infectious and recovered patients and hospital admissions/discharges to project discharge pathways to bedded and community settings, thus allowing services to understand their likely load in future spikes/waves. The flexibility of timings in the model, in combination with other early warning systems, produces a timeframe for these services to prepare and isolate capacity for likely and potential demand within regional hospitals. The model also allows local authorities to plan potential mortuary capacity and understand the burden on crematoria and burial services. The model algorithms have been integrated into a web-based multi-institutional toolkit, which can be used by NHS hospitals, local authorities, and public health departments in other regions of the UK and elsewhere. The parameters, which are locally informed, form the basis of predicting and forecasting exercises accounting for different scenarios and impact of COVID-19 transmission.FundingThis study was supported by the Higher Education Innovation Fund through the University of Sussex (ECF, JVY, AMa). This work was partly supported by the Global Challenges Research Fund through the Engineering and Physical Sciences Research Council grant number EP/T00410X/1: UK-Africa Postgraduate Advanced Study Institute in Mathematical Sciences (AMa, ECF). ECF is supported by the Wellcome Trust grant number 204833/Z/16/Z.Research in contextEvidence before this studySince the beginning of the COVID-19 pandemic, healthcare managers and policy makers relied on epidemiological models based on national datasets to predict and mitigate the spread of the disease. The performance of these models has not always been validated against the available data, and they depend strongly on the values for the model parameters. Statistical models, e.g. those arising from time-series analysis, lack the temporal dynamics of the compartmentalised epidemiological model for the evolution of the disease and thus fail to capture the evolution far into the future with great accuracy. Compartmental models, on the other hand, capture the underlying dynamics of an infectious disease but typically use parameters estimated using datasets from other regions or countries, thus lacking the ability to capture local demographics and policy and therefore lack predicting local dynamics with accuracy.Added value of this studyAlthough our compartmental model follows standard SEIR-D model structure, the inference algorithm described and applied in this report is novel, along with the prediction technique used to validate the model. We checked bioRxiv, medRxiv, and arXiv up to the end of August 2020 using the terms “mathematical inference”, “COVID-19”, and “SIR” and found that there is a substantial use of Bayesian approaches to fit parameters but none that use the combination of statistical approaches with compartmental models, hence the originality of our work. We designed a compartmentalised epidemiological model that captures the basic dynamics of the COVID-19 pandemic and revolves around the data that are available at the local/regional level. We estimated all the parameters in the model using the local surveillance data, and in consequence, our parameters reflect the characteristics of the local population. Furthermore, we validated the predictive power of the model by using only a subset of the available data to fit the parameters. To the best of our knowledge, this is the first study which combines statistical approaches with a compartmental model and as such benefits greatly from the ability to predict and forecast much further into the future using the dynamical structure of the compartmental model with a relatively much higher accuracy than previously presented in the literature. This research sets the gold-standard benchmark by laying the framework for future adaptations to the model when more precise (and comprehensive) datasets are made available.Implications of all the available evidenceThe predictive power of our model outperforms previously available models for local forecasting of the impact of COVID-19. Using local models, rather than trying to use national models at a local scale, ensures that the model reflects the local demographics and provides reliable local-data-driven predictions to guide the local healthcare demand and capacity, policy making, and public health decisions to mitigate the impact of COVID-19 on the local population. Local authorities can use these results for the planning of local hospital demand as well as death management services by developing scenario-based analysis to which different values of the reproduction number R exiting a COVID-19 lockdown are assumed and results, such as maximum hospital occupancy, are compared to the first wave to establish a potential strain on resources. This can work as an early warning detection system to see what value of R that is currently followed, which in turn informs the relevant capacity and resources needed to mitigate the impact of COVID-19. The Web toolkit developed by us as a result of this study (https://alpha.halogen-health.org) demonstrates the predictive power of our model as well as its flexibility with the scenario-based analysis. Although our model is based on the data from Sussex, using similar variables/data from other regions in our model would derive respective COVID-19 model parameters, and thus enable similar scenario-based investigations to predict and forecast the impact of local resurgence to guide the local healthcare demand and capacity, policy making, and public health decisions.

Asthma affects 300 million people across all age-groups and ethnicities and is the most common chronic condition affecting children1, 2. In the UK, the health care costs associated with asthma are estimated at £1.1 billion, however this amount typically excludes some societal costs (e.g. absence from work to care for children)3. The total number of days missed from school in England in the 2017/18 academic year was 59.1 million of which 54.7% were due to illness4 although the reasons for those illness-related absences are unknown. Given the high proportion of children with asthma and the fact that school absences are associated with low levels of achievement6, the primary aim of this study was to measure the proportion of asthma-related absences in school children and describe the factors reported by parents that predispose their children to these school absences. The secondary aim was to explore parents’ and school staff views on extending an app currently used for reporting school absences to one that might also provide tailored interventions.

EPI-Net, Combacte-Magnet and EUCIC Group for SUSPIRE: F. Burkert, E. Carrara, M. von Cube, L. Drgona, K. Gilchrist, H. Goossens, S. Harbarth, D. Hequet, H. Jafri, G. Kahlmeter, S. Kuster, C. Luxemburger, M. McCarthy, M. Niks, A. Oualim, M. Poljak, O. Sandulescu, A. Schweiger, C. Vuong, I. Wiegand, A. Widmer, A. T. Witschi, G. Zanetti, W. Zingg., [Objectives] Surveillance is a key component of any control strategy for healthcare-associated infections (HAIs) and antimicrobial resistance (AMR), and public availability of methodologic aspects is crucial for the interpretation of the data. We sought to systematically review publicly available information for HAIs and/or AMR surveillance systems organized by public institutions or scientific societies in European countries., [Methods] A systematic review of scientific and grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was performed. Information on HAIs and/or AMR surveillance systems published until 31 October 2016 were included., [Results] A total of 112 surveillance systems were detected; 56 from 20 countries were finally included. Most exclusions were due to lack of publicly available information. Regarding AMR, the most frequent indicator was the proportion of resistant isolates (27 of 34 providing information, 79.42%); only 18 (52.9%) included incidence rates; the data were only laboratory based in 33 (78.5%) of the 42 providing this information. Regarding HAIs in intensive care units, all 22 of the systems providing data included central line–associated bloodstream infections, and 19 (86.3%) included ventilator-associated pneumonia and catheter-associated urinary tract infections; incidence density was the most frequent indicator. Regarding surgical site infections, the most frequent procedures included were hip prosthesis, colon surgery and caesarean section (21/22, 95.5%)., [Conclusions] Publicly available information about the methods and indicators of the surveillance system is frequently lacking. Despite the efforts of European Centre for Disease Control and Prevention (ECDC) and other organizations, wide heterogeneity in procedures and indicators still exists., Funded by the Innovative Medicines Initiative (IMI), New Drugs for Bad Bugs (ND4BB) programme, European Union's Seventh Framework Programme (FP7/2007-2013) and EFPIA (European Federation of Pharmaceutical Industries and Association) companies' in-kind contribution (IMI 11th) under grant 115737, COMBACTE-MAGNET (Combatting bacterial resistance in Europe—Molecule against Gram negative infections). JRB and MDT receive funding for research from Ministerio de Economía y Competitividad, Instituto de Salud Carlos III, cofinanced by European Regional Development Fund (ERDF) ‘A way to achieve Europe,’ Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015 and REIPI RD16/0016).

SUMMARY Twenty-one pathologists and technicians participated in a study evaluating the variation present in mitotic counts for prognostication of breast cancer. The participants counted the mitotic figures in 20 breast cancer samples from ten high power fields (mitotic activity index, MAI, giving the results in mitotic figures per 10 fields) and also made a correction for field size and area fraction o f the neoplastic epithelium to get the standardized mitotic index (volume fraction corrected mitotic index, or M/Vv index, giving the result in mitotic figures per square mm o f neoplastic epithelium). The difference in variation between the two methods was not big, but the standardized mitotic index (SMI) showed consistently smaller variation among all participants and different subgroups. Experienced pathologists had the highest variation in mitotic counts, and specially trained technicians, the lowest. The efficiency o f the mitotic counts in grading (the grading efficiency) was used to evaluate the mitotic counts. I n groups without special training for mitotic counts the mean grading efficiency was lower (experienced and training pathologists both on average had the potential to grade 88% o f the cases correctly) than in the group specially trained for the purpose (trained technicians had the potential to grade 9S% o f the cases correctly). Among the specially trained technicians, the grading efficiency was o f the same magnitude as the grading efficiency achieved in determining the S-Phase fraction of cells from paraffin embedded breast cancers by flow cytometry in different laboratories. The results suggest that special training is helpful in making mitotic counts more reproducible, and that in trained hands, the mitotic counts give results comparable to more sophisticated methods o f determining proli ferative activity in breast cancer.

The bisphosphonate drug APD (pamidronate, 3-amino-1-hydroxypropylidene-1,1-bisphosphonate) has been shown to bind to human plasma proteins. This was an unexpected observation since this hydrophilic, anionic drug is not typical of molecules that exhibit this characteristic. At a concentration of 5 micrograms/ml the extent of binding of APD to fresh human plasma in vitro was variable between subjects 30.2% +/- 8.5% (mean +/- S.D., n = 10). Binding was not influenced by the time or concentration of APD over the range 0.05-10.0 micrograms/ml. At 20 and 50 micrograms/ml some precipitation of APD occurred. Both calcium and iron play a role in the binding of APD to plasma proteins, addition of calcium to plasma increased the degree of binding of APD, whereas the calcium chelators EDTA and EGTA reduced the binding of APD. Similarly, addition of iron to plasma increased the binding and the inclusion of the iron chelator desferrioxamine diminished the binding of the drug. The effects of iron and desferrioxamine were less pronounced than those of calcium and EDTA, indicating that the majority of the binding involves calcium ions and a smaller contribution is made by ferric ions. The equilibrium dissociation constants (Kd) for APD binding to calcium and iron binding sites on plasma proteins were estimated to be 852 microM and 29 microM, respectively. Calcium binding sites were of high capacity but low affinity and the iron binding sites were of lower capacity and higher affinity. Electrophoresis of plasma proteins following incubation with [14C]APD revealed binding to the transferrin and globulin fractions. However, there was some dissociation of protein bound APD during the electrophoresis. The consequences of hypercalcaemia on the pharmacokinetics of APD are discussed.

Malignant testicular tumors are an important clinical problem, and ultrasound is the most frequently ordered imaging modality once a palpable scrotal mass is discovered. Numerous articles discussing the role of ultrasound in the evaluation of testicular pathology have confirmed the value of preoperative imaging. This article presents a review of imaging literature regarding testicular neoplasms, with an emphasis on correlation of gross and microscopic tumor pathology and imaging findings. Also included are sections on anatomy, epidemiology, histogenesis, and tumor markers.

To summarize the current literature on the association between biologic prognostic factors and therapeutic implications.To illustrate how these biologic factors are determined and how they can affect treatment, three patients' biologic profiles and their implications for the patients' choice of therapeutic approaches were analyzed. Immunohistochemical techniques combined with image analysis was used to evaluate estrogen receptors, progesterone receptors, proliferation index and erbB-2. Visual assessment was used to evaluate P glycoprotein (MDR1), EGFR and p53.Data from the literature stress the importance of biologic profiles for defining tumor behavior and patient management. The examples of patients' biologic factors illustrated the possible importance of these factors for helping to design treatment.Today the data on the association of patient response to chemotherapy and molecular markers are only starting to accumulate. A larger database is needed for a more precise estimation of response probability in order to help physicians decide between treatment options.

Retroperitoneal paragangliomas are uncommon neoplasms that arise from neural crest cells. Typical retroperitoneal sites of origin include adrenal medulla, organs of Zuckerkandl, and along sympathetic and parasympathetic nerves. We present a case of a woman diagnosed with retroperitoneal paraganglioma treated with debulking, intraoperative radiotherapy and external beam radiation therapy. She experienced a 7-year disease-free interval prior to symptomatic metastatic recurrence. Such remissions are consistent with the natural history for paragangliomas. The purpose of this report and literature review is to summarize the pertinent biologic and therapeutic options for these uncommon tumors.

The current trial was designed to assess whether the addition of prednisone or prednisone + tamoxifen would enhance the therapeutic effectiveness of 1 year of adjuvant CMF therapy. Premenopausal women with ipsilateral axillary node-positive breast carcinoma and known estrogen receptor (ER) status were randomized to receive 1 year of postoperative treatment with 12 28-day cycles of cyclophosphamide, methotrexate, 5-fluorouracil (CMF), CMF plus prednisone (CMFP), or CMFP plus tamoxifen (CMFPT). There were 553 analyzed cases with 188 receiving CMF, 183 CMFP, and 182 CMFPT. The overall time to relapse (TTR) and survival comparisons between the regimens are not statistically different at a median follow-up time of 7.7 years. The major subgroups currently with a suggestive TTR difference are greater than 3N+ (CMFPT greater than CMF, P = 0.07) and estrogen receptor-negative (ER-) greater than 3N+ (CMFPT greater than CMF, P = 0.03). Patients receiving CMFPT appeared to have a superior survival to CMF in the ER- greater than 3N+ cohort (P = 0.02). The following patient characteristics were associated with a significantly longer TTR: decreasing nodal involvement or tumor size, positive ER status, age greater than or equal to 40 years, and decreasing obesity. The favorable effects of decreasing nodal involvement, positive ER status, age 40 years or greater, and decreasing obesity carried over to survival. Development of amenorrhea was also significantly associated with improved survival (P = 0.001). Toxicity was increased by the addition of prednisone to CMF and by the addition of tamoxifen to CMFP. Overall relapse patterns were similar among the three regimens. The results of the current trial do not currently suggest an overall therapeutic benefit for adding prednisone or only 1 year of tamoxifen to CMF adjuvant treatment.

Metastatic Leydig cell carcinomas account for less than 0.2% of all testicular cancers, and may be associated with sex hormone production. Leydig cell carcinoma is relatively refractory to radiotherapy and chemotherapy, and median survival of patients with metastatic disease is less than 2 years. Presented are three cases of metastatic Leydig cell cancer, and a review of the literature pertaining to this rare tumor.

THE PRESENT report deals with a case of tracheoesophageal fistula resulting from a severe blow over the sternum. This condition is extremely rare, and in a search of the literature only 2 similar cases with recovery were found. One of these, like the present case, presented no evidence of accompanying fracture of the ribs, cartilages or sternum. Both of the other cases were apparently reported twice. The relative frequency of tracheoesophageal fistula based on etiology is furnished by Mangabeira-Albernaz, 1 who in 1933 studied 682 cases collected from the world literature. His classification of these fistulas is given in the table. REPORT OF A CASE History. —On March 30, 1947, a 29 year old man was brought to the hospital by the police about fifteen minutes after injury. The patient stated that while driving home after having had some drinks he fell asleep at the wheel and his car struck

GENERALLY it is conceded that a greater operative risk attends the patient with coronary disease than is faced by the person with a normal heart. The mortality rate in surgical patients with myocardial infarction has been variously reported 1 from 5.2 to 44.5%. The unrelenting progress of medical science reflected in the increased life span necessarily brings to the surgeon a greater number of elderly patients with degenerative cardiac changes. Among these patients are those with evidence of severe angina pectoris or myocardial infarction harboring coexistent disease requiring urgent surgery. Usually these patients have some painful or malignant process in which delays in surgical therapeusis are costly, inviting reduced survival rates or even denying significant prolongation of a pain-free existence. In essence, the earliest auspicious application of a definitive operation designed to obviate these undesirable elements is implied by the term "urgent surgery." In most instances the operation is of

The value of decompression of the stomach and small bowel by means of nasal tubes passed into these organs has been proved in the treatment of paralytic ileus and the various types of peritonitis. Stricture of the esophagus is seen occasionally when nasal tubes have been kept in place for several days. A commoner complication is seen in persons who have bronchiectasis, chronic rhinitis, upper respiratory tract infection, or a poor cardiac reserve. With the use of a nasal tube in such patients, postoperative collapse of the lung or bronchopneumonia is a constant danger. Aged and debilitated patients may have a poor cough reflex, and, following laparotomy, it is often necessary to remove the nasal tube to give the patient a much needed rest and to keep the airways clear of mucus. When performing a laparotomy in such patients, I have used the following maneuver with great success (see the

• Two varieties of surgical operation are applied to high-lying gastric ulcers. One consists in resecting the ulcer (if it is on the lesser curvature) with all or part of the lesser curvature and a sufficient part of the greater curvature to give a two-thirds resection; this is followed by repair according to either the type 1 or type 2 Billroth operation. The other consists in leaving the ulcer undisturbed, resecting the distal one-half or two-thirds of the stomach, and concluding according to either the Hofmeister or the type 1 Billroth operation; the ulcer heals without trouble in most instances. Both varieties of operation have given excellent long-term results. In either case, specimens of tissue must be obtained and examined for malignancy, which is the greatest problem in the treatment of high-lying gastric ulcers. The unexpected finding of malignancy by microscopic examination is most common in small ulcers. Concomitant gastric and duodenal ulcers are frequent, and among 98 cases of this kind there was marked retention. When obstruction occurs it must be relieved. The temporary insertion of a gastrotomy tube for feeding is to be considered if obstruction is severe, and a posterior gastroenterostomy may be advisable in poor-risk patients.

WHEN A careful search is made, about one-third of people past 45 years of age will be found to have some diverticula of the colon. These lesions are found most commonly in the sigmoid, next in frequency in the descending colon, but may be scattered throughout the large bowel. We have never seen them below the peritoneal reflection. It is our feeling that these are pulsion diverticula. Figure 1 is a section of the sigmoid done post mortem in an 80-year-old patient who had no symptoms referable to the colon. The only barrier between the lumen of the bowel and the peritoneal cavity is the mucosa, some subperitoneal fat, and the peritoneum. In this section we also see that in one area the mucosa is beginning to herniate through the muscularis as if a new diverticulum is forming near the main one. However, even the completely formed diverticula are still

Surgeons have been reluctant to perform ileostomy for intractable ulcerative colitis in young women because the existence of the ileostomy was believed to militate against pregnancy and subsequent parturition. This belief is unsettled by a study of seven patients with ileostomy and colectomy. In all there were 13 subsequent pregnancies, of which 3 terminated in early spontaneous abortions while 10 went on to term and resulted in live births. In 9 of the 10 term pregnancies the patient was delivered per vaginam, and only one had to be delivered by cesarean section. There was no maternal mortality. In the past, unpredictable exacerbations of ulcerative colitis have been a serious danger in pregnancy. The experiences here recorded show that young women with otherwise intractable colitis can be treated by ileostomy and colectomy without fear of subsequent inability to bear children.

We wish to report on some of the more interesting experiences we have had with the use of the ileocecal-ascending colon type of substitute bladder. The operative technique has been previously described. 1,2 Most of the ureteral implants have been done by a modified Coffey I method. Some anastomoses were made by the combined mucosa-to-mucosa and tunnel technique We are now spatulating the end of the ureter (Fig. 1). Then the end of the ureter is drawn into the new bladder a short distance by two sutures (Fig. 2). The final position of the ureters in the bladder is shown in an open view of the bladder (Fig. 3). The completed anastomosis (on the right side only) is shown in Figure 4, before the left side has been transplanted and before the bladder has been tacked down over the brim of the pelvis. The ureteral transplantation is done as the

FOUR patients having acute obstruction due to volvulus of the sigmoid and 1 patient having acute obstruction due to volvulus of the cecum have served to emphasize certain diagnostic and therapeutic points. In volvulus of the sigmoid, in older patients, there is usually a history of repeated attacks of partial obstruction or of constipation, while in younger patients the acute obstruction often occurs without any previous history.1The obstruction may be of many hours' duration, but the patient is not so sick as one might expect with carcinoma. The hemoglobin value and the red blood cell count are usually not much below normal. The abdomen is apt to be markedly distended. There may be little vomiting. There is pain over the dilated loop and especially where the twist puts a pull on the root of the mesentery. This pain will be severe if there is much interference with circulation.

A DIAGNOSIS of an insulin-secreting tumor is tenable when the clinical symptom-complex conforms with the criteria set forth in Whipple's triad. These criteria are as follows: ( 1 ) signs and symptoms of insulin shock usually progressive, frequently induced by fasting or exercise; (2) repeated fasting bloodsugar concentrations below 50 mg. per 100 cc, and (3) symptomatic relief by dextrose administration. More than 400 cases of hypoglycemia due to pancreatic adenoma are reported in the literature, in half of which surgical treatment was employed. In about 45% of the patients explored, no tumor could be located by the surgeon. In more than one-half of these cases in which the surgeon did not find the tumor but proceeded with a subtotal pancreatectomy, the resected specimen was histologically normal. The over-all cure rate in patients is about 40% when the surgeon, in spite of finding no tumor, performs a subtotal pancreatic resection. 1 Reported

THE THESIS of this symposium implies that advanced cancer of the breast should be treated in a different manner than is cancer in the usual case of cancer of the breast. This immediately poses two questions: "What is advanced carcinoma of the breast?" and "How must the surgical procedure be altered in order to treat it adequately?" I shall consider a lesion advanced cancer when there is lymphatic metastasis present or when the skin is involved or when there is fixation to the fascia. Lesions with distant metastasis to bone or lung will be considered hopeless. When the surgical treatment of tumors is being discussed, those for which there is some chance of cure should be sharply separated from those which have been operated on without hope of completely removing all the cancer. An attempt will be made to determine the kind of operation which might be considered a radical

AT THE Presbyterian Hospital of Chicago, from January, 1950, to June, 1953, there were 140 cases of peptic ulcer in which gastric resection was done. Eleven patients were operated on for severe hemorrhage. In five of these no source of bleeding was found at exploration. This report is of these five cases. The nature of the lesions and the results of treatment are presented, and a program for surgical treatment of such cases is proposed. REPORT OF CASES Case 1. —(W. H., Admitted Oct. 12, 1952; died Oct. 18, 1952.) A 73-year-old retired white man had had four admissions during the previous nine years, once for suprapubic prostatectomy and tonsillectomy and three times for medical observations of focal cerebrovascular accidents. On the morning of the latest hospital admission, he had suddenly passed large amounts of grossly bloody stools, followed by a massive hematemesis of bright-red blood. The patient fainted in

• Experience with 189 patients aged 70 years or older undergoing major abdominal surgery is analyzed as to factors affecting the prognosis and safeguards to be recommended. The largest group consisted of 109 patients operated on for diseases of the colon and rectum, and the operation most frequently required in this group was intestinal resection. The commonest cause for emergency surgery in aged patients was massive gastrointestinal hemorrhage necessitating gastric resection. In the 21 patients who died, the most frequent cause of death was pulmonary embolism and the second most frequent was chronic infection. Elderly patients did not tolerate chronic infections, and emergency operations carried a much higher risk than did elective surgery, but in general neither age nor sex, nor coexisting chronic cardiovascular, pulmonary, or renal disease, significantly altered the mortality rate. On the basis of this experience, a list of seven safeguards is stated that have materially reduced the mortality and morbidity rates in the aged patient.

It is generally conceded that in spontaneous hypoglycemia of islet cell origin a surgical attack on the pancreas, designed to remove the hyperfunctioning incretory tumor, remains the therapy of choice. However, the need for accurate medical management is of great importance during the preoperative period, and it becomes of paramount importance when prolonged medical therapy is necessitated by the rejection of a definitive operation by the patient or when the surgical risk is believed too great. Moreover, the progressive systemic effects of functioning metastatic islet cells lying beyond the scope of ablative surgery may provoke even a greater challenge to the physician despite an ultimate grave prognosis. Three cases of insulinoma (insulin-secreting islet cell adenoma) are reviewed. Although each patient was ultimately treated by surgery, 1 experimental observations were made during the preoperative and interim hospital course on the clinical response to dietary, alloxan, corticotropin (ACTH), and cortisone therapy. It