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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.

Objectives: To examine how Americans’ opinions of the relative seriousness of various health problems have changed over time and to quantify the public’s preferences for research prioritization. Methods: We conducted a survey that asked respondents to rate the seriousness of 80 health problems on a four-point Likert scale (“very serious problem,” “somewhat serious problem,” “not too serious of a problem,” or “not a problem at all”). Results were compared to past surveys from 2001 and 2013 that examined the same set of health problems (with the exception of COVID-19). The survey also included 15 MaxDiff questions that asked respondents to select the health problems they considered most and least important for research funding. Respondents were recruited from the KnowledgePanel, a nationally-representative sample of American households. Results: A total of 768 adults competed the survey between September 3 and 14, 2020. The health problems that Americans consider to be very serious generally align with the leading causes of death and noncommunicable diseases like heart disease (rated “very serious” by 55.3% of sample), diabetes (45.0%), and mental health (e.g., mental illness - 53.6%;depression - 50.7%);however, several social determinants of health (e.g., violence - 62.6%;racial discrimination - 52.9%) are also identified. COVID-19 was a perhaps unsurprising top priority (ranked 3rd at 62.4%), while cancer remains the highest (ranked first at 65.5%) and a persistent priority for research funding. Conclusions: Americans consider a diverse set of health problems to be very serious, with recognition of social determinants of health rising. Our findings offer guidance as to the disease areas in which innovations would bring the greatest value to patients and society and also offers affirmations of the relief brought by recent innovations.

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).

Background The concept of wellbeing is now increasingly used as one of the key measures of societal progress, along with the traditional methods that are based on economic activity. Subjective wellbeing (SW) is a construct by which national wellbeing can be measured—this can inform development of health and social policy. The objective of this study was to determine the association between sociodemographic/personal factors and low subjective wellbeing. Methods Data from the health and wellbeing survey conducted in Brighton and Hove in 2012 (n=2035) were analysed. The survey included the Office of National Statistics (ONS) verified measure of SW, which consisted of four questions regarding life satisfaction, fulfilment, happiness and anxiety. Low SW was the outcome measure, the threshold of which was determined according to the Faculty of Public Health outcome framework. The survey also included a range of population measures, sixteen of which were chosen as explanatory variables. The analysis included descriptive statistics and multivariate logistic regression, using the SPSS statistical programme. Results are presented as adjusted odds ratio (OR) and corresponding 95% confidence interval (95% CI). Results In the multivariate analysis, poor general health (self-reported) was strongly associated with low SW: dissatisfaction with life (OR=3.9, 95% CI, 2.7-5.6), unfulfilled (3.4, 2.3-4.8), unhappiness (3.0, 2.1-4.2), anxiety (2.4, 1.7-3.3). Other factors significantly associated with low SW included: illness and disability, low social capital, lack of physical exercise, a history of self-harm, not owning a home, not being in a relationship and being middle aged. On the other hand, unemployment, deprivation and poor education were not associated with SW. Conclusion This study demonstrates that an individual’s SW is likely to be affected by a number of sociodemographic/personal factors. The limitations of this study include the extent of external validity, the lack of causality and potential selection and information bias. These findings are relevant to the design and delivery of policy aimed at improving the perception of wellbeing in individuals and the general population.

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.

Background Although childhood overweight and obesity rates have been falling in England in recent years, they remain an important public health concern because of the association between adolescent obesity and increased ill health risks in adult life including an increased risk of mortality from all causes independent of adult weight. Early intervention is important since behaviours contributing to obesity, higher energy diet and increased sedentary behaviour, are also prevalent during early childhood. We have conducted an epidemiological analysis of routine data collected at birth to examine the factors associated with overweight and obesity in children aged 10-11 years. Methods Administrative records of children in aged 10-11 years, measured between September 2006 and July 2010, as part of the National Child Measurement Programme in a large area on the South East coast of England were examined. Of the 19,924 children in the study with a valid height and weight measurement, 29% were overweight/obese. Factors identified from the literature as potential predictors of childhood overweight or obesity were extracted, where recorded. These are age; birth weight; gender; maternal smoking; previous live births; multiple birth; mother’s age; and Index of Multiple Deprivation quintile. Results Factors independently associated with an increased risk of overweight or obesity included deprivation (OR 1.6 [95% CI 1.4, 1.9]) (children born in most deprived areas compared with least deprived), regular maternal smoking during pregnancy (1.3 [1.2, 1.4]) and high brith weight (1.5 [1.2, 1.9]). Low birth weight (0.8 [0.7, 0.9]), being female (0.8 [0.8, 0.9]) and maternal age Conclusion Factors associated with childhood overweight and obesity at age 10-11 were neighbourhood deprivation, regular maternal smoking during pregnancy and high birth weight. Potential protective factors include low birth weight and young maternal age. Early intervention in tackling inequalities and maternal smoking in pregnancy are important strategies to help reduce childhood overweight and obesity.

Introduction The current UK spending cuts have brought into stark light the need for the Public Sector to do more with less. A lower cost but more engaged Public Sector is embodied in the political vision of a “Big Society” which seeks to build on individual and community resilience. Knowledge of what community resilience resources are available however, is incomplete. Methods This study presents the findings from a community resilience mapping exercise undertaken in the spring of 2011, using routine data in Brighton and Hove. The Well-being and Resilience Measure (WARM) Tool was used to map out the epidemiology of community resilience in eight domains: Education Health Material well-being Strong and stable families Local economy Public services Crime and antisocial behaviour Infrastructure and belonging Results A series of electoral ward maps with some time trends describes community resilience in these eight domains with reference to four population groups. Children and young people Working age adults Older people Natural community groups Conclusions We believe that this is the first time a Public Sector organisation (NHS Brighton and Hove) in England has comprehensively mapped local resilience using routine data. The approach is timely and the findings are key to understanding the public capacity to deliver the political vision of a ‘Big Society9 and to implement the 2010 Public Health White Paper “Healthy Lives, Healthy People”, which explicitly seeks to “give communities the tools to address their own, particular needs”.

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

From March, 1945, to June, 1960, 542 private patients 70 years or older were operated upon by us for general surgical disease excluding those of the gynecological, nervous, and genitourinary systems, bones and skin. Of this number, 45 died, yielding an 8.3% mortality. Such data is meaningless because neither the nature nor extent of the pathology is stated. For example, gastrectomy for cancer carries an entirely different risk than gastrectomy for peptic ulcer. Likewise, the mortality rate of colectomy for inflammatory disease is not comparable to that for malignancy. To be of value, a statistical survey should provide enough information to assist us in determining what we might anticipate with the next patient upon whom we might operate. To this end, we studied the records of 390 consecutive private patients 70 years or older who had been operated upon by us only for primary disease of the intraperitonealdigestive

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

To the Editor.— Dr Heimlich's maneuver to dislodge a food particle causing lethal choking is no doubt effective (234:398, 1975). However, Dr Visintine's article documents one of the dangers of the method (234:415, 1975). Before we could begin our surgical residency, Dr V. C. David required us to have three to six months of training in a contagious disease hospital. During the first three weeks of such training, I did 20 intubations for laryngeal diphtheria. As a result of this experience, it was obvious to me that fairly strong traction on the tongue will displace the larynx upward at least 2.5 cm (1 in). When the tongue is steadily pulled out, a finger of the other hand can easily reach the epiglottis. Several years ago, my 80-year-old dinner partner had a piece of meat impacted, obstructing his airway. He had not yet lost consciousness. He was instructed to raise his index

THE DIAGNOSIS of cecitis or typhilitis was popular until appendicitis became recognized as a pathologic entity. After this it became the general opinion that every case of inflammation of the cecal region was secondary to appendicitis and many authorities denied the existence of primary cecitis as a disease entity. Gradually more evidence is accumulating that primary inflammation in the cecum, though rare, may occur. Two patients were treated recently who had cecitis of two distinctly different types. The first had a typical circumscribed phlegmon of the cecum characterized by a severe, submucosal inflammation and presented the picture described in the following report. REPORT OF CASES Case 1.—History. —A. G. was a 61 year old Polish housewife who entered the Presbyterian Hospital on Jan. 14, 1948, with the history of recurrent attacks of severe pain in the right upper abdominal quadrant following meals over a period of twenty-three years. Cholecystograms

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