A rare case of a superior lumbar hernia secondary to penetrating injury

Lumbar hernias are rare occurrences, with only 300 cases reported in the literature. We present a unique case of a superior lumbar hernia secondary to penetrating trauma to the right flank. We performed a herniorrhaphy using porcine mesh, and provided additional support by mobilizing the external oblique and latissimus dorsi into the defect. At follow up three months after repair, the patient was asymptomatic and exam revealed an intact lumbar abdominal wall with normal contour. Although literature displays a consensus on the need for lumbar hernia repair, specific repair techniques must be tailored to defect etiology, size, location, and contents.

Processing two-dimensional X-ray diffraction and small-angle scattering data in DAWN 2

The Powder Calibration and Processing packages implemented in DAWN 2 provide an automated diffraction-geometry calibration and data processing environment for two-dimensional diffraction experiments. The customizable processing chains permit the execution of data processing steps to convert raw two-dimensional data into meaningful data and diffractograms. The provenance of the processed data is maintained, which guarantees reproducibility and transparency of the data treatment.

A software package for the calibration and processing of powder X-ray diffraction and small-angle X-ray scattering data is presented. It provides a multitude of data processing and visualization tools as well as a command-line scripting interface for on-the-fly processing and the incorporation of complex data treatment tasks. Customizable processing chains permit the execution of many data processing steps to convert a single image or a batch of raw two-dimensional data into meaningful data and one-dimensional diffractograms. The processed data files contain the full data provenance of each process applied to the data. The calibration routines can run automatically even for high energies and also for large detector tilt angles. Some of the functionalities are highlighted by specific use cases.

Experimental simulation of cat electromyogram: evidence for algebraic summation of motor-unit action-potential trains

Prompted by the observation that the slope of the relationship between average rectified electromyography (EMG) and the ensemble activation rate of a pool of motor units progressively decreased (showing a downward nonlinearity), an experimental study was carried out to test the widely held notion that the EMG is the simple algebraic sum of motor-unit action-potential trains. The experiments were performed on the cat soleus muscle under isometric conditions, using electrical stimulation of alpha-motor axons isolated in ventral root filaments. The EMG signals were simulated experimentally under conditions where the activation of nearly the entire pool of motor units or of subsets of motor units was completely controlled by the experimenter. Sets of individual motor units or of small groups of motor units were stimulated independently, using stimulation profiles that were strictly repeatable between trials. This permitted a rigorous quantitative comparison of EMGs that were recorded during combined activation of multiple motor filaments with EMGs that were synthesized from the algebraic summation of motor unit action potential trains generated by individual nerve filaments. These were recorded separately by individually stimulating the same filaments with the same activation profiles that were employed during combined stimulation. During combined activation of up to 10 motor filaments, experimentally recorded and computationally synthesized EMGs were virtually identical. This indicates that EMG signals indeed are the outcome of the simple algebraic summation of motor-unit action-potential trains generated by concurrently active motor units. For both recorded and synthesized EMGs, it was confirmed that EMG magnitude increased nonlinearly with the ensemble activation rate of a pool of motor units. The nonlinearity was largely abolished when EMG magnitude was estimated as the sum of rectified, instead of raw, motor-unit action-potential trains. This suggests that the downward nonlinearity in the EMG-ensemble activation rate relation is due to signal cancellation arising from the perfectly linear summation of positive and negative components of action-potential waveforms. The findings provide a much needed post hoc validation of the concept of EMG generation by strict algebraic summation of motor unit action potentials that is generally relied on in theoretical modeling studies of EMG and in EMG decomposition algorithms.

A new method for experimental simulation of EMG using multi-channel independent stimulation of small groups of motor units

The experimental simulation method was based upon the separate activation of up to 10 small groups of motor units (MU) in an acute nerve-muscle preparation. The investigator was able to precisely control and systematically alter the features of MU pool activation strategies. No implicit assumptions were made regarding MU properties. The purpose of this study was to evaluate the validity of this method. Three criteria were formulated and found to be satisfied: First, in the time domain, visual and audio displays of simulated EMG were indistinguishable from physiological EMG. Secondly, in the frequency domain, power spectra of simulated EMG revealed the typical features of EMG recorded during voluntary activation in the cat. Thirdly, the well-known monotonic relationship between EMG magnitude and force was readily reproduced, although strictly linear relations were not found. In addition, the relationship between the pool's ensemble activation rate and EMG magnitude showed distinct gain compression, mostly attributable to signal cancellation.

Measuring dimensions: the regulation of size and shape

Over many years evidence has accumulated that plants and animals can regulate growth with reference to overall size rather than cell number. Thus, organs and organisms grow until they reach their characteristic size and shape and then they stop - they can even compensate for experimental manipulations that change, over several fold, cell number or average cell size. If the cell size is altered, the organism responds with a change in cell number and vice versa. We look at the Drosophila wing in more detail: here, both extracellular and intracellular regulators have been identified that link cell growth, division and cell survival to final organ size. We discuss a hypothesis that the local steepness of a morphogen gradient is a measure of length in one axis, a measure that is used to determine whether there will be net growth or not.

Evaluation of the genotoxicity of 2,4-dichlorophenoxyacetic acid and its derivatives in mammalian cell cultures

2,4-dichlorophenoxyacetic acid and its derivatives (collectively known as 2,4-D) are herbicides used to control a wide variety of broadleaf and woody plants. The genetic toxicity of an ester (2,4-D 2-butoxyethylester) and two salts (2,4-D isopropylamine and 2,4-D triisopropanolamine) was investigated in cultured mammalian cells. The end points used were the induction of chromosomal aberrations in primary cultures of rat lymphocytes and forward mutations at the HGPRT locus of Chinese hamster ovary cells. There was no evidence of genotoxicity for the test materials in the experimental systems used. These results were consistent with the general lack of genotoxic potential for 2,4-D in a number of other test systems.

Dominant lethal test with rats exposed to 1,3-dichloropropene by inhalation

The potential of 1,3-dichloropropene (1,3-DCP) to induce dominant lethal mutations in the germ cells of male CD rats following inhalation exposure was investigated. Groups of 11-week-old males (30 animals/group) were exposed to 1,3-DCP vapors by inhalation at targeted concentrations of 0 (negative control), 10, 60, and 150 ppm for 10 weeks (6 hr/day, 7 days/week). An additional group of 30 males (designated the pairfed group) was kept on dietary restriction for 10 weeks. This group served as a control for any effects of decreased feed consumption and the associated body weight loss on the dominant lethal indices in the males exposed to 1,3-DCP. At the termination of the exposures, each male was cohoused with naive adult virgin CD females for two consecutive mating trials (1 week/trial, 2 females/male). Females were necropsied 13 days after the conclusion of each weekly mating trial and the number of corpora lutea, live implantations, and resorptions were determined. There were no statistically significant increases in either the pre- or postimplantation embryonic/fetal loss in females mated with 1,3-DCP-exposed males relative to controls at any weekly mating period. Based on these results, it can be concluded that 1,3-DCP is not mutagenic to the male germ cells of CD rats at exposure levels < or = 150 ppm, the highest concentration tested.

Der(16)t(1;16)(q21;q13) as a secondary structural aberration in yet a third sarcoma, extraskeletal myxoid chondrosarcoma

Cytogenetic analysis of an extraskeletal myxoid chondrosarcoma revealed a der(16)t(1;16)(q21;q13) in addition to the t(9;22)(q22;12) described as characteristic for this chondrosarcoma clinicohistopathologic subtype. An identical der(16) has been identified as the most common secondary structural aberration in Ewing's sarcoma and alveolar rhabdomyosarcoma.

Use of confidence intervals and sample size calculations in health economic studies

OBJECTIVE

To discuss the calculation and application of confidence intervals in pharmacoeconomic studies.

DATA SYNTHESIS

The increasing frequency with which pharmacoeconomic evaluations are made within clinical trials makes it possible to obtain information on the outputs and costs of an intervention in each patient of a sample under study. This allows the same statistical principles commonly used in clinical trials to be applied to cost or cost-effectiveness data. The methodology described in this article would allow expression of cost-effectiveness ratios in the form of confidence intervals. The calculation of the cost-effectiveness ratio by means of a confidence interval may have important practical consequences, both in decision-making on the choice of 1 intervention versus another and in calculating the size of the sample necessary to identify statistically significant differences, from both clinical and economic points of view.

CONCLUSIONS

The complementary use of confidence intervals and sensitivity analysis makes it possible to measure uncertainty related and unrelated to variability in sample data, allowing the decision to adopt 1 technology or another to be based on the most objective information available. Although several ethical and methodologic concerns remain to be addressed, this methodology may contribute to improving the more rational and efficient use of drugs.

Internal pilot studies for estimating sample size

We develop the idea of using data from the first 'few' patients entered in a clinical trial to estimate the final trial size needed to have specified power for rejecting H0 in favour of H1 if a real difference exists. When comparing means derived from Normally distributed data, there is no important effect on test size, power or expected trial size, provided that a minimum of about 20 degrees of freedom are used to estimate residual variance. Relative advantages and disadvantages of using larger internal pilot studies are presented. These revolve around crude expectations of the final study size, recruitment rate, duration of follow-up and practical constraints on the ability to prevent the circulation of unblinded randomization codes to investigators and those involved in editing and checking data.

Diagnosis of motor neuron disease by neurologists: a study in three countries

Ninety four neurologists in the United Kingdom, China, and West Germany responded to two structured questionnaires. The first assessed the diagnostic weighting assigned to a number of symptoms, signs, and clinical investigations ascertained from classical descriptions and case notes of patients with motor neuron disease (MND). The second tested the likelihood and consistency of diagnosis in a series of case summaries representing the clinical data of 10 patients with clinically and pathologically documented motor neuron disease. There was a wide measure of agreement concerning the common clinical features of the disease, especially regarding fasciculation of the tongue, fasciculation associated with weakness seen in more than one limb, and dysphagia. In the case summaries, however, there was clear variation in the ranked likelihood of the diagnosis of MND and in the consistency of diagnostic behaviour in the different groups of neurologists. These findings support the need for internationally agreed criteria in the diagnosis of MND. Any such criteria will need to be tested against a standardised data set to establish their validity.

Sample size estimation for comparing two or more treatment groups in clinical trials

Methods for estimating required sample size for comparing two population means have been published. Most involve the use of complicated formulae and tables. These methods are limited to comparing two groups. Although techniques exist to determine sample sizes for comparing more than two groups, they are intrinsically far more complicated. A simple linear nomogram is proposed as a solution to these problems, and its use is illustrated with examples of parallel group, ordered parallel group and factorial designs.

Inter- and intraindividual variation in pressure-volume relations of the rectum in normal subjects and patients with the irritable bowel syndrome

The relation between intrarectal volume and pressure during increasing rectal distension by a latex balloon were studied on repeated occasions in 10 healthy adult volunteers to define variations within and between individuals. A wide intersubject variation in the maximum tolerable volume (58-908 ml) and pressure (12.2-108.8 cm H2O) at this end point was seen, and these two values were correlated (r = 0.78). Intrasubject variation in maximum tolerable volume also occurred which was related to study order and progressively reduced with repeated study. In 26 unselected patients with pain predominant irritable bowel syndrome similar intersubject variation was noted and virtually all patients data fell within the calculated 95% confidence limits of the normal individuals. Differentiation between patients and normal subjects was not possible from knowledge of rectal responses. These noticeable inter- and intrasubject variations in rectal responses to distension need to be considered whenever similar techniques are proposed for use in the study of rectal disease or of rectal response to treatment.

An investigation of factors influencing the longevity of restorations in primary molars

The treatment records of three dentists working in south-east England were screened and 361 chosen for the investigation of the longevity of restorations placed in primary molars. The analysis was carried out using an independent sampling technique, i.e., one restoration per patient. The median survival time for all the restorations was 70.6 months (standard error +/- 3.7 months). The survival pattern of the restorations for the three dentists was different and therefore the influence of six factors on the life-span of restorations was investigated using the Cox regression model. There was no evidence that the life-span of the restorations depended on the sex of the patients (p = 0.506), or the type of primary molars being treated (p = 0.776); there was weak evidence that the life-span depended on the caries susceptibility of the patient (p = 0.151) and preformed metal crown restorations (p = 0.106); there was good evidence that the life-span depended on the age of the patients at the time of treatment (p = 0.016), whether pretreatment radiographs had been taken (p = 0.023) and type of amalgam restoration (p = 0.003).

Perturbation of upper gastrointestinal transit and antroduodenal motility by experimentally applied stress: the role of beta-adrenoreceptor mediated pathways

A series of three experiments were performed on healthy adult volunteers to investigate the possible role played by beta-adrenoreceptor mediated pathways in the disturbance of human upper intestinal motor function by hand immersion in cold water. In the first experiment, (an extended pilot study on one individual), orocaecal transit of a standard meal was measured on 36 occasions with and without cold water stimulation and with and without a series of alpha and beta blocking drugs. Cold water stimulation consistently delayed transit in this individual, an effect which was attenuated by prior beta-blockade. In a double blind trial of the effect of beta-blocker atenolol v placebo on transit in nine individuals, a consistent reduction in the cold water induced transit delay was observed (p less than 0.01) independent of any direct effect of beta-blockade. In the third experiment seven individuals underwent repeated studies of antroduodenal pressure activity comparing the effects of cold and warm water stimulation with and without beta blockade to determine whether the observed transit effect could be related to an action on gastrointestinal motility. Cold water stimulation reduced antroduodenal motility, but no consistent effects of previous beta blockade were noted. These studies indicate the presence of a beta-adrenoreceptor mediated pathway in the cold water induced delay of orocaecal transit but not in the inhibition of gastroduodenal motility. Further studies are indicated to determine the site and mode of action of this transit effect more precisely.

Comparative quality assessment in immunocytochemistry: pilot study of CD15 staining in paraffin wax embedded tissue in Hodgkin's disease

The feasibility of comparative quality assessment studies in immunocytochemistry was examined. The reactions of three CD15 antibodies--anti-Leu M1, DM1, and Tü9--were examined in paraffin wax sections in Hodgkin's disease under a variety of different fixation and pre-treatment conditions, using four immunochemical detection techniques. All three antibodies stained Reed-Sternberg cells, but DM1 could be used at slightly higher dilutions to achieve comparable results. Tissue fixed in formol sublimate showed the most intense staining reactions, and formol saline and neutral buffered formalin gave relatively poor results. Although neuraminidase pre-treatment improved staining, its routine use is probably contraindicated by its high cost. Trypsinisation has some value for sections of tissue fixed in formol saline and neutral buffered formalin. The avidin-biotin complex technique produced the best results, but indirect immunoperoxidase produced acceptable results, is technically easier to perform, and is less expensive. It is concluded that information regarding variations in techniques and commercially available reagents, which may be of use in routine diagnostic histopathology, can be obtained by comparative quality assessment studies of this type.

Life-span of amalgam restorations in primary molars: some results and comments on statistical analyses

The life-span of amalgam restorations placed in primary molars by three general dental practitioners is investigated. Two methods of analysis have been carried out. In the analysis of "non-independent" restorations (i.e. using several restorations from each mouth), the median survival time was 52.8 months with an apparent standard error of 2.1 months. In the analysis of "independent" restorations (i.e. only using one restoration from each mouth), three random samples were chosen and their median survival times were 68.2 months (s.e. = 6.9), 60.5 months (s.e. = 6.9), and 56.8 months (s.e. = 3.7). The two methods are compared and discussed. It is concluded that the analysis of "independent" restorations should be the method of choice in studying the life-span of restorations.

Sample size and power for comparing two or more treatment groups in clinical trials

Methods for determining sample size and power when comparing two groups in clinical trials are widely available. Studies comparing three or more treatments are not uncommon but are more difficult to analyse. A linear nomogram was devised to help calculate the sample size required when comparing up to five parallel groups. It may also be used retrospectively to determine the power of a study of given sample size. In two worked examples the nomogram was efficient. Although the nomogram offers only 5% and 1% significance levels and can be used only for up to five treatment groups, this is sufficient for most researchers.

Glycopyrronium requirements for antagonism of the muscarinic side effects of edrophonium

We have compared, in 60 adult patients, the cardiovascular effects of glycopyrronium 5 micrograms kg-1 and 10 micrograms kg-1 given either simultaneously or 1 min before edrophonium 1 mg kg-1. Significant differences between the four groups were detected (P less than 0.001). Both groups receiving 10 micrograms kg-1 showed increases in heart rate of up to 30 beat min-1 (95% confidence limits 28-32 beat min-1). Use of glycopyrronium 5 micrograms kg-1 provided greater cardiovascular stability and, given 1 min before the edrophonium, was sufficient to minimize early, edrophonium-induced bradycardias. This low dose of glycopyrronium provided good control of oropharyngeal secretions.

Optimal placebo response rates for comparing two binomial proportions

This paper considers the problem of comparing proportions in clinical trials where two parallel groups are studied. The question of what will happen to the response rate of an active therapy if some external factor affects the placebo rate is asked and two different, but similar, answers are proposed. Assuming either a logistic or probit model has substantial influence on the sample size required to detect differences and optimal comparisons are suggested. The idea is illustrated by a clinical trial of treatment for peptic ulcer and suggestions for other possible applications are presented.

Motor responses of the small intestine to intraluminal distension in normal volunteers and a patient with visceral neuropathy

The motor responses of the small intestine to intraluminal distension were studied proximal and distal to an inflatable balloon in 13 normal volunteers. During fasting, distension rapidly induced a persistent localised inhibition of distal contractile activity with a small proximal increase. Proximally, phase III activity was unaffected during distension but its propagation across and appearance below the balloon was inhibited. Upon deflating the balloon a normal motor pattern rapidly returned. Similar changes were observed during distension in the fed state. The changes in the motor pattern resemble those of the intrinsically mediated 'peristaltic reflex', studied in animals, and suggest that in man the response to balloon distension may also be mediated through an intrinsic mechanism. A patient with a visceral neuropathy, studied in a similar manner, had no inhibition of distal motor activity during distension, suggesting a functional defect of the enteric nerves. Further observations of the motor responses to distension in similar patients seem indicated to determine the usefulness of this technique for evaluating enteric nervous system function when an abnormality is suspected.

Motor responses of the oesophagus to intraluminal distension in normal subjects and patients with oesophageal clearance disorders

Oesophageal motor responses to intraluminal distension were studied manometrically in 16 healthy volunteers and in nine patients with disordered swallowing, who had prolonged oesophageal clearance without structural abnormality. In the normal subjects distension was associated with an increased number of secondary contractions above the balloon, decrease of all contractile activity below the balloon and was accompanied by an aborally propulsive force which occurred independently of the perception of discomfort. Cholinergic blockade abolished the proximal distension induced contractile response, but did not affect primary peristalsis. Despite normal sensory thresholds, proximal excitatory responses to distension were absent in six and distal inhibition was absent in seven patients. These results show that the normal human oesophagus responds to distension with a proximal enhancement of propulsive motor activity, mediated through a cholinergic pathway. This may be defective in some patients with disordered oesophageal transit. Investigation of the motor responses to intraluminal distension may thus be a useful adjunct to standard manometry for studying patients with suspected oesophageal clearance dysfunction and might allow identification of disordered enteric nervous control.

Factors associated with joint mobility in an adolescent population

Fixed torque devices were used to measure joint mobility at three sites in 364 adolescents including 39 families with at least two siblings. Increasing age and being male were associated with reduced laxity, and a strong effect of family was observed in the 39 sibling sets studies. The population included 47 Asians whose mobility was similar to that of the non-Asians, though the female/male difference was apparently greater in the former group. None of the above conclusions apply to index finger hyperextension, and it is apparent that genetic and constitutional factors only affect mobility at some sites. Such observations could lead to a review of current scoring systems for clinical hypermobility.

Differential diagnosis of motoneurone disease from other neurological conditions

Analysis of 422 patients with clinical diagnoses of motoneurone disease (MND), multiple sclerosis, cervical spondylosis with myelopathy, or stroke, from two referral centres, suggested a simple four-step algorithm for diagnosing MND. The algorithm provided a 98% sensitivity (true positive diagnosis) and 86% specificity, and therefore gives a baseline for diagnostic criteria suitable for use in clinical research of MND.

Do wet suits affect swimming speed?

A randomised cross-over trial was conducted to see if wet suits increase swimming speed--a question which has been fiercely debated in the fat-growing endurance sport of Triathlon. Sixteen swimmers volunteered to undertake two 30 minute swims, one with and one without a wet suit. With wet suits the subjects swam an average of 24.9 lengths of a 66 m pool. Without wet suits they swam 23.2 lengths. A 95% confidence interval for the difference is from 0.8 to 2.6 lengths (p less than 0.001). This result suggests that regulations about the use of wet suits must be agreed internationally to ensure equal competition whilst promoting the health and safety aspects of sport.

The utilization of [3H] sugars by non-malignant and malignant human breast

The utilization of [3H] sugars and leucine by non-malignant and malignant human breast has been assessed using an organ culture technique with subsequent tissue autoradiography. The uptake of sugars by normal and hyperplastic breast was generally constant, with some differences observed in the utilization of galactose by acini of normal and hyperplastic tissues. After 24 h incubation localization was predominantly at the luminal cell periphery. The utilization of sugars by carcinomas was much more variable. Differences were observed between adjacent cells and cell groups of the same tumour. The uptake of individual sugars within a carcinoma was also varied being either similar to, or greater or lesser than normal breast. Variation between carcinomas was also present. No correlation between type and differentiation was noted in this respect, but there was between localization of sugars and differentiation. Better differentiated areas in tumours showed patterns similar to non-malignant breast whilst localization in poorly differentiated cell groups was cytoplasmic. The uptake of leucine was more constant and proved to be a useful indicator of viability. While this approach cannot give information with regard to differences in glycoprotein structure between non-malignant and malignant breast, it has been of value in determining the heterogeneity of tumour cells with regard to the enzymes involved in glycosylation. As such it would be of use in assessing the uniformity of response to agents modifying glycosylation.

The expression of fucosylated type 2 blood group chains in human breast and their significance

Monoclonal antibodies directed against O(H) blood group antigen and 3-fucosyl-N-acetyllactosamine have been used to investigate the incidence and significance of these type 2 blood group chains in non-malignant and malignant human breast tissue. The findings have been compared with those obtained with the fucose-binding lectins, Ulex europeus I and Lotus tetragonolobus. The expression of O(H) antigen in non-malignant breast is heterogeneous and shows no relationship to blood group status. Its expression in carcinomas shows no relationship to prognostic parameters such as differentiation and node status, whereas loss of Ulex europeus I binding is related to metastasis. The presence of 3-fucosyl-N-acetyllactosamine is limited in non-malignant breast, apart from pregnancy, but in carcinomas shows a relationship to differentiation, a feature not seen with fucose-binding lectins. It is apparent that to obtain the maximum amount of information about the modifications occurring in fuco-substances that appear to be of significance in breast malignancy, it is important to use monospecific probes as well as reagents with broader specificities, such as lectins.

Controlled trial of small bipolar probe in bleeding peptic ulcers

204 of 460 patients with upper gastrointestinal bleeding admitted to a busy district hospital were found to be bleeding from peptic ulcers or to have signs of recent haemorrhage at endoscopy within 24 h of admission. To determine if the small bipolar probe could stop bleeding or rebleeding, patients were allocated to electrocoagulation (101) or not (103); other aspects of treatment were identical. Groups were stratified by ulcer site to give similar numbers in each. To allow for differences in sex, age, initial haemoglobin, presence of other diseases, and shock, data were analysed by logistic regression. Fewer patients in the treated group (17) continued to bleed or rebled compared with controls (34). Rebleeding and mortality rates in the treated group were higher early in the trial, suggesting the need for experience in application of the probe. Further improvements in technology and technique may result in significant reductions in mortality.

Transferrin receptor expression in non-malignant and malignant human breast tissue

The expression of transferrin receptor by normal, pregnant and benign hyperplastic breast lesions and by breast carcinomas has been investigated immunohistochemically using two monoclonal antibodies directed against the receptor. Unlike a previous immunohistological study in which staining was confined to malignant breast, transferrin receptor has been detected in pregnant breast and in benign lesions as well as in all carcinomas examined. The latter showed variable reactivity but with staining of most cells in 70 per cent of cases. Although the expression of transferrin receptor in non-malignant conditions may be related to cell proliferation, as has been suggested from studies of activated cells, the extent of reactivity of carcinomas has shown no correlation with tumour characteristics such as differentiation and local tumour spread. It is therefore suggested that the immunologically active transferrin receptor of breast carcinomas may have significance other than that relating to proliferation. The finding that with some carcinomas differences in staining occurred between the two antibodies is a further illustration of the complexities of the nature of transferrin receptor.

Expression of the antigen detected by the monoclonal antibody Ca 19.9 in human breast tissues

The incidence and significance of the expression of the antigen defined by the monoclonal antibody Ca 19.9 (Sialyl Lea) has been assessed in human breast tissue. Frozen and formalin-fixed, paraffin embedded specimens of normal, hyperplastic, pregnant breast and carcinomas were examined using an immunoperoxidase technique. Ductal and acinar epithelium of normal and hyperplastic tissues showed variable reactivity in frozen sections but there was a reduction in staining in comparable samples after fixation and processing, such that in many instances only focal ductal epithelium reacted. A distinctive feature in the pregnant breast was the absence of staining in acini showing differentiated secretory activity, despite a reaction in adjacent nonsecretory acini and ducts. The overall incidence of detection of the Ca 19.9 antigen in breast carcinomas was 62%, but in half of these only a small number of cells stained. A significant relationship between expression of Sialyl Lea and poor differentiation of carcinomas was identified, but there was no correlation with local lymph node status. In contrast to the non-malignant tissue fixation and processing had little effect on the reactivity of carcinomas. It is suggested that this difference may be quantitative in nature, with malignant breast showing much greater expression, or be related to organisation of the antigen. The observations concerning carcinomas and pregnant breast indicate that the synthesis of the Ca 19.9 antigen is related to the state of differentiation and functional activity of human breast.