Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors

Endoscopic ultrasonography was used to examine 38 patients with a pancreatic neoplasm (mean size, 2.8 cm; range, 1 to 5 cm). Three EUS signs appear to be reliable criteria for the identification of tumor invasion of major veins forming the portal confluence: (1) peri-pancreatic venous collaterals in the area of a mass that obliterates the normal anatomic location of a major portal confluence vessel; (2) tumor within the vessel lumen; and (3) abnormal vessel contour with loss of the vessel-parenchymal sonographic interface. At least one of these signs was present in each of the 21 patients with vascular invasion; none of them was present in the 17 patients without vascular invasion. Findings were confirmed by laparotomy plus biopsy (33 patients), autopsy (1 patient), or angiography plus biopsy (4 patients). Arterial involvement was identified by alteration of vessel course and caliber. All 7 patients with arterial involvement also had venous involvement. These signs provide reliable criteria for endoscopic ultrasonographic definition of unresectable tumors in patients with a pancreatic neoplasm that appears to be resectable on standard radiologic tests.

Pancreatic pseudocysts and fluid collections: percutaneous approaches

Radiological imaging and intervention play important roles in the management of pancreatic fluid collections and pseudocysts. Computed tomography evaluation of the severity of pancreatitis and assessment of its course are now routine. Percutaneous drainage of pancreatic pseudocysts and abscesses is commonly performed as an adjunct to surgical treatment and is frequently definitive therapy. Percutaneous débridement of pancreatic necrosis has recently emerged as a viable alternative to open surgical treatment.

Association of incident gout and mortality in dialysis patients

Previous studies have shown that gout is associated with an increased risk for cardiovascular mortality in the general population, but this has not been well studied in patients with ESRD. In this study, the incidence of gout and its association with mortality was evaluated in 259,209 patients in the United States Renal Data System. Overall, the incidence of gout in the first year of dialysis was 5% and in the first 5 yr was 15.4%. Independent risk factors for gout in adjusted analyses included black race, older age, female gender, hypertension, ischemic heart disease, congestive heart failure, and alcohol use. Factors associated with a lower risk for gout included a history of diabetes, smoking, and peripheral vascular disease. Time-dependent Cox regression analysis suggested that an episode of gout was independently associated with a 1.5-fold increase in mortality risk (adjusted hazard ratio 1.49; 95% confidence interval 1.43 to 1.55). The mechanisms underlying this association require further study.

Retransplantation after BK virus nephropathy in prior kidney transplant: an OPTN database analysis

BK virus (BKV) has emerged as a major complication of kidney transplantation. Since June 30, 2004, the OPTN in the USA collects BKV as a primary or secondary cause of graft loss and also if treatment for BK virus (TBKV) is administered. In this study, we determined characteristics of those recipients of repeat kidney transplants from the OPTN database, where either (a) a graft loss occurred between June 30, 2004 and December 31, 2008 and database recorded prior TBKV in that allograft or (b) a graft loss between June 30, 2004 and December 31, 2008 was attributed primarily or secondarily due to BKV. In the study time period, 823 graft losses have occurred where TBKV or graft failure attributable to BKV was reported in prior transplant; of these, 126 have received a retransplant as of June 5, 2009. Induction and maintenance immunosuppression usage mirrored current trends. As of June 5, 2009, 118/126 grafts are still functioning, one graft failure attributed to BKV. TBKV was reported in 17.5% of the retransplants. In the retransplants performed through December 31, 2007, 1-year acute rejection rate was 7%, 1-year and 3-year Kaplan-Meier graft survival rates and median GFR were 98.5%, 93.6%, 65.5 and 68.4 mL/min, respectively. Retransplantation after BKV appears to be associated with good results.

Multivariate analysis of risk of perinatal telencephalic leucoencephalopathy

The hospital and autopsy records of 40 infants who died with perinatal telencephalic leucoencephalopathy (PTL) (hypertrophic astrocytes and amphophilic globules in telencephalic white matter) were compared to those of 76 control infants who had no white matter abnormality. A linear discromination procedure, which takes into account multiple confounding factors, was used to estimate risk ratios. PTL was found more commonly in infants who (a) had bacteria isolated from blood at autopsy, (b) received intravenous glucose and water for more than one day, or (c) received kanamycin or streptomycin. Infants were at reduced risk if they received penicillin, atropine, mercurhydrin or a transfusion of whole blood. It is hypothesized that endotoxin from bacteremia adversely affects developing white matter and that the other risk factors of PTL are markers of, or contributors to, increased risk of gram negative infection. No evidence was found for antibiotic-endotoxin interaction. The factors that are associated with reduced risk of PTL may be markers of, or contributors to reduced risk of gram negative infection.

Respiratory sinus arrhythmia in freely moving and anesthetized rats

Heart rate increases during inspiration and slows during postinspiration; this respiratory sinus arrhythmia helps match pulmonary blood flow to lung inflation and maintain an appropriate diffusion gradient of oxygen in the lungs. This cardiorespiratory pattern is found in neonatal and adult humans, baboons, dogs, rabbits, and seals. Respiratory sinus arrhythmia occurs mainly due to inhibition of cardioinhibitory parasympathetic cardiac vagal neurons during inspiration. Surprisingly, however, a recent study in anesthetized rats paradoxically found an enhancement of cardiac vagal activity during inspiration, suggesting that rats have an inverted respiratory sinus arrhythmia (Rentero N, Cividjian A, Trevaks D, Pequignot JM, Quintin L, and McAllen RM. Am J Physiol Regul Integr Comp Physiol 283: R1327-R1334, 2002). To address this controversy, this study examined respiratory sinus arrhythmia in conscious freely moving rats and tested whether the commonly used experimental anesthetics urethane, pentobarbital sodium, or ketamine-xylazine alter respiratory sinus arrhythmia. Heart rate significantly increased 21 beats/min during inspiration in conscious rats, a pattern similar to the respiratory sinus arrhythmia that occurs in other species. However, anesthetics altered normal respiratory sinus arrhythmia. Ketamine-xylazine (87 mg/kg and 13 mg/kg) depressed and pentobarbital sodium (60 mg/kg) abolished normal respiratory sinus arrhythmia. Urethane (1 g/kg) inverted the cardiorespiratory pattern so that heart rate significantly decreased during inspiration. Our study demonstrates that heart rate normally increases during inspiration in conscious, freely moving rats, similar to the respiratory sinus arrhythmia pattern that occurs in other species but that this pattern is disrupted in the presence of general anesthetics, including inversion in the case of urethane. The presence and consequences of anesthetics need to be considered in studying the parasympathetic control of heart rate.

Hypoxia recruits a respiratory-related excitatory pathway to brainstem premotor cardiac vagal neurons in animals exposed to prenatal nicotine

The most ubiquitous form of arrhythmia is respiratory sinus arrhythmia in which the heart beat slows during expiration and heart rate increases during inspiration. Whereas respiratory sinus arrhythmia benefits pulmonary gas exchange respiratory dysfunction presents a major challenge to the cardiorespiratory system. Hypoxia evokes a pronounced bradycardia mediated by increases in parasympathetic cardiac activity. It has been hypothesized that the fatal events in sudden infant death syndrome (SIDS) are exaggerated cardiorespiratory responses to hypoxia. This study tests whether premotor cardiac vagal neurons receive rhythmic respiratory-related excitatory synaptic inputs during normoxia and hypoxia, and if animals exposed to nicotine in the prenatal period have exaggerated responses to hypoxia. Premotor cardiac vagal neurons in the nucleus ambiguus were identified in rats by the presence of a fluorescent tracer in medullary slices that generate rhythmic inspiratory-related motor discharge. Respiratory activity was recorded from the hypoglossal nerve and excitatory synaptic events in cardiac vagal neurons were isolated using patch clamp techniques. Adult female rats were implanted with osmotic minipumps that delivered nicotine at a level approximately equivalent to those that occur in moderate to heavy smokers. During normal eupneic respiration, as well as during hypoxia, premotor cardiac vagal neurons from control animals did not receive any rhythmic respiratory-related excitatory inputs. However in animals exposed to nicotine throughout the prenatal period respiratory bursts during hypoxia dramatically increased the frequency of excitatory synaptic events in cardiac vagal neurons. In summary, in animals exposed to nicotine throughout the prenatal period, but not in unexposed animals, respiratory bursts that occur during hypoxia dramatically increase the frequency of excitatory synaptic events in cardiac vagal neurons. This study establishes a likely neurochemical mechanism for the heart rate responses to hypoxia and a link between prenatal nicotine exposure and exaggerated bradycardia responses during hypoxia that may contribute to sudden infant death syndrome.

Stochastic noise interferes coherently with a model biological clock and produces specific dynamic behaviour

The influence of noise is unavoidable in all living systems. Its impact on a model of a biological clock, normally running in regular oscillating modes, is examined. It is shown that in a specific system in which endogenous rhythmicity is produced by a beat oscillator acting on a feedback coupled metabolic pool system, noise can act coherently to produce unexpected dynamic behaviour, running from regular over pseudo-regular to irregular time-structures. If the biological system consists of a set of identical weakly coupled cells, stochasticity may lead to phase decoupling producing irregular spatio-temporal patterns. Synchronization via phase resetting can be achieved by external short-time temperature pulses. Explicit results are obtained for the well-studied circadian photosynthesis oscillations in plants performing crassulacean acid metabolism. Because of the generic structure of the underlying nonlinear dynamics they can, however, be regarded as a general property of the influence of noise on nonlinear excitable systems with fixed points occuring close to limit cycles.

Thermodynamics and energetics of the tonoplast membrane operating as a hysteresis switch in an oscillatory model of Crassulacean acid metabolism

The observed endogenous circadian rhythm in plants performing Crassulacean acid metabolism is effected by malate transport at the tonoplast membrane. Experimental and theoretical work asks for a hysteresis switch, regulating this transport via the ordering state of the membrane. We apply a schematic molecular model to calculate the thermally averaged order parameter of the membrane lipid structure in its dependence on external parameters temperature and area per molecule. The model shows a first order structural phase transition in a biologically relevant temperature range. Osmotic consequences of malate accumulation can trigger a transition between the two phases by changing the surface area of the cell vacuole. Estimation of the energy needed to expand the vacuole under turgor pressure because of osmotic changes while acidifying shows that energy needed as latent heat for the calculated change between phases can easily be afforded by the cell. Thus, malate content and the coexisting two phases of lipid order, showing hysteretic behavior, can serve as a feedback system in an oscillatory model of Crassulacean acid metabolism, establishing the circadian clock needed for endogenous rhythmicity.

Is bariatric surgery an option for women with gynecologic cancer? Examining weight loss counseling practices and training among gynecologic oncology providers

OBJECTIVE

The objective of this study was to evaluate gynecologic oncology provider (GOP) practices regarding weight loss (WL) counseling, and to assess their willingness to initiate weight loss interventions, specifically bariatric surgery (WLS).

METHODS

Members of the Society of Gynecologic Oncology were invited to complete an online survey of 49 items assessing knowledge, attitudes, and behaviors related to WL counseling.

RESULTS

A total of 454 participants initiated the survey, yielding a response rate of 30%. The majority of respondents (85%) were practicing GOP or fellows. A majority of responders reported that >50% of their patient population is clinically obese (BMI ≥ 30). Only 10% reported having any formal training in WL counseling, most often in medical school or residency. Providers who feel adequate about WL counseling were more likely to offer multiple WL options to their patients (p<.05). Over 90% of responders believe that WLS is an effective WL option and is more effective than self-directed diet and medical management of obesity. Providers who were more comfortable with WL counseling were significantly more likely to recommend WLS (p<.01). Approximately 75% of respondents expressed interest in clinical trials evaluating WLS in obese cancer survivors.

CONCLUSIONS

The present study suggests that GOP appreciate the importance of WL counseling, but often fail to provide it. Our results demonstrate the paucity of formal obesity training in oncology. Providers seem willing to recommend WLS as an option to their patients but also in clinical trials examining gynecologic cancer outcomes in women treated with BS.

Percutaneous drainage of abscesses in the postoperative abdomen that is difficult to explore

We have evaluated our experience with computerized tomography and ultrasonography guided percutaneous drainage of extrahepatic abdominal fluid collections in a group of 22 patients. The most common goal was to avoid or delay surgery on abdomens in which reoperation would be difficult, mainly in high-risk patients. Drainage of pancreatic fluid collections or abscesses was also attempted in a small number of the patients. Percutaneous drainage was curative in 69 percent of those with nonpancreatic abscesses but in only 33 percent of those with abscesses associated with the pancreas. There were no complications attributable to the procedure or to delays in subsequent surgical drainage. Two patients died from problems not directly related to the use of percutaneous drainage. Percutaneous catheter drainage of nonpancreatic abdominal abscesses can play a useful role in patients who are carefully selected because they possess a complex abdominal anatomy distorted by previous surgery and infection or they are at high risk if surgical exploration is carried out.

Grand mal seizure after extradural morphine analgesia

Following an elective Caesarean section under extradural anaesthesia, a 30-yr-old known epileptic woman (gravida 4, para 3) developed a tonic-clonic seizure, 6 h after the administration of morphine 3 mg into the extradural space. Possible aetiological factors are discussed.

Glycinergic inputs to cardiac vagal neurons in the nucleus ambiguus are inhibited by nociceptin and mu-selective opioids

Most parasympathetic regulation of heart rate originates from preganglionic cardiac vagal neurons within the nucleus ambiguus. Little is known regarding the modulation of glycinergic transmission to these neurons. However, the presence of mu-opioid receptors and opioid-receptor-like (ORL1) receptors within the ambiguus, together with the presence of endogenous ligands for both receptor types in the same area, suggests opioids may modulate synaptic transmission to cardiac vagal neurons. This study therefore examined the effects of endomorphin-1 and endomorphin-2 (the mu-selective endogenous peptides), DAMGO (a synthetic, mu-selective agonist), and nociceptin (the ORL1-selective endogenous peptide) on spontaneous glycinergic inhibitory postsynaptic currents (IPSCs) in rat cardiac parasympathetic neurons. All four of the opioids used in this study decreased spontaneous IPSCs. At concentrations of 100 microM, the amplitude of the IPSCs was reduced significantly by nociceptin (-56.6%), DAMGO (-46.5%), endomorphin-1 (-45.1%), and endomorphin-2 (-26%). IPSC frequency was also significantly reduced by nociceptin (-61.1%), DAMGO (-69.9%), and endomorphin-1 (-40.8%) but not endomorphin-2. Lower concentrations of nociceptin and DAMGO (10-30 microM) also effectively decreased IPSC amplitude and frequency. The inhibitory effects of DAMGO were blocked by d-Phe-Cys-Tyr-d-Trp-Orn-Thr-Pen-Thr-NH2 (C-TOP; 10 microM), a selective mu-receptor antagonist. Neither nociceptin nor DAMGO inhibited the postsynaptic responses evoked by exogenous application of glycine or affected TTX-insensitive glycinergic mini-IPSCs. These results indicate that mu-selective opioids and nociceptin act on preceding neurons to decrease glycinergic inputs to cardiac vagal neurons in the nucleus ambiguus. The resulting decrease in glycinergic transmission would increase parasympathetic activity to the heart and may be a mechanism by which opioids induce bradycardia.

Treatment of attention deficit hyperactivity disorder with monoamine amino acid precursors and organic cation transporter assay interpretation

BACKGROUND

This paper documents a retrospective pilot study of a novel approach for treating attention deficit hyperactivity disorder (ADHD) with amino acid precursors of serotonin and dopamine in conjunction with urinary monoamine assays subjected to organic cation transporter (OCT) functional status determination. The goal of this research was to document the findings and related considerations of a retrospective chart review study designed to identify issues and areas of concern that will define parameters for a prospective controlled study.

METHODS

This study included 85 patients, aged 4-18 years, who were treated with a novel amino acid precursor protocol. Their clinical course during the first 8-10 weeks of treatment was analyzed retrospectively. The study team consisted of PhD clinical psychologists, individuals compiling clinical data from records, and a statistician. The patients had been treated with a predefined protocol for administering amino acid precursors of serotonin and dopamine, along with OCT assay interpretation as indicated.

RESULTS

In total, 67% of participants achieved significant improvement with only amino acid precursors of serotonin and dopamine. In patients who achieved no significant relief of symptoms with only amino acid precursors, OCT assay interpretation was utilized. In this subgroup, 30.3% achieved significant relief following two or three urine assays and dosage changes as recommended by the assay results. The total percentage of patients showing significant improvement was 77%.

CONCLUSION

The efficacy of this novel protocol appears superior to some ADHD prescription drugs, and therefore indicates a need for further studies to verify this observation. The findings of this study justify initiation of further prospective controlled studies in order to evaluate more formally the observed benefits of this novel approach in the treatment of ADHD.

Synaptic activation of cardiac vagal neurons by capsaicin sensitive and insensitive sensory neurons

Little is known about the central circuitry involved in the sensory activation of cardioinhibitory vagal neurons (CVNs). To study the polysynaptic activation of CVNs from sensory neurons the postsynaptic currents in CVNs in the dorsal motor nucleus of the vagus (DMNX) were evoked by stimulation of the vagus nerve. In addition, the role of afferent A-fiber and C-fiber activation of CVNs was examined. CVNs were identified by a retrograde fluorescent tracer and were studied in an in vitro slice preparation using patch-clamp electrophysiology. Stimulation of the vagus nerve evoked excitatory postsynaptic currents in CVNs that were reversibly blocked by the NMDA antagonist D-2-amino-5-phosphonovalerate (AP5) and the non-NMDA antagonist 6-cyano-7-nitroquionoxaline-2,3-dione (CNQX). Vagal stimulation also evoked inhibitory postsynaptic currents (IPSCs) that were reversibly blocked by the GABA(A) antagonist gabazine. Capsaicin, which inactivates C-fibers, was used to examine the role of afferent A-fibers and C-fibers in the synaptic activation of CVNs. Capsaicin significantly (P<0.05) reduced the amplitude of evoked glutamatergic and GABAergic postsynaptic currents by 59% and 76%, respectively. The latency of the GABAergic response increased significantly (P<0.05) in the presence of capsaicin from 36+/-1 to 41+/-1 ms while the latency of the glutamatergic response (44+/-3 ms) was unaffected. There are three conclusions from this study. Stimulation of vagal afferents evokes both GABAergic and glutamatergic responses in CVNs, C-type afferent fibers are critical to the afferent stimulation of CVNs, and the A-fiber GABAergic pathway to CVNs may be more complex than the C-fiber GABAergic pathway.

Up-Front Multigene Panel Testing for Cancer Susceptibility in Patients With Newly Diagnosed Endometrial Cancer: A Multicenter Prospective Study

PURPOSE

Clinical utility of up-front multigene panel testing (MGPT) is directly related to the frequency of pathogenic variants (PVs) in the population screened and how genetic findings can be used to guide treatment decision making and cancer prevention efforts. The benefit of MGPT for many common malignancies remains to be determined. In this study, we evaluated up-front MGPT in unselected patients with endometrial cancer (EC) to determine the frequency of PVs in cancer susceptibility genes.

METHODS

Patients with EC were prospectively enrolled at nine Ohio institutions from October 1, 2017, to December 31, 2020. Nine hundred and sixty-one patients with newly diagnosed EC underwent clinical germline MGPT for 47 cancer susceptibility genes. In addition to estimating the prevalence of germline PVs, the number of individuals identified with Lynch syndrome (LS) was compared between MGPT and tumor-based screening.

RESULTS

Likely pathogenic variants or PVs were identified in 97 of 961 women (10.1%). LS was diagnosed in 29 of 961 patients (3%; 95% CI, 2.1 to 4.3), with PVs in PMS2 most frequent. MGPT revealed nine patients with LS in addition to the 20 identified through routine tumor-based screening. BRCA1 and BRCA2 PVs were found in 1% (10 of 961; 95% CI, 0.6 to 1.9) of patients and that group was significantly enriched for type II ECs.

CONCLUSION

This prospective, multicenter study revealed potentially actionable germline variants in 10% of unselected women with newly diagnosed EC, supporting the use of up-front MGPT for all EC patients. The discovery that BRCA1 or BRCA2 heterozygotes frequently had type II cancers points to therapeutic opportunities for women with aggressive histologic EC subtypes.

Day-to-night variations of cytoplasmic pH in a crassulacean acid metabolism plant

In crassulacean acid metabolism (CAM) large amounts of malic acid are redistributed between vacuole and cytoplasm in the course of night-to-day transitions. The corresponding changes of the cytoplasmic pH (pHcyt) were monitored in mesophyll protoplasts from the CAM plant Kalanchoe daigremontiana Hamet et Perrier by ratiometric fluorimetry with the fluorescent dye 2',7'-bis-(2-carboxyethyl)-5-(and-6-)carboxyfluorescein as a pHcyt indicator. At the beginning of the light phase, pHcyt was slightly alkaline (about 7.5). It dropped during midday by about 0.3 pH units before recovering again in the late-day-to-early-dark phase. In the physiological context the variation in pHcyt may be a component of CAM regulation. Due to its pH sensitivity, phosphoenolpyruvate carboxylase appears as a likely target enzyme. From monitoring delta pHcyt in response to loading the cytoplasm with the weak acid salt K-acetate a cytoplasmic H(+)-buffer capacity in the order of 65 mM H+ per pH unit was estimated at a pHcyt of about 7.5. With this value, an acid load of the cytoplasm by about 10 mM malic acid can be estimated as the cause of the observed drop in pHcyt. A diurnal oscillation in pHcyt and a quantitatively similar cytoplasmic malic acid is predicted from an established mathematical model which allows simulation of the CAM dynamics. The similarity of model predictions and experimental data supports the view put forward in this model that a phase transition of the tonoplast is an essential functional element in CAM dynamics.

The mutational spectrum of FOXA2 in endometrioid endometrial cancer points to a tumor suppressor role

BACKGROUND

Forkhead box protein A2 (FOXA2) plays an important in development, cellular metabolism and tumorigenesis. The Cancer Genome Atlas (TCGA) identified a modest frequency of FOXA2 mutations in endometrioid endometrial cancers (EEC). The current study sought to determine the relationship between FOXA2 mutation and clinicopathologic features in EEC and FOXA2 expression.

METHODS

Polymerase chain reaction (PCR) amplification and sequencing were used to identify mutations in 542 EEC. Western blot, quantitative reverse transcriptase PCR (qRT-PCR) and immunohistochemistry (IHC) were used to assess expression. Methylation analysis was performed using combined bisulfite restriction analysis (COBRA) and sequencing. Chi-squared, Fisher's exact, Student's t- and log-rank tests were performed.

RESULTS

Fifty-one mutations were identified in 49 tumors (9.4% mutation rate). The majority of mutations were novel, loss of function (LOF) (78.4%) mutations, and most disrupted the DNA-binding domain (58.8%). Six recurrent mutations were identified. Only two tumors had two mutations and there was no evidence for FOXA2 allelic loss. Mutation status was associated with tumor grade and not associated with survival outcomes. Methylation of the FOXA2 promoter region was highly variable. Most tumors expressed FOXA2 at both the mRNA and protein level. In those tumors with mutations, the majority of cases expressed both alleles.

CONCLUSION

FOXA2 is frequently mutated in EEC. The pattern of FOXA2 mutations and expression in tumors suggests complex regulation and a haploinsufficient or dominant-negative tumor suppressor function. In vitro studies may shed light on how mutations in FOXA2 affect FOXA2 pioneer and/or transcription factor functions in EEC.

Intra-arterial chemotherapy for palliation of fungating breast cancer. A case report and review of the literature

The infusion of chemotherapy into arteries that feed locally advanced tumors has theoretical appeal, since the tumor mass may be exposed to high drug concentrations with administration of reduced or conventional doses of chemotherapy. Experience in applying this technique to patients with breast cancer in the United States is limited. Locally advanced, fungating breast cancers pose particularly difficult management problems for which intra-arterial drug delivery may be appropriate in carefully, selected cases. Disseminated cancer, physical deformity, foul odor, bleeding, and infection, as well as associated psychosocial factors, contribute to the complexity of caring for these patients. We report the case of a patient with a massive fungating breast cancer who was effectively palliated with intra-arterial administration of mitomycin, fluorouracil, cisplatin, and mitozantrone. The rapidity of our patient's response using this approach supports the observations of other investigators. We offer a review of the literature reporting the application of this technique for patients with locally advanced breast cancer. Further study of intra-arterial chemotherapy in carefully selected patients with locally advanced and fungating breast cancers is warranted.

Gallstone pancreatitis: combined endoscopic and laparoscopic approaches

Of 11 patients with gallstone pancreatitis, 10 underwent preoperative ERCP. Calculi were removed from the common duct in two patients. All patients underwent laparoscopic cholecystectomy, with normal rapid convalescence. The eleventh patient is recovering from pancreatitis with the bile duct accessed percutaneously. A combined endoscopic and laparoscopic approach to gallstone pancreatitis is safe and was associated with minimal risk in this small series.

Fetal death in eclampsia: II. The effect of non-therapeutic factors

The ability of 15 variables to predict fetal death is examined among 173 eclamptic women admitted to the only public maternity hospital in Cali, Colombia, between 1st Janurary 1964 and 31st December 1970. In addition to low gestational age and retarded fetal growth, high systolic pressure and the unmarried status carried excess risk. Primiparae appeared to be of lower risk because their eclampsia tended to occur late in gestation and was characterized by less retarded fetal growth. Older women and women with a history of abortion appeared to be of higher risk because they tended to have higher systolic pressures. A discriminant function risk formula is presented which generated groups with a nine-fold difference in fetal death rates. This formula could be used to standardize for relevant non-therapeutic factors which meant vary between patient groups who had received different therapeutic regimens.