Search for solar axions by the CERN axion solar telescope with 3He buffer gas: closing the hot dark matter gap.

The CERN Axion Solar Telescope has finished its search for solar axions with (3)He buffer gas, covering the search range 0.64 eV ≲ ma ≲ 1.17 eV. This closes the gap to the cosmological hot dark matter limit and actually overlaps with it. From the absence of excess x rays when the magnet was pointing to the Sun we set a typical upper limit on the axion-photon coupling of gaγ ≲ 3.3 × 10(-10) GeV(-1) at 95% C.L., with the exact value depending on the pressure setting. Future direct solar axion searches will focus on increasing the sensitivity to smaller values of gaγ, for example by the currently discussed next generation helioscope International AXion Observatory.

Hypoglycaemia symptoms and impaired awareness of hypoglycaemia in adults with Type 1 diabetes: the association with diabetes duration.

AIMS: To examine the association between diabetes duration and hypoglycaemia symptom profiles and the presence of impaired awareness of hypoglycaemia. METHODS: A cross-sectional study was performed, using validated methods for recording hypoglycaemia symptoms and assessing hypoglycaemia awareness. The associations between symptom intensity, hypoglycaemia awareness and diabetes duration were examined, and the prevalence of impaired awareness was ascertained for Type 1 diabetes of differing durations. RESULTS: Questionnaires were mailed to 636 adults with Type 1 diabetes, of whom 445 (70%) returned them. A total of 440 completed questionnaires were suitable for analysis. Longer diabetes duration was associated with lower intensity of autonomic symptoms (P for trend <0.001), but no association was observed with neuroglycopenic symptoms. The overall prevalence of impaired awareness of hypoglycaemia in this cohort was 17% (95% CI 14-21%) and increased with diabetes duration, from 3% for duration 2-9 years to 28% for duration ≥30 years (P for trend <0.001). Low autonomic symptom scores were not associated with a higher prevalence of impaired awareness. CONCLUSIONS: Longer diabetes duration was associated with lower intensity of autonomic symptoms and a higher prevalence of impaired awareness of hypoglycaemia, suggesting that subjective symptoms of hypoglycaemia change over time. These observations underline the need for regular patient education about hypoglycaemia symptomatology and clinical screening for impaired awareness of hypoglycaemia.

Can sea trout Salmo trutta compromise successful eradication of Gyrodactylus salaris by hiding from CFT Legumin (rotenone) treatments?

In this study, 34 anadromous brown trout (sea trout) Salmo trutta were equipped with acoustic transmitters in order to examine whether they performed avoidance behaviour in response to a CFT Legumin (rotenone) treatment in the Norwegian River Vefsna. Migratory behaviour of the S. trutta was monitored by use of 15 automatic listening stations and manual tracking in the lower part of the river, in the estuary and in the fjord. None of the studied S. trutta survived the rotenone treatment and no indications of successful avoidance behaviour were observed.

Search for sub-eV mass solar axions by the CERN Axion Solar Telescope with 3He buffer gas.

The CERN Axion Solar Telescope (CAST) has extended its search for solar axions by using (3)He as a buffer gas. At T=1.8 K this allows for larger pressure settings and hence sensitivity to higher axion masses than our previous measurements with (4)He. With about 1 h of data taking at each of 252 different pressure settings we have scanned the axion mass range 0.39 eV≲m(a)≲0.64 eV. From the absence of excess x rays when the magnet was pointing to the Sun we set a typical upper limit on the axion-photon coupling of g(aγ)≲2.3×10(-10) GeV(-1) at 95% C.L., the exact value depending on the pressure setting. Kim-Shifman-Vainshtein-Zakharov axions are excluded at the upper end of our mass range, the first time ever for any solar axion search. In the future we will extend our search to m(a)≲1.15 eV, comfortably overlapping with cosmological hot dark matter bounds.

Neutrophil CD64 as a marker for postoperative infection: a pilot study.

The aim of this pilot study was to evaluate the clinical utility of quantitative CD64 measurements to differentiate between systemic inflammation in response to surgical trauma and postoperative bacterial infection. In a consecutive series of 153 patients undergoing elective vascular surgery, peripheral venous blood samples were taken preoperatively on admission and postoperatively during the first 24h. The samples were analysed for C-reactive protein (CRP), total leucocyte counts (white blood cell (WBC)), serum procalcitonin (PCT) and neutrophil CD64 expression. Of the 153 patients, the focus is on those with (1) postoperative infection alone (group 1; n=1 4); (2) pre- and postoperative infection (group 2; n=6); and (3) postoperative fever with no other signs of infection (group 3; n=29). In group 1, all four markers were significantly increased in the 24h after surgery: CD64 (p=0.001), CRP (p=0.001), WBC (p=0.002) and PCT (p=0.012); in group 2, there was no significant difference in the CD64 (p=0.116), WBC (p=0.249) and PCT (p=0.138) values, whereas a marginal significance was shown for CRP (p=0.046); and the results for group 3 were similar to those of group 1. This pilot study suggests that the role of neutrophil CD64 measurements in facilitating the diagnosis of early postoperative infection merits further investigation.

Patients with a history of diabetes have a lower survival rate after in-hospital cardiac arrest.

AIM: To describe the association between a history of diabetes and outcome among patients suffering an in-hospital cardiac arrest. METHOD: All patients suffering an in-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted at Sahlgrenska University Hospital in Göteborg between 1994 and 2006 and at nine further hospitals in Sweden between 2005 and 2006. RESULTS: In all, 1810 patients were included in the survey, 395 (22%) of whom had a previous history of diabetes. Patients with a history of diabetes differed from those without such a history by having a higher prevalence of previous myocardial infarction, stroke, heart failure and renal disease. They were more frequently treated with anti-arrhythmic drugs during resuscitation. Whereas immediate survival did not differ between groups (51.7% and 53.1%, respectively), patients with diabetes were discharged alive from hospital (29.3%) less frequently compared with those without diabetes (37.6%). When correcting for dissimilarities at baseline, the adjusted odds ratio for being discharged alive (diabetes/no diabetes) was 0.57 (95% CL 0.40-0.79). CONCLUSION: Among patients suffering an in-hospital cardiac arrest in Sweden in whom CPR was attempted, 22% had a history of diabetes. These patients had a lower survival rate, which cannot simply be explained by different co-morbidity.

Variability in survival after in-hospital cardiac arrest depending on the hospital level of care.

BACKGROUND: Survival after in-hospital cardiac arrest (IHCA) differs considerably between hospitals. This study tries to determine whether this difference is due to patient selection because of the hospital level of care or to effective resuscitation management. METHODS: Prospectively collected data on management of in-hospital cardiac arrests from Sahlgrenska Hospital, a tertiary hospital in Gothenburg, Sweden (cohort one) and from five Finnish secondary hospitals (cohort two). A multiple logistic regression model was created for predicting survival to hospital discharge. RESULTS: A total of 954 cases from Sahlgrenska Hospital and 624 patients from the hospitals in Finland were included. The delay to defibrillation was longer at Sahlgrenska than at the five Finnish secondary hospitals (p=0.045). Significant predictors of survival were: (1) age below median (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.5-2.8); (2) no diabetes (OR 1.9, CI 1.2-2.9); (3) arrests occurring during office hours (OR 1.5, CI 1.1-2.2); (4) witnessed cardiac arrest (OR 6.3, CI 2.6-15.3); (5) ventricular fibrillation or ventricular tachycardia as the initial rhythm (OR 4.9, CI 3.5-6.7); (6) location of the arrest (compared to arrests in general wards, GW): thoracic surgery and heart transplantation ward (OR 2.9, CI 1.5-5.9), interventional radiology (OR 4.8, CI 1.9-12.0) and other in-hospital locations (3.0, CI 1.6-5.7) and (7) hospital (compared to arrests at Sahlgrenska Hospital); arrests at Etelä-Karjala Central Hospital [CH] (OR 0.3, CI 0.1-0.7), Päijät-Hame CH (OR 0.3, CI 0.1-0.8) and Seinäjoki CH (OR 0.4, CI 0.3-0.7). CONCLUSION: The comparison of survival following IHCA between different hospitals is difficult, there seems to be undefined factors greatly associated with outcome. A great variability in survival within different hospital areas probably because of differences in patient selection, patient surveillance and resuscitation management was also noted. A locally implemented strong in-hospital chain of survival is probably the only way to improve outcome following IHCA.

Assessment of CPR-D skills of nurses in Göteborg, Sweden and Espoo, Finland: teaching leadership makes a difference.

INTRODUCTION: Construction of an effective in-hospital resuscitation programme is challenging. To document and analyse resuscitation skills assessment must provide reliable data. Benchmarking with a hospital having documented excellent results of in-hospital resuscitation is beneficial. The purpose of this study was to assess the resuscitation skills to facilitate construction of an educational programme. MATERIALS AND METHODS: Nurses working in a university hospital Jorvi, Espoo (n=110), Finland and Sahlgrenska University Hospital, Göteborg (n=40), Sweden were compared. The nurses were trained in the same way in both hospitals except for the defining and teaching of leadership applied in Sahlgrenska. Jorvi nurses are not trained to be, nor do they act as, leaders in a resuscitation situation. Their cardiopulmonary resuscitation (CPR) skills using an automated external defibrillator (AED) were assessed using Objective Structured Clinical Examination (OSCE) which was build up as a case of cardiac arrest with ventricular fibrillation (VF) as the initial rhythm. The subjects were tested in pairs, each pair alone. Group-working skills were registered. RESULTS: All Sahlgrenska nurses, but only 49% of Jorvi nurses, were able to defibrillate. Seventy percent of the nurses working in the Sahlgrenska hospital (mean score 35/49) and 27% of the nurses in Jorvi (mean score 26/49) would have passed the OSCE test. Statistically significant differences were found in activating the alarm (P<0.001), activating the AED without delay (P<0.01), setting the lower defibrillation electrode correctly (P<0.001) and using the correct resuscitation technique (P<0.05). The group-working skills of Sahlgrenska nurses were also significantly better than those of Jorvi nurses. CONCLUSIONS: Assessment of CPR-D skills gave valuable information for further education in both hospitals. Defining and teaching leadership seems to improve resuscitation performance.

Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is technically feasible with acceptable long-term results.

OBJECTIVES: To investigate the results of endovascular treatment of symptomatic, atherosclerotic lesions of the infrarenal aorta. PATIENTS AND METHOD: This is a retrospective study including 30 procedures performed on 25 patients in the period from 1990 through 2003. There were 16 women (64%) and 9 men, with a mean age of 55 years (range 35-81 years). The indication was disabling intermittent claudication in all cases. Preoperative assessment was done with ankle-arm pressure measurement and angiography. The mean length of the lesions was 2.5cm (range 1-6cm). One lesion was a short occlusion and nine were >90% stenoses. The remaining 20 lesions were significant (>70%) stenoses. The procedure was done with PTA alone in 13 cases, and with additional stenting in 17. RESULTS: The procedures were technically successful in 28 cases and clinically successful in all 30. In two cases, a >50% residual stenosis was not dilated further because of stretch pain. The mean observation time was 40 months (range 0-135 months). The primary 2 and 5 year patency rates calculated on basis of intention to treat were 90 and 77%. The primary assisted patency rate was 90% at 2 years and 83% at 5 years. Eight patients developed significant restenosis, of which five were treated with a new endovascular procedure. Two failures were treated conservatively and one with surgical thrombendarterectomy. CONCLUSION: Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is feasible in patients with suitable anatomy. Clinical success rates are high and long-term patency is good. Complications are few and minor. The majority of failures are amenable to new endovascular treatment.

Has endovascular aneurysm repair improved outcome for patients with asymptomatic abdominal aortic aneurysm?

AIM: The aim of this study was to compare risk factors, complications, operative mortality and relative survival of patients treated with endovascular aneurysm repair (EVAR) for asymptomatic abdominal aortic aneurysm (AAA) to that of those subjected to open operation. SETTING: University Hospital. A total of 118 EVAR patients were compared with 386 with open repair during the period from 1995 through 2005, in a single center retrospective study. RESULTS: The two groups had similar risk profiles. EVAR patients were older and had shorter hospital stays than those with open operation. Throughout follow-up, 45.8% of EVAR patients had complications, as compared to only 26% of open repairs. Operative mortality, long-term survival and relative survival did not differ significantly between the two groups. CONCLUSION: EVAR appears initially safe in selected patients. The complication rate after EVAR is high, but declines throughout the study period. Focus must still be on patient selection and device improvement to reduce complications. The question whether EVAR has improved AAA treatment remains to be answered.

Survival and neurological outcome in the elderly after in-hospital cardiac arrest.

BACKGROUND: There have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival. AIM: The aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival. METHODS: We investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007-2015. For descriptive purposes, the patients were grouped according to age (70-79, 80-89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis. RESULTS: Altogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70-79 years, 20% for patients aged 80-89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.-8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate. We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1-2) (92%, 93%, and 88% in the three age groups, respectively). CONCLUSIONS: Increasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age.

The impact of comorbidity on long-term results of above-knee prosthetic femoropopliteal bypass for intermittent claudication.

AIM: The aim of this work was to report the impact of comorbidity on long-term results of prosthetic above-knee femoropopliteal bypass for intermittent claudication. METHODS: One hundred and forty-one consecutive operations (129 patients) between January 1990 and December 2001 in one single vascular unit were analyzed. All cases were prospectively registered. Survival and assisted primary patency rates were studied and subgroups of patients were compared. RESULTS: The 5-year survival was 77%, which is significantly lower than the survival of a demographically matched population (85%). Preoperative serum-creatinine >125 mmol/L was significantly associated with reduced survival (P<0.01). The assisted primary patency rates were 62% at 2 years and 44% at 5 years. The 5-year patency rate for smokers was 24% versus 67% for non-smokers (P<0.01). A previous history of cerebral infarction was significantly associated with reduced graft patency (P=0.02). CONCLUSIONS: Careful selection of patients submitted to surgical treatment of intermittent claudication is mandatory to achieve the optimal gain of the operation. Patients with intermittent claudication and renal impairment reveal poor survival. The reduced graft patency rates of patients with a history of a cerebral insult need further studies to be verified. Smokers should be treated conservatively due to their inferior graft patency rates.

The impact of patient characteristics on long-term results of above-knee prosthetic femoropopliteal bypass for critical ischemia.

AIM: The aim of this paper was to study the impact of risk factors on long-term results of above-knee prosthetic femoropopliteal bypass for critical ischemia. METHODS: One hundred and eleven consecutive operations (108 patients) were done between January 1990 and December 2001. All cases were prospectively registered. The patient characteristics were subjected to univariate analysis using the log rank test for impact on survival, limb salvage and patency rates. Variables approaching significance (P<0.1) were included in multivariate analyses performed with the Cox proportional hazard model. RESULTS: The 30-day mortality rate was 5.5%. The 2- and 5-year survival was 72% and 42%, respectively. Twenty-seven limbs were subjected to major amputations during follow-up. The limb salvage rates at 2 and 5 years were 83% and 73%. The 2- and 5-year assisted primary patency rates were 45% and 17% versus 52% and 27% for the secondary patency. The 2-year primary patency rate for smokers was 38% versus 62% for non-smokers (P=0.018, hazard ratio 2.18). Smoking and tissue loss were significantly associated with reduced secondary patency rates on multivariate analysis. CONCLUSIONS: The inferior primary patency rates of smokers indicate that prosthetic femoropopliteal bypass for critical leg ischemia should not be the primary treatment option for these patients. The poor secondary patency rates for smokers as well as for patients with tissue loss suggest that these patients may benefit from alternative treatment modalities, instead of reopening an occluded bypass.

The ASACUSA Micromegas Tracker: A cylindrical, bulk Micromegas detector for antimatter research.

The ASACUSA Micromegas Tracker (AMT; ASACUSA: Atomic Spectroscopy and Collisions Using Slow Antiprotons) was designed to be able to reconstruct antiproton-nucleon annihilation vertices in three dimensions. The goal of this device is to study antihydrogen formation processes in the ASACUSA cusp trap, which was designed to synthesise a spin-polarised antihydrogen beam for precise tests of Charge, Parity, and Time (CPT) symmetry invariance. This paper discusses the structure and technical details of an AMT detector built into such an environment, its data acquisition system and the first performance with cosmic rays.

Occurrence of hypotension during streptokinase infusion in suspected acute myocardial infarction, and its relation to prognosis and metoprolol therapy.

In all patients who received streptokinase infusion for strongly suspected acute myocardial infarction in 1 hospital during 1989 to 1990, the occurrence of hypotension during infusion is described and related to prognosis. In 54% of patients, the beta blocker metoprolol was simultaneously administered intravenously. The median systolic blood pressure (BP) before infusion was 135 mm Hg, and the median value for the lowest systolic BP recorded during infusion was 100 mm Hg (p < 0.001). A positive correlation between systolic BP before streptokinase and the lowest systolic BP during infusion was found (r = 0.53; p < 0.001). Among patients administered streptokinase and metoprolol, 23% had systolic BP < 90 mm Hg, and 12% had < 80 mm Hg at any time during infusion; corresponding values for patients administered streptokinase only were 47 and 30%, respectively. Patients with the lowest systolic BP < 80 mm Hg during infusion had a mortality during the first 2 weeks of 22 vs 11% for those with between 80 and 100 mm Hg, and 8% for those with > 100 mm Hg (p < 0.001). However, in a multivariate analysis the systolic BP before infusion rather than the lowest systolic BP during infusion was independently associated with death. It is concluded that although patients with low systolic BP during streptokinase infusion have a high mortality, the level of systolic BP before infusion is more strongly associated with the outcome. Simultaneous use of intravenous beta blockade does not increase the occurrence of hypotension during streptokinase infusion.

Long-term prognosis among survivors after in-hospital cardiac arrest.

AIM: To describe mortality and morbidity in the 2 years after discharge from hospital among patients surviving an in-hospital cardiac arrest. PATIENTS: All patients over a 2-year period who survived in-hospital cardiac arrest and could be discharged from hospital. SETTING: Sahlgrenska University Hospital in Göteborg. METHODS: The patients were followed prospectively for 2 years after discharge from hospital and evaluated in terms of mortality and morbidity and cerebral performance categories (CPC) score. CPC score was estimated by reference to the case notes. RESULTS: In all, 216 patients suffered in-hospital cardiac arrest and the resuscitation team was alerted: 79 patients (36.6%) were discharged alive. Among these 79 patients, 26.6% died, 7.8% developed a confirmed myocardial infarction and 1.3% developed a stroke during the subsequent 2 years. Among patients with a CPC score >1 at discharge (n=15), mortality was 66.7% as compared with 17.5% among patients with a CPC score of 1 (P=0.0008). Among patients aged >68 years (median) mortality was 39.5 versus 14.6% among patients < or =68 years of age (P=0.002). In all, 71% required rehospitalization for any reason and 51% required rehospitalization due to a cardiac cause. At hospital discharge 81% of all survivors had a CPC score of 1 and among survivors 2 years later 89% had a CPC score of 1. CONCLUSION: Among survivors of in-hospital arrest approximately 75% survived the subsequent 2 years. Survival was related to age and CPC score at discharge. Among survivors after 2 years the vast majority had a relatively good cerebral performance.

Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas.

AIM: To describe the characteristics and outcome among patients suffering in-hospital cardiac arrest in relation to whether the arrest took place in a ward with monitoring facilities. METHODS: All patients who suffered an in-hospital cardiac arrest during a 4-year period in Sahlgrenska Hospital, Göteborg, Sweden and in whom resuscitative efforts were attempted, were prospectively recorded and described in terms of characteristics and outcome. RESULTS: Among 557 patients, 292 (53%) had a cardiac arrest in wards with monitoring facilities. Those in a monitored location more frequently had a confirmed or possible acute myocardial infarction (AMI) as judged to be the cause of arrest (P < 0.0001), and the arrest was witnessed more frequently (96 vs. 79%; P < 0.0001). Ventricular fibrillation/tachycardia was observed more often as initial arrhythmia in monitored wards (56 vs. 44%; P = 0.006). The median interval between collapse and first defibrillation was 1 min in monitored wards and 5 min in non-monitored wards (P < 0.0001). Among patients with arrest in monitored wards 43.2% were discharged alive compared with 31.1% of patients in non-monitored wards (P = 0.004). Cerebral performance category (CPC-score) at discharge was somewhat better among survivors in monitored wards. CONCLUSION: In a Swedish University Hospital 47% of in-hospital cardiac arrests in which resuscitation was attempted took place in wards without monitoring facilities. These patients differed markedly from those having arrest in wards with monitoring facilities in terms of characteristics, interval to defibrillation and outcome. A shortening of the interval between collapse and defibrillation in these patients might increase survival even further.

Is there a difference between women and men in characteristics and outcome after in hospital cardiac arrest?

AIM: To describe the characteristics and outcome among patients suffering from an in-hospital cardiac arrest in women and men. METHODS: All patients who suffered an in-hospital cardiac arrest during a 4 year period in Sahlgrenska Hospital Göteborg, Sweden, where the cardiopulmonary resuscitation (CPR) team was called, were recorded and described prospectively in terms of characteristics and outcome. RESULTS: There were 557 patients suffering in-hospital cardiac arrest in whom the CPR-team was alerted. Among them, 217 (39%) were women. Women differed from men having a lower prevalence of earlier myocardial infarction, angina pectoris, renal disease and a higher prevalence of rheumatic disease. In terms of aetiology of the cardiac arrest, 47% men and 48% women were judged to have had a confirmed or possible AMI. More men than women were found in ventricular fibrillation/ventricular tachycardia (VF/VT) (57 vs. 41%; P<0.001), whereas more women were found in pulseless electrical activity (30 vs. 15%; P<0.0001). Cerebral performance categories (CPC)-score at discharge did not differ between men and women. Among women, 36.4% survived to discharge as compared with 38.0% among men (NS). Survival from VF/VT was 64.3% in women and 52.7% in men (NS). When correcting for dissimilarities at baseline, the adjusted odd ratio for being discharged alive from hospital among women as compared with men was 1.66 (95% confidence limit 1.06-2.62; P=0.028). CONCLUSION: Thirty nine percent of patients suffering in-hospital cardiac arrest for whom the CPR-team was alerted, were women. Women were less frequently found in VF/VT than men. After correcting for dissimilarities at baseline, female gender was associated with a small improvement in survival.

Immunoreactive glucagon and insulin C-peptide in man after resection of the pancreas and total pancreatectomy.

Pancreatic-type glucagon (PTG) has been found in the plasma of totally pancreatectomized human beings. Arginine infusion, however, caused no increase in PTG. Pancreas-resected patients had a normal response of PTG to arginine and a subnormal increase in C peptide. Gut glucagon-like immunoreactants (gut GLI) were increased in resected patients and further increased in totally pancreatectomized patients. Gut GLI showed no change during arginine stimulation.

Results of hepatic lobectomy for primary epithelial cancer in 31 adults.

Hepatic lobectomy for primary epithelial cancer was performed in 31 adults from 1964 through 1977 in the surgical departments of six Scandinavian hospitals. Twenty-three patients were discharged and had a 2 year survival rate of 62 per cent and a 5 year survival rate of 16 per cent. Alternatives to surgery have not yet emerged. Further progress requires centralization.