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The Multicenter Selective Lymphadenectomy Trial (MSLT-I) demonstrated that the sentinel node (SN) status in cutaneous melanoma affects prognosis and that completion lymphadenectomy in SN-positive patients may improve survival. Our objective was to evaluate sentinel lymph node biopsy (SLNB) in two regional hospitals in the Netherlands.Patients with localized melanoma were planned for wide excision and SLNB. Completion lymphadenectomy was recommended for positive SN status. Data were compared with the MSLT-I.A median of 2 (1-7) SNs were identified in 305 patients and complications occurred in 11%. Fifty-four patients (18%) demonstrated SN metastases and 45 underwent completion lymphadenectomy (20% additional metastases). Six patients with initially negative SN developed lymph node metastases (sensitivity 90%). Overall disease-free survival was 83% (SN-negative 91% vs. SN-positive 41%; p0.001) and melanoma-specific survival was 93% (SN-negative 97% vs. SN-positive 62%; p0.001). Multivariate regression analysis revealed the SN status to be the most significant predictor for recurrence and melanoma-related death.Our results of SLNB are comparable to data from high-volume centers participating in MSLT-I. From a patient perspective, the false-negative SN rate of 10% and complication rate of 11% should be weighed against being informed about prognosis and having a possible therapeutic benefit from completion lymphadenectomy.

Background The aim was to explore measurements of arm circumference and shoulder abduction as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. Methods Differences in arm circumference and shoulder abduction were measured in 465 consecutive women who underwent axillary lymph node dissection. These women received a treatment-specific questionnaire on the severity of physical disability and the effects on their daily life and well-being. Results The questionnaire was returned by 400 women (86 per cent). Of these 400, only the 332 women who did not receive axillary radiotherapy were included in the analysis. Their mean time since axillary lymph node dissection was 4·2 (range 0·3–28) years. For 86 patients (26 per cent) there was a difference in arm circumference of 2 cm or more, or a difference in abduction of 20° or more. These patients found it more difficult to do household chores, were more likely to have given up hobbies, felt more disabled and were more likely to be treated by a physiotherapist. However, complaints also occurred among the women with smaller differences in arm circumference and shoulder abduction, although the frequency and severity of their complaints were similar to those in women without swelling of the arm or without restricted shoulder abduction. Conclusion Measuring arm circumference and shoulder abduction during control visits identifies only some of the women whose daily life and well-being is affected by the side-effects of axillary lymph node dissection.

Background The sentinel node biopsy technique for breast cancer has been validated extensively in phase I and II studies. However, no data from phase III randomized clinical studies are available. It remains controversial whether a histologically negative sentinel node biopsy without further axillary dissection can be considered to be good clinical practice. Methods One hundred consecutive patients with breast cancer who had a negative sentinel node biopsy without additional axillary dissection were studied prospectively between 1997 and 2000 in order to identify tumour recurrence and to assess the morbidity of the sentinel node procedure. Special attention was paid to axillary or locoregional recurrence, distant metastases and overall survival. One year after the procedure patients were sent a questionnaire to assess any functional impairment of the arm or shoulder. Results Median follow-up was 24 (range 16–40) months. One patient had an axillary relapse 14 months after the initial diagnosis of breast cancer. She died after 2 years from metastatic disease. There were no other local axillary recurrences. There was a 94 per cent response rate to the questionnaire. Twelve patients developed mild disabilities, of whom two said that they had to change their hobbies, sports or daily activities owing to the sentinel node procedure. No patient developed lymphoedema or needed physiotherapy after the operation. Conclusion When strict criteria for the sentinel node biopsy procedure are used, the sentinel node biopsy without further axillary dissection after a negative histological investigation is a safe procedure. It may therefore be considered to be the standard of care for the treatment of patients with breast cancer.

Item does not contain fulltext OBJECTIVES: to determine the difference in renal and systemic response between open and endovascular aneurysm repair. MATERIALS AND METHODS: we studied prospectively 22 patients undergoing open repair (OR) and 15 patients undergoing endovascular repair (ER). Blood and urine samples were taken preoperatively (T0) and before clamping of the aorta or femoral artery (T1) and 5 min (T2), 1 h (T3), 6 h (T4), 24 h (Day 1) and 48 h (Day 2) after declamping. Albumin/creatinin ratio (AC ratio) in urine, serum albumin, serum creatinin, serum C-reactive protein and serum lactate were determined. RESULTS: the urinary AC ratio in ER was significantly lower than in OR (p

Objective: To review the anatomy, symptomatology, diagnosis, complications and management of symptomatic and asymptomatic Meckel's diverticula. Design: Retrospective study. Setting: Teaching hospital, The Netherlands. Subjects: 27 consecutive patients who underwent resection of a Meckel's diverticulum during the 16 year period 1 January 1981 31 August 1997. Main outcome measures: The symptomatology and histopathological findings. Results: 15 patients had symptoms and 12 did not. Haemorrhage and inflammation were the most common presenting symptoms. All histopathological signs of inflammation were found in those with symptomatic diverticula. Resected asymptomatic Meckel's diverticula were abnormal in only two occasions: one contained an adenocarcinoma and one a faecolith. Conclusion: All symptomatic Meckel's diverticula should be resected. The surgical treatment of asymptomatic Meckel's diverticula is still controversial.

Background Multiple studies suggest better efficacy of chemotherapy in invasive ductal breast carcinomas (IDC) than invasive lobular breast carcinomas (ILC). However, data on efficacy of adjuvant endocrine therapy regimens and histological subtypes are sparse. This study assessed endocrine therapy efficacy in IDC and ILC. The influence of semi-quantitative oestrogen receptor (ER) expression by Allred score was also investigated. Methods Dutch and Belgian patients enrolled in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial were randomized to exemestane (25mg daily) alone or following tamoxifen (20mg daily) for 5years. Inclusion was restricted to IDC and ILC patients. Histological subtype was assessed locally; ER expression was centrally reviewed according to Allred score (ER-poor ( n =235); ER-rich (⩾7; n =1789)). Primary end-point was relapse-free survival (RFS), which was the time from randomization to disease relapse. Findings Overall, 2140 (82%) IDC and 463 (18%) ILC patients were included. RFS was similar for both endocrine treatment regimens in IDC (hazard ratio (HR) for exemestane was 0.83 (95%confidence interval (CI) 0.67–1.03)), and ILC (HR 0.69 (95%CI 0.45–1.06)). Irrespective of histological subtype, patients with ER-rich Allred scores allocated to exemestane alone had an improved RFS (multivariable HR 0.71 (95%CI 0.56–0.89)). In contrast, patients with ER-poor Allred scores allocated to exemestane had a worse RFS (multivariable HR 2.33 (95%CI 1.32–4.11)). Significant effect modification by ER-Allred score was confirmed (multivariable p =0.003). Interpretation Efficacy of endocrine therapy regimens was similar for IDC and ILC. However, ER-rich patients showed superior efficacy to upfront exemestane, while ER-poor patients had better outcomes with sequential therapy, irrespective of histological subtype, emphasising the relevance of quantification of ER expression. Funding The Dutch/Belgian TEAM trial is supported by an unrestricted research grant from Pfizer. The sponsors have in no way influenced the design and conduct of the study, collection, management, analysis and interpretation of the data and preparation, review or approval of the manuscript.

A retrospective analysis was performed of the clinical features and results of surgical treatment modalities of 63 cases of anorectal melanoma collected in The Netherlands. Most tumours presented in an advanced stage due to the obscure location and lack of specific symptoms. There were 34 patients with clinical stage I disease who were treated by either local sphincter-saving surgery ( n = 16) or who had undergone an abdominoperineal resection (APR) ( n = 18). We could not find a survival advantage for either one of these two treatment modalities. However, after a local procedure far more local recurrences were seen (12:1), but this did not influence the clinical course of these patients, as they often rapidly succumbed to distant metastases. It is concluded that, in the future, patients presenting with an anorectal melanoma should be treated with a sphincter-saving surgical approach whenever possible.

Background Perioperative red blood cell (RBC) transfusion may be associated with a poor prognosis in cancer surgery. Allogeneic leucocytes are assumed to play a causal role. This study evaluated the long-term effect of transfusion with leucocyte-depleted (LD) blood in patients with gastrointestinal cancer. Methods The Transfusion Associated Complications = Transfusion Induced Complications? (TACTIC) study is a multicentre randomized controlled trial evaluating the short-term benefits of LD versus non-LD RBC transfusions. The present study evaluated 5-year survival and cancer recurrence among 512 patients with gastrointestinal cancer included in the TACTIC study. Results Some 89·2 per cent of patients had a primary tumour and 79·7 per cent underwent surgery with curative intent; 243 patients received perioperative RBC transfusion (median 3 units). The 5-year overall survival rate of patients with any type of gastrointestinal cancer was 50·8 per cent in the LD group and 45·8 per cent in the non-LD group (P = 0·191). Corresponding 5-year disease-free survival rates were 60·0 and 56·6 per cent (P = 0·482), and recurrence rates 32·9 and 34·3 per cent (P = 0·864). Conclusion Leucocyte depletion is not associated with better long-term survival and lower recurrence rates in patients with gastrointestinal cancer.

Contains fulltext : 52692.pdf (Publisher’s version ) (Closed access) The relatively small group of patients with breast tumors other than the ductal, lobular or mixed ducto-lobular types, has reached nonnegligible numbers due to the ongoing increase in the incidence of breast cancer. We investigated stage and grade distribution of uncommon breast tumors using the nation-wide Netherlands Cancer Registry (population 16.5 million) and incidence patterns, treatment and long-term survival (up to 19 years) using the regional Eindhoven Cancer Registry (population 2.4 million). Incidence of all uncommon breast tumors together was 9.2/100,000 person years (age-standardized, ESR). The proportion of stage I tumors was 70% among patients with tubular (n = 3,456) and 40-50% for mucinous (n = 3,482), papillary (n = 1,078), cribriform (n = 503) and neuroendocrine (n = 76) tumors, contrasting to 27, 28 and 36%, respectively among patients with Signet ring cell cancer (n = 75), Paget's disease (n = 818) and the common invasive ductal carcinomas (n = 121,656). A better age-, stage-, and grade-adjusted prognosis was observed for patients with lobular (death risk ratio 0.8, 95%CI: 0.7-0.9), mucinous (0.5, 0.3-0.9), medullary (0.5, 0.3-0.9) and tubular (0.4, 0.2-0.6) carcinoma or phyllodes tumor (0.02, 0.0-0.2), compared with invasive ductal carcinomas. For patients with papillary (0.6, 0.2-1.6) and cribriform (0.1, 0.0-5.1) tumors better prognosis was not statistically significant. In conclusion, histologic type was an essential determinant of survival for about 10% of all newly diagnosed women with invasive breast cancer. Because patients with mucinous, tubular, medullary and phyllodes tumors have such a good prognosis, less aggressive treatment should be considered in some cases whereby specific guidelines are becoming increasingly desirable. Communication to patients with these specific histological types should reflect this.

Contains fulltext : 50651.pdf (Publisher’s version ) (Closed access) AIMS: To evaluate the feasibility and consequences of lymphatic mapping and a ("repeat") sentinel lymph node (SLN) procedure in patients with breast cancer relapse after previous breast and axillary surgery. METHODS: Review and presentation of a patient cohort. All SLN procedures included lymphoscintigraphy and blue dye injection technique. RESULTS: Twelve cases are described: two patients after a previous SLN procedure and ten after a previous complete axillary lymph node dissection (ALND). Ten patients (83%) had a successful repeat SLN biopsy. After previous ALND, lymphoscintigraphy revealed drainage towards the internal mammary chain in three patients, and contralateral axillary drainage in four. Based on the information from the "repeat" SLN biopsy further treatment strategy was altered in seven of the 12 patients. CONCLUSION: Lymphatic mapping and (repeat) SLN biopsy is possible and can be informative in patients who present with a relapse of breast cancer after previous surgery for primary breast cancer.

PURPOSE: Mechanical bowel preparation is common practice in elective colon surgery. In recent literature the value of this procedure is under discussion. To verify the value of mechanical bowel preparation in elective open colon surgery, a randomized clinical trial was conducted. METHODS: During a prospective, multicenter, randomized study, 250 patients undergoing elective open colon surgery were randomized between receiving mechanical bowel preparation with polyethylene glycol (PEG group, 125 patients) and having a normal meal preoperatively (normal meal preoperatively group, 125 patients). Outcome parameters were wound infection with bacterial results of intraoperative swabs and anastomotic leak. RESULTS: In the polyethylene glycol group there were a total of nine wound infections (7.2 percent) and seven anastomotic leaks (5.6 percent) compared with seven wound infections (5.6 percent) (P = 0.61) and six anastomotic leaks (4.8 percent) (P = 0.78) in the normal meal preoperatively group. Bacterial results showed 52 percent sterile subcutis swabs in the PEG group and 63 percent sterile subcutis swabs in the normal meal preoperatively group (P = 0.11). CONCLUSION: In the present study we could not detect a difference in outcome parameters between patients receiving mechanical bowel preparation in elective open colon surgery and patients without preoperative treatment of the bowel. The present study, although underpowered, did not show a difference in the primary outcome of bacterial wound cultures between patients receiving preoperative mechanical bowel preparation and patients receiving no preoperative bowel treatment. We conclude that there may be no need to continue the use of mechanical bowel preparation in elective open colon surgery.

Aims: The use of axillary lymph node dissection (ALND) in women with breast cancer is associated with considerable morbidity. Sentinel node biopsy (SNB) removes the lymph node in the axillary basin indicative for receiving first lymphatic drainage from the breast. This study compares the nature and severity of physical morbidity among breast cancer patients who underwent primary surgery for breast cancer combined with either ALND or SNB. Also, it assesses influence of subsequent radiotherapy on morbidity. Method: Two hundred and thirteen ALND patients were compared with 180 SNB patients retrospectively. Morbidity was measured using a disease-specific quality-of-life questionnaire. Results:Patients' demographic characteristics were alike. The axillary procedure is the strongest and most consistent factor in explaining differences in a variety of self-reported complaints. Patients having had SNB have a 3.2-fold lower risk of experiencing pain, a 5-fold lower risk of lymph oedema, a 7.7-fold lower risk of numbness, a 3.7-fold lower risk of tingling sensations, a 7.1-fold lower risk of loss of strength in arm/hand, a 3.6-fold lower risk of loss of active motion range of the arm and a 2.9-fold lower risk of impaired use of the arm. Axillary radiation therapy adds to complaints next to the axillary surgical procedure by increasing the risk of lymph oedema 2.4-fold and enhancing the risk of impaired use of the arm by 2.6-fold. Axillary radiation therapy does not explain lymph oedema by itself. Conclusion: SNB is associated with less morbidity compared to ALND in patients with primary breast cancer.

Background: An increase in gut permeability can have serious consequences leading to sepsis and multiple organ failure. After lower torso ischemia an increase in gut permeability is seen in both animals and humans. There is proof that this can be modified by antioxidant supplementation. Methods: In this prospective, randomized study we have looked at the influence of a multiantioxidant supplementation regime, using allopurinol, vitamins E and C, mannitol and N-acetylcysteine, perioperatively. Twenty-two patients received standard treatment and 20 patients received supplementation. Gut permeability was determined using a double sugar test with lactulose and rhamnose. Results: A significant increase in gut permeability was found neither in the non-treatment group (p = 0.012) nor in the treatment group (p = 0.006) after 6 and 24 h. No difference was found between the group receiving antioxidants and the standard treatment group. p = 0.93 6 h post clamp; p = 0.97 24 h post clamp. Conclusion: In this study we have not found an influence of multiantioxidant supplementation on gut permeability after lower torso ischemia. Possible explanations for this negative result are being discussed.

Item does not contain fulltext BACKGROUND: open repair of intra-abdominal aortic aneurysm (AAA) is associated with lower torso ischaemia and reperfusion. OBJECTIVE: to examine the effect of antioxidants on the activation and sequestration of white blood cells and muscle injury during AAA repair. METHOD: forty-two patients undergoing elective infrarenal aneurysm repair, were randomised to either standard therapy (22 patients) or standard therapy with additional multiantioxidant supplementation (20 patients). Vitamin E and C, Allopurinol, N-acetylcysteine and mannitol was administered perioperatively. White blood cell count (WBC), serum creatine kinase, aspartateaminotransferase, lactate and lipofuscine were measured. RESULTS: WBC remained higher after reperfusion in the antioxidant group (p = 0.008). CK, ASAT and lipofuscine levels were significantly lower after reperfusion in the antioxidant group (p = 0.02, p = 0.018, p = 0.017). CONCLUSION: multi-antioxidant supplementation was associated with a reduction in serum CK and ASAT after AAA repair. This is likely due to a reduction in oxidative stress and a decreased leucocyte sequestration and activation.

Aim: This study was undertaken to gain insight into the risk factors for axillary recurrence among patients with invasive breast cancer who underwent breast-conserving treatment or mastectomy and axillary lymph node dissection. Methods: In a matched case-control design, 59 patients with axillary recurrence and 295 randomly selected control patients without axillary recurrence were compared. Matching factors included age, year of incidence of the primary tumour and postsurgical axillary nodal status. Results: For patients with negative axillary lymph nodes, those with a tumour in the medial part of the breast had a 73% (95% Cl: 4-92%) lower risk of axillary recurrence compared to those with a tumour in the lateral part of the breast. For the patients with positive axillary lymph nodes the risk of axillary recurrence was 65% (95% Cl: 16-86%) lower for those who had received axillary irradiation compared to those without axillary irradiation. Within the age group

Background The aim was to gain insight into the diagnosis, treatment and prognosis of axillary recurrence after axillary clearance for invasive breast cancer in a large patient series. Methods Between 1984 and 1994, 4669 patients with invasive breast cancer underwent axillary clearance in eight community hospitals in the south-eastern part of the Netherlands. Using follow-up data in a population-based cancer registry, 59 patients with axillary recurrence were identified. Results The median interval between treatment of the primary tumour and the diagnosis of axillary recurrence was 2·6 (range 0·3–10·7) years. In 51 patients (86 per cent), axillary recurrence was found by palpation during routine follow-up. Surgery was part of the treatment of recurrence for 41 of 59 patients. Regional control (complete eradication of axillary recurrence) was achieved in 34 patients (58 per cent). The 5-year actuarial survival rate was 39 (95 per cent confidence interval 25–53) per cent. Patients with negative axillary lymph nodes at the time of diagnosis of the primary tumour and complete eradication of axillary recurrence had the best prognosis. Conclusion Patients with axillary recurrence had a poor prognosis, except when complete eradication was achieved and axillary lymph nodes were negative at the time of diagnosis of the primary tumour.

The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3–28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (ods ratio (OR) 3.57; 95% confidence interval (CI) 1.66–7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women < 45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58–16.38) compared with those 565 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising. # 2001 Elsevier Science Ltd. All rights reserved.

To evaluate two different injection techniques (peri-tumourally and intradermally) used in search for the sentinel node(s) in patients with breast cancer. Methods: Ninety-nine patients were peri-tumourally injected with 2 ml 60 MBq 99m-Tc-Nanocoll and underwent lymphoscintigraphy about 18 h later to detect focal accumulations. Next, they were injected intradermally with 0.2 ml 15 MBq 99m-Tc-Nanocoll either in the skin overlying the tumour or para-areolarly in the quadrant of the tumour. Dynamic and static images were taken to visualize the (intradermal) lymphatic spread and accumulations. Special attention was paid to match or mismatch of hot spots visualized by both techniques. Results: Ninety-four patients had positive peri-tumoural and/or intradermal accumulations which could be compared. In 30 patients only peri-tumoural, and in nine only intradermal, identification was successful. Of the remaining 55 patients, in 52 there was complete concordance of the axillary hot spots. However, there was a so-called «regional mismatch» in nine of these patients concerning the internal mammary nodes. In the three remaining patients there was a sequential mismatch in the axilla: before draining lymph to the peri-tumourally visualized hot spot, an interposed node was encountered first after the intradermal injection technique. Conclusions: Intradermal injection is complementary to peri-tumoural injection for visualization of focal accumulations in patients with breast cancer. The two different injection techniques have a small number of sequential mismatches for hot spots in the axillary region. This means that it may be unclear which separate route leads to the true sentinel node. Internal mammary nodes visualized after peri-tumoural injection are not visualized by the intradermal technique. Para-areolar intradermal injection of Nanocoll for detection of sentinel nodes in patients with breast cancer needs further evaluation, because it seems to be a more practical procedure.

Objective: To find out which risk factors affect outcome after pneumonectomy.Design: Retrospective study.Setting: Teaching hospital, The Netherlands.Subjects: 62 patients who were treated for bronchial cancer by pneumonectomy between 1984 and 1995.Main outcome measure: Hospital mortality and postoperative complications.Results: Hospital mortality increased with age, being 5/51 (10%) in the 40-69 age group and 4/11 (36%) in patients aged 70 or more. In the American Society of Anesthesiologists (ASA) class I group hospital mortality was 8% (2/26), in class II 12% (3/26) and in class III 40% (4/10). Hospital mortality was highest when the FEV1:FVC-ratio was below 55%. Cardiac arrhythmias developed in 8 (13%), early bronchopleural fistulas in 7 (11%), and postpneumonectomy syndrome in 5 (8%). These major complications had a high mortality.Conclusion: Respiratory function, ASA class, and age over 70 years are the main prognostic factors for hospital morbidity and mortality after pneumonectomy.

To see whether personal preferences of surgeons can explain the trends in the use of breast-conserving therapy (BCT) of early breast cancer, questionnaires were sent to the surgeons of seven community hospitals in the south-eastern Netherlands in 1987 and 1995. The answers were set against the actual use of breast-conserving therapy in the hospitals in the period 1984-94, as monitored by the Eindhoven Cancer Registry. The proportion of surgeons who were willing to use BCT for tumoursor =3 cm increased from 43% in 1987 to 93% in 1995. In 1995, the majority of the surgeons considered multicentric tumour growth, diffuse microcalcifications on the mammogram and an extensive intraductal component around the tumour as contraindications for breast-conserving therapy. The proportion of patients with an operable, non-metastasized breast tumour ofor =5 cm in diameter undergoing breast-conservative surgery increased from 31% in 1984 to 60% in 1989 (P0.01) and remained at that level in 1990 and 1991. Between 1991 and 1993, the proportion receiving breast-conservative surgery decreased significantly for patients younger than 50 years and a tumour 2.1-3.0cm in diameter, and also for those 50-69 years old with a tumouror =2.0cm or 3.1-5.0cm across. The observed decrease in BCT in the south-eastern Netherlands in some subgroups seems to reflect the growing awareness of potential risk factors for local recurrence following BCT.

To evaluate the posttraumatic course of several inflammatory mediators or markers (complement components C3, C3a, terminal complement complex, thromboxane B2, C-reactive protein, elastase, and neopterin) in relation to the development of multiple organ failure and mortality.Prospective study of a selected patient group.Surgical intensive care units in three European trauma hospitals.Patients (n = 56) with severe blunt trauma (Injury Severity Score ofor = 33).Arterial blood samples were sequentially obtained.Nonsurvivors (n = 8) had significantly higher circulating C3a and elastase concentrations on the first postinjury day, compared with survivors (n = 48). No differences between these groups were found for terminal complement complex, thromboxane B2, C-reactive protein, and the neopterin/creatinine ratio. Five patients died before day 5. Eighteen patients developed multiple organ failure, which was diagnosed from day 5 onward, leaving 33 patients without multiple organ failure. The patients with subsequent multiple organ failure showed significantly higher mean circulating concentrations of C3a (914 +/- 190 [SEM] ng/mL), terminal complement complex (57 +/- 17 U/mL), and thromboxane B2 (275 +/- 37 pg/mL) at the first postinjury day than the patients without multiple organ failure (566 +/- 110 ng/mL, 27 +/- 2 U/mL, and 169 +/- 14 pg/mL, respectively). In patients with multiple organ failure, elastase concentrations were significantly higher on days 2, 3, 4, and 5 postinjury. Neopterin/creatinine ratios, on the other hand, were significantly higher in patients with multiple organ failure when the multiple organ failure had already become established (on days 8 and 10).In multiple trauma patients, excessive triggering of the inflammatory cascade-as expressed by complement activation and stimulation of neutrophils producing elastase--plays an important and early role in the development of multiple organ failure.