Trauma Communications Center Coordinated Severity-Based Stroke Triage: Protocol of a Hybrid Type 1 Effectiveness-Implementation Study

Background: Mechanical thrombectomy (MT) can improve the outcomes of patients with large vessel occlusion (LVO), but a minority of patients with LVO are treated and there are disparities in timely access to MT. In part, this is because in most regions, including Alabama, the emergency medical service (EMS) transports all patients with suspected stroke, regardless of severity, to the nearest stroke center. Consequently, patients with LVO may experience delayed arrival at stroke centers with MT capability and worse outcomes. Alabama's trauma communications center (TCC) coordinates EMS transport of trauma patients by trauma severity and regional hospital capability. Our aims are to develop a severity-based stroke triage (SBST) care model based on Alabama's trauma system, compare the effectiveness of this care pathway to current stroke triage in Alabama for improving broad, equitable, and timely access to MT, and explore stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability.

Methods: This is a hybrid type 1 effectiveness-implementation study with a multi-phase mixed methods sequential design and an embedded observational stepped wedge cluster trial. We will extend TCC guided stroke severity assessment to all EMS regions in Alabama; conduct stakeholder interviews and focus groups to aid in development of region and hospital specific prehospital and inter-facility stroke triage plans for patients with suspected LVO; implement a phased rollout of TCC Coordinated SBST across Alabama's six EMS regions; and conduct stakeholder surveys and interviews to assess context-specific perceptions of the intervention. The primary outcome is the change in proportion of prehospital stroke system patients with suspected LVO who are treated with MT before and after implementation of TCC Coordinated SBST. Secondary outcomes include change in broad public health impact before and after implementation and stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability using a mixed methods approach. With 1200 to 1300 total observations over 36 months, we have 80% power to detect a 15% improvement in the primary endpoint.

Discussion: This project, if successful, can demonstrate how the trauma system infrastructure can serve as the basis for a more integrated and effective system of emergency stroke care.

Understanding Mental Health Services and Help-Seeking Behaviors Among College Students in Vietnam

Objective: Due to the significant higher prevalence, yet less attention of mental health problems among Asian college students, we decided to investigate the effectiveness and efficiency of mental health services and help-seeking behaviors in Vietnamese universities. By conducting this study, we hope to contribute to current literature on the factors that contribute to professional mental health taking behavior of college students in Vietnam as well as suggest strategies to reduce possible barriers that prevent them from seeking professional help. Design: We first conducted a pilot study to test the reliability and validity of our measurements. We then made necessary adjustments and distributed the final questionnaires to a university in Ho Chi Minh City, Vietnam. Collected data was analyzed through exploratory factor analysis. Results: Among the three measurements of psychological openness, help-seeking propensity, and indifference to stigma, results indicated that the model explains students’ help-seeking intention reasonably well than others. Conclusions: Using theory of planned behavior, this study aims at examining predictors of professional mental health seeking behavior among college students in Vietnam. Our findings indicate that help-seeking propensity significantly influences Vietnamese students’ intention to seek professional healthcare. Through this study, we suggest some guidance to the school administrators the factors that encourage students to take professional mental care.

Abstract TP237: Can We Improve Clinical Detection of Right Hemisphere Large Vessel Occlusion?

Introduction: The Emergency Medical Stroke Assessment (EMSA) is a six point stroke severity scale with one point each for gaze preference, facial droop, arm drift, leg drift, abnormal naming, and abnormal repetition that was developed to help emergency medical services (EMS) providers identify acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We hypothesized that the EMSA would detect left hemisphere LVO with a higher sensitivity than right hemisphere LVO.

Methods: We trained 24 trauma system-based emergency communication center (ECC) paramedics in the EMSA. ECC-guided EMS in performance of the EMSA on patients with suspected stroke. We compared the sensitivity, specificity, area under the curve (AUC), and 95% confidence interval (CI) of ECC-guided prehospital EMSA for right versus left hemisphere ICA or M1 occlusion.

Results: We enrolled 569 patients from September 2016 through February 2018, out of which 236 had a discharge diagnosis of stroke and 173 had a diagnosis of AIS. We excluded patients with bilateral (n=21) and brainstem (n=21) AIS. There were 64 patients with left hemisphere AIS including 19 with LVO. There were 67 patients with right hemisphere AIS including 22 with LVO. A score of ≥ 4 points yielded a sensitivity of 84.2 (95% CI = 60.4-96.6) and specificity of 66.7 (51.1-80.0) for left hemisphere LVO compared to a sensitivity of 68.2 (45.1-86.1) and specificity of 73.9 (58.9-85.7) for right hemisphere LVO. For predicting a left hemisphere LVO, the AUC was 0.77 (0.65-0.90) compared to 0.66 (0.50-0.82) for right-sided LVO. Assigning 2 points for abnormal gaze yielded an AUC of 0.78 (0.66-0.91) versus 0.67 (0.52-0.83) for left and right hemisphere LVO, respectively.

Conclusions: The EMSA, like the National Institutes of Health Stroke Scale (NIHSS) upon which it is based, is more sensitive to left compared to right hemisphere LVO. More heavily weighting abnormal gaze did not improve the sensitivity of the EMSA for right hemisphere LVO. There is no comparable data on the right versus left hemisphere performance of other prehospital scales. There is a need to develop sensitive tests of right hemisphere dysfunction that are suitable for use in the field.

Centrally Guided Identification of Patients With Large Vessel Occlusion: Lessons From Trauma Systems

OBJECTIVE

Improve prehospital identification of acute ischemic stroke patients with large vessel occlusion (LVO) by using a trauma system-based emergency communication center (ECC) to guide the emergency medical service (EMS).

METHODS

We trained 24 ECC paramedics in the Emergency Medical Stroke Assessment (EMSA). ECC-guided EMS in performance of the EMSA on patients with suspected stroke. During the second half of the study, we provided focused feedback to ECC after reviewing recorded ECC-EMS interactions. We compared the sensitivity, specificity, and area under the receiver operator characteristics curve (AUC) and 95% confidence interval of ECC-guided EMSA to the NIH Stroke Scale (NIHSS) for predicting a discharge diagnosis of LVO.

RESULTS

We enrolled 569 patients from September 2016 through February 2018. Of 463 patients analyzed, 236 (51%) had a discharge diagnosis of stroke and 227 (49%) had a nonstroke diagnosis. There were 45 (19%) stroke patients with LVO. For predicting LVO, there was no significant difference between the EMSA AUC = .68 (.59-.77) and the NIHSS AUC = .73 (.65-.81). An EMSA score greater than or equal to 4 had sensitivity = 75.6 (60.5-87.1) and specificity = 62.4 (57.6-67.1) for LVO. During the first 9 months of the study, the EMSA AUC = .61 (.44-.77) compared to an AUC = .74 (.64-.84) during the second 9 months.

CONCLUSIONS

ECC-guided prehospital EMSA is feasible, has similar ability to predict LVO compared to the NIHSS, and has sustained performance over time.

Abstract WP298: Communication Center Guided Prehospital Stroke Assessment Scoring has High Inter-rater Agreement

Introduction: We are prospectively validating a model of communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO).

Goal: Assess the inter-rater agreement between a Vascular Neurologist and Alabama Trauma Communication Center (ATCC) personnel in diagnostic classification of stroke patients.

Methods: The ATCC is staffed by paramedic-trained dispatchers who field calls from Emergency Medical Service (EMS) responders and maintain up-to-the-minute status of hospitals and resources 24/7. We trained ATCC personnel in stroke pathology, pathophysiology, appropriate patient selection for thrombolytic and endovascular therapies; and the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC personnel guided EMS responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital stroke prenotification that included specific EMSA scale items (gaze, facial droop, arm drift, leg drift, naming, and repetition). All interactions between the ATCC and EMS responders were recorded, allowing review of audio files and ongoing quality improvement. ATCC personnel and a vascular neurologist separately reviewed recordings and assigned scores to each patient according to the deficit stated by the EMS. To determine inter-rater reliability we utilized the Kappa statistic with a significance level of 0.05, and 95% confidence intervals (CI).

Results: We sampled a total of 146 patients. We observed statistically significant agreement between the raters for all EMSA components, with 71% (CI=45-97%, p<0.0001) agreement in rating the gaze component, 54% (CI=26-82%, p=0.002) for the face, 57% (CI=29-85%, p=0.001) for the arm, 60% (CI=33-86%, p<0.0006) for the leg, 56% (CI=30-81%, p<0.001) for naming, and 34% (CI=6-61%, p<0.04) for repetition.

Conclusion: We conclude that there is moderate to substantial agreement in most stroke assessment items by a paramedic staffed communication center and a vascular neurologist. There was only fair inter-rater agreement for repetition. Paramedic-trained dispatchers can reliably guide EMS responders and score the Emergency Medical Stroke Assessment.

Applying Decision Theory to Medical Decision-Making — Concept of Regret and Error of Diagnosis

The aim of this study was to confront clinicians with the problem of expressing their intuitive evaluation of a diagnostic error by a numerical measure. The diagnosis of jaundice was used as a model and 6 experienced clinicians were included in the study. The results showed reasonable agreement between clinicians and evidence that values given by each clinician corresponded to his losses estimated by observing his decisionmaking on 50 diagnostic profiles.

Turn the Beat Around: A Stroke Prevention Program for African-American Churches

OBJECTIVE

The objective was to pilot a socioculturally tailored church-based stroke prevention program delivered by trained community health workers (CHWs) and to test its effects on participant knowledge scores.

DESIGN AND SAMPLE

A single-group, pre-post test pilot study was conducted with a convenience sample of 201 adult African-Americans recruited from nine churches in three Alabama counties. Measurements included participant weight, blood pressure (BP), physical activity level; knowledge related to hypertension, heart disease, and stroke; cigarette smoking; and access to care, as well as the Stages of Change constructs within the Transtheoretical Model. The intervention was a six-session group-based health education program delivered by trained CHWs.

MEASURES

Measurements included participant weight, blood pressure (BP), physical activity level; knowledge related to hypertension, heart disease, and stroke; cigarette smoking; and access to care, as well as the Stages of Change constructs within the Transtheoretical Model. The intervention was a six-session group-based health education program delivered by trained CHWs.

RESULTS

From baseline to 12 weeks, knowledge increased significantly (p < .001). Systolic BP measures improved (p = .0008). More than half of participants lost weight; however, weight change did not reach significance (p = .1380). Most (87%) participants indicated having a medical home at baseline; at the end of the study the percentage increased to 92% (p = .0138).

CONCLUSION

A church-based intervention delivered by trained CHWs is feasible and may be a promising public health strategy to increase knowledge regarding hypertension and stroke prevention among African-Americans.

New, strategic outsourcing models to meet changing clinical development needs

The impact of increasing clinical costs and the need for more data to support higher efficacy demands and overcome regulatory hurdles for market entry means that every Company is faced with the challenge of how to do more with a smaller budget. As budgets get squeezed the pharmaceutical Industry has been looking at how to contain or reduce cost and support an increased number of projects. With the growing sophistication of outsourcing, this is an increasingly important area of focus. Some Pharmaceutical Companies have moved from tactical, case by case, outsourcing to new, more strategic relationships, which involve outsourcing functions that were historically held as core pharmaceutical functions. An increasing number of Sponsors are looking at strategic relationships which are based on more creative outsourcing approaches. As the need and sophistication of these outsourcing models and the sponsors / CROs involved in them, these approaches are becoming more transformational and need to be based on a strong partnership. Lessons learned from working with sponsors in a partnership model have been examined and two key challenges addressed in detail: the need for bilateral central control though a strong governance model and the importance of early planning and commitment.

Microencapsulation of oils using whey protein/gum arabic coacervates

Microencapsulating sunflower oil, lemon and orange oil flavour was investigated using complex coacervation of whey protein/gum arabic (WP/GA). At pH 3.0-4.5, WP and GA formed electrostatic complexes that could be successfully used for microencapsulation purposes. The formation of a smooth biopolymer shell around the oil droplets was achieved at a specific pH (close to 4.0) and the payload of oil (i.e. amount of oil in the capsule) was higher than 80%. Small droplets were easier to encapsulate within a coacervate matrix than large ones, which were present in a typical shell/core structure. The stability of the emulsion made of oil droplets covered with coacervates was strongly pH-dependent. At pH 4.0, the creaming rate of the emulsion was much higher than at other pH values. This phenomenon was investigated by carrying out zeta potential measurements on the mixtures. It seemed that, at this specific pH, the zeta potential was close to zero, highlighting the presence of neutral coacervate at the oil/water interface. The influence of pH on the capsule formation was in accordance with previous results on coacervation of whey proteins and gum arabic, i.e. WP/GA coacervates were formed in the same pH window with and without oil and the pH where the encapsulation seemed to be optimum corresponded to the pH at which the coacervate was the most viscous. Finally, to illustrate the applicability of these new coacervates, the release of flavoured capsules incorporated within Gouda cheese showed that large capsules gave stronger release and the covalently cross-linked capsules showed the lowest release, probably because of a tough dense biopolymer wall which was difficult to break by chewing.

Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned

OBJECTIVES

Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms.

METHODS

Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months).

RESULTS

Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%).

CONCLUSION

While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.

The endovascular repair of abdominal aortic aneurysm: an update analysis of structural failure modes of endovascular stent grafts

Over the last decade, more than 25,000 endovascular stent grafts have been used to treat aortic aneurysms. Although results have been promising thus far, problems with endoleaks, material failure, device migration, and aneurysm rupture continue to be reported. Improvements in device material and design have contributed to the rapid growth and utility of these devices; however, material failure still remains a concerning mode for potential procedure failure. A review of the authors'experience with material failure and a review of the literature was conducted to help understand and comprehend the magnitude of this problem and try to determine its clinical significance.

"Subcortical" cognitive impairment in patients with systemic lupus erythematosus

Studies of cognitive functioning in patients with systemic lupus erythematosus (SLE) have found deficits even in patients without other evidence of neurologic involvement. The present study used scores on the 11 items of the Mini-Mental State Exam (MMSE) to classify the cognitive impairment of 93 SLE patients as suggestive of "cortical" or "subcortical" dysfunction using a validated statistical algorithm. Ninety-five percent of patients were categorized as having "subcortical" deficits, and 5% were categorized as having "cortical" deficits. When the analysis was limited to only those with total MMSE scores < or = 24, 81% were classified as "subcortical" and 19% as "cortical." These results suggest that SLE patients can have psychomotor and mental tracking deficits of a type seen in patients with subcortical brain disease, even in the absence of gross neurologic involvement.

Association of coping responses with fibromyalgia tender points in patients with systemic lupus erythematosus

OBJECTIVE

To determine the association between fibromyalgia (FM) tender points (TP) and psychological constructs in patients with systemic lupus erythematosus (SLE).

METHODS

One hundred seventy-three patients with SLE were examined for FM TP, and asked to complete 2 questionnaires at the same visit, the Health-Related Hardiness Scale (HRHS), and the Mishel Uncertainty in Illness Scale (MUIS).

RESULTS

The examination of FM TP showed that 38.2% had no TP, 44.5% had 1-10 TP, and 17.3% had > or = 11 TP. The mean +/- SD score of the HRHS was 155.6 +/- 19.7 (range 105.0-198.0; higher scores indicate greater hardiness), and the MUIS was 85.3 +/- 18.7 (range 41.0-132.0; higher scores indicate uncertainty). There were significant associations between FM TP and HRHS (no TP 161.2 +/- 20.2, 1-10 TP 152.5 +/- 19.7, > or = 11 TP 151.0 +/- 15.8; p = 0.0108) and between FM TP and MUIS (no TP 78.2 +/- 20.2, 1-10 TP 86.9 +/- 17.6, > or = 11 TP 95.8 +/- 14.7; p = 0.0001).

CONCLUSION

This study shows a strong association between FM TP and uncertainty or lack of "hardiness." We conclude that SLE patients with FM TP are less likely to be good "copers." Prospective studies to determine if "poor coping" predicts FM in SLE are recommended. If the association between coping and FM is causal, it will justify interventions to improve coping and similar constructs, such as self-efficacy.

Low-Frequency Dielectric Response of Polystyrene Latex Dispersions

The low-frequency permittivity and the conductivity increments of a well-characterized polystyrene sulfate latex with constant surface charge density were measured in KCl electrolyte solutions. The ionic strength was varied in the range 0.4-6 mM. The data could be explained with one absolute surface-conductivity parameter over the complete concentration range. The titratable surface charge density correlates well with the surface conductivity, the ions in the double layer having the bulk mobility. The results are in good agreement with static conductivities of plugs composed of the same particles obtained in a previous study (1). The electrokinetic charge obtained from streaming potentials (1) in that study is significantly lower, confirming the presence of conduction behind the shear plane. In order to interpret the conductivity data, simple analytical expressions have been derived for the frequency-dependent complex conductivity of a dilute dispersion of spherical particles with relatively thin double layers (kappaa >>1, where a is the particle radius and kappa-1 the Debye screening length). The expressions are restricted to binary suspending electrolytes. However, no restrictions on the ion mobilities and ion valencies are made. Our results agree well with the numerical results of the dielectric model of Mangelsdorf and White (2, 3) and reduce to O'Brien's static conductivity results (4) in the limit of low frequencies. Copyright 1998 Academic Press.

Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial

OBJECTIVE

To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia.

METHODS

Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program.

RESULTS

All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period.

CONCLUSION

This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.

Efficacy of low load resistive muscle training in patients with rheumatoid arthritis functional class II and III

OBJECTIVE

To determine the effect of a low load resistance exercise training program on muscle strength, functional outcome, and cardiovascular endurance.

METHODS

Forty-nine patients, 37 women and 12 men between the ages of 35-76 yrs (mean 60.5 yrs), with definite rheumatoid arthritis (RA) functional class II and III (mean disease duration of 10.5 yrs) were randomly assigned to exercise and control groups for a 12 wk resistive muscle training program. A circuit weight bearing form of training was incorporated using light loads with high repetitions. A video tape demonstrating the exercises was given to all exercising participants to enable them to continue the program at home at least 3 times per wk with a biweekly self-report evaluation. Baseline and post-intervention evaluations included joint activity, muscle strength, endurance, functional outcome, and self-report. Cardiovascular fitness measured by treadmill time, anaerobic threshold and peak oxygen consumption (VO2) in this group were assessed at baseline and 12 wks.

RESULTS

A significant improvement at 12 wks was noted in the exercise group for self-reported joint count (p = 0.02), number of painful joints (p = 0.004), HAQ (p = 0.012), sit-to-stand time (p = 0.02), grip strength (p = 0.05) knee extension 60 degrees (p = 0.03), Arthritis Impact Measurement Scales dexterity (p = 0.02), and time to anaerobic threshold (p = 0.03). Significant improvement in the exercise group compared to the control group was noted for self-reported joint count (p = 0.02), night time pain (p = 0.05), and sit-to-stand time (p = 0.02). Increase in treadmill time was not statistically significant nor was a change in peak oxygen consumption (VO2) noted. Abnormalities on initial treadmill screening were detected in 2 of 49 asymptomatic patients. They were excluded from the study and subsequent workup revealed significant coronary artery disease.

CONCLUSION

Low load resistive muscle training increased functional capacity as reported by patients and is a clinically safe form of exercise in functional class II and III RA. Screening this population for dormant coronary artery disease is recommended.

Conductivity and Dielectric Dispersion of Gram-Positive Bacterial Cells

The conductivity of bacterial cell suspensions has been studied over a wide range of ionic strengths and is interpreted in terms of their cell wall properties. The experimental data have been analyzed after improving the high kappaa double-layer theory of Fixman, by accounting for ionic mobility in the hydrodynamically stagnant layer, i.e., in the bacterial wall. Static conductivity and dielectric dispersion measurements both show that the counterions in the porous gel-like cell wall give rise to a considerable surface conductance. From a comparison of the mobile charge with the total cell wall charge it is inferred that the mobilities of the ions in the bacterial wall are of the same order but somewhat lower than those in the bulk electrolyte solution. The occurrence of surface conductance reduces the electrophoretic mobility in electrophoresis studies. If this effect is not taken into account, the zeta-potential will be underestimated, especially at low electrolyte concentrations.

Inadequate erythroid response to hypoxia in cystic fibrosis

An increase in hemoglobin concentration characterizes the normal compensatory response to chronic tissue hypoxia. We observed no such increase in 42 chronically hypoxic patients with cystic fibrosis, in whom the mean concentration was 12.6 gm/dl; one third of the patients were anemic. Compared with patients with cyanotic heart disease, patients with cystic fibrosis did not have a compensatory increase in P50 or 2,3-diphosphoglycerate. Despite anemia, erythropoietin levels in patients with cystic fibrosis were not significantly different from normal control values. The growth of colony-forming units-erythroid in patients with cystic fibrosis was similar to that in control subjects, and there was no inhibition of growth with the addition of autologous serum. Erythropoietin sensitivity, determined by measuring the CFUe dose response curve, was normal in both patients and controls. Results of iron studies were consistent with iron deficiency in the majority of patients. Impaired absorption of iron was observed in six of 13 iron-deficient patients with cystic fibrosis. An inverse correlation between erythrocyte sedimentation rate and peak serum iron was obtained during the iron absorption study. Eight patients who underwent a therapeutic trial of iron demonstrated a 1.8 gm/dl rise in hemoglobin concentration. Two patients with previously documented iron malabsorption responded to parenteral iron therapy after failure to respond to oral supplementation. These studies demonstrate that patients with cystic fibrosis not only have an impaired erythroid response to hypoxia, but are frequently anemic. Their inadequate erythroid response to hypoxia results in part from disturbances in erythropoietin regulation and iron availability.

Ectopic ACTH syndrome due to pheochromocytoma: case report and review of the literature

A 51-year-old female was diagnosed preoperatively to have a pheochromocytoma producing ACTH. This diagnosis was based upon her paroxysmal hypertension, hyperpigmentation, and hypokalemia. Elevated levels of serum and urine corticosteroids, plasma ACTH, urinary VMA, and catecholamines fell after a right adrenal pheochromocytoma was removed. Subsequently this tumor was found to have a high content of ACTH. Review of the literature indicates a mortality rate of 57% for this syndrome. Proper preoperative recognition and management can result in total cure.