669The results on the overnight urine specimens in all the subjects are shown in the figure. The mean overnight 1 1-hydroxycorticosteroid levels and the standard deviations in the control, obese, and hirsute groups were similar, being 119 +47 nmol (43 + 17 [g), 121 ± 50 nmol (44 ± 18 Lg), and 138 +55 nmol (50 +20 :'g) respectively. The highest value of 271 nmol (98 ug) occurred in an obese patient. By contrast, only one of the patients with Cushing's syndrome had a urinary 11-hydroxycorticosteroid excretion of less than 276 nmol (100 ug) during the night. On the night in question her midnight plasma 11-hydroxycorticosteroid was normal at 189 nmol/l (6-8 ,ug/100 ml), and her overnight urine contained 254 nmol (92 ,tg); on a subsequent occasion a repeat overnight collection gave a raised value of 389 nmol (141 ILg). The diagnosis of bilateral hyperplasia was confirmed at operation. The overnight specimens from all the other patients with Cushing's syndrome contained more than 276 nmol (100 bLg) of 1 1-hydroxycorticosteroids, the highest containing 2663 nmol (965 ,ug). DiscussionOur results confirm that there is a circadian rhythm in the urinary excretion of adrenal steroids in normal people, the lowest levels occurring during the night. In patients with Cushing's syndrome this rhythm is not so apparent, and the nocturnal excretion is much higher.2 3 We therefore thought that patients with adrenocortical overactivity might be identified by their higher overnight urinary excretion of 1 1-hydroxycorticosteroids, and this was found to be so.Our data were obtained solely from women because only one man with Cushing's syndrome was admitted during the study. The overnight 11-hydroxycorticosteroid level in this man with an adrenal carcinoma was grossly raised at 5382 nmol (1950 [Lg).Thus this test is probably applicable to both men and women.Clinical suspicion of Cushing's syndrome is often aroused by obesity and hirsutism in women, particularly if it is associated with hypertension or diabetes mellitus, but it is not practicable to investigate all such patients in hospital. This simple screening test, requiring only the collection of an overnight urine specimen for 1 1-hydroxycorticosteroid estimation, has proved useful in selecting those outpatients who require more extensive investigation. Our data indicate that levels over 276 nmol (100 ,ug) that were examined by electron microscopy aggregates of HBsAg and HBsAb were seen. In contrast, HBsAb was never detected by RIA in those with non-fulminant hepatitis, and in only one serum specimen (5%) were aggregates seen on electron microscopy. A significant sex difference between fulminant and non-fulminant hepatitis was observed, 65%' of patients with fulminant hepatitis but only 15% of patients with non-fulminant hepatitis being women (P <0 01).

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Sixty-one dental surgeons at King's College Hospital were interviewed to establish the incidence of attacks of viral hepatitis and to relate this to environmental risk factors. Six (10",,) had a history of hepatitis, in one case due to infection with the hepatitis B virus. Screening blood for HBsAg by radioimmunoassay showed no carriers of the antigen, but transient antigenaemia was observed in one dentist. Antibody to HBsAg, tested by radioimmunoassay, was detected in four dentists (7)0), only one of whom had had clinical hepatitis. Dental surgeons may be more at risk from infection with the hepatitis B virus than the general population, although this should be minimised in hospital practice, where the most infected patients will already have been identified and appropriate precautions can be taken. The risk of transmission from an antigen-positive dentist to his patients is probably much smaller, and there is no evidence to restrict his clinical activities.

58 patients with acute hepatitis type B, including 13 with fulminant hepatitis, were tested on presentation for HBeAg. Positive results were obtained in 24%. The frequency was highest in those with fulminant hepatitis (46% positive), and this was probably related to the earlier presentation of patients with this condition. Patients with acute hepatitis who were HBeAg-positive had had a significantly shorter duration of symptoms than those who were HBeAg-negative at presentation. HBeAg was still detectable more than 3 weeks after the onset of symptoms in only 2 patients, both of whom progressed to chronic active hepatitis. The early detection of HBeAg in patients with acute hepatitis is of no prognostic significance, but its persistence may provide the earliest evidence of potential chronicity.