Distribution of mast cells in the axillary lymph nodes of breast cancer patients

Fifty mastectomy specimens of carcinoma breast were studied for pattern of mast cell distribution in their axillary lymph nodes. When all axillary nodes were free of tumour, the mean mast cell count was 35.75/sq mm. In the metastatic node the mast cell count was inversely proportional to the amount of metastatic tumour. The mast cell number decreased (25.64/sq mm) as the metastasis developed in any of the enlarged axillary nodes. Their count diminished further (23.55/sq mm) as the amount of metastatic tumour increased in individual nodes and when tumour involved all enlarged nodes. Mean mast cell count was lowest (10.50/sq mm) in metaplastic carcinoma. The mast cells in metastatic nodes were found mainly at the edges of tumour deposits.

An outbreak of food poisoning in Tamil Nadu associated with Yersinia enterocolitica

An outbreak of food poisoning in a Tamil Nadu village, affecting 25 of 48 individuals who participated in a feast, was investigated. The risk of developing illness was associated with consumption of buttermilk (relative risk 3.8). None of the food items consumed during the feast was available for analysis. Toxin-producing Y. enterocolitica (serotype 3, biotype 4) was grown from 1 of 11 stool samples from affected individuals, as well as from a water sample from the source used to dilute the buttermilk. High titres of antibody of Yersinia were detected in 2 of 12 patients but in neither of the two groups of controls. Toxin production was noted in buttermilk incubated for 6 h with Y. enterocolitica. This is the first report from India of a food poisoning outbreak associated with this organism.

Multiple brown tumors in parathyroid carcinoma mimicking metastatic bone disease

An unusual case of multiple brown tumors due to parathyroid carcinoma is reported. The patient presented with lower leg pain. Plain radiographs demonstrated multiple lytic lesions of the lower legs and a Tc-99m MDP bone scan depicted multiple areas of increased uptake suggesting skeletal metastases. Tc-99m sestamibi tumor scintigraphy showed multiple sites of tumor uptake in bones and a large area of increased uptake with a cystic component in the right lower pole of the thyroid gland. An open biopsy from the right tibial lesion revealed a brown tumor. A large parathyroid carcinoma with a necrotic cyst was removed. After parathyroidectomy and right thyroid lobectomy, the patient became free of bone pain and serum PTH levels normalized. A 9-month follow-up Tc-99m MDP bone scan demonstrated less intense uptake in the pelvis, tibia, and fibulae. Nine-month follow-up tumor imaging with Tc-99m MIBI revealed disappearance of the preoperative uptake of multiple brown tumor.

An epidemic of diarrhoea in south India caused by enteroaggregative Escherichia coli

A diarrhoeal epidemic in a village close to Vellore was investigated in January 1996. Faecal samples were obtained from 20 subjects with diarrhoea and from 11 individuals without diarrhoea (controls) and were examined for bacterial, viral and parasitic enteropathogens. Water samples from all sources in the village were analysed. The epidemic affected all age groups (overall attack rate 15%). The mean duration of diarrhoea was 11 days. Individuals who consumed water exclusively from a borewell had a lower relative risk (RR) of disease (0.14, 95% Cl 0.02-1.01) compared to users of two open wells (RR 6.93, Cl 0.99-48.66 and RR 7.81, Cl 1.02-59.79, respectively). No conventional bacterial enteropathogens were isolated from the stool samples. Enteroaggregative Escherichia coli (EAggEC) were identified in the stool of 11 of 20 subjects with diarrhoea, and in 1 of 11 control samples (P = 0.02). All the EAggEC isolates from the patients had identical antibiotic sensitivity patterns and produced a toxin in Ussing chamber studies. Serotyping indicated that all the EAggEC from individuals with diarrhoea belonged to one or other of two serotypes. All water samples had high coliform counts and E. coli were cultured from the two open wells but not from the borewell. The evidence suggests that EAggEC was responsible for this outbreak of diarrhoea. EAggEC should be considered as a possible pathogen in unexplained diarrhoeal outbreaks in developing countries.

Cardiorespiratory status after treatment for acute lymphoblastic leukemia

The use of certain chemotherapeutic agents is associated with dose-related cardiotoxicity and, potentially, with restrictive lung disease. Therefore, we assessed the cardiopulmonary status and exercise capacity of 19 patients (pts; 9M:10F) 1.1 to 7.1 years (mean 4.6 +/- 1.5 years) after successful treatment of acute lymphoblastic leukemia (ALL) with Dana Farber Cancer Institute protocols. As body mass and nutritional status may influence exercise capacity, we also evaluated their anthropometric status and the plasma levels of rapid turnover proteins. Seven pts designated as "standard risk for relapse" (SR) had received low cumulative doses of doxorubicin (50 +/- 21 mg/m2), while twelve pts at "high or very high risk for relapse" (HR/VHR) had received higher doses (349 +/- 16 mg/m2). The evaluations included a questionnaire, anthropometric assessments, echocardiography, pulmonary function studies, exercise testing, and nutritional assays. Patients' data were compared with published normative data or with control values from our laboratories. In addition, we compared SR pt data with HR/VHR pt data. No pt had overt symptoms or signs of cardiorespiratory compromise. The pts had a higher percent of body fat than age-matched healthy controls (29.7 +/- 7.9% vs. 20 +/- 6%; P < 0.001). On echocardiography, cardiac systolic function was within normal limits in all. However, HR/VHR pts had lower left ventricular (LV) shortening fractions than SR pts (P < 0.05). LV filling velocity, indicative of diastolic function (the E/A ratio), was normal in most pts. Pulmonary function studies were normal. Exercise capacity was below predicted in most cases but heart rates at peak exercise and leg muscle function were within normal limits, suggesting a deconditioned state. Plasma levels of rapid turnover proteins were also normal. Despite lack of overt morbidity in our pt population, subtle abnormalities persist in cardiac function while pulmonary function is normal. Longitudinal studies will identify if further abnormalities or overt morbidity develop. In later years, continuing obesity and a sedentary state may contribute to clinically relevant heart disease.

The Canadian Hemophilia Registry as the basis for a national system for monitoring the use of factor concentrates

BACKGROUND

Canada's publicly funded blood system has recently introduced high-purity concentrates as the standard treatment for individuals with hemophilia. The added cost and the need to document patient outcomes have prompted the consideration of a national blood product monitoring system.

STUDY DESIGN AND METHODS

This study investigates the suitability of the Canadian Hemophilia Registry (CHR) as the basis of such a monitoring system by assessing the degree to which it represents users of factor concentrates.

RESULTS

Currently, there are 1978 individuals registered with the CHR, of whom 1594 (81%) have hemophilia A and 384 (19%) have hemophilia B. The total prevalence is 7.2 per 10(5) population, with the prevalence of severe cases being 2.3 per 10(5). This overall prevalence is similar to that seen in other countries with national registries. The CHR national prevalence also compares favorably with that in the province of Quebec, where registration of users of blood products is compulsory. The CHR figures indicate that the number of persons currently infected with human immunodeficiency virus, both alive and dead, is 652, which is similar to the number of applicants (658) to the federal government's assistance program. The registry is stable, and the number of persons with severe cases, other than young children, newly registered or lost to follow-up during the last 2 years is very small.

CONCLUSION

The CHR includes the vast majority of factor concentrate users and is therefore ideal as the basis for a national monitoring system.

An assessment of global health status in survivors of acute lymphoblastic leukemia in childhood

PURPOSE

Progressive improvement in survival rates of children with cancer demands an appraisal of the "cost of cure." Much information is available on the frequency and severity of individual late effects in long-term survivors, but there are few data on multiple sequelae in individual patients or on global morbidity burdens.

PATIENTS AND METHODS

To address this issue, we developed a multiattribute health status classification system. This consists of three to five levels of function within each of seven attributes: sensation, mobility, emotion, cognition, self-care, pain, and fertility. The system was applied to survivors of acute lymphoblastic leukemia (ALL).

RESULTS

Overall burdens of morbidity were greater in those who had had "high-risk" disease than in children treated less intensively for "standard-risk" ALL. Deficits in emotional and cognitive status were especially common (alone and in combination). These were more prevalent in younger patients and exhibited a dose relationship to cranial irradiation.

CONCLUSIONS

Such appraisals of morbidity must be compared with prevalence rates in the general population.

Mineral homeostasis and bone mass in children treated for acute lymphoblastic leukemia

Clinical observations of bone pain, abnormal gait, and unusual fractures during remission of leukemia led us to assess mineral status in a cohort of 16 children with acute lymphoblastic leukemia treated with intensive chemotherapy. During maintenance and 6 months after the completion of therapy, blood and urine were analyzed for calcium and magnesium and blood for osteocalcin, vitamin D, and parathyroid hormone. Bone mineral content and bone width of the distal one third of the radius of the nondominant arm was measured by single-photon absorptiometry. During therapy, mild ionic hypocalcemia (less than 1.19 mmol/L) and hypomagnesemia (less than 0.77 mmol/L) were demonstrated in 9 and 8 of 16 children, respectively; hypercalciuria (8/16) and hypomagnesiuria (12/16) were also observed. Plasma osteocalcin values correlated with plasma magnesium levels (r = 0.54; p less than 0.05). Oral magnesium supplements normalized plasma magnesium, calcium, and osteocalcin levels, all of which were normal at the postchemotherapy study. Plasma 1,25-dihydroxyvitamin D levels were nondetectable (less than 8 ng/ml) in 12 of 13 patients receiving therapy and in 7 of 14 patients not receiving therapy; alkaline phosphatase activity increased significantly after therapy (179 +/- 86 to 340 +/- 101 units/L), and parathyroid hormone levels were normal in both studies. Bone mineral content/bone width ratio was less than 1 SD below the mean for age- and sex-related population standards in 70% of patients. These data indicate that alterations in magnesium, calcium, and vitamin D metabolism in children treated for acute lymphoblastic leukemia may be instrumental in inducing or sustaining altered bone turnover during chemotherapy.

Lithium augmentation in the treatment of delusional depression

Five patients suffering with delusional depression, and who were resistant to tricyclic antidepressants, were successfully treated with lithium carbonate. Delusional depression does not usually respond to tricyclic antidepressants, and ECT has been considered the treatment of choice. Such patients often refuse to acknowledge that they are ill. They, therefore, understandably often refuse to accept ECT. In order to treat, the Mental Health Act 1983 must be invoked. Treatment with lithium carbonate is more acceptable to most patients, and in the cases described, patients agreed to take this drug whereas they had refused to accept ECT.

Simultaneous or sequential expression of lymphoid and myeloid phenotypes in acute leukemia

Acute mixed myeloid-lymphoid leukemia is uncommon. We report four cases in which myeloid and lymphoid cell markers were observed simultaneously or sequentially when 94 patients with acute leukemia were phenotyped according to the French-American-British (FAB) classification system, with cytochemical stains, and with immunologically defined differentiation markers (identified by monoclonal antibodies and antiterminal deoxynucleotidyl transferase [TdT]). In one case, conversion from acute lymphoblastic leukemia to acute myeloid leukemia was noted (FAB L1, TdT+ to FAB M4, Auer rods, TdT-). In another patient, two distinct populations of myeloid and lymphoid blast cells were observed simultaneously (TdT-, LeuM1+/TdT+, LeuM1-). In two additional patients, acute leukemia was characterized by the expression of both lymphoid and myeloid markers on the same cell (TdT+/Leu M1+, B4+/Leu M1+ and greater than or equal to 70% TdT+, T11+, My9+). The Philadelphia (Ph1) chromosome was negative in all cases, though other chromosomal abnormalities were noted in three out of four cases. Malignant transformation of a pluripotential stem cell for both lymphoid and myeloid lineages, with or without the Ph1 chromosome marker, could explain the coexistence of distinct populations of lymphoblasts and myeloblasts in acute leukemia. Acute leukemia with a biphenotypic profile may reflect genome depression accompanying neoplasia.

A new case of the unstable haemoglobin Genova (alpha 2 beta 2 28 (beta 10) leu leads to pro) in Canada: as a result of sporadic mutation and causing Heinz body haemolytic anaemia

The first case of the unstable Hb Genova as a result of sporadic mutation is described. It is found in a 3-year-old Canadian boy of East Indian extraction with chronic Heinz body haemolytic anaemia.