Hyponatremia and seizures after bowel preparation: report of three cases.

Oral sodium phosphate and sodium picosulfates/magnesium citrate are commonly used to evacuate the colon and rectum before colonoscopy or colorectal surgery. These substances, however, are known to cause electrolyte abnormalities. Seizures caused by electrolyte abnormalities associated with bowel preparation have only rarely been reported. We report the cases of three patients with no prior history of seizures, who had their first seizure associated with hyponatremia following ingestion of sodium phosphate or sodium picosulfates/magnesium citrate combination. Care must be taken with patients with a low seizure threshold and those with possible chronic sodium depletion, such as patients on thiazide diuretics, who are undertaking bowel preparation with oral sodium phosphate or sodium picosulfates/magnesium citrate combination.

Guillain-Barré syndrome and hyponatraemia.

BACKGROUND: Hyponatraemia is a recognized association of the Guillain-Barré syndrome (GBS) and is also known to occur after the administration of intravenous infusion of gamma globulin (IVIG), a treatment often used in management of GBS. AIMS: To document serum sodium concentration in GBS patients before, during and after management procedures (including IVIG) positive pressure ventilation (PPV) and the use of medications capable of causing a low serum sodium. To consider whether pseudohyponatraemia might be a contributory factor. To assess whether hyponatraemia is a predictor of poor outcome. METHODS: Clinical record audit of 84 patients with GBS admitted to Christchurch Hospital, New Zealand, over a 10-year period. RESULTS: Serum sodium concentration was significantly low (<133 mmol/L) in 26 of 84 (31%) patients. In 12 of these cases the hyponatraemia developed during or after IVIG, suggesting that pseudo-hyponatraemia was a contributing factor. Six (7%) significantly hyponatraemic patients died, but no eunatraemic or slightly hyponatraemic patient died (P = 0.001). Six of 38 patients aged > or =50 years died, whereas none of the 46 patients aged <50 years died (P = 0.007). Five of 19 ventilated patients died but only one of 65 non-ventilated died (P = 0.002). CONCLUSIONS: Significant hyponatraemia occurred in 26 (31%) of the patients, but in 12 of these it appeared likely that pseudohyponatraemia caused by IVIG was a contributing factor. Hyponatraemic patients have a poorer prognosis than eunatraemic patients, however it is difficult to separate this factor from other poor prognostic factors (older age and PPV).

Hemorrhagic lymphadenopathy as a presenting feature of primary al amyloidosis.

Lymphadenopathy associated with hemorrhage as a presenting feature of primary (AL) amyloidosis has not previously been described. We report two such cases one of whom had an acquired factor X and IX deficiency. The clinical presentations were characterized by sudden spontaneous enlargement of lymph nodes followed by partial regression. In both cases significant delay in diagnosis, and hence treatment, occurred due to the mode of presentation. One patient died with rapidly progressive disease but the other has had an excellent response to therapy with high-dose melphalan (HDM, 200 mg/m2) and peripheral blood stem cell rescue. AL amyloid should be considered in all patients presenting with hemorrhagic lymphadenopathy.

Late results of surveillance of clinical stage I nonseminoma germ cell testicular tumours: 17 years' experience in a national study in New Zealand.

OBJECTIVE: To re-evaluate a national prospective study in New Zealand after 17 years to define whether orchidectomy alone and surveillance for nonseminoma germ cell testicular tumour (NSGCTT) is a sound policy and matches the results achieved by other treatment protocols. PATIENTS AND METHODS: Between 1980 and 1997, 248 men with stage I NSGCTT, from six New Zealand centres, were managed by orchidectomy alone and surveillance, with treatment of relapses using combination chemotherapy. RESULTS: Seventy of the 248 patients (28%) relapsed; 42 of 92 (46%) with vascular and/or lymphatic invasion (VLI) in the primary tumour relapsed, whereas only 26 of 151 (17%) without this feature relapsed (P<0.001). VLI was the only identifiable risk factor for relapse in this series. Only one relapse occurred >28 months after orchidectomy. Despite poor compliance in some patients (12%) their survival was not prejudiced. Three patients died from disease despite chemotherapy at relapse. At 17 years and a median follow-up of 53 months, 242 of the 248 men are disease-free and the disease-specific survival rate is 98%. CONCLUSIONS: This study shows that orchidectomy alone and treatment of relapses produces excellent long-term results without the adverse effects associated with retroperitoneal node dissection or elective chemotherapy for high-risk cases.

Monoclonal gammopathy of undetermined significance (MGUS)-31 year follow up of a community study.

BACKGROUND: When unselected healthy adults in the community have their serum screened by cellulose acetate or paper electrophoresis, monoclonal gammopathy of undetermined significance (MGUS) may be found in 0.5-1%. AIM: To report upon a 31 year follow up of MGUS in a New Zealand community. METHODS: Serum from 2,192 subjects (82% of the adult population) of a New Zealand town was collected in 1967 and subsequently screened by cellulose acetate electrophoresis. Eleven of the 2,192 (0.5%) were found to have MGUS. Clinical correlation was sought in 1970 and subsequently to elucidate the underlying cause. RESULTS: Seven of the 11 patients have developed a haematological malignancy. Two have been diagnosed as having Waldenstrom's macroglobulinaemia, one malignant lymphoma and acute myelomonocytic leukaemia and four developed myeloma. Myeloma developed at one, nine, 23 and 25 years after the original screening. One myeloma patient and one patient with MGUS are currently alive and well, 31 years after discovery of their gammopathy. CONCLUSIONS: The incidence of MGUS in this community is only half that detected in a comparable study. The association with haematological malignancy in this study (64%) is considerably higher than that found in the Swedish study (6%), possibly because of the longer follow up in New Zealand. MGUS should not only be studied in depth at the time of its discovery, but needs very long term follow up as the underlying disease may not surface until the third decade.

Severe hypertriglyceridaemia and hypercholesterolaemia associated with tamoxifen use.

A patient who was given tamoxifen as adjuvant treatment for breast cancer developed very severe hypertriglyceridaemia, hypercholesterolaemia and acute pancreatitis after being treated for 4 months. The hyperlipidaemia was corrected after cessation of the tamoxifen and the institution of gemfibrozil treatment. This patient appears to have type IV hyperlipidaemia. It is suggested that, in such patients, tamoxifen should be used with extreme caution because the weakly oestrogenic effect of this agent can cause severe and life threatening hyperlipidaemia.

Hodgkin's cells express CD83, a dendritic cell lineage associated antigen.

Hodgkin's cells (HC) are considered to be the malignant cells of Hodgkin's disease (HD), but despite extensive studies, no conclusive evidence has emerged regarding their non-malignant counterpart and the ontogeny of these cells remains controversial. The analysis of a possible dendritic cell (DC) origin of HC has been hampered to date by the lack of a DC lineage specific marker. The expression of the two DC-associated antigens CD83 and CMRF-44, the B lymphocyte restricted molecule CD79, and the costimulator molecule CD86, was examined in lymph nodes from 23 HD patients using immunohistological techniques. The majority of HC expressed the CD83 (22/23) and CD86 antigens (20/23), whereas expression of the CMRF-44 antigen was variable (10/23) and usually only a subpopulation of HC stained. In contrast, the CD79 antigen was absent from most HC (17/23). The presence of the CD83 antigen on HC in the absence of the CD79 antigen supports a possible DC lineage origin for some HC. Regardless of its role in lineage assignment, CD83 may become a useful immunohistological marker for HD as the CD83 antigen was present on most HC.

Bilateral germ cell testicular tumors in New Zealand: experience in Auckland and Christchurch 1978-1994.

PURPOSE: The incidence of germ cell testicular tumors (GCTTs) is increasing world wide, and with effective treatment, the majority of patients are being cured. Thus, the clinical and social impact of a second testicular tumor is becoming more important. The frequency, cumulative risk, and relative risk of developing a second testicular cancer in New Zealand have been documented and compared with other reports. PATIENTS AND METHODS: The records of 741 men presenting with germ cell testicular cancer in Auckland and Christchurch between 1978 and 1994 have been reviewed, and these data have been compared with data from other published studies. Cumulative risk was assessed by the Kaplan-Meier method. RESULTS: Over 2% of the study population developed a second germ cell testicular cancer. The cumulative risk was 5.2% over 15 years. The relative risk of developing a contralateral testicular tumor is 27.5 times higher than age-matched New Zealand peers. These results match the only comparable report in the literature. Five of the 16 bilateral tumors (31%) were synchronous, which is a higher incidence than in any other reported series. There was no concordance of histology in the first and second tumors. Prior exposure to cisplatin combination chemotherapy did not prevent the development of a second tumor. CONCLUSION: Men who are cured of a germ cell testicular cancer have a greatly increased risk of developing a second testicular cancer. Such patients should be informed of this risk and ideally kept under long-term surveillance.

Elevated frequency of a SstI polymorphism of the Ets-1 oncogene in non-Hodgkin's lymphoma patients.

We studied the frequency of a SstI polymorphism of the Ets-1 oncogene in 100 patients with non-Hodgkin's lymphoma, 44 patients with Hodgkin's disease, 49 patients with chronic myeloid leukemia, and 100 controls. There was no difference in the genotype frequency between the controls and patients with either Hodgkin's disease or chronic myeloid leukemia. In contrast, there was a highly significant difference in the distribution of the three genotypes between the patients with non-Hodgkin's lymphoma and the controls (X2 = 10.76, 2df, p = 0.004) with the C2 allele being more frequent in the lymphoma patients. Molecular cloning indicated that the polymorphic SstI site lay 304 bp from exon 7. This is the second association of the SstI polymorphism of the Ets-1 oncogene with a lymphoid disorder and suggests that the presence of the C2 allele is associated with a predisposition to develop a lymphoid malignancy.

Second malignant neoplasms in patients with Hodgkin's disease.

AIM: To determine the incidence of second malignant neoplasms in patients treated for Hodgkin's disease. METHODS: The records were reviewed of all patients receiving primary treatment for Hodgkin's disease at the Oncology Service, Christchurch Hospital from 1969 to 1992. Second malignant neoplasms presenting at least six months after the diagnosis of Hodgkin's disease were noted and the cumulative risk estimated. RESULTS: Twenty-two second malignant neoplasms developed in 20 of the 209 patients. The risk was 5.6 +/- 3.8% (CI) at five years, 11.4 +/- 6.2% at ten years, and 21.7 +/- 11.2% at 15 years and continued to increase thereafter. Thirteen patients have died of their second malignancy, including two of a third malignancy, while four have been followed for less than one year. Three leukaemias (CML, 1; acute non lymphocytic leukaemia, 2), three lymphomas and 16 solid tumours developed. The risk was greater after six or more cycles of MOPP-like chemotherapy and after radiation doses exceeding 30 Gray. The risk was less after laparotomy and splenectomy (p = 0.0205). CONCLUSIONS: In view of the significant risk of a second neoplasm in survivors of Hodgkin's disease follow up should continue beyond ten years, after which time second malignancies were more likely than recurrence. Efforts should continue to minimise the carcinogenicity of therapy while preserving efficacy.

Increased frequency of the S allele of the L-myc oncogene in non-Hodgkin's lymphoma.

We studied 100 patients with non-Hodgkin's lymphoma, 44 patients with Hodgkin's disease and 100 controls for the prevalence of the EcoRI restriction fragment polymorphism of the L-myc oncogene. No difference in the frequency of the three genotypes (LL, LS, SS) was found between the patient and control groups. However, the S allele was found to occur more frequently in the non-Hodgkin's lymphoma patients (chi 2 = 4.57, P = 0.032). These data confirm an earlier report and suggest that the presence of the S allele is associated with susceptibility to non-Hodgkin's lymphoma.

Improving the preregistration experience: the New Zealand approach.

There is currently much debate about how to improve undergraduate medical education, and in particular on how best to prepare students for clinical responsibility. For 20 years a period of trainee internship has formed part of New Zealand medical students' undergraduate training, and the model could have much to offer the United Kingdom. Students take their final examinations at the end of the second clinical year; they spend their final year in a series of eight clinical attachments, during each of which they shadow a preregistration house officer or senior house officer. As trainee interns they are paid 60% of a house officer's salary for their clinical work, which is supervised by the firm's registrars and consultants under the overall responsibility of the head of the academic department. The order of the attachments is determined on educational, not service, grounds, and trainees have to attend educational sessions and pass assessments on each attachment. The trainee internship, funded jointly by the education and health departments, offers a more seamless transition from student to house officer and aims at improving both general medical education and clinical training.