Handling of radioactive seed localisation breast specimens in the histopathology laboratory: the Western Australian experience.

Radio-guided occult lesion localisation using iodine-125 seeds (ROLLIS) is a novel method of localisation for impalpable in situ and invasive carcinomas that has been the subject of a recent pilot study and pilot study extension in Western Australia. Robust protocols for radiation safety, specimen labelling, specimen tracking, seed retrieval and seed disposal were developed at two Western Australian laboratories to minimise the risk of seed loss. The processes are safe and effective with no significant radiation exposure to pathologists and with acquisition of all seeds intact and undamaged. The success can be attributed to developing specific seed retrieval techniques, suited to local preferences at each institution, with input from surgeons, radiologists and medical physics personnel. These techniques are now routine and will continue in the randomised control phase of the ROLLIS study.

Nephrotic syndrome in a patient with IgA deficiency-associated mesangioproliferative glomerulonephritis.

A case of mesangioproliferative glomerulonephritis in a 55-year-old woman with selective IgA deficiency and serum antinuclear antibodies who presented with nephrotic syndrome is described. The patient did not have clinical or laboratory features of systemic lupus erythematosus (SLE) other than antinuclear antibodies. Histology of the patient's renal biopsy revealed a mesangioproliferative glomerulonephritis and direct immunofluorescence showed that paramesangial deposits contained predominant IgM with lesser IgG, C3 and C1q. These findings are identical to those previously described in a form of glomerulonephritis associated with IgA deficiency and would be atypical for lupus nephritis. Glomerulonephritis is not a well recognized complication of IgA deficiency, though it has been rarely reported in the literature. This case provides further evidence that IgA deficiency is associated with a unique immune complex-mediated glomerulopathy with characteristic immunopathological and ultrastructural features. It is the first reported case to present with nephrotic syndrome.

Pulmonary capillaritis associated with the antiphospholipid antibody syndrome and rapid response to plasmapheresis.

OBJECTIVE: Pulmonary capillaritis is an uncommon complication of antiphospholipid antibody syndrome but has important therapeutic implications. CASE REPORT: A patient with antiphospholipid antibody syndrome presented with haemoptysis and respiratory failure. Investigation including open lung biopsy, demonstrated vasculitis as the underlying pathology, rather than thrombosis. The patient responded promptly to methylprednisolone, cyclophosphamide and plasmapheresis. CONCLUSION: Plasmapheresis has not previously been described in this setting and the rapid response suggests that it should be considered in severe disease.

Subtypes of chromophobe cell renal carcinoma: an ultrastructural and histochemical study of 13 cases.

The Mainz classification of renal epithelial neoplasms has become accepted as a reproducible morphologic and cytogenetic classification of epithelial tumors of the kidney. Chromophobe cell renal carcinoma (CCRC) is a distinct type of renal epithelial neoplasm, first described by Thoenes et al. in 1985. Both a typical type of CCRC, composed of cells with pale reticular cytoplasm, and an eosinophilic variant (EVCCRC) have been identified. Both variants have been reported to show cytoplasmic staining with the Hale's colloidal iron method. Cytogenetic analysis has tended to confirm the Mainz classification. CCRC has been shown to have consistent chromosomal abnormalities that are not shared by other renal tumors. Ultrastructurally, CCRC is typically characterized by a cytoplasm containing scant numbers of mitochondria, which have tubulovesicular christae, and by the presence of innumerable 150-300-microm microvesicles scattered between the mitochondria. Erlandson et al. recently described two subtypes of EVCCRC. One subtype has sparse microvesicles and abundant mitochondria that have tubulovesicular christae, whereas the second type (described as an oncocytic EVCCRC) has no microvesicles and abundant mitochondria containing pseudovesicular or lamellar christae. This was believed to be more akin to the ultrastructural appearances of a renal oncocytoma. The authors believe that the phenotype of the EVCCRC shows a range of appearances at both the light microscopic and the ultrastructural levels, from features similar to the typical type CCRC through to a neoplasm that is phenotypically similar to renal oncocytoma. A series of 13 cases of CCRC from the files of the Massachusetts General Hospital for which ultrastructural examination was available is described. These cases include six cases of typical type CCRC and seven cases of EVCCRC. The authors confirm the findings of Erlandson et al. of two subtypes of EVCCRC and designate them as type 1 EVCCRC (with some microvesicles and mitochondria with tubulovesicular christae) and type 2 EVCCRC (with no identifiable microvesicles and mitochondria with pseudovesicular or lamellar christae).

Fat necrosis in surveillance biopsies of heart transplants.

Fat necrosis was observed in surveillance biopsies of five patients following heart transplant. This reaction is poorly documented in the literature, but in personal communication, some pathologists working in the field have had experience with it. Four of the cases developed two to six days after transplantation, but in the fifth case, fat necrosis developed ten months after transplantation. Autopsy study of one case showed extensive severe fat necrosis involving both donor and recipient tissues. The cause is not known, and the changes are independent of rejection. However, the fat necrosis can be found within the interstitial tissues of the myocardium and subendocardium and may be mistaken for rejection if lymphocytes and polymorphs are part of the inflammatory response. The only clinical finding thought to be related to the fat necrosis was the development of transient complete heart block in a patient in whom the International Society for Heart and Lung Transplantation (ISHLT) standardised rejection grading was never greater than IA.

Collecting duct carcinoma of the kidney: a report of three cases and review of the literature.

Collecting duct carcinoma (CDC) of the kidney is a rare neoplasm arising from the medullary collecting ducts. The clinicopathological features of three cases are here presented to add to the 42 cases reported so far in the English language literature. Hematuria is the most common presenting symptom, although 10% of patients present with metastatic disease, often in neck lymph nodes. The tumor mass is typically centred on the medulla of the kidney and extends into the cortex. Radiological diagnosis may be difficult because the radiological features of CDC are poorly described. The histological appearances have been described as tubulo-papillary, tubular, solid and sarcomatoid. Intracytoplasmic mucin may be present. The typical immunohistochemical profile is positive staining with antibodies for low and high molecular weight keratin and epithelial membrane antigen (EMA) and positive staining with the lectin Ulex europaeus agglutinin. Literature reports of cytogenetic characterisation show loss of chromosomes resulting in monosomies. Prognosis is poor as more than half of the reported cases have developed metastases or died within two years of presentation.

Documented need for more effective diagnosis and treatment of familial hypercholesterolemia according to data from 502 heterozygotes in Utah.

A project to help Utah residents with heterozygous familial hypercholesterolemia (FH) identified affected individuals by collecting detailed questionnaires from: (1) very high-risk persons in computer files of screening data (very high cholesterol levels, very early coronary artery disease, and strong positive family history); (2) confirmed FH index cases from a university lipid clinic; and (3) relatives of any confirmed FH cases. Questionnaires were received from 2,143 persons identifying 101 living index cases and 502 relatives meeting the criteria for the diagnosis of FH. Finding new FH heterozygotes was about one fourth as expensive by tracing relatives of confirmed FH cases by evaluating very high-risk persons. Of those meeting criteria for the diagnosis of heterozygous FH, only 31% reported being told by their physicians that they had FH, only 42% indicated that they were taking a cholesterol-lowering prescription medication, and only 23% had reasonably controlled cholesterol levels (below the 90th percentile). However, the data also suggest that good control is achievable in motivated patients. Among 106 FH heterozygotes who were early responders to a second follow-up questionnaire, 79% were taking prescription medications, of whom 49% had achieved cholesterol levels below the 90th percentile, and 17% even achieved cholesterol levels below the 50th percentile. We conclude that most patients with heterozygous FH are not diagnosed and not adequately treated. We demonstrated how many of these persons needing help could be identified efficiently by tracing relatives of known index cases.

Case report: abnormal thyroid function tests in a patient and two normal volunteers treated with salsalate.

There are only three prior reports of abnormal thyroid function tests in patients who have received salsalate, the salicylate ester of salicylic acid. The authors report an elderly clinically euthyroid man who had thyroid function tests suggestive of central hypothyroidism while taking salsalate but whose thyroid tests returned to normal after the drug was discontinued. They also studied thyroid function tests, including free thyroxine (FT4) and reverse (T3), in two normal volunteers who took salsalate 750 mg twice daily for 1 week. In the normal subjects, total T4 and FT4 began to fall within 24 hours after the first dose of salsalate, and remained suppressed for at least 24 hours after the drug was discontinued. This rapidity of effect by salsalate is previously undescribed. There was also a fall in FT4, probably due to the use of diluted serum in the equilibrium dialysis FT4 assay. Because FT4 measurement using diluted serum or equilibrium dialysis may cause falsely low FT4 measurements, the authors believe ultrafiltration may be the only reliable method of measuring FT4 in these patients.

Immobilization hypercalcemia in an adult patient with pancreatitis and sepsis: case report.

We describe an adult patient who developed persistent hypercalcemia while bedridden for more than three months with pancreatitis and sepsis. On the basis of hypercalciuria, suppressed serum intact PTH, suppressed serum 1,25-dihydroxy vitamin D3 and no clinical evidence of malignancy, the diagnosis of immobilization hypercalcemia was established His hypercalcemia improved during treatment with saline, calcitonin and/or etidronate. With active mobilization and weight-bearing exercises, serum calcium finally normalized. We discuss clinical and laboratory features as well as current modalities of treatment of this rare form of hypercalcemia in adults.

Cataract patients' post-op eye-care: development and evaluation of a teaching program.

A project was undertaken to develop and trial an eye care education program for use in routine nursing care. It was initiated in response to research findings that suggested patients may have been discharged from a particular hospital inadequately prepared to perform their own eye care following cataract surgery. The trial assessed the program's effectiveness in relation to predetermined standards of eye care behaviour; its practicability and its performance relative to a conventional teaching approach. Outcomes of the trial indicated that neither the program nor the conventional teaching approach provided adequate preparation for the self delivery of eye care. This is believed to relate to the limited time nurses had for face-to-face teaching and, hence, for facilitating the consolidation and application of learning. The study concludes that the provision of effective eye care education in an inpatient context lies in approaches which reduce the amount to be taught in the limited teaching time that is available. It is suggested that the relevance may not be confined to eye care education.

Analgesia following extradural and i.m. pethidine in post-caesarean section patients.

The onset, quality and duration of analgesia following extradural pethidine 50 mg and i.m. pethidine 100 mg was assessed in 30 postoperative patients who had undergone Caesarean section under extradural anaesthesia. Saline and pethidine were given in a randomized, double-blind fashion using simultaneous extradural and i.m. injections. Extradural pethidine provided superior analgesia, of quicker onset but similar duration, and both treatments were associated with a low incidence of side effects.

The role of the thymus in the maintenance of natural killer cells in vivo.

This report describes a model for investigating the role of the thymus in regulating natural killer (NK) cell activity in vivo. Evidence is presented that the thymus can regulate NK cells, and that at least some NK cells can develop without thymic help. Marrow from thymectomized rats depleted of circulating T cells by thoracic duct cannulation was transplanted into rats without a thymus (1 degree ATX.BM). These 1 degree ATX.BM rats had NK cell levels above controls 3 months after reconstitution but markedly depressed NK cell levels by 9 months. When 1 degree ATX.BM marrow was used to reconstitute rats with or without a thymus, those without a thymus (2 degrees ATX.BM) exhibited low NK cell levels after 3 months, and a similar result was obtained when 2 degrees ATX.BM marrow was used to reconstitute 3 degrees ATX.BM rats. The low NK cell levels in 2 degrees and 3 degrees ATX.BM rats were due to a deficiency in spontaneously cytotoxic NK cells, as they had normal numbers of interferon-responsive pre-NK cells. Spleen cells from 2 degrees and 3 degrees ATX.BM rats produced less interferon than control spleen cells when cultured with P815 tumor cells in vitro. However, 2 degrees and 3 degrees ATX.BM rats had higher numbers of large granular lymphocytes than controls despite their low NK cell levels. In marked contrast to 2 degrees and 3 degrees ATX.BM rats, spleen cells from 4 degrees ATX.BM rats had higher levels of cytotoxicity and a higher frequency of both spontaneously cytotoxic and pre-NK cells than controls. The 4 degrees ATX.BM rats also had the highest frequency of large granular lymphocytes in the spleen.