Symptomatic vitamin E deficiency diagnosed after histological recognition of myometrial lipofuscinosis.

We report a 44-year-old woman in whom intestinal bypass for obesity at age 23 resulted in chronic malabsorption. After hysterectomy for menorrhagia due to atypical endometrial hyperplasia, the finding of myometrial lipofuscinosis led to a demonstration of vitamin E deficiency. Vitamin E supplementation led to an unexpected improvement in the unsteadiness of gait and slurring of speech of which she had also complained. We suggest that supplementation with vitamin E should be routine in all patients with persistent severe steatorrhoea.

Pathology of the liver in leukaemia and lymphoma. A study of 110 autopsies.

Histopathological findings in the liver in a series of autopsies on 110 patients suffering from leukaemia or lymphoma were reviewed. No treatment had been given to 23 patients, 50 had received chemotherapy alone, 23 chemo- and radiotherapy and 14 underwent bone marrow transplantation. The 23 untreated patients showed neoplastic infiltration in 10 (44%) and fibrosis in 16 cases (70%). The 14 bone marrow recipients showed mainly acute necrosis, zonal in six (43%) and focal in one (7%), and cholestasis in five (36%), together with marked siderosis in 11 (79%). Patients receiving chemotherapy or chemo-/radiotherapy showed similar changes consisting of neoplastic infiltration in 14 (28%) and in five (22%) cases respectively, and fibrosis in 31 (62%) and 17 (74%) cases respectively. Steatosis was seen in 70% of cases in the chemo-/radiotherapy group and in 50% of cases in the other groups. Infections were seen in all groups, particularly in the chemotherapy group (four fungal and two bacterial including one tuberculosis) and in the chemo-/radiotherapy group (one fungal and one bacterial). Cytomegalovirus infection was seen only in the bone marrow transplant group.

Design of a microwave system for endoscopy: an experimental study of energy, tissue contact, and hemostatic efficacy.

BACKGROUND: A microwave generator and delivery system for endoscopic use was built. Using a 650-W, 2450-MHz magnetron, 0-160 W were generated from the tip of a 180-cm flexible coaxial cable (2.1 mm diameter). METHODS: Three methods of achieving hemostasis with microwaves were identified studying standard bleeding canine ulcers: (1) interstitial method: inserting the coaxial tip into the tissue and heating slowly until bleeding stopped; (2) contact method: tip held in contact, light pressure applied; (3) noncontact method: microwave-induced sparking (dielectric breakdown) with tip held 1 mm from tissue. RESULTS: Studies of optimal energy levels for hemostasis showed that high power (70 W) noncontact methods required significantly less energy to stop bleeding than contact or interstitial methods. The noncontact method was more effective than the contact method, stopping 20 of 20 bleeding ulcers vs. 10 of 20 (P < 0.001) and was more rapidly effective causing less tissue damage (P < 0.05) than the interstitial method. CONCLUSIONS: In a randomized comparison using a non-contact method, microwave coagulation was superior (P < 0.001) to a polidocanol 1% + adrenaline 1:10,000 injection and control treatment stopping 40 of 40 vs. 0 of 20 and 0 of 20 standard bleeding ulcers. Microwaves stopped bleeding from 10 of 10 severed mesenteric vessels, whereas injection was ineffective (0 of 10, P < 0.001). Microwaves look promising for hemostasis at flexible endoscopy.

Crohn's disease in Bangladeshis and Europeans in Britain: an epidemiological comparison in Tower Hamlets.

The incidence of Crohn's disease in a defined Bangladeshi community was assessed in a retrospective, epidemiological study in the London Borough of Tower Hamlets from 1972 to 1989. The borough population of 164,000 includes over 28,000 Bangladeshis. Potential cases were identified from hospital pathology and medical records. There were 99 cases of Crohn's disease during the study period, of which five were Bangladeshi. The mean standardized incidence in Bangladeshis was 1.2/10(5)/year in the 1970s and 2.3/10(5)/year in the 1980s compared with 3.8/10(5)/year and 4.1/10(5)/year in Europeans, and 4.6/10(5)/year and 5.4/10(5)/year in West Indians, respectively. None of the changes with time was statistically significant. There were no cases amongst Hindus. The relative risk to Europeans, compared to Bangladeshis, was 2.5 during the 1970s and 2.0 in the 1980s. The difference between European incidence and that of other ethnic groups was not statistically significant; however, the number of Bangladeshi cases was small (five), and diminishes the power of the study. The apparent similarity of the incidences of Crohn's disease in Bangladeshis and Europeans contrasts with findings in other South Asians. Further investigations of the differences in incidence of Crohn's disease in South Asians is needed.

Low incidence of ulcerative colitis and proctitis in Bangladeshi migrants in Britain.

To assess the incidence of ulcerative colitis and proctitis in a defined migrant population, a retrospective, epidemiological community study was performed in the London Borough of Tower Hamlets from 1972 to 1989. The population of 164,000 includes 28,000 Bangladeshis. Potential cases were identified from hospital departments of pathology and medical records. There were 107 cases of ulcerative colitis in Europeans and 5 in Bangladeshis. There were 74 and 2 cases of proctitis in these communities, respectively. The mean standardised incidence of ulcerative colitis in Bangladeshis (1.8 cases/10(5)/year) was marginally lower than in Europeans (6.2 cases/10(5)/year, Z = 0.7, n.s.). The mean standardised incidence of proctitis in Bangladeshis was 0.6 cases/10(5)/year and in Europeans 3.2 cases/10(5)/year (Z = 0.6 n.s.). Anatomical extent of colitis was similar in all ethnic communities, although complications were less likely in minority groups. These findings suggest that the incidence of ulcerative colitis and proctitis in Bangladeshis, in Britain, is amongst the lowest in the world.

Observer study of the grading of dysplasia in ulcerative colitis: comparison with clinical outcome.

Patients with extensive ulcerative colitis are entered into surveillance programs that aim to detect premalignant changes. Biopsy specimens have been collected in the St Mark's Hospital (London) surveillance program over a 22-year-period. Specimens from patients reported as having dysplasia were reexamined. A total of 207 biopsy specimens from 86 patients were graded by five experienced pathologists according to the severity of the dysplasia. The overall agreement between the pathologists grading the specimens was poor; each pair agreed on between 42% and 65% of the slides. The best agreement was for slides that were said to show no dysplasia. Comparison with clinical outcome indicated that the pathologists most likely to diagnose dysplasia in patients with carcinoma were also likely to diagnose dysplasia in patients who did not go on to develop carcinoma. Calculating an average grade of dysplasia did not significantly improve diagnostic accuracy. Despite the findings of this interobserver study, dysplasia has been a successful marker in clinical practice. Pathologists should ensure that they have access to previous slides from the same patient and adequate clinical information before reporting biopsies as positive for dysplasia. An additional biopsy should usually be undertaken before surgery is considered.

Fatty tumours of the large intestine: a clinicopathological review of 13 cases.

Thirteen cases of benign fatty tumours of the colon have been reviewed. There were ten instances of submucosal lipoma, two of which were multiple, and three of lipohyperplasia of the ileocaecal valve. Abdominal pain and gastrointestinal bleeding were the commonest symptoms. Barium enema and angiography were misleading, the former in confusing polypoid lipomas and protruberant ileocaecal valves with carcinoma, the latter in misinterpreting fatty tissue vasculature as angiodysplasia in three patients. Most lesions were in the right side of the colon, and many were treated by limited colectomy as if for carcinoma or angiodysplasia. No patient has died as a result of their disease. Awareness of the possibility of colonic lipomas and knowledge of the normal ileocaecal valve anatomy are of importance to radiologists and endoscopists, particularly now that angiography is localizing the smaller fatty lesions.

Secretory carcinoma of the breast in adults: emphasis on late recurrence and metastasis.

Secretory (so-called juvenile) carcinoma of the breast, first described in children, occurs also in adult women, predominantly in the third decade. Less commonly it is seen in older age groups, up to the eighth decade. We report five patients with this tumour; one, a female aged 73, is the oldest age at which the tumour has been recorded, and one is the first report in an adult male in whom the disease recurred after 20 years, only the second recorded death attributable to this tumour type. Secretory carcinoma in adults is potentially more aggressive than in childhood. Nodal metastases are more frequent and sometimes more extensive. Recurrence of tumour after surgery developed in four of our five patients at 3, 8, 15 and 20 years. Slow growth and delayed recurrence are characteristic of many of these tumours. Death from systemic metastases is rare, but may ensue either rapidly or following a long latent period after treatment. Prolonged follow-up is needed to assess accurately the biological behaviour of this tumour.

Argyrophilic and hormone immunoreactive cells in normal and hyperplastic pancreatic ducts and exocrine pancreatic carcinoma.

Scattered argyrophil cells were present in normal, large, medium-sized and small pancreatic ducts (ductules). There was marked increase in argyrophil cells in ducts with hyperplastic epithelium. Argyrophil cells were also found in 67.7% of all exocrine pancreatic carcinomas. In a well differentiated group including cystadenocarcinoma, mucinous carcinoma and well differentiated ductal adenocarcinoma argyrophil cells were found in all cases examined. Using four antisera (against insulin, glucagon, somatostatin and gastrin), insulin, glucagon and somatostatin cells were identified in 2.65%, 0.001% and 1.2% of normal ducts, and 7.5%, 2.4% and 4.6% of ducts with hyperplastic epithelium respectively and were also greatly increased in numbers in the latter group. Immunoreactive cells were present in 66.7% of exocrine carcinomas. Cells reactive for insulin were found in 7/15 cases; glucagon in 6/15 cases; somatostatin in 5/15 cases and gastrin in 2/15 cases. Eight cases contained two or more than two types of immunoreactive cells. The presence of argyrophil and hormone immunoreactive cells in pancreatic ducts and carcinomas is indicative of the close developmental relationship between endocrine and exocrine parts of the pancreas. The inter-relationship of response in the different cell types following stimulus suggests that injury to a common precursor may be involved.

Malignant eccrine poroma: report of three cases.

The characteristic clinical and histological features of three cases of malignant eccrine poroma are discussed, in addition to the metastatic disease that had occurred in two cases. These cases were compared with previously reported cases of malignant eccrine poroma that had metastasised, and it is suggested that a strict classification of malignant eccrine sweat gland tumours should be made.

Enteroendocrine cell hyperplasia, carcinoid tumours and adenocarcinoma in long-standing ulcerative colitis.

Chronic ulcerative colitis may be accompanied by a variety of epithelial changes, including loss of goblet cells, Paneth cell metaplasia, villous metaplasia, and dysplasia. Total colitis is also accompanied by an increased incidence of adenocarcinoma. All these changes are assumed to be secondary to repeated mucosal damage, but how they develop is unknown. Little attention has been paid to the enteroendocrine cell population, despite the postulated role of these cells as producers of trophic hormones. We describe two patients with long-standing ulcerative colitis who developed both adenocarcinoma and carcinoid tumours. In both, there were increased numbers of enteroendocrine cells in the uninvolved colonic mucosa. We suggest that an increased enteroendocrine cell mass may be part of a non-specific reaction to chronic mucosal injury, and by producing an elevated level of trophic hormones may act as a promoter in the development of neoplasia.

Malignant histiocytosis of the intestine: a T-cell lymphoma.

Malignant lymphoma complicating coeliac disease has been characterised on morphological and immunocytochemical grounds as malignant histiocytosis of the intestine (MHI). Fresh tissue from four cases of MHI was studied by means of a panel of monoclonal antibodies; in three cases tumour DNA was studied for immunoglobulin and T-cell receptor (TCR) gene rearrangement. Immunocytochemistry showed a T-cell phenotype in all four cases, confirmed by the demonstration of a rearranged TCR beta-chain gene in the three cases studied. Lymphoma complicating coeliac disease thus appears to be of T-cell, rather than histiocyte, origin.

Coexistent ulcerative colitis and Crohn's disease.

This case report describes a patient with chronic ulcerative colitis and epithelial dysplasia of 17 y duration ultimately complicated by colonic carcinoma. At laparotomy, clinically unsuspected but typical Crohn's disease of the terminal ileum was also found. The macroscopic and histological features of the resected terminal ileum were characteristic of Crohn's disease.

Malignant sacrococcygeal teratoma in the adult.

This case of a malignant sacrococcygeal teratoma, usually a tumour of early childhood, presented as a bedsore in the lower end of the nuchal cleft of a 69-year-old man and proved to be malignant with a trophoblastic element. The literature of adult sacrococcygeal teratoma is reviewed; we have been able to find only three malignant examples.

Histological appearances of oesophagus, antrum and duodenum and their correlation with symptoms in patients with a duodenal ulcer.

Clinical data and histology from the oesophagus, gastric antrum, and duodenum were collected from 36 patients undergoing surgery for duodenal ulcer. Gastritis was present in 94% of the patients (25% of atrophic type), oesophagitis in 72% and duodenitis in 39%. Abnormal biopsies were present from all three sites in 33% of the patients. Only one patient showed three normal biopsies. The low incidence of duodenitis does not support the theory that duodenitis is part of the same spectrum as duodenal ulcer. Heartburn was related to the presence of gastritis (100%) and oesophagitis (76%) but not to duodenitis (52%). No relationship was found between the length of history, severity of pain, and histological abnormalities.

Cutaneous carcinoma in psoriatic patients treated with PUVA.

Eight of 216 psoriatic patients treated at The London Hospital with photochemotherapy (PUVA) have developed a total of twenty-five skin carcinomata. The type and site of tumour are discussed with special reference to the importance of PUVA compared with other risk factors. We suggest that a history of previous skin carcinoma, arsenic therapy or radiotherapy are relative contra-indications to PUVA therapy for psoriasis.

Acute osteomyelitis and septic arthritis in children. A simple approach to treatment.

A 12-month prospective study of 45 patients with bacteriologically proven acute osteitis and septic arthritis is presented. Sodium fusidate and erythromycin at the recommended dosage of 30 mg/kg/d for 3 weeks was found to be an effective first-line antibiotic regimen. The hazards of Haemophilus infection are emphasized. Immediate Gram staining is therefore strongly recommended. It was found that adequate drainage of a subperiosteal abscess without drilling of the bone always resulted in complete cure, while cases of septic arthritis consequent upon decompression of a contiguous metaphysitis were adequately treated by arthrotomy and irrigation alone. The authors believe that early limited surgery with adequate administration of antibiotics aided by early circumspect mobilization will provide a good functional and cosmetically acceptable result in most cases.

Antibiotic therapy in acute infections of bone and joints in children.

Effective antibiotic therapy forms the mainstay of the treatment of acute bone and joint infections in children. The causal organisms and bacterial sensitivities encountered in a prospective study are presented. Initial antibiotic therapy is discussed, while the need for immediate Gram staining to identify resistant organisms is stressed.