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PANCYTOPENIA WITH CELLULAR MARROW—P.N.H.?
846 NURSING RECRUITMENT SIR,-A quarter of a milllion pounds is to be spent on a nursing-recruitment campaign. Is it generally known that though some matrons can still select and recruit candidates for the nursing profession in sufficient numbers to form good ward teams, financial restrictions have obliged them to reduce the numbers admitted to schools of nursing, and have also prevented them from appointing the trained staff they need ? The result is that nurses and students are overburdened-the trained staff emigrate, and the students give up. Student wastage goes as high as 40%, and the misery of both staff and patients increases. Often when it is too late, and recruitment has broken down, the purse-strings are released. The lowest student-wastage rate is found in hospitals where the nurse-patient ratio is 1/1. This permits proper staffing over the 24-hour day and 7-day week, and allows an increased work-load when necessary. In this situation staff, students, and patients are content, and good recruitment is automatic. These satisfactory conditions could be obtained widely if a small proportion of the vast sums of money pouring into universities could be diverted to schools of nursing; this would allow Department of Health finances to be used entirely for services to patients. Ideally there should be a ratio of at least one trained nurse to two untrained. Unless the Government faces up to the necessity for proper financial allocations to hospitals-and this includes adequate salaries for all grades of nursing staff-recruitment drives will be useless. I urge doctors to campaign for financial backing for those matrons who can recruit, so that they may do so with all possible speed. Bangor, Co. Down.
DOROTHY HERMIONE LYNN.
DERMATOGLYPHICS AND LEUKÆMIA SIR,-The remarks of Dr. Wittwer and Dr. Giessmann (Feb. 21, p. 425) on the value of dermatoglyphic analysis, made in rebuttal to those of Verbovand Rosner,2 agree completely with our own approach to the problem, and we should like to offer some data in support, in the hope that the discipline will not be consigned to oblivion before it is fairly explored. We analyse finger and palm prints by the method which has been described best by Cummins and Meillo.3 The analysis yields 25 variables for each hand. To date, over 4000 pairs of prints have been studied. The persons from whom these were obtained were classified according to whether they were well or diseased, what their disease was, and the family history. Sufficient numbers of prints for statistical analysis were obtained from persons with diabetes, leukaemia, cancer (all types), Down’s syndrome, non-specific mental retardation, and schizophrenia. The healthy-control series was obtained predominantly from medical or paramedical people, and totals over 800. These people were selected because it was believed that they would be more knowledgeable about their family histories and less reticent in divulging the information to another
physician. Typical
results of analyses of right hands of White females with leukaemia are shown in the accompanying computer print-out. (Because of mechanical limitations only about 25%of patients are displayed in this figure.) The " 1 "s represent the normal controls and the " 3 "s patients. The X and Y axes are independent optimal linear discriminants determined from the original 25 variables. Statistically the results are highly significant. 1. 2. 3.
J. L. Lancet, 1969, F. ibid. p. 272.
323.
Verbov, ii, Rosner, Cummins, H., Meillo, C. Fingerprints, Palms and Soles; chaps. and 5. New York, 1961.
Computer print-out (retouched) for dermatoglyphic patterns of right hands of females with leukaemia and normal controls.
The results in other classes of
are
equally
encouraging. It is to be emphasised that this degree of discrimination has been possible even with incomplete data. With additional information from the left hands and both hands together the results can only be better. Suggestions on the possible usefulness of this technique appear, therefore, to be well grounded. DANIEL STOWENS St. Luke’s Memorial Hospital Center, JOHN A. SAMMON. Utica, N.Y.
PANCYTOPENIA WITH CELLULAR MARROW—P.N.H.? SIR,-The combination of pancytopenia with a cellular marrow (P.C.C.M.) is well known. Usually clinical and simple laboratory studies reveal the cause-e.g., acute leukasmia or megaloblastic anxmia.1 We have seen an unusual group of 13 cases with this combination in whom diagnosis was difficult. 12 of the 13 were males. The clinical presentation was similar to that of aplastic ansmia and they had pancytopenia. In addition, they had mild reticulocytosis and red-cell morphological changes. The marrow examination in all these patients repeatedly revealed either normal cellularity or increased cellularity due to myeloid and erythroid precursors. The myeloid erythroid ratio was usually less than 1, and the red-cell precursors had an open chromatin and nuclear immaturity relative to their hsemoglobinisation. Myeloid maturation was normal. Megakaryocytes were somewhat decreased and no cells foreign to the marrow were seen. Such changes have been described in patients classified as having aplastic anxmia. 1-3 We felt, however, that the diagnosis of aplastic ansemia in patients with cellular marrow was not justified. We suggest that the presence of a cellular marrow when the patient has pancytopenia may be a feature of paroxysmal nocturnal hxmoglobinuria (P.N.H.). We carried out the tests for P.N.H. in 7 of these patients and obtained a positive result in 2. Since all of them had similar clinical and hsmatological findings, we wonder whether all the patients had P.N.H. The transfusion requirements of some of our patients were very variable. At times
they required 8-10 units in
a
short time
Wintrobe, M. M. Clinical Hematology. Philadelphia, 1967. Lewis, S. M. Br. J. Hœmat. 1962, 8, 322. 3. Scott, J. L., Cartwright, G. E., Wintrobe, M. M. Medicine, 1. 2.
4
patients
Baltimore, 1959, 38,
119.
847 and still had only a modest rise in the haemoglobin, and at other times they required no transfusions for several months. This was possibly a result of the known variability of the haemolytic process. In aplastic anaemia the transfusion requirements are usually fairly constant. Pancytopenia is a well known finding in P.N.H. This may occur before, during, or after the haemoglobinuria phase.4 In most cases of P.N.H. without pancytopenia, the marrow is cellular. When pancytopenia develops the marrow is said Dacie4 has asserted that at this stage the to be aplastic. appearance of the marrow is indistinguishable from that in aplasia due to other causes. A total of 116 published case-reports of patients with P.N.H. have been reviewed. (We shall not cite all the references.) 46 had pancytopenia at some stage of their illness. Of these, 21 had cellular or hypercellular marrows during the phase of pancytopenia; in 20 the marrow was reported as being hypocellular, while in the rest the information is not available. The 20 patients with hypocellular marrow are difficult to evaluate fully, either because of differences in patient-selection criteria,5 or because of some confusion about the composition of the series. 6,7 The bulk (13 of 20) of these patients are accounted for by 3 series.5,6,7 Thus, it appears that although P.C.C.M. has been observed frequently in patients with P.N.H., it has never been clearly stated that pancytopenia may be present with coexisting cellular marrow in the pancytopenia phase of
National Iranian Oil Company,
Abadan, Iran.
P.N.H.
These
problems
have
lately been discussed in
substantial number of On the marrow. basis of definite observations on 2 patients, and some suggestive data, we put forward the idea that pancytopenia associated with a cellular marrow may be an important feature of P.N.H. This finding has been noted individually on a number of occasions, but has not been considered of In summary,
we
have
seen
a
patients with pancytopenia and cellular
imnortance in the
J. E. CAUGHEY.
two
reviews, but no significance has been attached to the finding of pancytopenia with cellular marrow in relation to P.N.H. Vilter et al.,8 in an extensive review of refractory anaemia with hyperplastic marrow, mentions P.N.H. very briefly. Gardner and Blum,9 while discussing the problem of aplastic anaemia in P.N.H., do not discuss the cellularity of the marrow in this disease. They do, however, mention the reticulocytosis and the preponderance of men among patients with " aplastic anaemia " with P.N.H. This was true of our cases also-12 out of 13 were males, and all showed mild reticulocytosis.
anv
the children. The dose administered was an equivalent of approximately 1430 {ig. per day. The World Health Organisation’s recommended requirement of iodine intake is 150 {jLg. per day, so all these children received almost ten times the normal requirements, which I believe resulted in hypertrophy due to iodine-induced goitre. In the second trial, when iodated bread was distributed for general consumption throughout Tasmania, the estimated iodine intake per person was 270 {g. per day. The notable increase in thyrotoxicosis following the instigation of this prophylactic measure, especially in older people with adenomas, emphasises the danger of giving extra iodine to older patients with adenomatous goitres. The World Health Organisation has rather categorically laid down that the presence of goitre in 10% of a population indicates an endemic-goitre area, and this opens the door for wholesale iodine prophylaxis. I think these two experiences indicate the need for more accurate assessment of the degree of endemicity in any given area, as indicated by the incidence and size of goitre in teenage girls, the level of urinary iodide excretion in this group, the level of iodine in drinking-water, and the presence of other goitrogens in the area. With this information the level of iodine supplement can then be planned according to need. Also, individuals with adenomatous goitres should be watched with care.
FREE FATTY ACIDS AND CARDIAC ARRHYTHMIAS SIR,-Dr. Nelson (April 11, p. 783) is entitled to report that, under the conditions described, elevation of free fatty acids (F.F.A.) by heparin does not appear to increase the incidence of arrhythmias during the hour after the injection in patients with acute myocardial infarction. This is encouraging, and it is to be hoped that his findings will be confirmed with a fuller study. However, he has not presented any evidence to suggest, as he does, that F.F.A. are unimportant in the causation of arrhythmias fnllnwing of
acute
Department Cardiology, Royal Infirmary, Edinburgh.
mvoc5Ircii:oll tnfarftmn
V. A. KURIEN M. F. OLIVER.
Tinst
Department of Medicine, All-India Institute of Medical New Delhi-16, India.
Sciences,
A. MANGALIK A. N. MALAVIYA.
UNIVERSITY UPHEAVAL
SiR,—The letter from Dr. Huhle (April 11, p. 775) shows EFFECTS OF IODATION OF BREAD
SiR,—The value of iodine prophylaxis against goitre in endemic areas has been clearly established in many parts of the world. However, the reports of two recent experiences in Tasmania of goitre prophylaxis (March 7, p. 489 and p. 520) do pinpoint two dangers inherent in wholesale blanketing of an endemic area with iodine. In the first trial in Tasmania 10 mg. of potassium iodide was given weekly for a period of 5 years to children from infancy up to the age of 16 years. At the end of 5 years, there was a substantial increase in the goitre prevalence in 4.
5. 6. 7. 8. 9.
Dacie, J. V. The Hæmolytic Anaemias: Congenital and Acquired; part IV. London, 1968. Quagliana, J. M., Cartwright, G. E., Wintrobe, M. M. Ann. intern. Med. 1964, 6, 1045. Dacie, J. V., Lewis, S. M. Br. J. Hœmat. 1961, 7, 442. Lewis, S. M., Dacie, J. V. ibid. 1967, 13, 286. Vilter, L. W., Will, J. J., Jarrold, T. Semin. Hemat. 1967, 4, 175. Gardner, F. H., Blum, S. F. ibid. p. 250.
that he belongs to the radical faction of university assistants who feel that the academic teachers and, in particular, the full professors, are unfitted for their jobs, which they have obtained " by nepotism and protection ", and that things would be done just as well by their assistants. This generalisation is palpable nonsense. Nepotism and protection occur occasionally, in my experience, in most countries, when a desirable position is to be filled, whatever the method of selection. The scientific standard of the medical professors in West Germany is generally high, although the pre-Hitler level has not been reached yet. During recent years the younger academic teachers and the students have been well represented on the faculty boards. To pack these boards now to one third with students just beginning to learn medicine, to another third with assistants who may know some medicine but lack scientific experience, with a cleaner or a technician thrown in for good measure, leaves the academic teachers in the minority and is unreasonable. It is well known that in the past, some full professors have had too large departments and have exercised almost
DOROTHY HERMIONE LYNN.
DERMATOGLYPHICS AND LEUKÆMIA SIR,-The remarks of Dr. Wittwer and Dr. Giessmann (Feb. 21, p. 425) on the value of dermatoglyphic analysis, made in rebuttal to those of Verbovand Rosner,2 agree completely with our own approach to the problem, and we should like to offer some data in support, in the hope that the discipline will not be consigned to oblivion before it is fairly explored. We analyse finger and palm prints by the method which has been described best by Cummins and Meillo.3 The analysis yields 25 variables for each hand. To date, over 4000 pairs of prints have been studied. The persons from whom these were obtained were classified according to whether they were well or diseased, what their disease was, and the family history. Sufficient numbers of prints for statistical analysis were obtained from persons with diabetes, leukaemia, cancer (all types), Down’s syndrome, non-specific mental retardation, and schizophrenia. The healthy-control series was obtained predominantly from medical or paramedical people, and totals over 800. These people were selected because it was believed that they would be more knowledgeable about their family histories and less reticent in divulging the information to another
physician. Typical
results of analyses of right hands of White females with leukaemia are shown in the accompanying computer print-out. (Because of mechanical limitations only about 25%of patients are displayed in this figure.) The " 1 "s represent the normal controls and the " 3 "s patients. The X and Y axes are independent optimal linear discriminants determined from the original 25 variables. Statistically the results are highly significant. 1. 2. 3.
J. L. Lancet, 1969, F. ibid. p. 272.
323.
Verbov, ii, Rosner, Cummins, H., Meillo, C. Fingerprints, Palms and Soles; chaps. and 5. New York, 1961.
Computer print-out (retouched) for dermatoglyphic patterns of right hands of females with leukaemia and normal controls.
The results in other classes of
are
equally
encouraging. It is to be emphasised that this degree of discrimination has been possible even with incomplete data. With additional information from the left hands and both hands together the results can only be better. Suggestions on the possible usefulness of this technique appear, therefore, to be well grounded. DANIEL STOWENS St. Luke’s Memorial Hospital Center, JOHN A. SAMMON. Utica, N.Y.
PANCYTOPENIA WITH CELLULAR MARROW—P.N.H.? SIR,-The combination of pancytopenia with a cellular marrow (P.C.C.M.) is well known. Usually clinical and simple laboratory studies reveal the cause-e.g., acute leukasmia or megaloblastic anxmia.1 We have seen an unusual group of 13 cases with this combination in whom diagnosis was difficult. 12 of the 13 were males. The clinical presentation was similar to that of aplastic ansmia and they had pancytopenia. In addition, they had mild reticulocytosis and red-cell morphological changes. The marrow examination in all these patients repeatedly revealed either normal cellularity or increased cellularity due to myeloid and erythroid precursors. The myeloid erythroid ratio was usually less than 1, and the red-cell precursors had an open chromatin and nuclear immaturity relative to their hsemoglobinisation. Myeloid maturation was normal. Megakaryocytes were somewhat decreased and no cells foreign to the marrow were seen. Such changes have been described in patients classified as having aplastic anxmia. 1-3 We felt, however, that the diagnosis of aplastic ansemia in patients with cellular marrow was not justified. We suggest that the presence of a cellular marrow when the patient has pancytopenia may be a feature of paroxysmal nocturnal hxmoglobinuria (P.N.H.). We carried out the tests for P.N.H. in 7 of these patients and obtained a positive result in 2. Since all of them had similar clinical and hsmatological findings, we wonder whether all the patients had P.N.H. The transfusion requirements of some of our patients were very variable. At times
they required 8-10 units in
a
short time
Wintrobe, M. M. Clinical Hematology. Philadelphia, 1967. Lewis, S. M. Br. J. Hœmat. 1962, 8, 322. 3. Scott, J. L., Cartwright, G. E., Wintrobe, M. M. Medicine, 1. 2.
4
patients
Baltimore, 1959, 38,
119.
847 and still had only a modest rise in the haemoglobin, and at other times they required no transfusions for several months. This was possibly a result of the known variability of the haemolytic process. In aplastic anaemia the transfusion requirements are usually fairly constant. Pancytopenia is a well known finding in P.N.H. This may occur before, during, or after the haemoglobinuria phase.4 In most cases of P.N.H. without pancytopenia, the marrow is cellular. When pancytopenia develops the marrow is said Dacie4 has asserted that at this stage the to be aplastic. appearance of the marrow is indistinguishable from that in aplasia due to other causes. A total of 116 published case-reports of patients with P.N.H. have been reviewed. (We shall not cite all the references.) 46 had pancytopenia at some stage of their illness. Of these, 21 had cellular or hypercellular marrows during the phase of pancytopenia; in 20 the marrow was reported as being hypocellular, while in the rest the information is not available. The 20 patients with hypocellular marrow are difficult to evaluate fully, either because of differences in patient-selection criteria,5 or because of some confusion about the composition of the series. 6,7 The bulk (13 of 20) of these patients are accounted for by 3 series.5,6,7 Thus, it appears that although P.C.C.M. has been observed frequently in patients with P.N.H., it has never been clearly stated that pancytopenia may be present with coexisting cellular marrow in the pancytopenia phase of
National Iranian Oil Company,
Abadan, Iran.
P.N.H.
These
problems
have
lately been discussed in
substantial number of On the marrow. basis of definite observations on 2 patients, and some suggestive data, we put forward the idea that pancytopenia associated with a cellular marrow may be an important feature of P.N.H. This finding has been noted individually on a number of occasions, but has not been considered of In summary,
we
have
seen
a
patients with pancytopenia and cellular
imnortance in the
J. E. CAUGHEY.
two
reviews, but no significance has been attached to the finding of pancytopenia with cellular marrow in relation to P.N.H. Vilter et al.,8 in an extensive review of refractory anaemia with hyperplastic marrow, mentions P.N.H. very briefly. Gardner and Blum,9 while discussing the problem of aplastic anaemia in P.N.H., do not discuss the cellularity of the marrow in this disease. They do, however, mention the reticulocytosis and the preponderance of men among patients with " aplastic anaemia " with P.N.H. This was true of our cases also-12 out of 13 were males, and all showed mild reticulocytosis.
anv
the children. The dose administered was an equivalent of approximately 1430 {ig. per day. The World Health Organisation’s recommended requirement of iodine intake is 150 {jLg. per day, so all these children received almost ten times the normal requirements, which I believe resulted in hypertrophy due to iodine-induced goitre. In the second trial, when iodated bread was distributed for general consumption throughout Tasmania, the estimated iodine intake per person was 270 {g. per day. The notable increase in thyrotoxicosis following the instigation of this prophylactic measure, especially in older people with adenomas, emphasises the danger of giving extra iodine to older patients with adenomatous goitres. The World Health Organisation has rather categorically laid down that the presence of goitre in 10% of a population indicates an endemic-goitre area, and this opens the door for wholesale iodine prophylaxis. I think these two experiences indicate the need for more accurate assessment of the degree of endemicity in any given area, as indicated by the incidence and size of goitre in teenage girls, the level of urinary iodide excretion in this group, the level of iodine in drinking-water, and the presence of other goitrogens in the area. With this information the level of iodine supplement can then be planned according to need. Also, individuals with adenomatous goitres should be watched with care.
FREE FATTY ACIDS AND CARDIAC ARRHYTHMIAS SIR,-Dr. Nelson (April 11, p. 783) is entitled to report that, under the conditions described, elevation of free fatty acids (F.F.A.) by heparin does not appear to increase the incidence of arrhythmias during the hour after the injection in patients with acute myocardial infarction. This is encouraging, and it is to be hoped that his findings will be confirmed with a fuller study. However, he has not presented any evidence to suggest, as he does, that F.F.A. are unimportant in the causation of arrhythmias fnllnwing of
acute
Department Cardiology, Royal Infirmary, Edinburgh.
mvoc5Ircii:oll tnfarftmn
V. A. KURIEN M. F. OLIVER.
Tinst
Department of Medicine, All-India Institute of Medical New Delhi-16, India.
Sciences,
A. MANGALIK A. N. MALAVIYA.
UNIVERSITY UPHEAVAL
SiR,—The letter from Dr. Huhle (April 11, p. 775) shows EFFECTS OF IODATION OF BREAD
SiR,—The value of iodine prophylaxis against goitre in endemic areas has been clearly established in many parts of the world. However, the reports of two recent experiences in Tasmania of goitre prophylaxis (March 7, p. 489 and p. 520) do pinpoint two dangers inherent in wholesale blanketing of an endemic area with iodine. In the first trial in Tasmania 10 mg. of potassium iodide was given weekly for a period of 5 years to children from infancy up to the age of 16 years. At the end of 5 years, there was a substantial increase in the goitre prevalence in 4.
5. 6. 7. 8. 9.
Dacie, J. V. The Hæmolytic Anaemias: Congenital and Acquired; part IV. London, 1968. Quagliana, J. M., Cartwright, G. E., Wintrobe, M. M. Ann. intern. Med. 1964, 6, 1045. Dacie, J. V., Lewis, S. M. Br. J. Hœmat. 1961, 7, 442. Lewis, S. M., Dacie, J. V. ibid. 1967, 13, 286. Vilter, L. W., Will, J. J., Jarrold, T. Semin. Hemat. 1967, 4, 175. Gardner, F. H., Blum, S. F. ibid. p. 250.
that he belongs to the radical faction of university assistants who feel that the academic teachers and, in particular, the full professors, are unfitted for their jobs, which they have obtained " by nepotism and protection ", and that things would be done just as well by their assistants. This generalisation is palpable nonsense. Nepotism and protection occur occasionally, in my experience, in most countries, when a desirable position is to be filled, whatever the method of selection. The scientific standard of the medical professors in West Germany is generally high, although the pre-Hitler level has not been reached yet. During recent years the younger academic teachers and the students have been well represented on the faculty boards. To pack these boards now to one third with students just beginning to learn medicine, to another third with assistants who may know some medicine but lack scientific experience, with a cleaner or a technician thrown in for good measure, leaves the academic teachers in the minority and is unreasonable. It is well known that in the past, some full professors have had too large departments and have exercised almost