Use of advanced care directives by ambulatory chemotherapy patients with malignant disease: Likely predictors and impact of physician intervention

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Background: Despite their poor prognosis, few cancer patients have advanced care directives (ACD). Most often, ACD is discussed in an inpatient setting, when the patient is acutely ill and often nearing the end of life. Timely and thoughtful discussion would be better accomplished for both the patient and the family before such hospitalization. Methods: Interviews were done in 108 outpatients in an ambulatory chemotherapy center. A questionnaire noted whether ACD was executed or not, demographics (including education, religion and insurance status), performance status, characteristics of their cancer, and family status. All patients without ACD were counseled on the importance of ACD. The presence of an ACD was documented at each visit. Statistical comparison of patients with and without ACD at each visit was done. Results: The following variables were significantly associated with having an ACD at the first visit. Patients living alone could not be included in the logistic regression model, as none had advanced directives. However ACD execution differed significantly in patients living alone, compared with those living with family (0/33 vs 15/75; p=0.005). An additional 42 patients executed an ACD by the third visit. At the third visit, only living with family vs living alone remained significantly associated with having ACD. [OR=3.17 95% CI: 1.34, 7.50; p=0.009]. Conclusions: The following findings are noteworthy. Only 15/108 (14%) cancer outpatients had ACD. This disturbingly low rate increased to 55/108 (51%) after physician- initiated discussion. The following characteristics predicted not having ACD before intervention: younger age, absence of metastasis, better performance status, lower education status and living alone. After several physician interventions, only living alone remained a significant barrier to ACD execution by cancer outpatients. These results provide new insights and strategies to encourage improved advanced directive execution.

[Table: see text]

No significant financial relationships to disclose.

Prevalence of HTLV-I-associated T-cell lymphoma

In order to assess the prevalence rate of HTLV-1-associated T-cell lymphomas and human retrovirus infection in general, approximately 21,000 individuals representing various patient populations, retroviral risk groups, and blood donors were examined for HTLV-I, HTLV-II, HIV-1, or HIV-2 infection using serologic and PCR assays. The prevalence rates among volunteer blood donors were 0.02% and 0% for HTLV and HIV, respectively. Significantly increased HTLV prevalence rates were observed among paid blood donors, African American health care clinic patients, Amerindians, recipients of HTLV-positive cellular blood products, intravenous drug users, sexual contacts and family members of HTLV-positive people, and patients with primary thrombocytosis and other-than-low-grade non-Hodgkin's lymphoma (NHL). Among some of these groups there were significant differences in the prevalence of HTLV-I versus HTLV-II. The eight HTLV-positive NHL patients all had mature, high-grade, CD4+ T-cell lymphomas with clonally integrated HTLV-I, for a prevalence of 4% among other-than-low-grade NHL patients. Seven of the eight died from their disease within 2 years despite treatment. Interestingly, two groups at risk for HTLV infection, namely needle stick victims and recipients of HTLV-infected and/or pooled plasma products, showed no evidence for infection. Significantly increased HIV-1 prevalence was observed among paid blood donors, African Americans, homosexuals, female prostitutes, hemophiliacs, and other-than-low-grade NHL patients. Only one patient was infected with HIV-2. Of the nine HIV-positive, other-than-low-grade NHL patients, seven HIV-1 positives had B-cell lymphomas, one HIV-1 positive had an HTLV-I-positive CD4+ T-cell lymphoma, and one infected with HIV-2 had a CD4+ T-cell lymphoma that was HTLV negative. The data indicate that HTLV-I lymphoma, while uncommon, is not necessarily rare among other-than-low-grade NHL cases in the United States and, given its poor prognosis, should probably be studied separately in clinical trials.

A study of adult T-cell leukemia/lymphoma incidence in central Brooklyn

Adult T-cell leukemia/lymphoma (ATL), a rare outcome of infection with human T-lymphotropic virus (HTLV-I), is endemic in central Brooklyn, which has a large Caribbean migrant population. Previous studies have suggested that HTLV-I prevalence in central Brooklyn may be similar to that recorded in the Caribbean islands. We established a pilot 1-year surveillance program to identify cases of ATL in 7 of 10 hospitals serving the residents of 18 zip codes of central Brooklyn with a combined population of 1,184,670. Of the 6,198 in-patient beds in the catchment area, approximately 83% were covered. Twelve incident cases of ATL were ascertained, all among persons of Afro-Caribbean descent, indicating an annual incidence in African-Americans in this community of approximately 3.2/100,000 person-years. Unexplained hypercalcemia was the most useful screening method, identifying 3 of 5 patients not referred for possible ATL by a local hematologist. The female:male ratio was 3:1. The age pattern was different from that reported in the Caribbean Basin and closer to the pattern seen in Japan. Our study supports evidence that HTLV-I infection and ATL are endemic in central Brooklyn and suggests that a more intensive surveillance program for this disease coupled with intervention efforts to reduce HTLV-I transmission are warranted.

Undiagnosed adult T-cell leukemia/lymphoma in central Brooklyn, NY

We present a case, identified by surveillance for adult T-cell leukemia/lymphoma (ATL), who had initial symptoms not specifically related to ATL, and who would not have been identified as having ATL otherwise. A 51-year-old Trinidadian black woman was hospitalized for abdominal pain, nausea, and vomiting. Hematology and clinical chemistry revealed leukocytosis (19,600/mm3), an elevated lymphocyte percent (63%), and hypercalcemia (19.4 mg/dl). The patient was serologically confirmed with HTLV-I-associated ATL. Lymphoma was diagnosed at autopsy. This case is representative of ATL, which along with HTLV-I infection, may be emerging public health problems in urban communities of the northeast and southeast United States.

Chronic hepatitis C in patients with sickle cell disease

OBJECTIVE

To determine the prevalence of hepatitis C virus (HCV) antibody in patients with sickle cell disease and to analyze the nature of chronic liver disease in these patients.

METHODS

A total of 99 patients attending a comprehensive sickle cell and thalassemia program at the Interfaith Medical Center, Brooklyn, NY, participated in the study. Eighty-five patients had sickle cell anemia (ss), eight had sickle C disease (sc), and six had sickle B thalassemia. History of blood transfusion, i.v. drug use, homosexuality, and alcohol abuse was obtained with a questionnaire and chart review. All patients were screened for HCV antibody by a first generation enzyme-linked immunosorbent assay. All positive results were confirmed with radioimmunoblot assay II (RIBA II). Patients were also checked for the presence of hepatitis B surface antigen. ALT levels were measured, and percutaneous liver biopsies were performed in patients positive for HCV antibody and greater than 1.5 times the normal ALT levels.

RESULTS

Antibody to HCV was detected in 10/99 patients (10.10%). Seven of 30 patients (23.33%) who received more than 10 U of packed red blood cells were positive for HCV antibody. Only 3/38 (7.9%) patients with less than 10 U of packed red blood cells in the past were positive for HCV antibody. None of the patients who never received blood transfusion were positive for HCV antibody (0/31 or 0%). A total of seven liver biopsies were performed in patients positive for HCV antibody. Two out of seven specimens (28.57%) showed significant liver damage. One revealed cirrhosis, and the other showed chronic active hepatitis. The remainder of liver biopsies (5/7; 71.42%) showed only mild portal inflammation.

CONCLUSIONS

The prevalence of HCV antibody is directly related to the number of blood transfusions in patients with sickle cell disease. Chronic HCV infection could be a major cause of cirrhosis of the liver in these patients.

An enhanced surveillance program for adult T-cell leukemia in central Brooklyn

The Brooklyn Adult T-cell Leukemia/Lymphoma (ATL) study was developed to estimate the incidence of the human T-cell lymphotropic virus type I (HTLV-I)-associated ATL in the Crown Heights/Bedford Stuyvesant community. This central Brooklyn black community is an area which has already been shown in earlier reports to be endemic for HTLV-I-associated ATL. Surveillance has been conducted at seven area hospitals that serve this community, with surveillance already completed at five hospitals. Potential study subjects who are 20 years or older are identified by the review of admission records, discharge summaries, pathology and clinical chemistry reports, or physician referrals. Diagnoses of leukemia or lymphoma, or the presence of leukocytosis or hypercalcemia are used as criteria to identify the subjects. Participating subjects give a sample of blood for the determination of HTLV-I infection by serologic tests. At the time of enrollment, subjects provide demographic information including age, sex and birthplace. After one year of surveillance at five hospitals (39.5% of inpatient beds in the catchment), we have identified 12 cases of HTLV-I-associated ATL. The mean age of the ATL patients was 50 years, with patients being predominantly female (83.3%) and often Caribbean immigrants (83.3%). Interestingly, 42% of our cases were identified solely by findings of hypercalcemia from clinical chemistry reports. The remaining ATL cases were identified by physician referral. This enhanced surveillance program that uses both clinical and laboratory criteria for ATL case ascertainment can serve as a prototype for similar surveillance in other areas endemic for HTLV-I-associated ATL--an important effort because of the strong potential for disease prevention.

Seroprevalence of human T-lymphotropic virus in blacks from a selected central Brooklyn population

Human T-cell leukemia virus type I (HTLV-I) has been causally linked to adult T-cell leukemia/lymphoma and tropical spastic paraparesis/HTLV-I-associated myelopathy. Few seroprevalence studies have been carried out in the United States. Because of the number of reports of adult T-cell leukemia/lymphoma and tropical spastic paraparesis/HTLV-I-associated myelopathy in blacks from central Brooklyn, New York, we decided to initiate a seroprevalence study in this community. Intravenous drug users and male homosexuals were excluded. A total of 480 individuals from medical clinics and health fairs were surveyed via questionnaire, and their sera were assayed for HTLV-I/II antibody by two laboratories. An overall seroprevalence rate was 21/480 (4.4%). This is almost 200 times greater than a study of a national sample of U.S. blood donors. Rates were similar for individuals originating from the United States and the Caribbean. Nine of the 21 seropositive individuals returned for further testing. Polymerase chain reaction assays revealed that 8 were positive for HTLV-I and 1 for HTLV-II. Although this group may not be representative of the "normal" black population of central Brooklyn, the high seroprevalence rate necessitates that the incidence of HTLV-I-associated illnesses be determined in this community.

Photosensitivity, abnormal porphyrin profile, and sideroblastic anemia

Cutaneous photosensitivity in a 43-year-old man with idiopathic sideroblastic anemia associated with an abnormal porphyrin profile is reported. This condition was associated with elevated free erythrocyte porphyrin, plasma protoporphyrin, urine porphyrins (predominantly coproporphyrin), stool porphyrins (predominantly protoporphyrin), decreased ferrochelatase activity, and deletion of portions of the long arms of chromosomes 18 and 20. Five other patients with sideroblastic anemia and abnormal porphyrin profiles have been described; all but one of these patients had photosensitivity. The porphyrin profile of this patient is similar to that of three other previously described patients.

Case report: adult T-cell leukemia/lymphoma associated with recurrent strongyloides hyperinfection

Adult T-cell leukemia/lymphoma (ATLL) was demonstrated postmortem in a 47-year-old woman initially manifesting severe hypercalcemia and a vertebral compression fracture. Hyperinfection with Strongyloides stercoralis preceded the appearance of ATLL by several months and ultimately dominated the terminal course. Although HTLV-I and S. stercoralis commonly infect the same host, only three other cases of concomitant ATLL and hyperinfection have been reported in English. The apparent rarity of this association suggests that immunologic sequelae of ATLL do not predispose to dissemination and multiplication of Strongyloides. Observations pertinent to this conclusion are reviewed.

Transfusion and alloimmunization in sickle cell disease. The Cooperative Study of Sickle Cell Disease

In 1,814 patients with sickle cell disease who had been transfused, the overall rate of alloimmunization to erythrocyte antigens was 18.6%. The rate of alloimmunization in this group appears to be an explicit function of the number of transfusions received because it increases exponentially with increasing numbers of transfusions. Alloimmunization usually occurred with less than 15 transfusions, although the rate of alloimmunization continued to increase when more transfusions were given. The rate of alloimmunization was less in patients with hemoglobin SC disease and sickle-beta+ thalassemia because these patients had received fewer transfusions. Children less than 10 years old had a slightly lower rate of alloimmunization than patients in other age groups even after correction for the number of transfusions given. Women were more frequently alloimmunized than men; this was largely due to the fact that women received more transfusions than men, but in the age group 16 to 20 years the increase may have been due in part to alloimmunization owing to pregnancy. Forty-five percent of those alloimmunized made antibodies of only one specificity; 17% made four or more antibodies reacting with different antigens. Antibodies to the C and E antigens of the Rh group, the Kell antigen, and the Lewis antigens were most commonly made. These findings may be important in formulating a rational transfusion policy in sickle cell disease.

Endoscopic leukemic polyposis

Gastrointestinal involvement in leukemia and lymphoma is common and may present with varying clinical manifestations (1). We report a case of gastrointestinal bleeding with endoscopic findings of diffuse leukemic polyposis and the response to radiotherapy, with a brief review of the literature.

Immunodetection of human T-cell lymphotropic virus type I core protein in biological samples by using a monoclonal antibody immunoassay

A monoclonal antibody-based enzyme immunoassay (EIA) has been developed for detection of human T-cell lymphotropic virus type I (HTLV-I) core protein. The monoclonal antibody (clone 6.11) specifically recognizes the p19 gag gene-encoded protein of the virus. The EIA was over 100 times more sensitive than reverse transcriptase measurement and was capable of responding to less than 500 pg of whole-virus lysate. The assay exhibited type specificity in that HTLV-II antigens failed to produce a positive signal. In addition, a panel of other viruses demonstrated no antigenic cross-reactivity. These included herpesviruses, measles virus, human immunodeficiency viruses, and others. Viral p19 was followed during the course of density gradient ultracentrifugation in the presence of detergent, where it was noted to associate with viral membrane proteins. In comparison, reverse transcriptase activity localized in fractions of higher density containing envelope-free cores. Of clinical interest, the EIA was used to detect HTLV-I antigen in the viral cultures of patients with HTLV-I-associated myelopathies and from symptom-free individuals with proviral integration.

Acute pancreatitis in sickle cell crisis

A case of acute pancreatitis, complicated by pseudocyst formation, is described in a patient with sickle cell crisis. The differential diagnosis is discussed and the literature reviewed.

Thrombotic thrombocytopenic purpura in patients with the acquired immunodeficiency syndrome (AIDS)-related complex. A report of two cases

Immune thrombocytopenia has been reported with increased incidence in high-risk persons such as intravenous drug addicts and homosexual men who have serologic evidence of infection with human immunodeficiency virus (HIV). Thrombotic thrombocytopenic purpura, generally regarded as a rare disorder, has also been seen in association with exposure to HIV. Two patients had classical symptoms and laboratory findings of thrombotic thrombocytopenic purpura and the acquired immunodeficiency syndrome (AIDS)-related complex. Both patients belong to high-risk groups. They were treated with conventional therapy for thrombotic thrombocytopenic purpura and followed for 3 months. Their response to treatment was no different from that of other groups of patients with this syndrome. This article alerts physicians to the possible association of thrombotic thrombocytopenic purpura, AIDS, and AIDS-related complex.

Adult T-cell leukemia/lymphoma in Brooklyn

Fifteen patients with adult T-cell leukemia/lymphoma (ATLL) were identified in less than a two-year period in the Crown Heights-Bedford Stuyvesant section of Brooklyn, NY. All patients were black; nine patients originated from the Caribbean islands and six from the southern United States. Two of the patients were father and daughter, the first evidence of familial occurrence in the United States. Their clinical course was similar to that of previously described patients with this disorder. To our knowledge, these 15 patients represent the largest series of ATLL reported in the United States. We recommend that ATLL be seriously considered in the differential diagnosis of patients with non-Hodgkin's lymphoma, mycosis fungoides, lymphatic leukemia, or hypercalcemia.

The first report of familial adult T-cell leukemia lymphoma in the United States

Two patients, a daughter and her father, developed the acute type of adult T-cell leukemia/lymphoma (ATLL) within a 3-month period. Antibodies against HTLV-I have been found in both wives of the father. The second wife acquired the infection from her husband within 3 years of marriage. The patients described represent the first cases of familial ATLL in the United States. ATLL continues to be frequently misdiagnosed in the United States. A positive family history consistent with this disease in a patient with a lymphoid malignancy may be a helpful clue for earlier diagnosis.

Chromosomal abnormalities in adult T-cell leukemia/lymphoma (ATL). A report of six cases with review of the literature

Chromosomal studies were performed on six patients with adult T-cell leukemia (ATL). Structural abnormalities of chromosome 3 were the most common. In one case a complete loss of the short arm of chromosome 10 (10 p-) was noted while in another case a balanced translocation involving chromosome 10p and 4q was found. These abnormalities have not been previously reported. After reviewing the literature, it was concluded that chromosomes 3, 6, 10, 13, 14, and X were most frequently involved in abnormalities. Specific and consistent chromosomal abnormalities were noted in each study. Therefore, it is hypothesised that the mutation rate for this virus may be higher than first expected. Furthermore, the relative consistency of heterogeneous findings in different localities may reflect a geographic clustering of specific chromosomal abnormalities which may in turn be related to specific and geographically associated viral mutations. To support these suggestions not only are more cytogenetic data required but a molecular evaluation of these patients must be carried out to establish a relationship, if any, between genetic abnormalities and the epidemiology of ATL.

Length polymorphisms of the human Y chromosome in patients with chronic myelogenous leukemia

The extent of length heteromorphisms of the human Y chromosomes was measured in 50 patients with chronic myelogenous leukemia and was compared with 50 normal controls. No significant difference (p greater than 0.05) in the size of the Y chromosome was noted between these two groups. These findings differ from an earlier investigation, where a longer heterochromatic segment of Y chromosome was noted in malignant tumors and it was stressed that constitutive heterochromatin plays a role in susceptibility of cancer. Present investigation, however, suggests that this is not the case in patients with chronic myelogenous leukemia.

Role of heterochromatin during preferential 9q;22q translocation in chronic myelogenous leukemia

The secondary constriction region (h) of human chromosome 9 was evaluated in 55 chronic myelogenous leukemia (CML) patients with respect to its size and position. Each case was examined by C-banding and distamycin A-4,6-diamidino-2-phenylindole techniques for the expression of the h regions. When one h region of chromosome 9 was larger, it was more frequently involved in the reciprocal translocation with chromosome 22. In addition, there was a higher incidence of pericentric inversions in the h regions in the translocated chromosome 9 when compared with normal homologues. The role of the constitutive heterochromatin of chromosome 9 as a possible influencing factor during 9q;22q translocation in CML is suggested.

Long Survival in Philadelphia-Chromosome-Positive Acute Leukemia

A case of Philadelphia (Ph')-chromosome-positive acute leukemia (AL) is presented who went into remission with disappearance of the Ph1chromosome and later on developed the chronic phase of chronic granulocytic leukemia (CGL) with reappearance of the Ph1chromosome. The patient is alive 6+ years following the diagnosis. The entity of Ph1-positive AL is discussed. It is suggested that the patients with Ph1-positive AL who develop CGL have a better prognosis than previously described.

Position of the Y-chromosome at somatic metaphase in patients with chronic myelogenous leukemia (CML)

A random distribution of the Y-chromosome at somatic metaphase was found in 50 patients with Ph' positive chronic myelogenous leukemia (CML). Thus, it is concluded that the 'positive' of the Y-chromosome at somatic metaphase does not appear to influence the loss from bone marrow cells.

A possible cause of non-disjunction of additional chromosome 21 in Down syndrome

A possible cause of non-disjunction of chromosome 21 in Down Syndromes has been cytogenetically evaluated by examining the parents by Ag-staining technique. In all the cases studied so far, the contributing parents have active ribosomal cistrons on both chromosomes 21 i.e. both chromosomes are stained positively by silver staining. These results show that the active NORs might play an essential role in meiotic non-disjunction. Furthermore, the preliminary results demonstrate that the acrocentric associations of homologous and non-homologous nature involving chromosome 21 are the most frequent in the contributing parent which may further indicate the role of multiple cellular factors affecting the associations in promoting the nondisjunction in addition to active NORs. The possible mechanisms regarding the non-disjunction of chromosome 21 have been described.

Evidence of a new chimeric bcr/c-abl mRNA in patients with chronic myelocytic leukemia and the Philadelphia chromosome

The hallmark of chronic myelocytic leukemia is the presence of the Philadelphia chromosome (Ph1). In recent studies, we obtained data that strongly suggested the involvement of an oncogene, c-abl, in this type of leukemia. This oncogene, normally located on chromosome 9, is translocated to chromosome 22 as a result of the Ph1 translocation. In addition, we identified a region on chromosome 22, the breakpoint cluster region (bcr), which contains the chromosomal breakpoint in all patients with chronic myelocytic leukemia who are positive for Ph1. Recent studies have suggested that the bcr is part of a gene that is truncated as a consequence of the Ph1 translocation. The deleted part of this gene could be replaced by c-abl sequences; to test this hypothesis we analyzed the RNA of five patients with chronic myelocytic leukemia. All five had chimeric bcr/c-abl messenger RNA, suggesting that the deleterious effects of this disease can be associated with an abnormal chimeric protein encoded by the bcr and the c-abl oncogene.

"Masked" Ph1-chromosome in chronic myelogenous leukaemia (CML)

The CML patients with so called masked Ph1-chromosome have been reviewed. Although the importance of c-sis and c-abl oncogenes is gaining popularity yet their role in the genesis of CML remain obscure. Patients with masked Ph1-chromosomes where chromosome 9 is not involved in the translocation(s) will provide a clue to the role of c-abl and/or c-sis in oncogenesis.

Extramedullary presentation of blast crisis in chronic myelogenous leukemia

We present a case with the clinical and pathological impression of Ph1-positive chronic myelogenous leukemia in extramedullary blast crisis involving lymph nodes as demonstrated by morphological and cytogenetic studies. The hyperploid cell lines that were present in the lymph node were not present in the bone marrow. The present case demonstrates that cytogenetic and morphological studies of extramedullary organs are helpful in the confirmation of the diagnosis of blast crisis, especially when lymph nodes are the site of original presentation.

Unusual translocations involving chromosomes 12;22 and 9;12 in a case of chronic myelogenous leukemia

A case of chronic myelogenous leukemia (CML) with highly unusual translocations involving both chromosomes #12 is reported. The origin of the Ph1 chromosome was due to a 12p/22q translocation. Chromosome #9 was involved in a translocation with the other chromosome #12. By critical examination of the "size" of the Philadelphia chromosome, it was noted that the breakpoints on 22q were different when compared with a previous case (see Verma and Dosik [16]), although the short arm of chromosome #12 (12p) was involved in both instances. So far, no apparent differences in the course of the disease have been attributed to the types of translocation observed in these cases.

Chromatin of h regions of human chromosomes at high resolution

Segmentation of the secondary constriction region (h) of human chromosomes 1, 9 and 16 is demonstrated by a high resolution banding technique. Based on these staining properties, it is suggested that the composition of the h region in human chromosomes is heterochromatic as well as euchromatic.

Chromosome fragility in Bloom's syndrome cell line GM 1492

Chromosomal aberrations in skin fibroblasts from Bloom's syndrome cell line GM 1492 are described. As expected, the sister chromatid exchange (SCE) frequency was high. Four very common chromosomal rearrangements included dup( 6q ), t(13;15), dic(16), and del(11q). The nucleolar organizer regions (NOR) in the dicentric t(13;15) were active. The increased incidence of chromosomal markers suggests an evolution of clones in the cell line.

Cytogenetic studies of blast cells in the cerebrospinal fluid in meningeal leukemia

Chromosome analysis can be performed by culturing cerebrospinal fluid from patients with CNS leukemia. The quality of the metaphase spreads are adequate for banding studies. This approach is useful, especially when the bone marrow is difficult to aspirate or when CNS involvement is the only manifestation of the leukemia.

Peripheral location of the Y chromosome: relationship to race and length heteromorphism

In the present report we examined the position of the Y chromosome with respect to its size and race to determine their relationship to its peripheral location. Peripheral blood lymphocytes were cultured from 172 normal male individuals (70 Asian Indians; 49 American Blacks; and 53 Caucasians) and 2770 QFQ cells were photographed. The length of the Y chromosome was classified into four groups i.e., small, average, large and very large as described earlier (Verma et al., J. Med. Genet., 15, 227-281, 1978). The average incidence of peripheral location of all races for small, average, large and very large was 3.64, 5.84, 10.51 and 11.17 per cent respectively. For blacks and caucasians, the peripheral location was influenced by its size while the incidence remained the same for Indians for all sizes. Consequently, it is presumed that the position of the Y chromosome in somatic metaphases depends upon race as well as its size. Furthermore, we have provided a method for determining the position of the Y chromosome which should suffice for most situations.

Random single chromatid and nonrandom double chromatid type segregation of human acrocentric chromosomes in BrdU-labeled mitoses

Chromatid segregation was analyzed using satellite association of 5-bromodeoxyuridine (BrdU) differentially stained acrocentric chromosomes of human leukocytes. Data were classified into cis and trans configurations in second and third division cycles. It was found that single chromatid types have random segregation (1:1) while nonrandom segregation was noted for double chromatid types. The nonrandom segregation hypothesis of earlier investigators needs to be reexamined.

Are breakpoints variable on the long arm of chromosome 5 (5q-) in patients with refractory anemia?

A 74-year-old female was referred with a diagnosis of refractory anemia (RA). Direct bone marrow preparation without phytohemagglutinin-stimulated lymphocytes revealed an abnormal karyotype in 50% of the cells. By RFA technique, it was determined that chromosome 5q had a terminal deletion (band 5q31----qter). A review of cases of RA in which 5q is involved shows that the deleted segment varies from case to case.

Expression of ribosomal cistrons of human chromosomes at high resolution

The expression of ribosomal cistrons in the nucleolar organizer regions (NORs) has been studied with high resolution banding in the acrocentric chromosomes of 10 normal individuals. It was found that if a particular chromosome did not stain with silver nitrate at metaphase, then it did not stain at prophase either. Therefore, it is concluded that some of the acrocentric chromosomes have variable expression of NORs.

A simple technique for obtaining prometaphase chromosomes from lymphocytes

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Human chromosomes in prenatal diagnosis: a one step high resolution technique

A simple high resolution technique for human chromosomes is described for fibroblasts obtained from amniotic fluid cell cultures. The application and clinical significance of this technique in prenatal diagnosis is discussed.

Size of Y chromosome not associated with abortion risk

The average length of the Y chromosome in men whose wives had multiple fetal loss was 1.046 +/- 0.106, which is not significantly different from the average length in controls (1.068 +/- 0.096). Therefore, it is concluded that there is no evidence for an association of the size of the Y chromosome with an increased risk of abortions as previously suggested. Furthermore, the authors suggest that the definition of a large Y be revised, as the majority of normal males have a Y/F index of more than 1.0, so a Y/F ratio of greater than 1.0 should not be considered a long Y chromosome.

Preferential association of nucleolar organizing human chromosomes as revealed by silver staining technique at mitosis

The frequency of different types of satellite associations of nucleolar organizing human chromosomes (i.e. acrocentric chromosomes; 13, 14, 15, 21, and 22) is reported using 10 normal individuals by Ag-staining technique. The preferential involvement of acrocentric chromosomes in satellite association is suggested. Only acrocentric chromosomes with active NORs (i.e. Ag-stained) were found in association while unstained (inactive NORs) chromosomes were never seen in satellite association. In general as number of NORs expression increase, the frequency of association per cell was also increased. A possible mechanism and the clinical consequences of such an unusual phenophenon is described.

Racial variation of a non-fluorescent segment of the Y chromosome in East Indians

Seventy normal male East Indians were selected to study the length of the fluorescent (f), non-fluorescent (nf), and total length of the Y chromosome by the QFQ technique. The length of the Y chromosome was classified into five groups using subjectively defined criteria, namely, very small, small, average, large, and very large. The frequencies of Y/F indices for these groups were 0.0%, 1.42%, 15.71%, 58.57%, and 24.28%, respectively. The variation in the total length of the Y chromosome was accounted for by variations in the length of the nf as well as the f segments. The mean Y/F, f/F, and nf/F indices for East Indians were 1.20, 0.47, and 0.73, respectively. A longer Y was noted in East Indians primarily owing to an increase in size of the nf segment in comparison to normal black and Caucasian populations. Furthermore, it is emphasised that the definition of 'average' or 'large' Y varies from race to race.

Higher incidence of small Y chromosome in humans with trisomy 21 (Down syndrome)

The length of the Y chromosome was measured in 42 black patients with trisomy 21 (47,XY,+21) and a similar number of normal individuals of American black ancestry. The length of the Y was expressed as a function of Y/F ratio and arbitrarily classified into five groups using subjectively defined criteria as follows: very small, small, average, large, and very large. Thirty-eight % of the trisomy 21 patients had small or very small Ys compared to 2.38% of the controls (P less than 0.01). In both populations the size of the Y was not normally distributed. In the normals it was skewed to the left, whereas in the Downs the distribution was flat (platykurtic). A significantly higher incidence of Y length heteromorphisms was noted in the Down as compared to the normal black population. In the light of our current understanding that about one-third of all trisomy 21 patients are due to paternal nondisjunction, it may be tempting to speculate that males with small Y are at an increased risk for nondisjunction of the 21 chromosome.

Cytosine arabinoside with daunorubicin or adriamycin for therapy of acute myelocytic leukemia: a CALGB study

A randomized comparison of the relative efficacy and toxicity of daunorubicin (DNR) at 30 or 45 mg/sq m or adriamycin (ADM) at 30 mg/sq m, given on the first 3 days of a 7-day continuous infusion of cytosine arabinoside (ara-C) at 100 mg/sq m/day, shows the outcome to be dependent on anthracycline, dose, and patient age. DNR 45 is significantly better than DNR 30 or ADM 30 for inducing complete remissions (CR) in patients younger than 60 yr, (72%, 59%, 58% CRs, respectively). DNR 30 is better than DNR 45 or ADM 30 for inducing CR in patients older than 60 yr (47%, 31%, 35%, respectively). There was a corresponding shift in the induction mortality for the age, dose, and anthracycline groups. Adriamycin was significantly more toxic to the gastrointestinal tract than daunorubicin. The duration of complete remission, with cyclic courses of maintenance therapy, was independent of the patient's age, the dose, or choice of anthracycline used in induction, and of whether the maintenance courses were given every 4 wk or every 8 wk.

Human chromosomal heteromorphisms in American blacks. VI. Higher incidence of longer Y owing to non-fluorescent (nf) segment

Sixty normal male American blacks were selected to study the length of fluorescent (f), non-fluorescent (nf), and total length of the Y chromosome by the QFQ technique. The length of the Y chromosome was classified into five groups: very small, small, average, large, and very large. The frequencies of Y/F indices for these groups were 0.0, 3.33, 56.67, 30.00, and 10.00%, respectively. The variation in the total length of the Y chromosome was accounted for by variations in the length of the nf as well as the f segment. A longer Y was noted in blacks owing to an increase in size of the nf segment in comparison with a normal Caucasian population. Forty percent of American blacks had large or very large Y chromosomes, while this class comprised only 18.3% of Caucasians, which is significantly different (p less than 0.05). Furthermore, the length of the Y chromosome was normally distributed among Caucasians, while among blacks the distribution was skewed to the left. The mean Y/F, f/F, and nf/F indices were 1.09 +/- 0.10, 0.42 +/- 0.09, and 0.67 +/- 0.04, respectively.

The clinical significance of pericentric inversion of the human Y chromosome: a rare "third" type of heteromorphism

A 28-year-old normal East Indian was found to have a pericentric inversion of the Y chromosome. After reviewing the literature, it was concluded that an inverted Y chromosome does not impede the production of normal sperm and does not predispose to non-disjunction of other chromosomes in the progeny. Thus, the earlier concept of nondisjunction was rejected, and it is suggested that aberrant cases with aneuploidy and an inverted Y are fortuitous. The pericentric inverted Y is inherited from generation to generation and has no clinical significance. The prevalence of males with pericentric Y inversion in the general population is approximately 1 per 1000. It is suggested that a pericentric inversion of the Y chromosome is a rare chromosomal heteromorphism and should be called type III.

Influence of renal failure on myelosuppressive effects of melphalan: Cancer and Leukemia Group B experience

The influence of renal insufficiency on melphalan-induced myelosuppression was examined during the initial 10 weeks of treatment in 295 patients with multiple myeloma. Patients were randomized to receive either oral melphalan (0.15 mg/kg/day for 7 days, followed by 0.05 mg/kg/day after recovery from the wbc count nadir) or iv melphalan (16 mg/m2 every 2 weeks for four doses, followed by a single dose every 4 weeks). All patients received a 6-week tapering course of prednisone. Patients with renal insufficiency (BUN greater than or equal to 30 mg/100 ml) had a significantly higher frequency of severe leukopenia (less than or equal to 1000 cells/mm3) following iv melphalan than did patients with normal renal function (50% vs 15%, respectively; P = 0.007). The latter effect resulted in an increased frequency of drug-related deaths secondary to infection. The frequency of severe thrombocytopenia (less than or equal to 25,000 cells/mm3) was also greater in patients with renal failure following iv melphalan therapy. Reduction of iv melphalan dose to 50% in patients with elevated BUN reduced the frequency of these complications to levels that were not significantly different from those observed in patients with normal renal function. The frequency of severe myelosuppression was independent of renal function in patients receiving oral melphalan. Possible explanations for these findings are discussed.

A rapid method for identification of constitutive heterochromatin of secondary constriction regions of human chromosomes 1, 9, and 16

The secondary constriction regions (h) of chromosomes 1, 9, and 16 stained deep red by RBA (R-bands by BrdU using Giemsa)--a useful tool for demonstrating the constitutive heterochromatic heteromorphisms in these regions. The unusual staining pattern of bands p 12 to q11 of chromosome 3, which is late replicating, also is reported. The extended deep red region does not correspond to C-banding on chromosome 3. This technique does not require sequential banding by QFQ and CBG for detecting the h-region heteromorphisms.

Human chromosomal heteromorphisms in American blacks. IV. Intensity variation in centromeric regions of chromosomes 3 and 4

One hundred normal American Blacks were studied by q-banding technique in order to estimate the type and frequency of heteromorphisms in the centromeric regions of chromosomes 3 and 4. Heteromorphisms were classified using the scale of five intensity levels namely, negative, pale, medium, intense and brilliant fluorescence. QFQ intensity heteromorphisms (greater than or equal to level 3) for chromosomes 3 and 4 were 54.5 and 7%, respectively. The distribution of different intensities was significantly different in American Blacks compared with Caucasians.