Paul R. Meyer

Non-Hodgkin's lymphoma in 90 homosexual men: relation to generalized lymphadenopathy and the acquired immunodeficiency syndrome

We describe the histologic and clinical features of non-Hodgkins lymphoma diagnosed between January 1980 and December 1983 in 90 homosexual men from San Francisco, Los Angeles, Houston, and New York. The median age was 37 years, with an age distribution identical to that for cases of AIDS reported to the Centers for Disease Control. Sixty-two per cent of the patients had high-grade (aggressive) subtypes of lymphoma, 29 per cent had subtypes of intermediate grade, and 7 per cent had low-grade subtypes. Histologic subtypes and malignant cell phenotypes were consistent with a B-cell origin. All but two men had extranodal lymphoma: central-nervous-system, bone-marrow, bowel, and mucocutaneous sites were most commonly involved. Thirty-five of 66 evaluable men (53 per cent) had complete responses to combination chemotherapy or radiotherapy or both, and thus far, 19 (54 per cent) of them have had a relapse. Mortality and morbidity were closely related to prodromal manifestations; death or illness have occurred in 19 (91 per cent) of the 21 men who presented with AIDS, in 26 (79 per cent) of the 33 who presented with generalized lymphadenopathy, and in 5 (42 per cent) of the 12 who had no prodromal manifestations. Mortality rates analyzed according to histologic grade were higher than currently reported rates in other patient populations. Kaposis sarcoma or severe opportunistic infections characteristic of AIDS developed in 14 of 33 men (42 per cent) who presented with generalized lymphadenopathy and in 3 of 12 (33 per cent) without prodromal manifestations. We conclude that non-Hodgkins lymphoma in members of an AIDS risk group is a serious manifestation of AIDS and the AIDS-related complex.

Development of B-cell lymphoma in homosexual men. Clinical and immunologic findings.

Serious infections, neoplasms, and immunologic abnormalities have been found in homosexual men. We describe the development of malignant lymphoma in six such patients, three of whom had persistent, generalized lymphadenopathy. In biopsies done before the lymphoma developed, the lymphadenopathy was characterized morphologically by a distinctive pattern of B-cell follicular hyperplasia. All lymphomas were of B-lymphocytic origin, including B-cell immunoblastic sarcoma; small noncleaved, Burkitt-like lymphoma; and plasmacytoid lymphocytic lymphoma. Extranodal presentation with B symptoms occurred in five patients. Median age of our patients was 33 years. Three patients had histories of repeated systemic infections. The peripheral blood lymphocyte count was depressed in four, with depression of OKT 4+ (helper phenotype) cell levels and reversal of the T-helper: T-suppressor ratio in all. We conclude that these patients are at risk for the development of abnormalities of the B-lymphocytic system, manifested by abnormal hyper-B-cell response in enlarged reactive lymph nodes and aggressive, extranodal B-cell lymphomas.

Prevention of Thromboembolism after Spinal Cord Injury Using Low-Molecular-Weight Heparin

OBJECTIVE To examine the safety and effectiveness of a low-molecular-weight heparin in the prevention of thromboembolism in patients with recent spinal cord injury and complete motor paralysis. DESIGN Randomized evaluation of two heparin regimens in 41 consecutive patients meeting eligibility requirements for anticoagulant prophylaxis. Daily bedside examinations were supplemented by serial venous flow studies; suspicious or positive tests were confirmed by venography. INTERVENTION Standard heparin, 5000 units subcutaneously three times a day; low-molecular-weight heparin 3500 anti-Xa units subcutaneously once daily. MEASUREMENTS AND MAIN RESULTS Five patients in the standard heparin group had thrombotic events, including two patients with fatal pulmonary embolism; two other patients had bleeding severe enough to necessitate withdrawing the heparin. The cumulative event rate was 34.7% (95% CI, 13.7% to 55.2%). None of the patients treated with low-molecular-weight heparin had thrombosis or bleeding (CI, 0% to 14%). The difference between the two groups was significant (P = 0.006, log-rank test). CONCLUSIONS Low-molecular-weight heparin is safe and effective in the prevention of thromboembolism in selected patients with spinal cord injury and complete motor paralysis, and is superior to standard heparin in fixed doses of 5000 units three times a day.

AIDS-related malignant lymphoma: results of prospective treatment trials.

Twenty-two consecutive patients with high-grade, B-cell lymphomas related to the acquired immunodeficiency syndrome (AIDS) were accrued onto two sequential phase II studies, consisting of a standard regimen (M-BACOD, group no. 1, N = 13), or a novel, intensive regimen (group no. 2, N = 9), which included high-dose cytosine arabinoside (HD-Ara-C), and high-dose methotrexate (HD-MTX), in an attempt to prevent CNS relapse and improve response rates. Stage IV disease was present in 82%. Complete remission (CR) was achieved in seven of 13 patients (54%) in group no. 1, and in three of nine (33%) group no. 2 (P = NS). By multivariate analysis, the most significant factor in predicting response was a Karnofsky performance score (KPS) greater than 60 (P = .04). Three of the ten patients who achieved CR on either regimen have relapsed; in all, five of 13 patients (31%) in group no. 1 have achieved disease-free survival for more than 1 year, compared with one of nine (11%) in group no. 2. CNS progression occurred in six patients in group no. 2, and in two patients in group no. 1. Hematologic toxicity was significantly greater in group no. 2, and these patients had an increased risk of opportunistic infection (one in group no. 1 v seven in group no. 2; P less than .01). Survival was similar, with a median of 11 months in group no. 1 and 6 months in group no. 2. We conclude that the intensive regimen of combination chemotherapy described here is associated with significant risk of early death due to opportunistic infection in patients with AIDS-related lymphoma, and that progression in the CNS remains a major problem. Trials of combination chemotherapy of a less intensive nature, perhaps in combination with immunomodulators or antiretroviral agents should be explored.

Primary central nervous system lymphoma in homosexual men. Clinical, immunologic, and pathologic features☆

Primary central nervous system lymphoma constitutes one of the criteria for the acquired immune deficiency syndrome (AIDS), yet a paucity of information is currently available regarding the clinical, immunologic, or pathologic features of these patients. Six homosexual men presenting with primary central nervous system lymphoma were evaluated. Five of these patients presented with altered mental status. All lymphomas were intracranial. B cell immunoblastic sarcoma was found in five. Immune phenotyping studies performed in five patients revealed monoclonal lambda light chain in three, whereas one expressed only IgG heavy chain, and one demonstrated another B cell (LN-1) surface antigen. Hypodense, contrast-enhancing lesions were apparent on computed axial tomographic scanning of the brain, in sharp contrast to isodense or hyperdense lesions reported in primary central nervous system lymphomas without underlying immunodeficiency. Immunologic abnormalities in these patients were similar to those in AIDS presenting as Kaposis sarcoma or with opportunistic infections. In spite of therapeutic interventions, survival was short, and only one patient is currently alive.

Pathology of Mycobacterium aviumintracellulare infection in acquired immunodeficiency syndrome

The clinical setting, gross organ distribution, and microscopic pathologic findings of disseminated Mycobacterium avium-intracellulare (MAI) infection are described at autopsy in 12 patients with acquired immunodeficiency syndrome (AIDS). All patients were diagnosed by premortem mycobacterial cultures. The clincical course of MAI infection was often prolonged, and death was usually due to an additional infection. In every patient, the distinctive microscopic feature on hematoxylin-eosin staining was a poorly defined granuloma consisting of pale blue, striated histiocytes filled with mycobacteria. Well-formed granulomas with fibrosis, necrosis, and epithelioid histiocytes were present in less than one third of cases. MAI is an opportunistic pathogen that may complicate the course of AIDS but only rarely leads to death. The characteristic appearance of striated histiocytes may aid in the recognition of this infection.

Primary central nervous system lymphoma in AIDS. Results of radiation therapy.

Primary central nervous system (CNS) lymphoma is one of the clinical presentations of the acquired immune deficiency syndrome (AIDS). Ten patients had biopsy‐proven high‐grade lymphomas that were confirmed by further staging as limited to the CNS. All ten patients received cranial irradiation (total dose, 2200 to 5000 cGy). Six patients demonstrated complete response (CR) of the intracranial masses at the time of repeat computed tomography (CT) scan, whereas one attained a partial response (PR). Two of the CR patients died multiple opportunistic infections, two experienced relapse of lymphoma, and died at 7 and 16 months diagnosis, and two were alive without evidence of disease at 8 and 14 months from diagnosis. The moon survival of the whole group was 5.5 months (range, 2 to 16 months). Patients with AIDS‐related primary CNS lymphoma may respond to radiation treatment; however, response duration is usually short, and survival is influenced by refractory disease or systemic opportunistic infections.

Series of ninety-two traumatic cervical spine injuries stabilized with anterior ASIF plate fusion technique.

This report details the results of 92 patients who underwent a single anterior procedure involving appropriate anterior decompression, tricortical inlay bone grafting, and application of anteriorly applied cervical vertebral plates and screws for the treatment of their acute lower cervical spine trauma. This allowed for needed anterior spinal decompression, correction of deformity, and excellent initial stability. A lightweight SOMI orthosis was used in the immediate postoperative period and continuing for 3 months on average. Follow-up detected a less than 2% incidence of significant complications related specifically to the use of anterior hardware and an excellent fusion rate (98.9%) occurring on average at 3.2 months postoperatively. Anterior decompression, bone grafting, and metallic osteosynthesis are thought to provide a valuable means of treating acute lower cervical spine trauma.

On the Setting Properties of Acrylic Bone Cement

In the one batch of methylmethacrylate tested the surface of the setting cement never exceeded 70 degrees centigrade while the setting time was prolonged by lowering the ambient temperature, decreasing the powder to liquid ratio, and increasing the mass of cement. Working time, that is, the interval between the dough stage and setting, did not change as the powder-liquid ratio varied but decreased with rises in ambient temperature and mass. Batch to batch variation should be expected, and even greater variation will occur with minor variations in composition of cement.

Prevalence and incidence of pressure sores in acute spinal cord injuries

The prevalence of pressure sores following acute spinal cord injury was determined on 549 patients who entered the Midwest Regional Spinal Cord Injury Care Centre from 1973 until June 1978- The compiled data was based upon system versus non-system entry, anatomical levels of injury, multiple site or single site location, complete or incomplete physiological injury, and the presence of pressure sores on admission or their development during system hospitalisation. The results showed that non-system patients had a significantly higher prevalence of pressure sores in all categories. The level of anatomical injury as well as the physiological intactness of the spinal cord were found to be the most important factors in the actual prevalence. The cervical region was found to have the highest prevalence of pressure sores at single and multiple sites. Complete lesions and quadraplegics had a higher prevalence of pressure sore than incomplete lesions and paraplegics. The probable explanations are presented.