Aims-A series of patients with myeloma were investigated to assess whether immunological risk factors predisposing to serious infection could be identified. Methods-Patients (n = 102) with predominantly plateau phase myeloma were monitored prospectively for infections. Immunological parameters including total non-paraprotein immunoglobulins and specific antibody titres were measured in all patients and compared with a control population ofhealthy individuals of a similar age; response to immunisation with Pneumovax II, tetanus and diphtheria toxoids and IgG subclasses were measured in a subgroup of 41 patients. Other characteristics investigated for any association with infection included age, sex, paraprotein type, disease stage, and chemotherapy. Results-Specific antibody titres to pneumococcal capsular polysaccharides and tetanus and diphtheria toxoids were significantly reduced compared with the control population. Low antipneumococcal and anti Escherichia coli titres correlated with risk of serious infection and low antipneumococcal titres with severity of nonparaprotein immunosuppression. In 41 immunised patients responses to Pneumovax II, tetanus and diphtheria toxoids were poor; IgG subclass levels were significantly reduced and a poor IgG response to Pneumovax II immunisation was associated with an increased risk of septicaemia and low IgG2 levels. The overall serious infection rate was 0'92 infections per patient year and was four times higher during periods of active disease (1.90) compared with plateau phase myeloma (0.49). The predominant site of infection was the respiratory tract. Clinical and laboratory parameters showed only male sex and reduced non-paraprotein IgG and IgA levels to be significantly associated with at least one serious infection. Conclusions-A subgroup of patients with myeloma with poor IgG responses to exogenous antigens, who are at increased risk of serious infection, can be identified and may benefit from replacement immunoglobulin therapy to reduce the risk of infection. (J Clin Pathol 1995;48:260-266)

SummaryTreatment with heparin or streptokinase was allocated randomly to 30 patients with life-threatening pulmonary embol'sm verified by angiography. Treatment was given for 72 hours and pulmonary angiography was repeated. There was significantly greater (P <0001) evidence of thrombolysis in those patients treated with streptokinase compared with those treated with heparin. The reduction of systolic and mean pulmonary arterial pressures was also significantly greater (P < 0 05 and P < 0-02 respectively) in the streptokinase group.Seven patients failed to complete 72 hours of the trial treatment: five successfully underwent pulmonary embolectomy. Six of these "failures" had initial pulmonary angiographic scores of 24 or more and systemic systolic blood pressure recordings of 100 mm Hg or less. Patients with these features should probably be considered for pulmonary embolectomy as the initial treatment.

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In the investigation of patients with hypochromic anaemia the assessment of the part played by gastrointestinal or menstrual blood loss is often extremely difficult. This paper describes a method for the measurement of blood loss over periods of up to three months by means of 59Fe and the simple whole-body counter recently designed in this department (Callender et al., 1966). The principles involved are that 7 to 10 days after the administration of 59Fe all or most of the dose will be incorporated into circulating red cells. In normal males and postmenopausal females the whole-body radioactivity will remain stable and any loss in total body radioactivity must represent loss of blood. The technique was evaluated by studying patients with polycythaemia from whom known quantities of blood were removed by venesection. Its clinical use is illustrated by studies of five patients with hypochromic anaemia. MethodsThe design of the whole-body counter and its uses in measuring absorption have been described in detail elsewhere Callender et al., 1966). The majority of subjects studied were given an intravenous tracer dose of 59Fe ferric citrate with 1.5 to 1.0 juCi activity; subjects in whom additional information on the ability to absorb iron was required were given an oral dose of 5 mg. of ferrous iron labelled with approximately 5 /Ci 59Fe.Patients Studied.-Four patients who had recovered from a myocardial infarct agreed to act as control subjects. All were outpatients and none was receiving anticoagulant drugs. They were studied over a period of three months in order to measure the normal daily iron loss as blood and to assess the week-toweek variation of the whole-body counter. Twelve patients with polycythaemia who required therapeutic venesection were studied; three were postmenopausal females and nine were males. Ten had polycythaemia vera and two had secondary polycythaemia. Plasma iron disappearance curves were plotted and used for estimation of blood volume. Seven to 10 days after the injection of 5-Fe (day zero of the experiment) the whole-body radioactivity was measured. Thereafter venesections were carried out at varying intervals of a few hours to three weeks. The whole-body radioactivity was measured immediately before and after each venesection. Five patients with iron-deficiency anaemia in whom either gastrointestinal bleeding or excessive menstrual loss was suspected were investigated. The proportion of the oral dose retained at 10 days was a measure of iron absorption. Thereafter the total body activity was measured at intervals.Calculation of Blood Loss.-L= Percentage loss of wholebody radioactivity between counts. BV = Blood volume in ml.Blood loss in ml. -10X BV 100In control subjects and patients with iron-deficiency anaemia the blood volume was taken to be 65.6 ml./kg. body weight (Wasserman et al., 1951 iron-deficiency anaemia the red-cell utilization of 59Fe could be taken as 100%. This was verified in a number of subjects. When 100 % utilization was not expected-for example, in control subjects-...

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SYNOPSIS Three patients with multiple myeloma who developed a plasma cell sarcoma during apparently successful chemothapy are described. It is postulated that the.chemotherapy induced the sarcomatous change.

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