740
strength of buffers we also observed that the percentage glycosylated haemoglobins increased with increasing hxmolysate concentrations in the range 0-5—3 g/dl within the same sample. In all cases we could see an apparently clean banding of the eluting hmmoglobins. However, on measurement, more fast-fraction ha:moglobins were eluted with higher lysate concentrations for a given specimen. (3) The rate of elution was also critical, percentage glycosylated hxmoglobins and elution-rate being directly related. Using similar quantities of resin and haemolysate as Dr Davis and Mr Nichol (Aug. 12, p.350) we found that the elution-time had to be at least 10 min if consistent results were to be obtained; shorter elution-times gave higher values for glycosylated haemoglobins.
These three factors
least must be rigorously checked if results is to be maintained. Neither Davis and Nichol nor Kynoch and Lehmann’ provide qualitycontrol data in their papers. Within-run and between-run variation of results, particularly over several batches of resin, would be valuable data (we have found great variation in results when changing batches of bio-rex resin). Some indication of normal range and clinical values would have been helpful, as well as data relating to comparison of their method with others. The correlation of their’ results with the clinical assessment of patients would have allowed readers to assess the validity of the method. Perhaps these workers could state more clearly the limits within which buffer concentrations, haemolysate concentrations, and elution-times must fall to produce an acceptably controlled assay.
quality control
at
over test
Departments of Hæmatology and Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042
R. G. RYALL J. J. GRAHAM
MATERNAL/FETAL TRANSMISSION OF HBSAg NEGATIVE HEPATITIS be transmitted from mother to to mothers who had acute offspring.2-4 viral hepatitis B during pregnancy had hepatitis B antigen (HBsAg) in their blood.35 Though Stokes et awl. hypothesise transplacental transmission of virus, others suggest that the virus is transmitted around the time of labour and delivery. 34 There is no evidence for such transmission with hepatitis A virus. A 28-year-old gravida 3 had hepatitis in the ninth month of pregnancy. Her husband had had hepatitis immediately before his wife’s illness. She was brought to hospital on March 20, 1978 in the second stage of labour and with fulminant hepatic failure. Fetal heart sounds were absent. She delivered spontaneously a fresh stillborn male fetus weighing 2.5 kg (maturity approximately 36 weeks) with no obvious congenital malformation. Investigations of the mother showed Hb 13 g/dl, normal total and differential leucocyte-count, and low prothrombin index (20-30%). Bilirubin ranged from 17 to 25-55 mg/dl (conjugated 9.5-15 mg/dl), serum glutamic-oxaloacetic transaminase 258 l.u., alkaline phosphatase 300 King-Armstrong units. HBsAg was negative by cotintercurrent immunoelectrophoresis. The patient died on March 24, 1978. Complete necropsies were done on both mother and fetus. The maternal liver showed fulminant hepatitis with massive hepatic necrosis. The fetal liver also showed massive hepatic necrosis (see figure). Autolysis was ruled out because no other
SIR,-Hepatitis
B virus
can
40-50% of babies born
1. 2.
3. 4. 5.
Kynoch, P. A. M., Lehmann, H. Lancet, 1977, ii, 16. Stokes, J., Wolman, I, J., Blanchord, M. C., Farquhar, J. D Am. J. Dis. Child. 1951, 82, 213. Schweitzer, I. L., Wing, A., McPeak, C., Spears, R. L. L.J. Am. med. Ass. 1972, 220, 1092. Stevens, C. E., Beasley, R. P., Tsin, J., Lee, W. C. New Eng J. Med. 1975, 292, 771. Schweitzer, I. L., Dunn, A. E. G., Peters, R. L., Spears, R. L. Am. J. Med. 1973, 55, 762.
Photomicrograph of fetal liver showing extensive hepatocytic damage characterised by swelling, vacuolation of cytoplasm, and necrosis. There are foci of haemorrhage with dilatation of sinusoids. Hepatocytes in the immediate vicinity of the central vein are much less affected. (Hasmaioxytin and eosin; x about 350.)
organ showed autolysis and because the histological picture of liver-cell damage with areas of haemorrhage is unlike that seen in autolysis. Cord blood was negative for HBsAg, and so were the post-mortem blood samples and liver tissues of both mother
and baby. A hepatitis virus was transmitted to the fetus in utero, possibly via the transplacental route, leading to massive hepatic necrosis. Since serum and hepatic tissue of both mother and baby were negative for HBsAg, (which is positive in 80-90% of cases of acute viral hepatitis B in the icteric phase) it seems that the hepatitis in mother and baby was not due to hepatitis B virus. However, because of lack of tests of hepatitis A antigen, we cannot say whether this was hepatitis A or acute
hepatitis non-A, non-B. Departments of Obstetrics and Gynæcology and Pathology
Postgraduate Institute of
Medical Education and Research,
Chandigarh, India
BIPIN GUPTA
SHARDA AGARWAL
V. V. JOSHI
NITROUS OXIDE AND BONE-MARROW to correct that part of your editorial which was concerned with our paper, published in your issue of Aug. 12. First, in the deoxyuridine suppression test 3H-thymidine is used, not 3H-deoxyuridine. Secondly, in this test the uptake of 3H-thymidine by normal bone-marrow cells, but not by cells deficient in vitamin B12 or folate, is almost completely suppressed by preincubation with deoxyuridine. Thirdly, our results were typical of those seen with vitamin-B12 deficiency (i.e., the incorporation of deoxyuridine into D.N.A. in vitro was partially corrected by adding cyanocobalamin or pteroylglutamic acid whereas in folate deficiency the addition of cyanocobalamin has no effect). Fourthly, your editorial may give the impression that this abnormality could be reversed by the invivo administration of hsematinics. The pretreatment of one patient with large doses of parenteral vitamin B12 did not alter the morphological or biochemical effect produced by the administration of 50% nitrous oxide and 50% oxygen mixture.
SIR,-We would like
(Sept. 16,
p.
613)
of Hæmatology, St. Bartholomew’s Hospital, London EC1A 7BE
Department
J. A. L. AMESS J. F. BURMAN D. L. MOLLIN
strength of buffers we also observed that the percentage glycosylated haemoglobins increased with increasing hxmolysate concentrations in the range 0-5—3 g/dl within the same sample. In all cases we could see an apparently clean banding of the eluting hmmoglobins. However, on measurement, more fast-fraction ha:moglobins were eluted with higher lysate concentrations for a given specimen. (3) The rate of elution was also critical, percentage glycosylated hxmoglobins and elution-rate being directly related. Using similar quantities of resin and haemolysate as Dr Davis and Mr Nichol (Aug. 12, p.350) we found that the elution-time had to be at least 10 min if consistent results were to be obtained; shorter elution-times gave higher values for glycosylated haemoglobins.
These three factors
least must be rigorously checked if results is to be maintained. Neither Davis and Nichol nor Kynoch and Lehmann’ provide qualitycontrol data in their papers. Within-run and between-run variation of results, particularly over several batches of resin, would be valuable data (we have found great variation in results when changing batches of bio-rex resin). Some indication of normal range and clinical values would have been helpful, as well as data relating to comparison of their method with others. The correlation of their’ results with the clinical assessment of patients would have allowed readers to assess the validity of the method. Perhaps these workers could state more clearly the limits within which buffer concentrations, haemolysate concentrations, and elution-times must fall to produce an acceptably controlled assay.
quality control
at
over test
Departments of Hæmatology and Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042
R. G. RYALL J. J. GRAHAM
MATERNAL/FETAL TRANSMISSION OF HBSAg NEGATIVE HEPATITIS be transmitted from mother to to mothers who had acute offspring.2-4 viral hepatitis B during pregnancy had hepatitis B antigen (HBsAg) in their blood.35 Though Stokes et awl. hypothesise transplacental transmission of virus, others suggest that the virus is transmitted around the time of labour and delivery. 34 There is no evidence for such transmission with hepatitis A virus. A 28-year-old gravida 3 had hepatitis in the ninth month of pregnancy. Her husband had had hepatitis immediately before his wife’s illness. She was brought to hospital on March 20, 1978 in the second stage of labour and with fulminant hepatic failure. Fetal heart sounds were absent. She delivered spontaneously a fresh stillborn male fetus weighing 2.5 kg (maturity approximately 36 weeks) with no obvious congenital malformation. Investigations of the mother showed Hb 13 g/dl, normal total and differential leucocyte-count, and low prothrombin index (20-30%). Bilirubin ranged from 17 to 25-55 mg/dl (conjugated 9.5-15 mg/dl), serum glutamic-oxaloacetic transaminase 258 l.u., alkaline phosphatase 300 King-Armstrong units. HBsAg was negative by cotintercurrent immunoelectrophoresis. The patient died on March 24, 1978. Complete necropsies were done on both mother and fetus. The maternal liver showed fulminant hepatitis with massive hepatic necrosis. The fetal liver also showed massive hepatic necrosis (see figure). Autolysis was ruled out because no other
SIR,-Hepatitis
B virus
can
40-50% of babies born
1. 2.
3. 4. 5.
Kynoch, P. A. M., Lehmann, H. Lancet, 1977, ii, 16. Stokes, J., Wolman, I, J., Blanchord, M. C., Farquhar, J. D Am. J. Dis. Child. 1951, 82, 213. Schweitzer, I. L., Wing, A., McPeak, C., Spears, R. L. L.J. Am. med. Ass. 1972, 220, 1092. Stevens, C. E., Beasley, R. P., Tsin, J., Lee, W. C. New Eng J. Med. 1975, 292, 771. Schweitzer, I. L., Dunn, A. E. G., Peters, R. L., Spears, R. L. Am. J. Med. 1973, 55, 762.
Photomicrograph of fetal liver showing extensive hepatocytic damage characterised by swelling, vacuolation of cytoplasm, and necrosis. There are foci of haemorrhage with dilatation of sinusoids. Hepatocytes in the immediate vicinity of the central vein are much less affected. (Hasmaioxytin and eosin; x about 350.)
organ showed autolysis and because the histological picture of liver-cell damage with areas of haemorrhage is unlike that seen in autolysis. Cord blood was negative for HBsAg, and so were the post-mortem blood samples and liver tissues of both mother
and baby. A hepatitis virus was transmitted to the fetus in utero, possibly via the transplacental route, leading to massive hepatic necrosis. Since serum and hepatic tissue of both mother and baby were negative for HBsAg, (which is positive in 80-90% of cases of acute viral hepatitis B in the icteric phase) it seems that the hepatitis in mother and baby was not due to hepatitis B virus. However, because of lack of tests of hepatitis A antigen, we cannot say whether this was hepatitis A or acute
hepatitis non-A, non-B. Departments of Obstetrics and Gynæcology and Pathology
Postgraduate Institute of
Medical Education and Research,
Chandigarh, India
BIPIN GUPTA
SHARDA AGARWAL
V. V. JOSHI
NITROUS OXIDE AND BONE-MARROW to correct that part of your editorial which was concerned with our paper, published in your issue of Aug. 12. First, in the deoxyuridine suppression test 3H-thymidine is used, not 3H-deoxyuridine. Secondly, in this test the uptake of 3H-thymidine by normal bone-marrow cells, but not by cells deficient in vitamin B12 or folate, is almost completely suppressed by preincubation with deoxyuridine. Thirdly, our results were typical of those seen with vitamin-B12 deficiency (i.e., the incorporation of deoxyuridine into D.N.A. in vitro was partially corrected by adding cyanocobalamin or pteroylglutamic acid whereas in folate deficiency the addition of cyanocobalamin has no effect). Fourthly, your editorial may give the impression that this abnormality could be reversed by the invivo administration of hsematinics. The pretreatment of one patient with large doses of parenteral vitamin B12 did not alter the morphological or biochemical effect produced by the administration of 50% nitrous oxide and 50% oxygen mixture.
SIR,-We would like
(Sept. 16,
p.
613)
of Hæmatology, St. Bartholomew’s Hospital, London EC1A 7BE
Department
J. A. L. AMESS J. F. BURMAN D. L. MOLLIN
