Noninvasive methods for haemoglobin screening in prospective blood donors.

BACKGROUND AND OBJECTIVES: The haemoglobin level of prospective blood donors is usually performed on blood obtained by from the finger pulp by fingerstick with a lancet and filling a capillary tube with a sample. New noninvasive methods are now available for rapid, noninvasive predonation haemoglobin screening. MATERIALS AND METHODS: Prospective blood donors at our blood centre were tested, in two different trials, as follows: by the NBM 200 (OrSense) test (n = 445 donors) and by the Pronto-7 (Masimo) test (n = 463 donors). The haemoglobin values of each trial and the haemoglobin of finger pulp blood obtained by fingerstick with a lancet (HemoCue) were compared with the haemoglobin values obtained from a venous sample on a Cell Counter (Beckman Coulter). RESULTS: Comparison of Beckman Coulter Cell Counter and OrSense and results showed a bias of 0.29 g/dl, the standard deviation of the differences (SDD) of 0.98 and 95% limits of agreement from -1.64 to 2.21, using Bland and Altman statistical methodology. Comparison of Masimo and Beckman Coulter Cell Counter results showed a bias of -0.53 g/dl, SDD of 1.04 and 95% limits of agreement from -2.57 to 1.51. Cumulative analysis of all 908 donors, as tested by the usual fingerstick test showed a bias of 0.83 g/dl, SDD of 0.70 and 95% limits of agreement from -0.54 to 2.20 compared with the Coulter Cell Counter. Compared with the Coulter Counter, the specificity of the methods was 99.5% for fingerstick, 97% for OrSense and 83% for Massimo, and the sensitivity was 99, 98 and 93%, respectively. CONCLUSIONS: Analysis of finger pulp blood by either direct sampling by fingerstick and Hemocue, or by noninvasive haemoglobin tests does not replicate the results of cell counter analysis of venous samples. Compared with fingerstick, noninvasive haemoglobin tests eliminate pain and reduce stress, but have a lower level of specificity and sensitivity.

Cardiac function during breath-hold diving in humans: an echocardiographic study.

Breath-hold diving induces, in marine mammals, a reduction of cardiac output due to a decrease of both heart rate and stroke volume. Cardiovascular changes in humans during breath-hold diving are only partially known due to the technical difficulty of studying fully immersed subjects. Recently, a submersible echocardiograph has been developed, allowing a feasible assessment of cardiac anatomy and function of subjects during diving. Aim of the study was to evaluate, by Doppler-echocardiography, the cardiovascular changes inducedby breath-hold diving in humans. Ten male subjects were studied by Doppler echocardiography in dry conditions and during breath-hold diving at 3 m depth. In addition 14 male subjects were studied, using the same protocol, before and during breath-hold diving at 10 m depth. At 3 m depth significant reductions in heart rate (-17%), stroke volume (-17%), cardiac output (-29%), left atrial dimensions, and deceleration time of early diastolic transmitral flow (DTE) were observed. At 10 m depth similar but more pronounced changes occurred. In particular, increase in early transmitral flow velocity became significant (+33%), while DTE decreased by 34%. At both depths dimensions of right cardiac chambers remained unchanged. Breath-hold diving at shallow depth induced, in humans, cardiovascular changes qualitatively similar to those observed in natural divers such as seals. The reduced dimensions of left atrium associated to a left ventricular diastolic pattern resembling that of restrictive/constrictive heart disease, suggest that the hemodynamic effects of diving could be explained, at least in part, by a constriction exerted on the heart by the reduced chest volume and the increased blood content of the lungs. Finally, the absence of dimensional changes in the right chambers suggests that most of the pulmonary blood shift occurred before cardiac imaging.

Quality assessment and cataloguing of telemedicine applications.

We created a Web catalogue of approved telemedicine systems that authoritative Italian research bodies had made available for more general use. The evaluation process was divided into two stages: (1) classification of the telemedicine systems and rough preliminary evaluation; (2) assessment of the telemedicine products and services. The scoring method was applied to four well-known telemedicine systems that had been tested in health-care settings: an echocardiology teleconsulting and analysis system; a ward nursing management system; a virtual cooperative system for the management of oncology patients and a telepathology system based on remotely controlled microscopy. After technical revision during the standardization/qualification process, the applications were transferred successfully to eight new health-care facilities. The methodology achieved the main goal of providing effective tools, such as a set of quality control procedures for telemedicine and telehealth projects and a Web catalogue of telemedicine applications with a standardized level of quality, available to all interested parties.

An effective algorithm for quick fractal analysis of movement biosignals.

The problem of numerically classifying patterns, of crucial importance in the biomedical field, is here faced by means of their fractal dimension. A new simple algorithm was developed to characterize biomedical mono-dimensional signals avoiding computationally expensive methods, generally required by the classical approach of the fractal theory. The algorithm produces a number related to the geometric behaviour of the pattern providing information on the studied phenomenon. The results are independent of the signal amplitude and exhibit a fractal measure ranging from 1 to 2 for monotonically going-forwards monodimensional curves, in accordance with theory. Accurate calibration and qualification were accomplished by analysing basic waveforms. Further studies concerned the biomedical field with special reference to gait analysis: so far, well controlled movements such as walking, going up and downstairs and running, have been investigated. Controlled conditions of the test environment guaranteed the necessary repeatability and the accuracy of the practical experiments in setting up the methodology. The algorithm showed good performance in classifying the considered simple movements in the selected sample of normal subjects. The results obtained encourage us to use this technique for an effective on-line movement correlation with other long-term monitored variables such as blood pressure, ECG, etc.

High-dose busulfan and cyclophosphamide are an effective conditioning regimen for allogeneic bone marrow transplantation in chemosensitive multiple myeloma.

The present clinical trial was undertaken to investigate the toxicity and antimyeloma activity of busulfan (BU) and cyclophosphamide (CY) at the maximum tolerated doses of, respectively, 16 mg/kg and 200 mg/kg (BU-CY 4) as conditioning therapy for allogeneic bone marrow transplantation (BMT) in 19 consecutive patients with multiple myeloma (MM). Twelve (63%) had failed to respond to prior chemotherapy, while the remaining 37% had chemosensitive disease. No life-threatening or fatal regimen-related complications were observed. The incidence of veno-occlusive disease of the liver was zero according to Jones' criteria and 21% according to McDonald's system. Transplant-related mortality was 37%. Using stringent criteria, the frequency of complete remission (CR) was 42% among all patients and 53% among those who could be evaluated. With a median follow-up of 21 months for all patients and 66 months for survivors, the actuarial probability of survival and event-free survival at 4 years from BMT was 26% (95% CI: 7-46) and 21% (95% CI: 3-39), respectively. A more favorable outcome of transplantation was observed in the subgroup of patients with chemosensitive disease who had a transplant-related mortality of 14%, an overall CR rate of 86% (95% CI: 49-97) and a 4-year projected probability of event-free survival of 57% (95% CI: 20-93). Four of these patients are currently alive in continuous CR after 54, 66, 80 and 94 months, respectively. It is concluded that BU-CY 4 as conditioning for allogeneic transplantation for MM is associated with acceptable morbidity and relatively low mortality. This regimen exerts substantial antimyeloma activity, resulting in a high CR rate and durable responses, especially in patients with chemosensitive disease. Long-lasting remission and probable cure is possible following allogeneic stem cell transplantation for MM.

On the contribution of biomedical engineering and technology to the understanding and the management of arterial hypertension.

There are several reasons why arterial blood pressure, i.e. the pressure within the large arterial vessels, is out of the physical parameters of the human body, one of the most frequently measured. Firstly, arterial blood pressure is a physiologically meaningful parameter, since it represents the driving pressure generated by the heart which maintains blood perfusion in the periphery. Secondly, it is a clinically important parameter: a decline of arterial blood pressure (e.g. in shock) may represent a life-threatening emergency which requires prompt recognition and correction; elevated blood pressure (hypertension) on the other hand is a very common condition, which bears a high risk of cardiovascular mortality and morbidity and can be controlled with appropriate pharmacological means. Thirdly, but not lastly, arterial blood pressure is easily measurable with a fair degree of accuracy by the standard manual sphygmomanometric method and, more recently, by non-invasive automatic techniques. This paper discusses some of the aspects related to arterial blood pressure measurement, in which, in the author's opinion, medical engineering and technology are expected to provide useful advancements. Two major areas will be considered. The first regards the methodologies for arterial blood pressure assessment; the second the identification and acquisition of information additional to blood pressure which would be helpful for a better understanding of blood pressure measurements and/or of risk profiling. For the purpose of this brief paper, we shall mainly use examples and reasonings from our own experience.

Autologous bone marrow transplantation in late first complete remission improves outcome in acute myelogenous leukemia.

We evaluated the role of ABMT in late 1st CR AML adult patients using busulfan plus cyclophosphamide as preparative regimen. Fifty-one adult patients (mean age 36 years, range 15-59) with AML underwent ABMT in 1st CR. Three of them had a prior diagnosis of myelodysplastic syndrome; one patient had a secondary leukemia. The median interval between CR and ABMT was 8 months (range 4-20). Patients received busulfan, 4 mg/kg/day for 4 days plus cyclophosphamide 50 mg/kg/day for 4 days or 60 mg/kg/day for 2 days. No maintenance chemotherapy was administered after ABMT. Median days to reach 0.5 x 10(9)/I PMN and 20 x 10(9)/I platelets were 26 (range 12-250) and 74 (range 16-740), respectively. No transplant-related deaths were observed. Five-year actuarial overall survival rate is 76.9%; actuarial leukemia-free survival rate is 70.6%. Mean follow-up from ABMT is 35 months. Leukemia-free survival of this group was compared with that of 38 non-transplanted patients younger than 60 years, who maintained a CR longer than 8 months in the same period. This analysis shows a statistically significant difference in favor of ABMT patients. These results suggest that, even if performed late after 1st CR as post-remission intensification, ABMT can improve the outcome of AML patients.

Toxicity of high-dose busulphan and cyclophosphamide as conditioning therapy for allogeneic bone marrow transplantation in adults with haematological malignancies.

The toxicity of the conditioning regimen high-dose busulfan (BU) 16 mg/kg followed by cyclophosphamide (CY) 200 mg/kg has been analysed in 60 adult patients (mean age 36 +/- 9 years) with haematological malignancies, a third of whom had advanced disease, all received the graft from fully HLA-identical siblings. Significant nausea and vomiting were rare during BU administration but occurred in 44% of the patients with CY. Severe mucositis occurred in 30% of patients. Haemorrhagic cystitis occurred in 16% of patients; interstitial pneumonia occurred in 3 patients and was fatal in one. Veno-occlusive disease of the liver occurred in 2 patients and was fatal in one: however, increase of bilirubin of at least twice the baseline value and/or isolated weight gain > 5% of pre-transplant value occurred in 28% of patients. These signs of liver toxicity disappeared in all patients after appropriate therapy. Normalisation of bilirubin levels took twice as long as normalisation of body weight: median 35 and 18 days, respectively. Hyperpigmentation of the skin, mainly involving flexural and pressure areas, occurred in 47% of patients and was manageable topically. Eight patients died of relapsed disease; 15 died of transplant complications but in six the original malignancy persisted or had recurred at the time of death. Overall transplant-related mortality was 15%. We conclude that the toxicity of this regimen has not been high, with the liver being the most seriously affected organ. A longer follow-up is necessary to assess long-term consequences.

Hematological recovery after autologous bone marrow transplantation for high-grade non Hodgkin's lymphomas: a single center experience.

BACKGROUND: Both rhGM-CSF and rhG-CSF can accelerate hematological recovery after high-dose therapy and autologous bone marrow transplantation in patients with high grade non Hodgkin's lymphoma and reduce transplant-related morbidity after ABMT. METHODS: The clinical course of 23 non randomized patients was analyzed and compared with a historical control group of 10 patients. Ten patients received GM-CSF at a dose of 10 micrograms/kg in a 6-h IV infusion, and 13 received G-CSF at a dose of 5 micrograms/kg subcutaneously. Control patients received no GFs. RESULTS: Mean granulocytic recovery to 0.5 x 10(9)/L was obtained 13.1 +/- 3.2 days after marrow reinfusion in the G-CSF arm vs 16 +/- 2.7 in GM-CSF pts (p = 0.03) and vs 19.6 +/- 7.6 in controls (p < 0.01); this reduction led to a statistically significant shorter duration of fever and parenteral antibiotic therapy. Platelet recovery to 20 x 10(9)/L was not significantly influenced by GFs. CONCLUSIONS: These results indicate that only G-CSF accelerates hematological recovery after high-dose chemotherapy and autologous bone marrow transplantation and induces a significant decrease in terms of infection morbidity and duration of hospital stay.

Donor origin of hematopoiesis after a case of allogeneic transplantation with cryopreserved marrow.

In allogeneic marrow transplantation (BMT), fresh donor marrow is generally given like a simple transfusion immediately after collection. Cryopreservation, on the other hand, is extensively used in autologous marrow transplantation (ABMT). However, there could be a few instances in which donor marrow should be cryopreserved for later reinfusion mainly because of the donor's inability, for logistic or medical reasons, to undergo marrow harvesting immediately prior to transplantation. We wish to describe a case of ALL transplanted with donor harvested earlier and cryopreserved. The bone marrow was cryopreserved with 10% DMSO in a controlled rate freezer and stored for 1 month in liquid nitrogen. The VNTR (variation number tandem repeat) technique was used to demonstrate the donor origin of blood cells. Hematological reconstitution was rapidly achieved and we demonstrated the allogeneic origin of the recipient's blood cells. We confirm the possibility of using cryopreserved marrow stem cells for BMT. Cryopreservation of stem cells from other origin may also find a useful application in BMT.

Hypercoagulability in patients undergoing autologous or allogeneic BMT for hematological malignancies.

Severe thrombotic alterations, such as veno-occlusive disease of the liver, may occur in the early phase following high-dose chemoradiotherapy and BMT. In this study, performed in patients with hematological malignancies subjected to allogeneic (10 cases) and autologous (20 cases) BMT, we have monitored laboratory hemostatic parameters to better understand the pathogenetic mechanism of thrombosis and particularly of veno-occlusive disease. Prothrombin time, activated partial thromboplastin time, plasma fibrinogen, markers of hypercoagulability (thrombin-antithrombin complex and prothrombin fragment F1+2); natural anticoagulants (protein C, protein S and antithrombin) together with fibrinolytic parameters (plasminogen, alpha 2-antiplasmin, tissue-plasminogen activator, plasminogen activator inhibitor and D-dimer) were assessed before transplant, on day 0 and weekly for 1 month thereafter. A hypercoagulability state, not related to an impairment of the anticoagulant and fibrinolytic systems, was documented before and after autologous and allogeneic transplant. Two patients developed veno-occlusive disease: they did not show any difference from the other patients before transplant while they presented a decrease of the natural anticoagulants along with altered fibrinolytic parameters only at the clinical onset of veno-occlusive disease. In conclusion, in this study a state of marked hypercoagulability was documented in BMT patients and the hemostatic laboratory parameters evaluated were not able to predict the occurrence of the thrombotic complications.

In vitro amplification of hypervariable DNA regions for the evaluation of chimerism after allogeneic BMT.

The role of mixed hematopoietic chimerism in engraftment and relapse after allogeneic BMT remains unclear. To better evaluate post-transplant chimerism we used polymerase chain reaction (PCR) in vitro amplification of four single locus simple repetitive DNA sequences, all of which vary extensively in their repeat number among different individuals: variable number of tandem repeats D1S80, APOB and D17S5, and the tetranucleotide repeat F8VWF. We tested 13 cases of CML, four of multiple myeloma (MM), three of ANLL and one of B-CLL. In a sequential analysis protocol with the different loci, the donor could be distinguished from the recipient in 14 of 20 (70%) pairs with the first marker used (D1S80). When a donor of opposite sex was involved, karyotyping and Y chromosome-specific PCR were also used. With the use of the four markers, chimerism was identified in all the pairs. Mixed chimerism was present in 5 patients, and complete chimerism in 15. No patients relapsed. The application of PCR for documenting post-transplant chimerism has several advantages over Southern blotting: increased sensitivity, use of small amounts of sample, ease of preparation of DNA, elimination of restriction enzyme analysis and of radioisotopes, and speed.

A regimen for antithrombin III substitution in patients with acute lymphoblastic leukemia under treatment with L-asparaginase.

BACKGROUND AND METHODS: Seventeen adult patients with acute lymphoblastic leukemia (ALL) treated with L-asparaginase (20,000 IU/m2 on six alternate days) were infused with antithrombin III (AT III) concentrates (Kybernin P, Behring). Substitution therapy was aimed at increasing the reduced AT III concentration usually found in these patients, since AT III deficiency is thought to be associated with an increased risk of thrombosis. Two schedules of AT III administration, different in dosage, timing and duration were evaluated. The first 7 patients (group A) received a fixed dose of 2,000 U every day for 6 times, starting with the second L-asparaginase (L-ase) infusion, independently of their plasma AT III levels. In the following 10 patients (group B), 20-25 U/Kg b.w. were administered daily for 7 times only when the plasma AT III level was lower than 60% with plasma fibrinogen higher than 100 mg/dl and platelet count higher than 50 x 10(9)/l, or when AT III was below 40%. Thirteen patients who received L-ase without AT III substitution served as controls. RESULTS AND CONCLUSIONS: Both substitution regimens resulted in mean plasma AT III nadir values significantly (p less than 00.1) higher than in the controls. Our data suggest that, in ALL patients receiving L-ase according to the L20 protocol, satisfactory plasma AT III levels may be assured with infusions of 20-25 U/Kg b.w./day for 7-10 days, starting by day 2 of L-ase treatment.

Platelet function and interferon alpha-2a treatment in essential thrombocythaemia.

The effects of interferon (IFN) alpha-2a treatment on platelet function were evaluated in 20 patients affected by essential thrombocythaemia (ET). Baseline data documented the well-known abnormalities of in vitro platelet aggregation and the constant presence of a delta-storage pool deficiency. The therapy in all patients reduced the platelet count, and in the majority of them caused a partial improvement of in vitro platelet aggregation. Although the mean intraplatelet ADP level improved during treatment, it always remained below the normal range documenting persistence of the delta-storage pool deficiency. The plasma beta-TG levels, which initially were high, significantly decreased during treatment, but the beta-TG ratio and the platelet beta-TG values always remained within the normal range--this suggests an absence of platelet activation either before or during therapy. Our results demonstrate that, despite significantly reducing the platelet count, IFN alpha-2a treatment only partially corrects the qualitative platelet abnormalities in ET.

Prompt plasma-exchange treatment and coma reversibility in two patients with thrombotic thrombocytopenic purpura.

We report on the cases of two women with acute thrombotic thrombocytopenic purpura (TTP) whose clinical courses were characterized by the onset of a coma state. Prompt commencement of plasma-exchange (PE) treatment led to complete hematological and neurological remission, which can still be observed without any maintenance therapy. No CNS abnormalities were observed in either patient using brain CT and NMR scans.

Ticlopidine in the treatment of thrombotic thrombocytopenic purpura: report of two cases.

The observation of two clinical cases make possible an evaluation of the potential therapeutic activity of platelet function inhibitors in thrombotic thrombocytopenic purpura (TTP). In particular, the clinical and hematological effects of ticlopidine (TC), employed alone in two TTP patients, are reported. The mechanism of action of this peculiar antiplatelet drug is mainly represented by the inhibition of fibrinogen binding on the platelet surface. In the first patient, a 45-year-old female in whom plasma-exchange (PE) and corticosteroids (C) led to a partial remission (platelets 80 x 10(9)/l), treatment with TC at a dose of 750 mg/day was carried out, and after 6 weeks a normal platelet count was observed. A complete remission was maintained for 31+ months, even after reduction of the TC dose to 250 mg/day. In the second patient, an 18-year-old female affected by relapsing TTP, a complete remission obtained with PE and C was maintained for 19 months in concomitance with TC treatment, started at a dose of 750 mg/day and lowered to 250 mg/day. After 11 months of treatment at this low dosage there was a relapse (platelets 20 x 10(9)/l), but the increase of the TC dose to 750 mg/day in a few weeks induced a complete remission again. These data, in accord with a few other recent preliminary reports, suggest that TC, even alone, may play an interesting role in the management of TTP patients.