Optimal water supply reservoir operation by leveraging the meta-heuristic Harris Hawks algorithms and opposite based learning technique.

To ease water scarcity, dynamic programming, stochastic dynamic programming, and heuristic algorithms have been applied to solve problem matters related to water resources. Development, operation, and management are vital in a reservoir operating policy, especially when the reservoir serves a complex objective. In this study, an attempt via metaheuristic algorithms, namely the Harris Hawks Optimisation (HHO) Algorithm and the Opposite Based Learning of HHO (OBL-HHO) are made to minimise the water deficit as well as mitigate floods at downstream of the Klang Gate Dam (KGD). Due to trade-offs between water supply and flood management, the HHO and OBL-HHO models have configurable thresholds to optimise the KGD reservoir operation. To determine the efficacy of the HHO and OBL-HHO in reservoir optimisation, reliability, vulnerability, and resilience are risk measures evaluated. If inflow categories are omitted, the OBL-HHO meets 71.49% of demand compared to 54.83% for the standalone HHO. The HHO proved superior to OBL-HHO in satisfying demand during medium inflows, achieving 38.60% compared to 20.61%, even though the HHO may have experienced water loss at the end of the storage level. The HHO is still a promising method, as proven by its reliability and resilience indices compared to other published heuristic algorithms: at 62.50% and 1.56, respectively. The Artificial Bee Colony (ABC) outcomes satisfied demand at 61.36%, 59.47% with the Particle Swarm Optimisation (PSO), 55.68% with the real-coded Genetic Algorithm (GA), and 23.5 percent with the binary GA. For resilience, the ABC scored 0.16, PSO scored 0.15, and real coded GA scored 0.14 whilst the binary-GA has the worst failure recovery algorithm with 0.09.

Comparison between the effects of deep and moderate neuromuscular blockade during transurethral resection of bladder tumor on endoscopic surgical condition and recovery profile: a prospective, randomized, and controlled trial.

PURPOSE: To compare between deep neuromuscular blockade (NMB) and moderate NMB with respect to endoscopic surgical conditions and recovery profiles in patients with general anesthesia for transurethral resection of bladder (TURB). METHODS: 108 patients undergoing elective TURB were randomized into two groups: the moderate NMB (n = 54) or deep NMB (n = 54) group. After the operation, NMB was reversed with 2 mg/kg sugammadex at a train-of-four (TOF) count of 1 or 2 (moderate NMB group) or with 4 mg/kg sugammadex at post-tetanic count (PTC) of 2 (deep NMB group). Surgeons, who were blinded to the study design, rated the endoscopic surgical condition on a 5-point scale (1 = extremely poor, 2 = poor, 3 = acceptable, 4 = good, 5 = optimal) immediately following the operation. Recovery profiles, including postoperative residual curarization (PORC), respiratory complication, and recovery time, were recorded. RESULTS: No difference was observed between the two groups regarding patients and anesthesia characteristics. There were statistically significant differences in endoscopic surgical conditions between the two groups (P < 0.001). Thirty-eight patients in the deep NMB group (74%) showed optimal surgical conditions, whereas 16 patients in the moderate NMB group (30%) showed optimal endoscopic surgical conditions. No PORC and respiratory complications occurred in both groups, and no difference was found between the two groups in terms of recovery profiles, including recovery time and other adverse events. CONCLUSIONS: Deep NMB and reversal with sugammadex improved the endoscopic surgical condition without complications compared with moderate NMB and reversal with sugammadex in patients undergoing TURB.

Intraoperative naloxone reduces remifentanil-induced postoperative hyperalgesia but not pain: a randomized controlled trial.

Background: Intraoperative use of a high-dose remifentanil may induce postoperative hyperalgesia. Low-dose naloxone can selectively reverse some adverse effects of opioids without compromising analgesia. We thus hypothesized that the intraoperative use of a high-dose remifentanil combined with a low-dose naloxone infusion reduces postoperative hyperalgesia compared with the use of remifentanil alone. Methods: Patients undergoing elective thyroid surgery were randomly assigned into one of three groups, depending on the intraoperative effect-site concentration of remifentanil, with or without a continuous infusion of naloxone: 4 ng ml-1 remifentanil with 0.05 µg kg-1 h-1 naloxone in the high-remifentanil with naloxone group, and 4 or 1 ng ml-1 remifentanil with a placebo in the high- or low-remifentanil groups, respectively. We measured the pain thresholds (primary outcome) to mechanical stimuli using von Frey filaments and incidence of hyperalgesia on the peri-incisional area 24 h after surgery. We also measured pain intensity, analgesic consumptions and adverse events up to 48 h after surgery. Results: The pain threshold presented as von Frey numbers [median (interquartile range)] was significantly lower in the high-remifentanil group (n=31) than in the high-remifentanil with naloxone (n=30) and the low-remifentanil (n=30) groups [3.63 (3.22-3.84) vs 3.84 (3.76-4.00) vs 3.80 (3.69-4.08), P=0.011]. The incidence of hyperalgesia was also higher in the high-remifentanil group than in the other groups [21/31 vs 10/30 vs 9/30, P=0.005]. Postoperative pain intensity, analgesic consumptions and adverse events were similar between groups. Conclusions: The intraoperative use of low-dose naloxone combined with high-dose remifentanil reduced postoperative hyperalgesia but not pain. Clinical trial registration: NCT02856087.

Performance of the Minto model for the target-controlled infusion of remifentanil during cardiopulmonary bypass.

We studied the predictive performance of the Minto pharmacokinetic model during cardiopulmonary bypass in patients undergoing cardiac surgery. Patients received remifentanil target-controlled infusion using the Minto model during total intravenous anaesthesia with propofol. From 56 patients, 275 arterial blood samples were drawn before, during and after bypass to determine the plasma concentration of remifentanil, and the predicted concentrations were recorded at each time. For pooled data, the median prediction error and median absolute prediction error were 21.3% and 21.8%, respectively, and 22.1% and 22.3% during bypass. Both were 148.4% during hypothermic circulatory arrest and measured concentrations were more than three times greater than predicted (26.9 (17.0) vs. 7.1 (1.6) ng.ml-1 ). The Minto model showed considerable bias but overall acceptable precision during bypass. The target concentration of remifentanil should be reduced when using the Minto model during hypothermic circulatory arrest.

Effect of early vs. late tracheostomy on clinical outcomes in critically ill pediatric patients.

BACKGROUND: Few studies investigated the optimal timing for tracheostomy and its influence on the clinical outcomes in critically ill pediatric patients. This study evaluated the differences in clinical outcomes between early and late tracheostomy in pediatric intensive care unit (ICU) patients. METHODS: We assessed 111 pediatric patients. Patients who underwent a tracheostomy within 14 days of mechanical ventilation (MV) were assigned to the early tracheostomy group, whereas those who underwent tracheostomy after 14 days of MV were included in the late tracheostomy group. Clinical outcomes, including mortality, duration of MV, length of ICU and hospital stays, and incidence of ventilator-associated pneumonia (VAP) were compared between the groups. RESULTS: Of the 111 pediatric patients, 61 and 50 were included in the early and late tracheostomy groups, respectively. Total MV duration and the length of ICU and hospital stay were significantly longer in the late tracheostomy group than in the early tracheostomy group (all P < 0.01). The VAP rate per 1000 ventilator days before tracheostomy was 2.6 and 3.8 in the early and late tracheostomy groups, respectively. There were no significant differences in mortality rate between the groups. No severe complications were associated with tracheostomy itself. CONCLUSIONS: Tracheostomy performed within 14 days after the initiation of MV was associated with reduced duration of MV and length of ICU and hospital stay. Although there was no effect on mortality rate, children may benefit from early tracheostomy without severe complications.

Safety and comfort during sedation for diagnostic or therapeutic procedures.

Sedation during diagnostic or therapeutic procedures must be safe and comfortable for patients. To achieve this, additional suitably qualified staff must be available throughout the procedure to administer sedation and monitor the patient. Anaesthesiologists possess the necessary knowledge and skills to perform sedation safely but are often unavailable. Non-anaesthesiologists performing sedation should be fully trained in the physiology of sedation, the pharmacology of sedatives and analgesics, the monitoring of patients, and in airway support, ventilatory care, and cardiopulmonary resuscitation. The presence of an anaesthesiologist is desirable when dealing with patients at high-risk of complications. Good sedation practice involves presedation assessment and optimal selection of patients, careful monitoring and support from dedicated staff, and adherence to recovery and discharge criteria.

Hemophagocytic syndrome in pregnancy.

BACKGROUND: Hemophagocytic syndrome is characterized by nonmalignant histiocytes that undergo uncontrolled phagocytosis of normal hematopoietic cells. Clinical severity ranges from complete recovery to rapid deterioration and death. CASE: Thrombocytopenia was discovered upon routine initial prenatal evaluation of a 24-year-old, gravida 2, para 1, at 29 weeks' gestation with a history of necrotizing lymphadenitis. Cytopenia and elevated transaminases developed, followed by hyperpyrexia. The patient delivered and her postpartum course was complicated by coagulopathy, multiorgan failure, and death. Bone marrow biopsy confirmed hemophagocytic syndrome. CONCLUSION: Early diagnosis of hemophagocytic syndrome during pregnancy might be helped by recognizing symptoms and signs, including a history of necrotizing lymphadenitis, and obtaining a bone marrow biopsy.

Intravascular large B-cell lymphoma. A report of five cases initially diagnosed by bone marrow biopsy.

We report 5 cases of intravascular lymphoma (IVL) initially diagnosed by bone marrow aspiration and biopsy. Each patient had generalized symptoms; 1 also had neurologic deficits. CBC counts revealed anemia (4 patients), thrombocytopenia (4 patients), or mild leukopenia (1 patient). The bone marrow biopsy specimen was diagnostic in each case. Lymphoma cells were present in small groups or single file in sinusoids (in 1 patient, sinusoids were distended markedly by IVL) and were detected in bone marrow aspirate smears (4 patients) and peripheral blood smears (all patients). Immunohistochemical studies demonstrated that every neoplasm was of B-cell lineage, CD20+, positive for other B-cell antigens, and CD3- or CD43-. Immunophenotypic studies revealed at least 2, and possibly 3, distinct immunophenotypic groups of B-cell IVL: CD20+ CD5+ (3 neoplasms), CD20+ CD5- CD10+ (1 neoplasm), and CD20+ CD5- CD10 unknown (1 neoplasm). B-cell IVL may be detected by morphologic examination of peripheral blood and bone marrow, and involvement of these sites may be more common than is reported in the literature. Immunophenotypic studies are helpful in establishing the diagnosis and suggest that B-cell IVL is a heterogeneous group of neoplasms that may arise from more than 1 normal B-cell precursor.

Stability, blood partition, and protein binding of a chemoprotective agent, 2-(allylthio)pyrazine.

The stability of 2-AP, a chemoprotective agent, in various pH solutions and human gastric juice, the blood partition of 2-AP between plasma and blood cells, and the factors influencing the binding of 2-AP to 4% human serum albumin (HSA) were evaluated. 2-AP was stable in human gastric juice and pH solutions ranging from 1 to 12, however, 2-AP was unstable in pH 13 solution; the disappearance rate constant was 0.00759/h. 2-AP reached equilibrium rapidly between plasma and blood cells of rabbit blood. The equilibrium plasma/blood cells partition ratios were independent of initial rabbit blood concentrations of 2-AP, 1, 5, and 10 micrograms/ml; the values were in the range of 5.99-11.8. Binding of 2-AP to 4% HSA was dependent on HSA concentration, incubation temperature, 'the buffer' pH, and addition of acetylsalicylic acid. The binding of 2-AP was independent of buffers containing various concentrations of chloride ion, heparin, and alpha-1-acid glycoprotein.

Intravascular large B-cell lymphoma: the CD5 antigen is expressed by a subset of cases.

The CD5 antigen is a T-cell associated marker that is also usually expressed by two B-cell neoplasms, chronic lymphocytic leukemia/small lymphocytic lymphoma and mantle cell lymphoma. We observed CD5 antigen expression in a subset of cases of intravascular large B-cell lymphoma (IVLBL), and we report here five cases. The patients, two men and three women, ranged in age from 59 to 81 years. Biopsy specimens were obtained from kidney, lung, bone marrow, abdominal wall, and neck, the latter involving a lymphangioma. All of the cases had histologic features typical of IVLBL, with large and atypical lymphoid cells located predominantly within blood vessels. Immunohistochemical studies performed using routinely fixed, paraffin-embedded tissue sections showed that the neoplastic cells were B cells, positive for the CD20 antigen and negative for the CD3 or CD43 antigens. All cases were also positive for the CD5 antigen. One case had an immunoglobulin heavy chain gene rearrangement shown by using a polymerase chain reaction method. The finding of CD5 antigen expression in a subset of IVLBL cases adds to other evidence in the literature suggesting that IVLBL is a heterogeneous entity. We considered the possibility that these cases were related to or represented unusual histologic forms of transformation from either chronic lymphocytic leukemia/small lymphocytic lymphoma or mantle cell lymphoma. All of the cases, however, were negative for the CD23 antigen and cyclin D1 (bcl-1) protein, which is evidence against this interpretation. The biologic significance of CD5 antigen expression in cases of IVLBL is uncertain. These neoplasms might arise from a separate lineage of CD5-positive B cells or from a specific, early stage of B-cell differentiation. Alternatively, some investigators have suggested that CD5 antigen expression by B cells is a marker of activation.

Determination of a chemoprotective agent, 2-(allylthio)pyrazine, in plasma, urine and tissue homogenates by high-performance liquid chromatography.

A high-performance liquid chromatographic method was developed for the determination of a chemoprotective agent, 2-(allylthio)pyrazine (I), in human plasma and urine, and in rat blood and tissue homogenate using diazepam as an internal standard. The sample preparation was simple; 2.5 volumes of acetonitrile were added to the biological sample to deproteinize it. A 50-100 microl aliquot of the supernatant was injected onto a C18 reversed-phase column. The mobile phase employed was acetonitrile-water (55:45, v/v), and it was run at a flow-rate of 1.5 ml/min. The column effluent was monitored using an ultraviolet detector at 330 nm. The retention times for I and the internal standard were 4.0 and 5.1 min, respectively. The detection limits of I in human plasma and urine, and in rat tissue homogenate (including blood) were 20, 20 and 50 ng/ml, respectively. The coefficients of variation of the assay (within-day and between-day) were generally low (below 6.1%) in a concentration range from 0.02 to 10 microg/ml for human plasma and urine, and for rat tissue homogenate. No interferences from endogenous substances were found.

Pharmacokinetics of a chemoprotective agent, 2-(allylthio)pyrazine, after intravenous administration to rabbits.

The pharmacokinetics of 2-(allylthio)pyrazine (2-AP) were evaluated after intravenous administrations of the drug to rabbits. The reason for the multiple peaks in the plasma concentration of 2-AP after intravenous administration of the drug to rabbits were also investigated. After intravenous administration of 2-AP, 10, 20, and 50 mg/kg, to rabbits, the pharmacokinetic parameters of 2-AP, such as the total area under the plasma concentration-time curve from time 0 to 12 h (261, 672, and 1190 micrograms min/ml), the total body clearance (38.3, 42.0, 44.6 ml/min/kg), and the percentages of intravenous dose of 2-AP excreted in 24 h as unchanged drug (0.0306, 0.0252, and 0.0492%), were independent of the dose ranges studied. Since the amount of 2-AP excreted in 12-h bile as unchanged drug after intravenous administration of 2-AP, 20 mg/kg, was only 0.0241 +/- 0.00156%, and some of 2-AP excreted in gastrointestinal tract as unchanged drug was reabsorbed, the reason for the appearance of multiple peaks after intravenous administration of 2-AP could be at least partly due to gastrointestinal excretion of the drug.

Aspalatone, a new antiplatelet agent, attenuates the neurotoxicity induced by kainic acid in the rat.

The antioxidant efficacy of aspalatone (APT; acetyl salicylic acid maltol ester), a new antiplatelet agent, has been characterized in vivo as well as in vitro, and several observations indicated that the antioxidant could prevent the neuroexcitation caused by oxidative stress. In this report, the effect of APT was evaluated on kainic acid (KA)-induced neurotoxicity, since the neurotoxicity induced by KA is, at least in part, mediated via the formation of free radicals. The results showed that pretreatments with APT or maltol (MAL) significantly attenuated seizure activity, oxidative stress (lipid peroxidation and protein oxidation) and the loss of hippocampal neurons induced by KA. On the other hand, the pretreatments with aspirin (ASP), ASP together with MAL or vitamin E failed to protect against the toxicity produced by KA suggesting that the mechanism of action for APT on the KA-induced neurotoxicity is different from that of ASP. These finding raise the possibility that salicylmaltol, a metabolite of APT, plays a role in preventing the neurotoxicity evoked by KA. Therefore, our results suggest that an APT-related antioxidant mechanism, which is linked to the MAL moiety, is involved in the neuroprotective effect against KA.

Rosette-forming non-Hodgkin's lymphomas.

Homer Wright rosettes, typically found in neuroblastomas and consisting of neoplastic cells surrounding an eosinophilic fibrillary centre without a lumen, have been considered as an important finding in the differential diagnosis of small round cell tumours. Rosettes in a neoplasm involving lymph nodes or bone marrow traditionally excluded a diagnosis of malignant lymphoma. In this report, we describe three cases of malignant lymphoma (two small lymphocytic and one diffuse large cell) with pronounced rosette formation. One of the two cases of small lymphocytic lymphoma was observed in the bone marrow, the other small lymphocytic lymphoma and the large cell lymphoma were in lymph nodes. The rosettes consisted of neoplastic lymphoid cells, often with participation of reactive macrophages, and ultrastructurally they had a central mass of interdigitating fibrillary cytoplasmic projections. Two cases were of B-cell lineage and one was of T-cell lineage. To the best of our knowledge, this is the first report of T-cell lymphoma with rosettes. Based on these findings, it is suggested that non-Hodgkin's lymphoma be included in the differential diagnosis of rosette-forming round cell neoplasms.

p53 mutations in Hodgkin's disease.

Although numerous studies have demonstrated increased expression of p53 protein in the Reed-Sternberg cells of Hodgkin's disease, little data exist as to whether mutations of the p53 gene is a common occurrence in this neoplasm. Using a microdissection technique coupled with PCR, single-strand conformation analysis, and DNA sequencing, we studied 23 cases of Hodgkin's disease for mutations within exons 5 to 8 of the p53 gene. We found seven mutations within six cases; six were missense mutations. An identical missense mutation was found in three cases (codon 243, methionine to isoleucine), and another identical missense mutation was found in an additional two cases (codon 204, glutamic acid to lysine). Verification of the mutations was accomplished either by direct Southern blotting of PCR-amplified p53 exon products from re-extracted DNA or by hybridization of cloned PCR-amplified p53 exon products from re-extracted DNA with a mutant-specific oligonucleotide. There was no good correlation between the presence of p53 mutations and the level of p53 protein expression, which was found to be overexpressed in all cases, the level of MDM2 protein expression, or the proliferation rate as determined by K-67 antibody. None of the cases with p53 mutation had evidence of Epstein-Barr virus within the Reed-Sternberg cells, as compared with 7 of 17 of the other cases (p < 0.06). These results suggest that p53 mutation may represent an important mechanism in the pathogenesis of Hodgkin's disease, and this mechanism may be independent of Epstein-Barr virus.

Synchronous Hodgkin's disease and granulocytic sarcoma with no prior therapy.

We describe a case of simultaneous nodular sclerosing Hodgkin's disease and a granulocytic sarcoma in a cervical lymph node without any previous therapy. The condition evolved into acute myelogenous leukemia approximately 8 months after the initial diagnosis of the granulocytic sarcoma. The unexpected presence of a granulocytic sarcoma made the diagnosis challenging, and appropriate immunohistochemical studies were required for accurate diagnosis. To the best our knowledge, this is the first report of synchronous Hodgkin's disease and granulocytic sarcoma with eventual development of acute myelogenous leukemia.

Trafficking of cell-surface amyloid beta-protein precursor. I. Secretion, endocytosis and recycling as detected by labeled monoclonal antibody.

Amyloid beta-protein, the principal constituent of amyloid fibrils found in senile plaques and blood vessels in Alzheimer's disease, is constitutively produced and released into medium of cultured cells. Amyloid beta-protein is derived by proteolysis of the beta-amyloid precursor protein by unclear mechanisms. Beta-amyloid precursor protein is a transmembrane protein which can be processed to release a large secretory product or processed in the endosomal/lysosomal pathway without secretion. Previous studies have shown that from the cell surface, beta-amyloid precursor protein may be released after cleavage or internalized without cleavage, the latter in a pathway that both produces amyloid beta-protein and also targets some molecules to the lysosomal compartment. Analysis of beta-amyloid precursor protein trafficking is confounded by the concomitant secretion and internalization of molecules from the cell surface. To address this issue, we developed an assay, based on the binding of radioiodinated monoclonal antibody, to measure the release and internalization of cell surface beta-amyloid precursor protein in transfected cells. With this approach, we showed that surface beta-amyloid precursor protein is either rapidly released or internalized, such that the duration at the cell surface is very short. Approximately 30% of cell surface beta-amyloid precursor protein molecules are released. Following internalization, a fraction of molecules are recycled while the majority of molecules are rapidly sorted to the lysosomal compartment for degradation When the C terminus of beta-amyloid precursor protein is deleted, secretion is increased by approximately 2.5-fold as compared to wild-type molecules. There is concomitant decrease in internalization in these mutant molecules as well as prolongation of the resident time on the cell surface. This observation is consistent with recent evidence that signals within the cytoplasmic domain mediate beta-amyloid precursor protein internalization.

Molecular diagnosis of mantle cell lymphoma in paraffin-embedded tissue.

Mantle cell lymphoma (formerly known as intermediate lymphocytic lymphoma, diffuse centrocytic lymphoma, or diffuse small cleaved lymphoma) is one of the small cell non-Hodgkin lymphoma entities that is clinically more aggressive than small lymphocytic lymphoma, and needs to be separated from it. Mantle cell lymphoma is strongly associated with the t(11;14) chromosomal translocation that rearranges the bcl-1 oncogene (PRAD-1 gene) and immunoglobulin heavy chain gene. In this study, we developed a nested polymerase chain reaction system to evaluate the t(11;14) translocation. The study material consisted of 10 mantle cell lymphomas fulfilling the criteria suggested by other authors (P. M. Banks et al. Surg Pathol 16:637, 1992). A novel nested polymerase chain reaction system was used to evaluate the bcl-1 breaks in the major translocation cluster using two successive polymerase chain reaction amplifications. This reaction yielded a background-free single product of the size of 200 to 300 base pairs in four of 10 mantle cell lymphomas. The identity of the product from the nested polymerase chain reaction was confirmed by Southern blotting followed by hybridization with a specific probe. The amplification products were also evaluated by Sst-I, Alu-I, Dde-I, and Ita-I restriction enzymes and showed different patterns of digestion reflecting individual differences between the MTC/ IgH junctions. A selection of other low-grade lymphomas, including lymphocytic, follicular, and mucosa-associated lymphoid tissue lymphoma, and hairy cell leukemia and 29 hyperplastic lymph nodes were negative. This nested polymerase chain reaction system for the t(11;14) translocation involving major translocation cluster offers a convenient specific identification for mantle cell lymphoma. However, this test has a limited diagnostic power because only about half of the mantle cell lymphomas show the bcl-1 breaks in the major translocation cluster. The test performs well in formaldehyde-fixed and paraffin-embedded material, allowing the study of large numbers of retrospective cases of mantle cell lymphomas.

Cytokeratin-positive large-cell lymphomas of B-cell lineage. A study of five phenotypically unusual cases verified by polymerase chain reaction.

Five cases of clinically aggressive, keratin-positive malignant lymphomas of B-cell type with unusual immunophenotypes were studied. All cases were extranodal: two from the stomach, one from soft tissue, one from the skin, and one from the spleen. These tumors were undifferentiated large-cell neoplasms that showed reactivity for low-molecular-weight keratin 8, but they were negative for keratin 19; three cases were also positive for epithelial membrane antigen. The immunohistochemical diagnosis was complicated by the fact that two of these cases lacked reactivity for leukocyte common antigen and three were CD20 negative. These findings simulated the immunophenotype of a carcinoma and led to an initial misdiagnosis of carcinoma. Although only two cases showed immunohistochemical evidence of B-cell lineage (CD20+), all five cases were documented as B-cell lymphomas on the basis of the clonal immunoglobulin heavychain gene rearrangement, as demonstrated by polymerase chain reaction (PCR) in all the cases and by Southern blot hybridization in three cases; all cases were negative for T-cell markers, and three cases showed germline configuration for T-cell receptor beta-chain. One case was strongly CD30 positive and represented large-cell anaplastic lymphoma of B-cell type. Our results show that some B-cell lymphomas can have unusual and confusing immunophenotypes, including keratin positivity and leukocyte antigen negativity. Use of PCR-based molecular genetic demonstration of clonal immunoglobulin heavychain gene rearrangement is helpful in establishing the correct diagnosis in such cases.

Trisomy 12 in Richter's transformation of chronic lymphocytic leukemia.

Conventional cytogenetic data and fluorescence in situ hybridization (FISH) interphase cytogenetic studies have shown that trisomy 12 is found in many cases of B-cell chronic lymphocytic leukemia (B-CLL). Several reports indicate that +12 is an acquired numerical cytogenetic abnormality, and may be associated with a worse prognosis or more extensive disease. Wright-Giemsa-stained blood or bone marrow smears obtained after initial diagnosis, and subsequent lymph node cells, bone marrow aspirate smears, or effusions were retrospectively studied from five patients whose disease underwent morphologic transformation from typical B-CLL to a high grade lymphoproliferative disease (Richter's syndrome). Using an alpha-satellite DNA probe to the centromere of chromosome 12, trisomy 12 was found in a proportion of cells from all five specimens with high grade lymphoproliferative disease, but in only one of five samples collected before transformation. These data suggest that +12 is an acquired cytogenetic abnormality in CLL and has a high frequency in Richter's syndrome. Because only a subpopulation of the neoplastic cells contain an extra copy of chromosome 12, it is unlikely that this numerical abnormality plays a direct role in transformation to high grade lymphoproliferative disease.