Recruiting, interviewing, and hiring the right person.

In 1998 and 1999, unprecedented changes occurred in the U.S. economy: unemployment rates dropped below 4.5%, the stock market soared to more than 11,000, and about 3 million new technology-related jobs were created (1). Faced with worldwide competition and new technologies, many industries and businesses have had to relook at and reengineer their operations. Human resource management has played a key role. Significant resources always have been allocated to the recruiting process to hire competent and loyal employees. To not spend the time and effort to recruit good employees can be costly in many ways. This review offers guidelines to managers and emphasizes just how important this process is to the success of an organization.

Telemedicine: emerging opportunities and future trends.

Remote location, lack of specialty services, or managed care capitation contribute to limited access to health care. As reimbursement rates decline, availability to expert or high-tech care is affected. The need to "make do" with available personnel, existing technologies, or dated facilities is not uncommon and affects the quality of health care. Telemedicine accounts for these issues and serves as an alternative to providing interactive evaluation and management of patients. As computer hardware and software improve and become less costly, access to this technology will be more commonplace and establish itself as an acceptable standard of practice. The Internet may serve as a highway to resources that currently are not available in rural areas or in third-world countries. Access to Web sites that provide comprehensive and instructive material is just one part of a complex, developing area of health care.

Etiology of neutrophilic granulocytic hypoplasia in a case of large granular lymphocytic leukemia with paraproteinemia.

The association between large granular lymphocytic leukemia (LGLL) and neutropenia is poorly understood. We attempted to assess whether neutropenia in LGLL with paraproteinemia has a different etiology than LGLL without paraproteinemia. We found neither direct serum inhibition of granulocyte/monocyte-colony forming units in vitro nor increased immunoglobulin binding to granulocytic neutrophils, neutrophil precursors, or granulocyte/monocyte-colony stimulating factor. Clonogenic assay experiments suggested that suppression of the patient's granulocyte/monocyte-colony forming units by the neoplastic T-cells and decreased granulocyte/monocyte-colony stimulating factor production contributed to the pathogenesis of neutropenia in this particular case.

The use of monoclonal antibodies against primary myeloid granules in normal and leukemic cells.

Three monoclonal antibodies, K101, D46, and H36/71 (CD15), reactive with membrane components of primary granules of human promyelocytes, were studied to assess their binding to normal and leukemic cells. Using the alkaline phosphatase antialkaline phosphatase technique, these antibodies were applied to sections of normal organs and to peripheral blood and bone marrow films from hematologically normal individuals and patients with hematologic malignancies. In control experiments, antibodies showed reactivity with cytoplasmic constituents of granulocytes from the promyelocytic to the neutrophilic stage. In acute myeloid leukemia, antibody K101 was positive (more than 20% of blasts) in 13 of 21 (62%) cases, while antibody D46 was positive in 11 of 17 (65%) cases. Antibody H36/71 was positive in only 4 of 24 (17%) cases of acute myeloid leukemia. At least one marker was present in 6 of 8 (75%) cases of acute lymphoblastic leukemia with myeloid antigen-positive blasts and was negative in 20 cases of acute lymphoblastic leukemia with myeloid antigen-negative blasts. These results support the view that abnormal granules (with defective expression of the D46, K101, and H36/71 antigens) form in blastic and leukemic cells of patients with acute myeloid leukemia. Data also suggest that membrane components of myeloid granules are made in the cytoplasm of cells from some acute lymphoblastic leukemia patients with myeloid antigen-positive blasts.

Immunophenotypic subclassification of chronic lymphocytic leukaemia (CLL).

To determine the significance of the immunophenotypic heterogeneity of B-cell chronic lymphocytic leukaemia (CLL), surface immunoglobulins (SIgs), mouse rosette assays (MR), and a panel of monoclonal antibodies for B cells, T cells and myeloid cells were performed on peripheral blood samples from 61 newly diagnosed cases. Four groups were observed: group I (SIg+, MR+, CD19/20+, CD5+, T antigen (Ag)-; 27 cases); group II (SIg+, MR+, CD19/20+, CD5+, T Ag+; 17 cases); group III (SIg+, MR+ CD19/20+, CD5-, T AG-; 12 cases); and group IV (SIg-, MR+, CD19/20+, Cd5+, T Ag-; 5 cases). Groups were compared according to French-American-British Cooperative Group subtypes, clinical and laboratory features, Rai staging, and survival. Typical CLL morphology (greater than 90% small lymphocytes) was present in 20/20 (100%) of group I cases and 23/27 (85%) group II, III and IV cases (P = 0.09). Expression of a myeloid antigen was seen in 5/27 group I cases (18%) and 1/16 group II cases (6%), but was not predictive of survival (P = 0.36). The CD5- group III had a lower haemoglobin level (P less than 0.0001), higher Rai stage (P less than 0.002), and poorer survival at 5 years (P less than 0.02) than the other groups. We conclude that at least four distinct immunophenotypic subgroups of B-cell CLL can be determined. Expression of myeloid or T-cell antigens does not appear to predict for patient survival; however, lack of CD5 antigen may be associated with more advanced stage of disease and poor patient survival.

Large granular lymphocytosis terminating in a polymorphous B-lymphocytic proliferation after low-dose cyclophosphamide therapy: a case report with necropsy findings.

A 70-year-old man presented with clonal large granular lymphocytosis of T-suppressor/cytotoxic immunophenotype, neutropenia, paraproteinemia, and proneness to infection. The patient became severely leukopenic during 14 days of chemotherapy with low-dose cyclophosphamide, and remained so after discontinuation of the drug. Clinically, he was thought to have prolonged chemotherapy-induced marrow hypoplasia. At death, 16 days after the last dose of chemotherapy, autopsy confirmed bone marrow hypoplasia and revealed that well-differentiated, polymorphous, and (immunophenotypically and genotypically) polyclonal B-lymphocytes predominated in normal hematopoietic and lymphoid organs. A similar lymphoid infiltrate was intimately associated with multiple ulcers and smooth muscle necrosis in the stomach. These terminal findings resemble B-lymphoproliferative conditions described in certain forms of immune deficiency.

Significance of aberrant immunophenotypes in childhood acute lymphoid leukemia.

Leukemic cells from 51 pediatric patients (younger than 18 years) diagnosed with acute lymphoid leukemia by standard morphologic and cytochemical methods were subjected to flow cytometric studies using a panel of monoclonal antibodies against T-cell (CD1, 2, 3, 4, 5, 7, 8), B-cell (CD10, 19, 20, 21), myeloid (CD13, 14, 15, 33), and HLA-DR antigens. Cases of "conventional" acute lymphoid leukemia (leukemic cells with a normal configuration of B-cell or T-cell differentiation antigens) were observed in 26 of 51 (51%) cases, whereas cases of "aberrant" acute lymphoid leukemia (cells with abnormal patterns of B-cell or T-cell antigens or with concomitant myeloid antigens) were noticed in 25 (49%) cases. Myeloid antigen-positive acute lymphoid leukemia was observed in the leukemic cells of eight (16%) individuals. No significant differences were observed between conventional and aberrant ALL in the distribution of sex, age, leukocyte count, hemoglobin concentration, platelet count, blast count, French-American-British (FAB) type, lymphadenopathy, organomegaly, rate or duration of remission, or survival. When only myeloid antigen-positive cases were compared with myeloid antigen negative-cases, no significant correlations were observed except for duration of first remission (myeloid antigen positive, 26+ +/- 22 months; myeloid antigen negative, 40+ +/- 18 months; P less than 0.001), and duration of survival (myeloid antigen positive, 27+ +/- 24 months; myeloid antigen negative, 62+ +/- 17 months; P = 0.001). These data suggest that pediatric patients with ALL blasts possessing myeloid antigens may represent a high-risk group for length of remission and survival.

Immunophenotyping of non-Hodgkin's lymphomas in paraffin-embedded tissue sections. A comparison with genotypic analysis.

Several monoclonal antibodies (MoAbs) are now available for immunophenotyping non-Hodgkin's lymphomas (NHLs) in paraffin-embedded tissue sections. To determine the reliability of these reagents in predicting the genotype, 44 cases of NHL were studied with the alkaline phosphatase-anti-alkaline phosphatase technique with the use of the following MoAbs: leukocyte common antigen (CD45), Mac 387, L26, 4KB5, MB1, MB2, LN2, UCHL1, MT1, and MT2. The lineage of the neoplastic cells was determined in all cases by gene rearrangement studies for immunoglobulin heavy chain and for the T-cell receptor beta-chain. Genotypic results showed B-cell lineage in 33 cases (75%), T-cell lineage in 6 cases (14%), and mixed or undetermined lineage in 5 cases (11%). A concordance of lineage assignment by paraffin section immunophenotyping with gene rearrangement studies was observed in 37 of 39 (95%) lymphomas with an unequivocally defined genotype. MoAb L26 was the most sensitive in detecting B-cell genotype; MoAbs MT1 and UCHL1 were the most sensitive and specific, respectively, in detecting T-cell genotype. The authors conclude that lineage assignment of NHLs in paraffin sections is reflective of the corresponding genotype when an appropriate panel of MoAbs is used.

Granulocytic sarcoma.

Granulocytic sarcoma is a variant presentation of acute myeloblastic leukemia, occurring in extramedullary locations. It is uncommon, but it may occur at any site and at any age, which necessitates its inclusion in the differential diagnosis of all undifferentiated tumors. Histology, touch-imprint cytology, cytochemistry, immunocytochemistry, electron microscopy, and molecular studies all contribute to the diagnosis.

Immunophenotyping of hematologic neoplasms in paraffin-embedded tissue sections.

Several immunohistochemical methods are now available for the staining of neoplastic cells in tissue sections. The authors have found that the alkaline phosphatase-anti-alkaline phosphatase (APAAP) method is sensitive and reliable. Murine monoclonal or nonmurine polyclonal antibodies can be used to label a variety of membranous and/or cellular constituents in tissues that have been routinely processed in a histopathology laboratory. The monoclonal antibody against leukocyte common antigen (CD45) can be used to differentiate hematologic from nonhematologic tumors. Monoclonal antibodies (L26, LN1, LN2, LN3, MB1, MB2) label B-cell lymphomas, whereas other monoclonal antibodies (UCHL1, MT1) more characteristically stain T-cell lymphomas. Polyclonal antibodies against CD3 specifically mark neoplastic cells from T-cell lymphomas and leukemias but as yet are not commercially available. Monoclonal antibodies Leu-M1 (CD15), Ber H2 (Ki-1; CD30), and LN2 label Reed-Sternberg cells from most cases of nodular sclerosis, mixed cellularity, and lymphocyte-depleted Hodgkin's disease. Monoclonal antibodies Mac 387, KP1 (CD68), and NP57 (antielastase), as well as polyclonal antibodies against lysozyme, help identify subtypes of acute myeloid leukemia and extramedullary myeloid cell tumors. Although there are now excellent reagents ready for use, there is still a significant need for more lineage-specific (particularly against CD epitopes) monoclonal antibodies capable of labeling neoplastic cells in paraffin-embedded tissue sections from patients with hematologic malignancies.

Immunophenotyping of acute leukemias using paraffin-embedded tissue sections.

In a study of 55 patients with either acute lymphoid leukemia (ALL; 25 cases) or acute myeloid leukemia (AML; 30 cases), paraffin-embedded bone marrow particle sections were examined with a panel of monoclonal and polyclonal antibodies reactive toward lymphoid and myeloid-associated antigens, using the alkaline phosphatase-anti-alkaline phosphatase (APAAP) technique. All cases were previously classified according to the French-American-British (FAB) Co-operative Group, and cases of ALL were immunophenotyped by flow cytometry. Results indicated that myeloid-associated antibodies (Mac 387, KP 1 [CD68], antielastase, antilactoferrin, and antilysozyme) did not react with any case of ALL, M1-AML, or M6-AML, whereas at least one of these antibodies reacted with 20 of 21 (95%) cases of M2, M3, M4, and M5-AML. Anti-glycophorin C marked cases of M6-AML, whereas anti-CD3 labeled T-cell ALL. None of the antibodies tested specifically identified cases of B-cell ALL. The authors conclude that use of a selected panel of antibodies on paraffin-embedded bone marrow particle sections may be of value in the diagnosis and immunophenotypic classification of many cases of acute leukemias.

The immunophenotyping of extramedullary myeloid cell tumors in paraffin-embedded tissue sections.

Extramedullary tissue infiltrates of acute myeloid leukemia are rare and often difficult to recognize in routine paraffin-embedded tissue sections. Since appropriate therapy for these tumors depends on their precise identification, we have studied a series of tissues infiltrated with primitive myeloid cells using monoclonal and polyclonal antibodies capable of labeling cells of the myeloid/monocytic system in paraffin-embedded tissue sections. The current retrospective study involved tissues from 15 patients (eight men and seven women) with a mean age of 51 years (range, 23-77). A diagnosis of extramedullary myeloid cell tumors had been made on the basis of routine histology, chloroacetate esterase cytochemical stain, and--in some cases--electron microscopy. Paraffin-embedded tissue sections were cut and stained employing the alkaline phosphatase antialkaline phosphatase (APAAP) immunocytochemical procedure with monoclonal antibodies against leukocyte-common antigen (PD7/26-2B11), restricted components of the leukocyte-common antigen (UCHL1, 4KB5), granulocytes (Mac-387, Leu-M1), leukocytes (MT1, MT2, LN1, LN2), HLA-DR (LN3), and elastase (NP57), as well as polyclonal antibodies against lactoferrin, lysozyme, alpha-1-antitrypsin, and alpha-1-antichymotrypsin. Results indicate that antibodies against Mac-387, elastase, and lysozyme are most useful in the recognition of neoplastic myeloid cells. We conclude that tissues containing granulocytic tumors can be identified in paraffin-embedded tissue sections using a panel of antibodies and the APAAP procedure.

Use of the APAAP method in the classification and diagnosis of hematologic disorders.

The APAAP technique is a sensitive and relatively easy immunocytochemical method to perform. It requires only a modest amount of laboratory space and no expensive equipment with the exception of a light microscope. Staining can be performed on peripheral blood and bone marrow films as well as cryostat and paraffin-embedded tissue sections. Prior to staining peripheral blood and bone marrow films as well as cryostat sections, slides can be stored at -70 degrees C, thus allowing for batch processing of specimens. Stained slides can be kept at room temperature for prolonged periods of time without loss of label. Surface or cytoplasmic determinants can be stained with the APAAP method. Because the preparations are usually counterstained, the identification of the labeled cells can be observed and photographed. The APAAP method is a reliable procedure and a significant addition to the routine hematology and histopathology laboratory.

Lymphocytic surface markers in lymphoid leukemoid reactions.

Although mononuclear cell surface markers are primarily used to determine the lineage and stage of differentiation of leukemias and lymphomas, they can also be helpful in discriminating between some cases of neoplastic and reactive conditions. Peripheral blood lymphocytosis secondary to infection most often shows increased numbers of activated T cells of the suppressor/cytotoxic subset. A few exceptions, such as in pertussis, show predominantly T-helper cells. Although persistent B-cell lymphocytosis is most often associated with neoplastic conditions, B-cell predominant reactive conditions may also occur. Lack of light chain restrictions on B-cell membranes suggests non-neoplastic disorders. Reactive lymphadenopathy most often shows a predominance of T cells with normal to increased T-helper/T-suppressor cell ratios. In addition, normal ratios of kappa/lambda light chain surface immunoglobulin usually occur on B cells of reactive lymph nodes. Benign lymphocytic infiltrates in skin most often show a predominance of activated T-helper cells. Distinguishing reactive from neoplastic dermal infiltrates by mononuclear cell markers can be extremely difficult and may require DNA genotypic analysis. Mononuclear cell markers applied to bone marrow in patients treated for leukemia and other disorders must also be interpreted with caution. The presence of CD10 antigen (CALLA) may herald recurrence of leukemia; however, this determinant is not leukemia-specific and may be found on normal cells. Similarly, lymphoid cells bearing TdT often represent recurrent leukemia, and they must be differentiated from immature nonmalignant TdT-positive cells. Immunologic surface markers must be interpreted together with a careful review of the morphology of the tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

T6 monoclonal antibody reacts with blasts from cases of common antigen acute lymphocytic leukemia.

The expression of the T6 antigen on malignant lymphoid cells has been considered strong evidence in support of T-cell lineage and thymic stage of differentiation of the neoplastic cells. Thus, the authors have used the T6 monoclonal antibody for the last three years in the immunophenotyping of blasts from 60 consecutive cases of acute lymphocytic leukemia (ALL) and 8 cases of T-cell lymphoma. Blasts from 12 of 46 (26%) cases of common type ALL, 4 of 7 (57%) cases of T-cell ALL, 2 of 3 (66%) cases of lymphoblastic lymphoma, and 1 of 5 (20%) cases of peripheral (postthymic) T-cell lymphoma were positive for the T6 antigen. The authors conclude that the expression of T6 antigen on malignant lymphoid cells may not always indicate T-cell lineage.

Impaired synthesis of immunoglobulin in patients with chronic lymphocytic leukemia.

The cause of hypogammaglobulinemia in patients with chronic lymphocytic leukemia (CLL) is unknown. Experiments were performed to determine if sera, monocytes, or non-T cells from patients with CLL suppress the proliferative response and synthesis of immunoglobulin (Ig) following incubation with pokeweed mitogen (PWM) in cocultures with lymphocytes from normal individuals. The data indicate that sera and monocytes from patients with CLL did not suppress the proliferative response or synthesis of Ig normal non-T cells. When various numbers of normal non-T cells and CLL non-T cells were cocultured with a constant number of normal T cells, the proliferative response and the concentration of supernatant Ig decreased as the proportion of CLL non-T cells increased. Since similar results were obtained when irradiated non-T cells from normal individuals were substituted for non-T cells from patients with CLL, we believe that the decrease in proliferative response and diminished synthesis of Ig is not the result of the suppressor non-T cells but is related to the dilution of normal B cells by inert non-T cells. We conclude that these experiments serve as as in vitro model for patients with CLL and suggest that the hypogammaglobulinemia observed in this disease is related to the diluting out of normal B cells by the accumulation of neoplastic B cells in the peripheral blood, bone marrow, and lymphoid tissue of these patients.

Comparison of bleeding times performed on the arm and the leg.

The standardized bleeding time (SBT) is used to assess hemostatic function in patients suspected of having coagulation disorders. Because injury to the arm or the presence of intravascular cannulae often preclude the determination of SBTs on the upper extremity, the authors compared the SBT on the arm with the bleeding time on the leg to ascertain the efficacy of the lower extremity for this test. Thirty healthy volunteers were enrolled in the study. Bleeding times were performed on the forearm and on the medial aspect of the calf. The subjects then ingested 650 mg of aspirin, and the tests were repeated two hours later on the contralateral extremities. The mean preaspirin SBT (5.6 +/- 1.7 minutes did not differ significantly from the mean bleeding time on the leg (5.8 +/- 2.3 minutes) (P greater than 0.50), nor was there a significant difference between the mean postaspirin bleeding time on the arm (10.2 +/- 4.3 minutes) and that on the leg (9.9 +/- 3.7 minutes) (P greater than 0.50). On the basis of this study, the authors conclude that the arm and leg are equally reliable sites for determining bleeding times in normal persons and are equally sensitive for detection of aspirin-induced prolongation of bleeding.

Serum immunoglobulins and lymphocyte subsets in chronic lymphocytic leukemia.

The concentrations of serum immunoglobulins were correlated to the stage of disease and the proportions of peripheral blood lymphocyte subsets in 25 untreated patients with B-cell chronic lymphocytic leukemia (CLL). Diminished levels of at least one serum immunoglobulin were present in 77% of all patients with CLL and 73% of patients with Stage 0 disease. The mean concentration of IgG, IgM, and IgA decreased with advancing stage of CLL. The percentages of total T, T-helper (TH), and T-suppressor (TS) cells in the peripheral blood were less in patients with CLL than in healthy persons, but the absolute concentrations of total T, TH, and TS cells were greater in patients with CLL than controls (P less than 0.02). The absolute number of B-cells (P less than 0.01) and null cells (P less than 0.001) was also increased in patients with CLL, particularly those patients in advanced stages of CLL. These findings suggest that the hypogammaglobulinemia associated with CLL first occurs during the earliest stage of disease and may be related to the alterations in the proportion of peripheral blood lymphocytes.

Cell volumes of lymphoblasts in patients with acute lymphocytic leukaemia.

Cell volumes of lymphoblasts from 75 cases of acute lymphocytic leukaemia (ALL) and lymphocytes from 33 normal individuals were determined using a Coulter Counter Model H4 Channelyzer. The average mean cell volume (MCV) and the model volume (MV) of lymphoblasts were larger than the MCV and MV of normal lymphocytes (P less than 0.01). In addition, the cell volumes of lymphoblasts from patients with ALL were more heterogeneous than normal lymphocytes. When the volumes of lymphoblasts were compared to the FAB classification, lymphoblasts from cases of L3 were larger than those from L2 and the latter were larger than lymphoblasts from the L1 subtype. When the volumes of lymphoblasts were compared to an immunological classification, lymphoblasts from cases of B cell ALL were larger than those from non-B, non-T and T cell ALL. The volume of lymphoblasts, however, showed no significant predictive value in the determination of complete remission, duration of first remission, or survival.