Diagnosis of lymphoma in the new millennium.

Finally, it may be that if there were a complete understanding of lymphoid neoplasms, with tools and methods to dissect precisely each patient's cell of origin, genetic abnormality and level of differentiation or proliferation, every patient's lymphoma might be different, one from the other. One wonders whether such complete knowledge would be helpful. Each patient, given enough time and advanced technology, might prove to have a unique defect. Currently flow cytometry allows us to characterize patients into a reasonable number of subgroups for therapy. DNA and molecular biology techniques in the future may allow for gene replacement, gene piece insertion, antisense DNA inhibition and other exciting and as yet undreamed of miracles.

HIV-associated autoimmune hemolytic anemia complicated by pulmonary embolism following a red blood cell transfusion: case report and review of the literature.

BACKGROUND: Though positive direct antiglobulin tests are common in AIDS patients, overt hemolysis is rare. A hypercoagulable state has recently been recognized in these patients and may contribute to the thromboembotic complications previously reported in three patients with HIV-associated autoimmune hemolytic anemia. CASE REPORT: An AIDS patient with severe warm autoimmune hemolytic anemia developed a pulmonary embolus after a single red blood cell transfusion. CONCLUSION: There may be an increased risk of thromboembolism in AIDS patients with autoimmune hemolytic anemia who receive red blood cell transfusions, a concern we have previously raised. Prophylactic anticoagulation should be considered in this setting.

Exchange transfusion with red blood cells preserved in adenine clears a child of severe falciparum malaria.

Falciparum malaria may be associated with significant morbidity and mortality. The degree of mortality and morbidity usually corresponds to the degree of parasitemia. Quinine and other antimalarial drugs are relatively slow acting and not always effective owing to the presence of drug resistance falciparum. Rapid reduction of the number of circulating parasites may be required. Exchange transfusion has been used as a safe and quick approach to decreasing the parasitemia and antimalaria drugs used to eradicate the rest of the Plasmodium. In the present report, a case is described of a child with severe falciparum malaria who was successfully treated with exchange transfusion using the new adenine and mannitol enriched preservative media, Adsol.

Outcomes assessment of a residency program in laboratory medicine.

During a down-sizing of residency programs at a State University Medical School, hospital based residents' positions were eliminated. It was determined to find out the characteristics of the residents who graduated from the Laboratory Medicine Program, to compare women graduates with men graduates, and to compare IMGs with United States Graduates. An assessment of a 25 year program in laboratory medicine which had graduated 100 residents showed that there was no statistically significant difference by chi 2 analysis in positions (laboratory directors or staff), in certification (American Board of Pathology [and subspecialties], American Board of Medical Microbiology, American Board of Clinical Chemistry) nor in academic appointments (assistant professor to full professor) when the male graduates were compared with the female graduates or when graduates of American medical schools were compared with graduates of foreign medical schools. There were statistically significant associations by chi 2 analysis between directorship positions and board certification and between academic appointments and board certification. Of 100 graduates, there were 57 directors, 52 certified, and 41 with academic appointments. Twenty-two graduates (11 women and 11 men) attained all three.

Ovariectomy enhances and estrogen replacement inhibits the activity of bone marrow factors that stimulate prostaglandin production in cultured mouse calvariae.

To examine PG production in estrogen deficiency, we studied effects on cultured neonatal mouse calvariae of bone marrow supernatants (MSup) from sham-operated (SHAM), ovariectomized (OVX), or 17 beta-estradiol (OVX+E)-treated mice. MSups were obtained 3 wk after OVX when bone density had decreased significantly. 10-60% MSup increased medium PGE2 and levels of mRNA for inducible and constitutive prostaglandin G/H synthase (PGHS-2 and PGHS-1) and cytosolic phospholipase A2 in calvarial cultures. OVX MSups had twofold greater effects on PGHS-2 and medium PGE2 than other MSups. IL-1 receptor antagonist and anti-IL-1 alpha neutralizing antibody decreased MSup-stimulated PGHS-2 mRNA and PGE2 levels and diminished differences among OVX, sham-operated, and OVX+E groups. In contrast, antibodies to IL-1 beta, IL-6, IL-11, and TNF alpha had little effect. There were no significant differences in IL-1 alpha concentrations or IL-1 alpha mRNA levels in MSups or marrow cells. PGHS-2 mRNA in freshly isolated tibiae from OVX mice was slightly greater than from sham-operated. We conclude that bone marrow factors can increase PG production through stimulation of PGHS-2; that OVX increases and estrogen decreases activity of these factors; and that IL-1 alpha activity, together with additional unknown factors, mediates the differential MSup effects.

Iron deficiency and anemia of chronic disease in elderly women: a discriminant-analysis approach for differentiation.

To differentiate iron-deficiency anemia and anemia associated with chronic inflammatory diseases in elderly women, subsets of laboratory, dietary, and functional assessment variables were obtained by using discriminant analysis. Fifty-one subjects (70-79 y of age) were classified into one of four groups on the basis of the presence of iron deficiency and chronic inflammatory disease. Iron deficiency was defined on the basis of a significant response in hemoglobin concentration after iron supplementation. The discriminating subset of laboratory tests consisted of measures for serum ferritin, plasma transferrin receptors, and erythrocyte sedimentation rate. The discriminant function classified subjects into iron-deficient, anemia of chronic disease, or a category in which the two coexist, with an error rate of 18.6%. The addition of other variables (dietary iron and functional assessment information) did not appreciably improve the classification. The results of these three key laboratory tests may help to identify functional iron deficiency in the presence of chronic inflammation.

The role of flow cytometry in the diagnosis of lymphoma: a critical analysis.

Flow cytometry, now used routinely to aid in the classification of leukemias, is increasingly being evaluated as a rapid technique for determination of surface antigens on the cells teased from lymph nodes and other masses with suspected lymphoma. The present study reviews biopsy specimens from patients examined during a two year period which were sent for flow cytometry with a diagnosis of suspected lymphoma. Sixteen of 25 samples (64 percent) produced cell suspensions of sufficient quantity and quality to be diagnostically helpful. Results showed that in 9/16 (56 percent) the diagnosis of lymphoma or cancer could be suspected by flow cytometry alone, while 4/16 were consistent with the final tissue diagnosis of normal or reactive hyperplasia. Three samples that came from patients who had morphologic evidence of malignant disease on biopsy (two Hodgkin's disease and one large cell lymphoma) had flow cytometry results that were interpreted as normal. Flow cytometry is rapid and appears to be virtually diagnostic of non-Hodgkin's lymphoma when a majority of cells are B cells with an abnormal kappa/lambda ratio (> 4.0 or < 0.25). Nonhematologic malignancy can be suspected if less than 75 percent of the cells show CD45 (common leukocyte antigen). Hodgkin's disease cannot be detected by flow cytometry as it is currently used, and as many as 15 percent (1/6 in this study) of lymphomas may show normal results. It is extremely helpful when the biopsy sample actually contains the cells of interest in large proportion. Loss of architectural relationships in the course of processing specimens for flow cytometry is a major disadvantage when small foci of lymphoma or tumor cells exist together with large amounts of stroma or normal lymphocytes.

Reemergence of the International Normalized Ratio for the standardization of prothrombin time.

A survey of physicians demonstrated that half had knowledge of the International Normalized Ratio (INR) but none used the value for monitoring their patients because it was not available from the Coagulation Laboratory. The Laboratory then provided the INR value at a physician's request. A six month review of prothrombin time (PT) results showed that only the physicians from the Cardiology Clinic and the Hematology Clinic employed the INR for monitoring their patients. General Medical and Surgical, Vascular, and Orthopedic Clinics continued to use the PT in seconds. This dichotomy allowed the unique opportunity to compare variability of PT in patients followed by INR and those followed by PT in seconds. Inpatients on daily monitoring were used as the standard for close control. During a six month period, laboratory reports from all patients having regular PTs and/or INRs recorded were analyzed for mean level of PT maintained, variability between individual PTs in any given patient, and instances when the PT changed > or = 5 seconds (sec) or increased to > or = 30 sec. Physicians intended to keep the PTs between 16 and 19 sec (INR 2.0 to 3.0). Results showed statistically significantly lower values of PT, less variation in values of PT and a smaller fraction of patients with changes in PT of > or = 5 sec in the group followed by INR. This group was comparable to the inpatient group but significantly different from the outpatient group followed by PT in sec.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting recovery after peripheral blood stem cell transplantation.

To determine the factors that might be involved in successful engraftment following administration of autologous peripheral blood stem cells (PBSC) obtained by leukapheresis to replace bone marrow after ablation therapy for malignant disease, four patients were examined in detail. One who had had pelvic radiation as well as chemotherapy had a prolonged, gradual but complete recovery. One who received granulocyte-macrophage-colony stimulating factor (GM-CSF) following PBSC infusion showed a rapid recovery phase, but developed high fever (culture negative) associated with arrested hematopoiesis and died with central nervous system (CNS) symptoms after 120 days. Two other patients recovered without major incident. Concentration of PBSC was analyzed by: (1) approximation by counting mononuclear cells (MNC); (2) CD34 cells by flow cytometric analysis; and (3) colony forming units-granulocyte macrophage (CFU-GM) by colony formation in microtiter plates. The time to BM recovery (retics > 1.0 percent, neutrophils > 500 per cumm, platelets > 50,000 per cumm) was determined by following daily counts. Engraftment appeared to depend upon an adequate minimum dose of PBSC, but ultimate recovery of the patient seemed to be determined by ancillary factors, especially CNS infection. These patients illustrate that while rapidity of bone marrow (BM) recovery may be related to PBSC dose, other factors, particularly infection, influence patient outcome.

Immunological techniques to differentiate lymphoma from other malignancies.

Seven patients, who had lymph nodes or masses examined by both immunoperoxidase staining and flow cytometry, are presented to illustrate the value of each technique including a critical analysis of the current application of these techniques in the pathology laboratory. All seven patients had diagnoses established by immunoperoxidase staining using antibodies directed against: Leukocyte Common Antigen (LCA), Epithelial Membrane Antigen (EMA), Neuron Specific Enolase (NSE), Leu M1, B4 or chromagrafin and synaptosin. Flow cytometry, which could be more rapidly performed, when sufficient cells could be separated from the node or mass, was diagnostic in two of the seven cases. Flow cytometry failed to show abnormalities in Hodgkin's disease or solid tumors, but it was useful in rapid diagnosis of lymphoma, provided that the sample contained mostly involved tissue. Nodes in which there was a minor infiltration with lymphoma cells could only be detected by immunoperoxidase technique.

Peripheral blood stem cell transfusion for marrow replacement.

A patient is presented who was treated with ablative therapy for Hodgkin's disease and rescued by reinfusion of peripheral blood stem cells (PBSC). The PBSC were used because previous therapy (chemotherapy and radiation to the pelvis) had resulted in fatty hypocellular marrow which was inadequate for marrow transplantation. The PBSC were collected by leukapheresis before and after recovery of the marrow from suppression with cyclophosphamide to bring the stem cells into cohort cycle and to increase the proportion of stem cells in the peripheral blood for collection. The patient showed a successful recovery on a time scale somewhat longer cells administered, the absence of stimulation by granulocyte macrophage-colony stimulating factor or other cytokine, or potential damage done to stromal elements during previous radiation and chemotherapy. The patient remains in clinical complete remission, fully engrafted, more than one year since his autologous transplant.

Quality assurance in the intensive care unit--monitoring hematocrit orders.

To provide a quality assurance (QA) study in the intensive care unit (ICU), hematocrit orders were monitored for five months (September 1989-January 1990) in an attempt to determine appropriate practice. Computer prints of all hematocrits (hct) ordered in the ICU were reviewed. Of all patients admitted to the unit in this time (528), 61 percent (319) had hematocrits ordered. The maximum number ordered per day varied from one to six with a mean of 1.4. All patients having three or more hcts per day (46) were reviewed by one or more of the authors to determine the circumstances. The patients consisted of 27 men and 19 women between the ages of 16 to 92 years with a median of 70 years. Thirty-three (72 percent) were 60 years of age or older. Twenty-seven were patients with active bleeding. Most had need for hct clearly delineated. In 11 others, justification was not clearly delineated, but resulted from blanket orders when vital signs were stable. In eight patients, multiple hcts were not necessary, but were obtained because of confusing orders or clerical error. These observations suggest that QA review of laboratory orders from the ICU will detect a few abuses and will find some patients whose laboratory tests could be optimized in an educational setting.

Mechanisms of hemolysis in liver disease.

Liver disease, particularly alcoholic cirrhosis, is associated with a number of interesting chemical changes which result in structural and metabolic abnormalities of the erythrocyte membrane leading to microscopically observable cell shape changes and hemolytic anemia varying from very mild to potentially lethal. Increase in unesterified serum cholesterol owing to lecithin cholesterol acyl transferase (LCAT) deficiency in cirrhosis leads to expansion of the lipid bilayer and macrocytosis without megaloblastic changes in precursors. Substitutions of phosphatidyl choline (PC) moieties in the erythrocyte lipid bilayer lead to echinocytes (disaturated PC) or to stomatocytes (diunsaturated PC). In some patients, high density lipoprotein (HDL) abnormalities lead to erythrocyte surface changes causing rapid formation of echinocytes. The rapidity and reversibility of these changes suggest blockade of metabolic transport channels critical to the maintenance of erythrocyte membrane shape. Metabolic changes involving vitamin E deficiency leading to lipid peroxidation and pyruvate kinase instability leading to adenosine triphosphate (ATP) reduction have also been invoked to explain hemolysis associated with acute liver damage. The most severe hemolysis in liver disease is associated with acanthocytes (spur cells) and a marked imbalance in cholesterol-phospholipid ratio. These patients usually have hypersplenism, as well as rigid erythrocyte membrane transformations which are irreversible. Any of the other erythrocyte membrane shape changes described appear to be reversible if the liver disease abates, but they too may become irreversible if bits of projecting membrane are repeatedly removed by the macrophages of an enlarged spleen.

Automated differential leukocyte counts.

Automated differential counts have the advantage of precision, efficiency, safety, and economy. They could potentially serve effectively in 90 percent of patients with normal counts or in 75 percent of patients with anemia only (64 percent of the total in this study). Even patients with increased white blood cell counts and major population shifts (toward granulocytes or lymphocytes) could be followed with automated differential counts. Such a tactic would decrease turnaround time for results, be less expensive, and reduce exposure of technologists to direct contact with patients' blood. However, presently available instruments fail to detect patients' blood samples with small numbers of abnormal cells, e.g., blasts in early relapse of acute leukemia, atypical lymphocytes in viral diseases such as infectious mononucleosis, eosinophils in allergic or parasitic disease, and band forms in early infectious diseases. Clinical judgment should be used in selectively ordering manual differential counts for these patients. While automated differential counts can be very useful in screening general medical and surgical patients in the ambulatory setting, in referral centers where hematologic abnormalities are more prevalent, the manual differential count and further examination of a smear is particularly necessary at least on initial presentation. Selective manual differential counts may improve efficiency, economy, and safety while not compromising patient care. Further studies of the correlation of clinical disease with automated differential counts are necessary.

Factors involved in the regulation of hematopoiesis.

With recombinant deoxyribonucleic acid (DNA) technology and better cell separation techniques, it is possible to demonstrate individual factor activity in the development of uncommitted and committed stem cells and their differentiation into functional mature cells. Much remains to be learned about the individual cell membrane receptors and their interactions with the polypeptide cytokines, as well as with other small molecules such as hemin. Some membrane perturbations must lead to complex and wonderful intracellular machinations to set in motion DNA and ribonucleic acid (RNA) changes leading to cell division and cell differentiation.

Iron supplementation in female blood donors deferred by copper sulfate screening.

Female blood donors with low hematocrit levels detected by copper sulfate screening were selected randomly to receive either 75 mg of iron per day, as ferrous gluconate, or a calcium phosphate placebo. Their ferritin, serum iron, total iron-binding capacity, zinc protoporphyrin, and hemoglobin values, as well as their suitability to donate blood, were determined initially (Visit 1) and at four follow-up visits (Visits 2-5). By the second visit, the serum ferritin and iron values of donors receiving iron supplementation differed significantly from those of donors receiving placebo. By the fifth visit, a less marked but significant increase in hemoglobin had occurred in the iron group, but not in the placebo group. At no time was there a significant difference between the groups' suitability to donate blood, with each group donating at almost half of their visits. The authors conclude that iron supplementation at this dose level in deferred female blood donors improves their iron status and hemoglobin levels, but does not significantly increase their suitability to donate blood as compared with the suitability of placebo-treated donors.

Toxic effects of drugs on erythrocytes.

The erythrocyte abnormality most often associated with the toxic effects of commonly used drugs is premature destruction. The mechanisms of erythrocyte destruction include: denaturation of unstable hemoglobins, oxidation of sulfhydril groups in hemoglobin and the erythrocyte membrane in the presence of glucose-6-phosphate dehydrogenase deficiency, direct effects on enzymes, cholesterol or phospholipids of the erythrocyte membrane, and various autoimmune reactions. Therapy includes stopping the drug and transfusions when anemia is severe. Splenectomy and steroids are rarely needed. A careful medical history and use of drugs only for good indications may avoid many of these reactions.