The use of autologous blood in patients undergoing subcutaneous mastectomy or reduction mammaplasty.

Adverse reactions are reported following 2% of transfusions. Posttransfusion viral hepatitis may occur in 8% of patients receiving homologous blood. Plastic surgery procedures, such as reduction mammaplasty and subcutaneous mastectomy, are associated with moderate blood loss that may require transfusion. Over a five-year period we offered autologous blood transfusions to 88 patients scheduled for such surgery. Approximately ten days before their operation, 72 patients each donated 450 ml of blood, which was then available for transfusion during surgery. When admitted for surgery, the patients' mean reduction in hemoglobin was 6.9%. Their average calculated blood loss was 930 ml, with a net loss of 483 ml after receiving their own blood. No complications occurred. Only 2 of these patients required an additional unit of homologous blood. Six of the 16 patients who did not donate blood preoperatively required homologous blood transfusions. The use of safe autologous blood was enthusiastically accepted by the surgical and anesthesia staff, blood bank personnel, and the patients.

Hyperviscosity syndrome in paraproteinemia. Managed by plasma exchange; monitored by serum tests.

Clinical and laboratory indices of hyperviscosity were studied in three patients presenting with this complication of paraproteinemia. Serum viscosity correctly predicted the presence of clinical hyperviscosity syndrome in patients with stable hemoglobin and albumin concentrations. Serum viscosity also correlated with total protein and paraprotein levels. A simple exponential model proved not only to describe the kinetics of blood viscosity during plasma exchange but also to predict protein concentration at symptomatic recovery. Construction of such a protein-viscosity curve helps manage by plasma exchange patients with paraproteinemia who develop hyperviscosity syndrome.

The "iron screen": modification of standard laboratory practice with data analysis.

Multivariate analysis was applied to iron deficiency anemia to generate an efficient sequence of diagnostic laboratory tests. A three step diagnostic system--serum ferritin level and mean corpuscular volume as a screen in all patients, followed by serum iron level and total iron binding capacity in some patients, and by erythrocyte sedimentation rate in a few patients--was constructed using a previously validated data reduction system. When compared to bone marrow iron stores, this system was found to have 96 per cent accuracy. In one year of clinical trial the "iron screen" classified 396 of 416 patients in a hospital setting. This sequential strategy shows how clinical laboratory data can be utilized to render diagnoses of defined probability.

A proposal for a department of pathology improvement program.

A quality assurance program for Departments of Pathology was first proposed by William Beautyman, MD, while he was a member of the Board of Governors of the College of American Pathologists. Subsequently, this proposal has been reviewed in detail by the CAP Clinical Pathology Committee under the chairmanship of William Cole, MD, and more recently Mario Werner, MD. At this time, the Clinical Pathology Committee believes a thorough discussion of the merits, format, and content of the program is desirable to bring the concept to maturation. Only after being subjected to widespread scrutiny will it be ready for more formal consideration and possible implementation by the College. It is published at this time with such intent.

Statistical forecasting in a hospital clinical laboratory.

Three forecasting methodologies were applied to monthly laboratory test count data in order to arrive at a best procedure for forecasting ahead to cover the next fiscal year. The purpose of the forecasting was, first, to aid in reimbursement and income decisions and, second, to assist in operations management decisions within the laboratory itself. The Box-Jenkins ARIMA models were found to be superior in all cases, and forecasts for individual test counts (as opposed to packages of tests billed as a unit) were improved if forecasts for inpatients and outpatients were done separately and then aggregated. With 2 years of experience to go on, the annual forecast error stands at around 4.5%.

Multivariate approach to predictive diagnosis of bone-marrow iron stores.

The authors constructed a computer-assisted multivariate data analysis system that finds the subset of a group of laboratory tests (i.e., experimental variables) best able to discriminate between previously identified subpopulations. A Bayesian decision-analysis algorithm was devised for predictive diagnosis by the use of sample means and standard deviations of those identified tests. This approach was used on a set of nine hematologic laboratory tests to find a subset capable of efficiently predicting the presence or absence of bone-marrow iron stores. This identified subset proved to have a diagnostic efficiency of 0.90. The success of this system suggests the feasibility of such an approach in finding a "best" subset of loosely related variables.

A multivariate data reduction system.

The problem of predictive diagnosis based on laboratory data is approached from a mathematical standpoint. A descriptive system is introduced which examines the current information about a clinical problem and identifies best predictors of the problem. Algorithms are described for the assessment of current diagnostic ability, the evaluation of new laboratory tests, and the identification of patients to study for the development of new procedures. The laboratory approach to the predictive diagnosis of iron deficiency is chosen as an example of the system.

Plasma cell granulomas in non-lipemic xanthomatosis: apparent induction by indomethacin.

A 71-year-old man with non-lipemic, generalized, plane xanthomas developed nodules and tumors within one month of starting indomethacin therapy. These enlarged and spread during 5 months of daily indomethacin but promptly and spontaneously involuted when the indomethacin was discontinued. Within 4 months, the nodules and tumors were completely gone. The process is viewed as an "indoderma", i.e. a granulomatous drug reaction, analogous to an iododerma.