Ten-color 15-antibody flow cytometry panel for immunophenotyping of lymphocyte population.

We have developed a lymphoproliferative disorder screening tube (LPD-ST) with the aim to provide comprehensive immunophenotyping of lymphocyte subsets with minimal need for additional testing. The LPD-ST consists of CD4/kappa FITC, CD8/lambda PE, CD3/CD14ECD, CD38PC5.5, CD20/CD56PC7, CD10APC, CD19APC-A700, CD5APC-A750, CD57/CD23PB and CD45KO. The LPD-ST was validated against previously used lymphocyte subset panels in Canada (n=60) and in Sweden (n=43) and against the OneFlow™ LST (n=60). The LPD-ST panel was then implemented in clinical practice using dried monoclonal antibody reagents (Duraclone® ) on 649 patient samples in Sweden. In 204 of 649 samples (31%), a monotypic B-cell population was found. Of these cases, a final diagnosis could be rendered in 106 cases (52%), and in the remainder, additional B-cell immunophenotyping was performed. In 20 (3%) samples, an aberrant T-cell population was confirmed by additional testing. Of 425 samples diagnosed as normal/reactive lymphoid tissue, 50 (12%) required additional immunophenotyping, mostly due to an abnormal CD4/CD8 ratio. The LPD-ST tube significantly minimizes the need for additional testing, improves the turn-around time, and reduces the cost of LPD immunophenotyping. It is also suitable for investigating paucicellular samples such as cerebrospinal fluid or fine needle aspirates.

An investigation of serum concentration of apoM as a potential MODY3 marker using a novel ELISA.

OBJECTIVE: To investigate the fitness of serum apolipoprotein M (apoM) concentration as a marker for maturity-onset diabetes of the young 3 (MODY3). STUDY DESIGN AND SUBJECTS: This study consisted of two parts. A family study included 71 carriers of the P291fsinsC mutation in hepatocyte nuclear factor-1alpha (HNF-1alpha) from the Finnish Botnia study, 53 of whom were diabetic, and 75 matched family controls. A second, case-control study included 24 MODY3 patients, 17 healthy MODY3 mutation carriers, 11 MODY1 patients, 18 type 2 diabetes patients and 19 healthy control individuals. Subjects in the case-control study were recruited from the Botnia study or the Clinic of Endocrinology, Malmö University Hospital. Serum apoM levels were measured using a novel ELISA based on two monoclonal apoM antibodies. RESULTS: In the family study, mean serum apoM was 10% lower in female carriers of the P291fsinsC mutation compared to the family controls (P = 0.0058), a difference which remained significant after adjustment for diabetes status. There was no observed difference between groups for men. In the case-control study, no significant difference in apoM concentration was observed between MODY3 and type 2 diabetes patients, neither before nor after adjustment for total cholesterol. CONCLUSIONS: Female carriers of the P291fsinsC mutation in HNF-1alpha displayed slightly lower apoM serum levels. This difference is too small for apoM to be reliably employed as a biomarker for HNF-1alpha mutation status.

Comparison of cardiac output measured with echocardiographic volumes and aortic Doppler methods during mechanical ventilation.

OBJECTIVE: To compare two transesophageal echocardiographic methods of cardiac output and stroke volume measurement in mechanically ventilated patients. DESIGN: Prospective clinical study. SETTING: Operating room (group I) and intensive care unit (group II) in two university hospitals. PATIENTS: Fifteen deeply anesthetized patients undergoing gynecological laparoscopy for sterility (group I) and 40 patients with septic shock (group II). INTERVENTIONS: Transesophageal echocardiography with modification of hemodynamic conditions. MEASUREMENTS AND RESULTS: Left ventricular (LV) volumes, cardiac (CI) and stroke index (SI) were measured with two methods using either LV volumes or aortic Doppler. These values were significantly lower in group I compared to group II. Using ANOVA and paired t-tests, there were no significant differences between the two methods of measurement. Correlation between these methods was better in group II than in group I, although not significantly so. In group I, bias for CI measurements was low (0.05 l/min per m(2)), with a weak agreement in terms of the 95% confidence interval (-1.17; 1.06 l/min per m(2)) compared to the mean values obtained with both methods (1.3 l/min per m(2)). In group II, bias for CI measurements was lower (0.2 l/min per m(2)). Agreement was weak, regarding 95% confidence intervals (-1.7; 1.3 l/min per m(2)) compared to the mean values (3 l/min per m(2) with the LV volumes method and 3.2 l/min per m(2) and with the Doppler method). CONCLUSIONS: Cardiac output and stroke volume can be measured from LV volumes in mechanically ventilated patients, yielding relevant information. However, the accuracy of LV volume measurements is not excellent compared to the aortic Doppler method. Thus, this latter technique should still be considered as the gold standard.

Haemodynamic changes and vasopressin release are not consistently associated with carbon dioxide pneumoperitoneum in humans.

BACKGROUND: Conflicting haemodynamic changes, suggested to be caused by vasopressin release, have been reported during carbon dioxide (CO2) pneumoperitoneum. However, peritoneal stimulations including open surgery cause both a systemic vasopressor response and a vasopressin release, which are suppressed by opiate administration. Also, a decreased venous return of blood to the heart causes vasopressin release. Furthermore, previous haemodynamic assessments of laparoscopic surgery have been conducted using various anaesthetic regimens, which are likely to have caused various haemodynamic effects. We hypothesised that intraoperative haemodynamic and/or humoral changes would not be observed in association with laparoscopic surgery provided that, (a) normovolaemia is continuously maintained using transoesophageal echocardiographic (TEE) assessment, and (b) adequate depth of general anaesthesia is continuously maintained by bispectral index (BIS) monitoring and high plasma Ievel opiate administration. METHODS: Twenty ASA 1 women undergoing laparoscopic surgery received 10 ml. kg-1 lactated Ringer's solution and thereafter were randomly allocated to receive intraoperatively either 8 ng. ml-1 or 4 ng. ml-1 plasma remifentanil concentrations while BIS was maintained at 50+/-5 by isoflurane alteration. The group receiving 4 ng. ml-1 remifentanil was used as control. Expired CO2 was maintained within a 32-38 kPa range throughout the investigation. Complete TEE haemodynamic investigation was performed before pneumoperitoneum (PP) (T1), and during PP horizontal (T2), with a head-up tilt (T3), with a head-down tilt (T4), horizontal (T5), and PP released (T6). Plasma vasopressin, epinephrine and norepinephrine levels were measured at T1, T3, and T6. ANOVA, Student's t-test and Mann-Whitney U-test were used for statistical analysis. RESULTS: Haemodynamic indices and humoral values did not change significantly within and between remifentanil groups throughout the investigation (all P<0.05). CONCLUSION: Continuous adequate depth of anaesthesia and normovolaemia may have prevented both a humoral and a haemodynamic response, initiated in the peritoneum by the contact with CO2 in previous investigations.

Acute pancreatitis caused by severe Legionella pneumophila infection.

We report three cases of severe community-acquired Legionella pneumophila pneumonia with acute pancreatitis. Pancreas involvement is unusual. The clinical presentations consisted of painless pancreatitis with only elevation of serum pancreatic enzymes (case 1), tender abdomen with edematous pancreas on computed tomography scan (case 2) and necrosis (case 3). We discuss the possible mechanisms of L. pneumophila associated acute pancreatitis for which the pathophysiology is still undetermined: infection, toxin release or cytokine secretion.

Streptococcus salivarius acute meningitis with latent petromastoiditis.

A 48-y-old woman, with a previous history of neurosurgical intervention for a trigeminal neurinoma, presented with acute meningitis due to Streptococcus salivarius. There were significant changes in the petrous region, as revealed by MRI, leading to the diagnosis of associated latent subacute mastoiditis.

Amyloidosis and cardiac involvement.

BACKGROUND: Amyloidosis is a rare disease characterized by the extracellular accumulation of a protein polysaccharide complex: amyloid. Cardiac involvement may occur with or without clinical manifestations, and is considered as a major prognostic factor. AIM OF THE STUDY: Firstly, to analyze the clinical, electrocardiographic, radiological and echocardiographic features in a group of patients with extracardiac biopsy-proven amyloid infiltration and evidence of echocardiographic amyloid heart disease. Secondly, to compare the survival of amyloidosis patients, with or without cardiac involvement. PATIENTS AND METHODS: We retrospectively analyzed the main echocardiographic features of 47 patients with biopsy proven amyloidosis. No clinical, electrocardiographic, radiological or scintigraphic criterium were selective for cardiac involvement. Thirty patients with echographic features of amyloid heart disease were identified and compared to 17 patients without echographic features of amyloid heart disease. RESULTS: Amyloid disease with heart involvement was AL in 25/30 (83%) patients and occurred more commonly in middle age men (mean age: 53+/-11 years). The main clinical presentation was congestive heart failure (59%), but 37% of patients had no clinical cardiac features. The electrocardiogram was abnormal in 86% and the cardiac silhouette was enlarged on chest roentgenogram in 27% of patients. The main echocardiographic findings were: diffuse ventricular wall thickening in 21 patients (70%) and isolated septal wall thickening in 9 patients (30%); restrictive pattern of left ventricular (LV) diastolic function in 17 patients (57%); pericardial effusion in 12 patients (40%); impaired LV systolic function in 8 patients (27%); atrial enlargement in 8 patients (27%); characteristic granular sparkling of LV myocardium in 8 patients (27%); mitral and/or aortic valve thickening in 4 patients (13%). Cardiac symptoms developed in 72% of the non symptomatic patients having echocardiographic evidence of cardiac involvement. Twenty-five patients died during the study period and the death was due to cardiac disease in 76%. Median survival time was 36 months from time of amyloidosis diagnosis, and it was 23 months from time of amyloid myocardiopathy diagnosis. It shortened to 6 months when congestive heart failure appeared. CONCLUSION: Patients with a histologically proven amyloidosis should be examined by echocardiography, because cardiac involvement is frequently found in patients with no clinical symptoms, and non symptomatic patients having echocardiographic evidence of cardiac involvement will almost always develop cardiac symptoms. Survival actuarial study confirms the significant adverse influence of cardiac involvement in amyloidosis.

Fatal Mycobacterium tuberculosis brain abscess in an immunocompetent patient.

A non-HIV-infected 63-y-old woman presented seizures and coma during the course of Mycobacterium tuberculosis infection. Computerized tomography scan led to the diagnosis of a large compressive brain abscess. The patient died with multiorgan failure. Systematic central nervous system investigations should be done in cases of disseminated tuberculosis.

Hypothermia with indoor occurrence is associated with a worse outcome.

OBJECTIVE: To describe patients admitted to intensive care unit (ICU) for hypothermia, evaluate prognostic factors, and test the hypothesis that patients found indoors have a worse outcome. DESIGN AND SETTING: Retrospective clinical investigation in a medical ICU. PATIENTS: Eighty-one consecutive patients admitted to ICU, with a body temperature of 35 degrees C or lower and rewarmed passively or with minimally invasive techniques, over a 17-year period. MEASUREMENTS AND RESULTS: Patients were analyzed by age, gender, and causes of hypothermia and split into two groups (indoors and outdoors), according to the location where hypothermia occurred. Prognostic factors were determined by univariate method and stepwise logistic regression. The major complications were acute renal failure (43 %), aspiration pneumonia (22 %), rhabdomyolysis (22 %), and acute respiratory distress syndrome (12%). Principal comorbidities in the outdoor patients (21%) were alcohol and drug intoxication, and those in the indoor patients (79 %) were sepsis and neuropsychiatric disorders. Stepwise logistic regression identified two variables predictive of death: illness severity at admission (SAPS II > or = 40) and the location where hypothermia occurred (indoors versus outdoors). CONCLUSIONS: With equivalent body temperature, patients found indoors were more severely affected and died more frequently than those found outdoors.

Small hemodynamic effect of typical rapid volume infusions in critically ill patients.

OBJECTIVES: To determine what volumes are commonly used for rapid volume infusions in critically ill patients admitted to the intensive care unit (ICU) for > 12 hrs; and to determine the effectiveness of a typical rapid volume infusion in producing hemodynamic change and increasing left ventricular end-diastolic volume. DESIGN: A prospective survey of clinical practice (part 1) and a prospective clinical investigation (part 2). SETTING: Two hospital ICUs (11 and six beds) of which one is university affiliated. PATIENTS: Critically ill patients admitted to the ICU for > 12 hrs. INTERVENTIONS: Infusion of 500 mL of normal saline over 5 to 10 mins. MEASUREMENTS AND MAIN RESULTS: For 1 month, we recorded the volume and composition of all volume infusions given as a rapid bolus in patients admitted to the ICU for > 12 hrs. We then measured the effected the median rapid volume infusion in a subset of 13 patients by measuring hemodynamics (using arterial and pulmonary artery flotation catheters) and left ventricular end-diastolic area (using transgastric short-axis views from transesophageal echocardiograms). During 470 patient days, 159 rapid volume infusions were administered. The average rapid volume infusion administered was 390 +/- 160 mL (median 500; interquartile range 250 to 500). Crystalloid solutions were used for two thirds of the rapid volume infusions and colloid solutions were used for one third of the rapid volume infusions. The rapid volume infusion of 500 mL of saline did not significantly increase mean arterial pressure (78.0 +/- 11.9 to 79.3 +/- 14.6 mm Hg), cardiac index (4.3 +/- 1.7 to 4.6 +/- 1.8 L/min/m2), right atrial pressure (11.1 +/- 3.8 to 12.4 +/- 3.3 mm Hg), left ventricular end-diastolic area (8.6 +/- 1.7 to 9.1 +/- 1.8 cm2/m2), or left ventricular end-systolic area (3.5 +/- 1.5 to 3.6 +/- 1.5 cm2/m2). Pulmonary artery occlusion pressure increased slightly but significantly from 12.9 +/- 3.4 to 14.7 +/- 3.3 mm Hg (p < .05). CONCLUSIONS: After patients are admitted to the ICU for > 12 hrs, rapid volume infusions are common therapeutic interventions but the rapid volume infusions are typically small. The effect of a typical rapid volume infusion on hemodynamics and left ventricular areas in these patients is surprisingly small.

Pitfalls in the diagnosis of airport malaria. Seven cases observed in the Paris area in 1994.

Clinical and biological pitfalls that lead to incorrect or delayed diagnoses of airport malaria are described based on 7 cases reported from the Paris region in the summer of 1994. We also report the outcome and the epidemiological features of these patients.

Comparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients.

PURPOSE: Recent observations have highlighted errors in the thermodilution technique of measuring cardiac output. Thus, cardiac output measurements using transesophageal echocardiography and the Fick method were compared with simultaneous thermodilution measurements. METHODS: In 13 mechanically ventilated critically ill patients, cardiac output was determined simultaneously using (1) transesophageal echocardiography (COTEE, (2) the Fick method (COFICK, and (3) thermodilution (COTD immediately before and after a rapid infusion of 500 mL of saline. Left ventricular end-diastolic and end-systolic areas were measured using the transesophageal echocardiographic transgastric short axis view, and COTEE was calculated from the corresponding volumes. Absolute cardiac output values and the changes from before to after saline infusion (delta CO) were compared using analysis of variance, linear regression, and the Bland and Altman method. RESULTS: There were no significant differences between COTEE (8.0 +/- 3.4), COFICK (8.4 +/- 3.3), and COTD (8.3 +/- 3.0) or between delta COTEE, delta COFICK, and delta COTD using analysis of variance. However, correlations between COTEE and COTD (r2 = 0.46; P < .00001), COFICK and COTD (r2 = 0.46; P < .0001), and COTEE and COFICK (r2 = 0.42; P < .0001) were only moderately good. Using the method of Bland and Altman, the mean difference (+/-2 standard deviations) between COTEE and COTD was 0.3 +/- 4.3 L/min, between COFICK and COTD was -1.0 +/- 3.8 L/min, and between COTEE and COFICK was 0.6 +/- 5.6 L/min, whereas the difference between delta COTEE and delta COTD was 0% +/- 26%, between delta COFICK and delta COTD was 9% +/- 46%, and between delta COTEE and delta COFICK was 8% +/- 39%. CONCLUSIONS: There are substantial differences in cardiac output as measured by these three methods, best demonstrated using the method of Bland and Altman. The variability of cardiac output and its derivatives (eg, oxygen delivery) should be borne in mind when making clinical decisions on individual patients.

Intensive use of general ultrasound in the intensive care unit. Prospective study of 150 consecutive patients.

OBJECTIVE: To assess the impact of systematic ultrasound (US) examination in patients admitted to the ICU. DESIGN: An observational study of 150 consecutive patients. SETTING: A medical ICU of a University-affiliated hospital. PATIENTS: All consecutively admitted patients were examined, but patients discharged within < 48 h were excluded from the analysis. INTERVENTIONS: A systematic examination of the abdomen, pleural space, cervical and femoral vein, was performed at the bedside by the same investigator. MEASUREMENTS: Results of US examinations were compared to findings from CT-scan, surgery, endoscopic procedures, autopsy, or other diagnostic tests. The impact of U.S. findings on immediate patients management was evaluated. RESULTS: In 33 of 150 patients (22%), U.S. findings influenced the diagnosis, work up of the patients, and had a direct impact on the therapeutic plan. In 30/33 cases, confirmation of diagnosis was obtained by another diagnostic and/or therapeutic procedure. CONCLUSIONS: Routine US examination may alter therapeutic plans in up to 1/4 of critically ill patients admitted to the ICU. US examination should be liberally performed on such patients.

[Cavitary pneumocystis carinii pneumonia in AIDS: a new semiologic aspect. Apropos of 3 cases]. / Pneumocystoses excavantes au cours du SIDA: un nouvel aspect sémiologique. A propos de 3 cas.

Three cases of AIDS patients hospitalized for Pneumocystis carinii (PNC.C) pneumonia are reported. These cases are of interest because of the unusual radiological semiology of these pneumocytoses, i.e., their partially or totally pitted nodules. In addition, 4 related facts merit attention: the occurrence of pneumocytosis in 1 patient under prophylactic aerosol pentamidine therapy: the rarity, unusual in AIDS, of PNC.C in the bronchoalveolar lavage fluid from 2 patients; the association of pitted nodules with mediastinal adenopathies due to PNC.C in 1 patient; and the favorable outcome in all cases.

[Evolution of the resistance of Streptococcus pneumoniae to erythromycin at the Pitié-Salpêtrière Hospital (1980-1984)]. / Evolution de la résistance de Streptococcus pneumoniae à l'érythromycine à l'Hôpital de la Pitié-Salpêtrière (1980-1984).

From January 1980 to December 1984, 563 swabs for Streptococcus pneumoniae were isolated at the Pitié-Salpêtrière hospital in Paris, and of these 63 were resistant to erythromycin. The percentage of swabs resistant to erythromycin rose from 2.7% in 1980 to 19.6% in 1984 and was similar for cultures of blood, serous fluid, bronchial secretions, otolaryngological specimens and smears from the conjunction. For swabs resistant to erythromycin these belonged almost exclusively (57 out of 60 or 90%) to the serotypes 6, 14, 19 and 23; one may ask whether the rise in resistance of S. pneumoniae to erythromycin was due to a rise in the frequency of isolation of these serotypes? Between 1980 and 1984 such rise took place since the frequency of isolation of S. pneumoniae belonging to the serotypes 6, 14, 19 or 23 rose from 38% in 1980 to 50% in 1984, but the rise was not significant (p = 0.1). In fact S. pneumoniae serotypes 6, 14, 19 or 23 have become resistant is significant (p less than 0.05). Two factors should be taken into consideration when interpreting these facts. The first is the increased consumption of macrolide antibiotics which doubled overall between 1979 and 1983, both at the Pitié-Salpêtrière hospital and in the Public Assistance hospitals of Paris as well as provincial hospitals throughout France. The second factor is the strictly hospital nature of this study which may have led to an overestimation of the frequency of resistance of S. pneumoniae to erythromycin.