Granulocyte colony-stimulating factor accelerates neutrophil engraftment following peripheral-blood stem-cell transplantation: a prospective, randomized trial.

PURPOSE: It is well-established that the infusion of hematopoietic growth factors (HGF) accelerates neutrophil recovery in patients undergoing high-dose therapy followed by autologous bone marrow infusion. In addition, there is evidence that the infusion of autologous peripheral-blood stem cells (PBSC) accelerates engraftment in comparison to patients who receive bone marrow alone. However, few data are available regarding the ability of HGF to accelerate engraftment further in patients who receive PBSC following high-dose therapy. PATIENTS AND METHODS: Forty-one patients undergoing high-dose therapy followed by infusion of autologous PBSC with or without bone marrow were randomized to receive granulocyte colony-stimulating factor (G-CSF) 5 micrograms/kg/d beginning on day + 1 following transplant or standard posttransplant supportive care without HGF. RESULTS: The median time to a neutrophil count > or = 500/microL was 10.5 days in the G-CSF group versus 16 days in the control group (P = .0001). G-CSF was associated with statistically significant reductions in the time to neutrophil engraftment among patients who received PBSC alone (11 v 17 days, P = .0003) and in patients who received PBSC in conjunction with bone marrow (10 v 14 days, P = .02). The median duration of posttransplant hospitalization (18 v 24 days, P = .002) and the median number of days on nonprophylactic antibiotics (11 v 15, P = .03) were also significantly reduced. CONCLUSION: Administration of G-CSF in the posttransplant period accelerates the rate of neutrophil engraftment, shortens the duration of hospitalization, and reduces the number of days on nonprophylactic antibiotics in patients who receive autologous PBSC with or without autologous bone marrow following high-dose therapy.

Utility of a rapid lamellar body count in the assessment of fetal maturity.

The authors investigated the use of a recently described method for the rapid determination of the lamellar body count (LBC) as a means of evaluating fetal pulmonary maturity. Results of the rapid LBC were compared, alone and in combination with the foam stability index (FSI), with the results obtained by thin-layer chromatography (TLC). The study used 90 consecutive amniotic fluid specimens from 82 patients. Rank ordering of the data suggested cutoff points of 19,000/microL for the rapid LBC and 46 for the FSI. Statistical analysis indicated that the addition of the LBC improved the sensitivity of the FSI (P less than 0.01 by the McNemar test), although the reverse was not the case (P greater than 0.1). The linearity and reproducibility of the LBC were considered acceptable.

When to transfuse blood in sickle cell disease? Lessons from Jehovah's Witnesses.

Hemoglobin concentration of 7 to 8 g/dl has been considered an indication for transfusion in the general adult population and has also been frequently applied to patients with sickle cell disease (SCD). Through a review of the case histories of two patients with SCD who were also Jehovah's Witnesses and developed severe anemia, and considering as well the clinical characteristics of this population and the basic physiology of oxygen transport, the appropriateness is questioned of this transfusion "trigger" in patients with SCD. It is suggested for the latter that a Hb of 5.5 g/dl be used as an indication for transfusion except in very specific clinical circumstances.

False-positive human immunodeficiency virus screening test related to rabies vaccination.

We report a false-positive result on an enzyme immunoassay screening test for antibodies to human immunodeficiency virus in a 32-year-old nonpregnant woman who belonged to none of the usual risk groups. Because of the patient's employment in an animal care facility, she had received a series of three vaccinations for rabies, and 16 days after the last vaccination, she had donated a unit of blood. It was during routine screening on a sample drawn at the time of donation that the repeatedly reactive enzyme immunoassay screening test occurred. The results of a Western blot were indeterminant. A polymerase chain reaction assay was negative for proviral DNA.

Transbronchial needle aspiration biopsy in the diagnosis of pulmonary neoplasms.

To evaluate the usefulness of transbronchial needle aspiration biopsy (TBNAB) in the primary diagnosis of lung cancer, we undertook a prospective study of this technique, assessing specimens from 124 patients over a 3-yr period. Cytologic and/or histologic material obtained by an alternate technique was available for 105 (84.7%) of the patients. The diagnostic sensitivity of TBNAB was comparable with that of other bronchoscopic techniques; with the addition of TBNAB, the overall sensitivity of bronchoscopy was increased from 54% to 72% (P less than 0.001). Because of its usefulness for diagnosis of submucosal tumors and its safety, we conclude that TBNAB is a useful addition to current methods for the diagnosis of suspicious pulmonary lesions.

Quantitative histology of the hypertrophied human heart.

Myocardial hypertrophy accompanies systemic hypertension and aortic stenosis, i.e., pressure overload. In man cardiac failure only appears after years of pressure overload, during which time cardiac function had been maintained. The structural correlates of cardiac failure have been a subject of much interest for many years. Several hypotheses relating alterations in muscle fiber alignment, capillary density, or collagen content have been offered. The application of morphometric techniques has provided essential quantitative information on the structural components of the normal and diseased heart. These data indicate that muscle fiber alignment remains normal in the pressure overloaded heart despite the presence of hypertrophy or the appearance of clinical failure. On the other hand, capillary density is decreased and collagen content is increased in hypertrophied hearts. Chemical studies on collagen concentration however have yielded inconsistent results. The relative contribution of the microcirculation and collagenous structure of the myocardium on its respective O2 availability, mechanical behavior, and deterioration in pump function will require further investigation.

Selection factors in the choice of immunoassay technology: implementing technology in the new era.

Centralized Laboratory Services, Inc. is a large, freestanding laboratory that underwent a major equipment reconfiguration for the performance of endocrine/tumor marker/anemia assays (N = 15) in August 1995. Before the transition these assays were done on six instruments, none of which were computer interfaced. All assays were subsequently consolidated on four ACS-180+ instruments (Chiron Diagnostics, Norwood, MA), which were interfaced to our laboratory information system (Cerner Corp, Kansas City, MO). Our experience suggests that significant increases in productivity and reductions in cost are possible through instrument upgrades. Both laboratory-specific and analytical system-specific factors were found to be important in the optimal selection of immunoassay technology. As laboratorians necessarily adjust to changing economic and organizational circumstances and are compelled to "do more with less," technology assessment will become an increasingly important function for senior laboratory management.

The role of reflexive (algorithmic) testing in laboratory medicine: adapting to the new era.

Centralized Laboratory Services, Inc. (CLS) is a large, freestanding laboratory that is an affiliate of the Health Insurance Plan of New York, a managed care organization with more than 1 million members in New York and New Jersey. The laboratory work for this membership is consolidated at CLS, which thus serves an ambulatory patient population. The Medical Director at CLS is charged with optimizing laboratory utilization by clinicians who are part of the system.

Utilization management and information technology: adapting to the new era.

Overuse of clinical laboratory services has been written about for many years (1), but remedies that easily could be implemented and effective over the long term have been in short supply. This issue has been acute for CLS, Inc., which is wholly owned by a managed care organization (HIP Health Plan of New York). Because CLS is assessing the possibility of acquiring a new laboratory information system, we reviewed past reports on approaches to utilization management (UM) and considered how developments in information technology (IT) may affect the latter. We feel there is a distinct possibility for implementation of UM in real time, and we propose this as a new paradigm whose realization has implications for choice of IT and for how clinical laboratories operate in the future.

Muscle fiber orientation and connective tissue content in the hypertrophied human heart.

To elucidate the structural correlates of cardiac failure in myocardial tissue, muscle fiber alignment and connective tissue volume fraction were measured at multiple sites in the left ventricular free wall and in the interventricular septum of 14 human hearts. Group 1 (five hearts; 280 +/- 20 gm.) had no evidence of cardiac disease, group 2 (five hearts; 380 +/- 30 gm.) had a history of systemic hypertension without clinical heart failure, and group 3 (four hearts;; 590 +/- 40 gm.) had both left ventricular overload and congestive failure. Fiber orientations were determined by measuring fiber angle relative to the circumferential direction (helix angle). The fraction of the myocardial volume occupied by connective tissue was determined by point counting. Our results indicate a smooth transition of helix angle from epi- to endocardial surface in the normal left ventricular free wall with nearly 55 per cent of the wall occupied by circumferentially oriented fibers near the cardiac equator (latitude of largest ventricular diameter); morphologically, the interventricular septum was nearly identical with the free wall. Fiber alignment was maintained in all three groups as was the fraction of wall occupied by circumferential fibers. Connective tissue volume fraction was, however, significantly increased (p less than 0.02) in hypertrophied hearts (groups 2 and 3) as compared with normal hearts, and at two of six sites in clinically failed hearts as compared with hypertrophied but functionally compensated hearts. Thus, muscle fiber orientation is not altered in the hypertrophied pressure-overloaded left ventricle, whereas connective tissue content is increased with the increase being greatest in the failing heart.