The relevance of tissue thiol histochemistry to diagnostic hematopathology.

Expression analyses suggest that alterations of the antioxidant state of some diffuse large B-cell lymphomas can assist prognosis; reversibly oxidized thiols may serve as a surrogate marker for identifying such cases. Little is known about the distribution of free thiols and reversibly oxidized thiols in human tissues. We developed a staining technique that enables visualization of tissue thiols in situ using bright field microscopy and validated it using gastrointestinal tissue specimens. We used our thiol staining technique to assess benign tonsillectomy and diffuse large B-cell lymphoma specimens. The gastrointestinal series revealed the presence of free thiols within epithelial cells and cells of the lamina propria. Staining for reversibly oxidized thiols was robust in gastric foveolar cells, intestinal goblet cells and the mucus they produce. Tonsillectomy specimens exhibited diffuse presence of free thiols. Staining for reversibly oxidized thiols was confined to germinal center macrophages and sinus histiocytes. Among the diffuse large B-cell lymphoma specimens, we observed strong staining for free thiols within malignant cells. By contrast to benign B-cells, the malignant cells demonstrated pronounced and diffuse staining for reversibly oxidized thiols. We demonstrated intrinsic differences between benign and malignant cells.

Myelodysplastic syndrome in elderly patients: correlation of CBC with cytogenetic and FISH analysis.

Unexplained anemia in the elderly could represent myelodysplastic syndrome (MDS). We assessed the utility of using a fluorescence in situ hybridization (FISH) panel for common chromosomal abnormalities seen in MDS. A total of 101 elderly outpatients with anemia of unknown etiology were evaluated. Complete blood count, bone marrow biopsy, conventional cytogenetic analysis (CC), and FISH panel were reviewed. A total of 21 (21%) of the 101 patients had MDS. A combination of CC and FISH identified chromosomal abnormalities in 17 (81%) of the patients with MDS. The remaining 4 (19%) were diagnosed with MDS based solely on morphologic criteria. Except in two cases, FISH did not reveal abnormalities not already detected by CC. Furthermore, MDS patients infrequently had isolated anemia (14%) as opposed to those without MDS (75%). A MDS FISH panel is not more sensitive than CC in elderly outpatients with unexplained anemia. MDS is more likely if in addition to anemia, leukopenia and/or thrombocytopenia are also present.

Sertraline to improve arousal and alertness in severe traumatic brain injury secondary to motor vehicle crashes.

OBJECTIVE: To establish whether or not the serotonin reuptake inhibitor (SSRI) sertraline can improve arousal and alertness of patients with traumatic brain injury (TBI) and associated diffuse axonal injury (DAI). Serotonin is a major inhibitory as well an excitatory neurotransmitter, and serotonergic neurons modulate the activity of brain regions responsible for motor control, arousal, attention, and emotional regulation. SETTING: Tertiary care inpatient rehabilitation centre directly attached to a university hospital level-one trauma centre. DESIGN: Prospective placebo-controlled randomized trial utilizing sertraline on admission to acute rehabilitation. DATA SET: Eleven subjects, post-high speed motor vehicle crash and post-severe TBI (GCS < or = 8) with presumed DAI randomized to receive either sertraline 100mg per day or placebo for 2 weeks. All subjects were within 2 weeks of acute injury. Outcome measures recorded were the Orientation Log (daily), Agitated Behaviour Scale (daily), and the Galveston Orientation and Amnesia Test (weekly). RESULTS: Both placebo and active medication groups demonstrated similar rates of improvement on all three scales. There was no difference in the rates of recovery for either study group (p > 0.05, ANOVA with repeated measures). The groups did not demonstrate a statistically significant negative effect on recovery either, although the size is too small for a statistically reliable beta-effect. CONCLUSION: This pilot study fails to establish whether the early use of sertraline may improve alertness, decrease agitation or improve cognitive recall of material. This may be due to the small size of the study group, the brief duration of treatment or by a skewed placebo group. Larger studies will be required to prove any efficacy. There were no complications with its use and sertraline did not demonstrate a detrimental effect on recovery. This indicates that sertraline may be safe to use in the treatment of psychiatric or behavioural complications attributable to TBI.

Waldenstrom macroglobulinemia presenting as a pleural effusion.

We describe a patient with Waldenstrom macroglobulinemia who presented with a lymphocytic pleural effusion. Pleural involvement in Waldenstrom macroglobulinemia is very rare. In addition, to our knowledge, there are no reports in the literature in which a primary diagnosis was made on the basis of pleural fluid analysis. The presence of small lymphocytes in serous cavity fluid can pose great difficulty in the differentiation between a low-grade lymphoproliferative disorder and reactive lymphocytosis. The diagnosis of malignancy in this case was established on the basis of morphologic testing, flow cytometry, and the detection of B-cell immunoglobulin gene rearrangement.

Primary angiitis of the central nervous system as a first presentation in Hodgkin's disease: a case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Granulomatous angiitis of the central nervous system is a rare cause of neurological deterioration. It is often diagnosed posthumously, and a high index of suspicion is necessary to make the correct diagnosis on a timely basis. CLINICAL PRESENTATION: A 27-year-old woman presented to the emergency room with complaints of worsening headache, nausea, and vomiting for 10 days, which were preceded by swelling of her tongue. At the examination, she had mild ocular tenderness, but no cranial nerve abnormalities. Radiographic examination revealed a right temporal lobe area with edema, and mild contrast enhancement was noted on computed tomography and magnetic resonance imaging. A similar but smaller region was present in the left frontal lobe. INTERVENTION: Stereotactic biopsy of the left temporal lobe revealed granulomatous angiitis. Further workup revealed Hodgkin's disease in the mediastinum. Dexamethasone as well as chemotherapy for Hodgkin's disease was initiated. The patient's symptoms resolved, and she returned to work with her disease in remission. CONCLUSION: Previous reports of central nervous system angiitis have shown an association with Sjogren's syndrome, herpes zoster infection, human immunodeficiency virus, and Hodgkin's disease. A review of the literature revealed a total of 12 patients with central nervous system angiitis and Hodgkin's disease. As a group, these patients had very poor outcomes. However, of six patients who presented with central nervous system angiitis and concurrent Hodgkin's disease and who underwent aggressive treatment for both conditions, three had a full recovery, two had a partial recovery, and one died.

c-fos and c-jun mRNA expression in activated cord and adult lymphocytes: an analysis by Northern hybridization.

BACKGROUND AND OBJECTIVES: To further analyze the neonatal immune response to an antigenic challenge such as blood transfusion, c-fos and c-jun mRNA expression were analyzed in twelve in-vitro-stimulated normal cord blood and ten in-vitro-stimulated normal adult peripheral blood lymphocyte samples. MATERIALS AND METHODS: Lymphocyte samples were stimulated by either the mitogen phytohemagglutinin (PHA) or the monoclonal antibody alphaCD3. Proliferation rate and Northern blot hybridization were employed. RESULTS: Cord lymphocytes revealed a greater proliferation rate with PHA and alphaCD3 than adult lymphocytes (p = 0.0081 and 0.0023, respectively). In addition, Northern blot analysis of cord and adult samples revealed similar maximal increases in c-fos (99+/-15 and 126+/-11%, p = 0.0126) and c-jun (123+/-9 and 185+/-38%, p = 0.0291) mRNA expression, respectively, as early as 15 min post-alphaCD3 stimulation. Adult lymphocytes showed an equivalent increase in mRNA expression of c-fos and c-jun (140+/-25 and 155+/-31%) at 30 min post-PHA stimulation, while cord lymphocyte maximum c-fos and c-jun expression (82+/-6 and 142+/-12%) occurred at 15 min post-PHA stimulation (c-fos, p = 0.0354; c-jun, p = 0.0112). CONCLUSION: Although cord lymphocyte proliferation rates were significantly greater than those of adult lymphocytes following stimulation, lymphocyte activation, as analyzed by c-fos and c-jun mRNA expression, appears similar in both cord and adult samples. We conclude that cord lymphocyte activation exhibits an adult-type profile.

The effect of decalcification and choice of fixative on histiocytic iron in bone marrow core biopsies.

IRon stains are often used for bone marrow core biopsies obtained by needle biopsy of the iliac crest. Because bone must be decalcified by brief treatment with acid, it is possible that an undetermined amount of stainable histiocytic iron may be lost. A study was carried out to determine whether decalcification results in loss of histiocytic iron and the effects of fixatives and the recovery of histiocytic iron in decalcified bone marrow tissue. Aspirates of bone marrow were stained for iron with Prussian blue. Because aspirate material does not require decalcification, it served as a control for the study. One hundred bone marrow biopsies and accompanying aspirates from 100 adult subjects were evaluated. Fifty bone marrow biopsies were fixed using a fixative containing mercuric chloride (B-5) and the remaining 50 were fixed in zinc-formalin. Histiocytic iron was graded as minimal, moderate or marked depending on whether less than 5, 6-10, or more than 10 iron positive histiocytes, respectively, were observed. When histiocytic iron was markedly present in aspirate material, at least moderate amounts of stainable iron were found in 22 of 25 B-5 fixed and 21 of 25 zinc-formalin fixed decalcified bone marrow. When aspirate histiocytic iron was minimal or moderate, 14 of 25 B-5 fixed and 7 of 25 zinc-formalin fixed decalcified bone marrow specimens revealed histiocytic iron. Decalcification results in decreased recovery of stainable iron, and where histiocytic iron is minimally or moderately present, B-5 fixation results in greater postdecalcification recovery. There was no significant difference in recovery when larger quantities of histiocytic iron were present prior to the decalcification step.

Diagnostic discrimination and cost effective assay strategy for leukocyte alkaline phosphatase.

Decreased leukocyte alkaline phosphatase (LAP) is a first line test for chronic myelogenous leukemia (CML), generally preceding a diagnostic algorithm which also includes bone marrow biopsy, cytogenetic analysis, and molecular diagnostics. We found the analytical uncertainty of LAP assays to range from over 100% coefficient of variation at low scores to about 20% at high scores. However, the receiver-operator characteristics derived from LAP determinations in 50 consecutive cases suggest that a suitably high diagnostic decision threshold still can eliminate false negatives. As a consequence of such a strategy, as many as half the tested patients, classified unequivocally as the negatives, can avoid further invasive and costly workup. On the other hand, serial LAP determinations, whether performed to detect change to a lower or to a higher score, are unlikely to produce conclusive diagnostic signals exceeding analytical 'noise.'

Prolonged survival in pyruvate carboxylase deficiency: lack of correlation with enzyme activity in cultured fibroblasts.

OBJECTIVE: To report the clinical history and laboratory evaluation of a patient presenting with lactic acidosis secondary to pyruvate carboxylase deficiency. METHODS AND RESULTS: Enzyme analysis of cultured skin fibroblasts revealed 2-5% of normal pyruvate carboxylase activity. Although most patients with this condition die in early infancy, this child has survived to age 8-1/2 years, with only occasional episodes of metabolic acidosis, usually responding rapidly to intravenous hydration and bicarbonate. Despite having a seizure disorder and moderate mental retardation, he continues to thrive and make progress in his acquisition of motor and language skills. Of the 35 patients described in the literature with pyruvate carboxylase deficiency, only two other patients have lived beyond 5 years of age. CONCLUSION: There does not seem to be a correlation of prolonged survival with residual pyruvate carboxylase activity on assay of cultured fibroblasts. Possible explanations for this patient's prolonged survival include tissue heterogeneity, increased residual enzyme activity in vivo, or partial stabilization of the enzyme by supplemental biotin.

Current neuropharmacologic interventions for the management of brain injury agitation.

Agitation following brain injury is a significant and difficult problem; severe agitiation is most effectively treated by concurrent environmental, behavioral, and pharmacologic interventions. Delirium and agitation are briefly compared, however, a more thorough discussion of this topic appears in other articles within this issue. This article reviews the current literature in regard to practical pharmacologic interventions for agitation following brain injury and outlines short-term and long-term strategies. Common and serious side effects, as well as unique characteristics for each medication are highlighted.

Transfusion-transmitted diseases. Current status and future directions.

Blood transfusion is associated with a number of potential risks, including the transmission of infectious diseases. Although a zero-risk blood supply may never be attainable, much effort is directed toward the identification of blood donors with evidence of transmissible infectious agents. This article summarizes the current knowledge of transfusion-transmitted diseases. In addition, possible future directions in decreasing the incidence of such diseases are discussed.

Minimal allogeneic donor exposure with the use of dedicated donors and a sterile connecting device in a newborn undergoing bone marrow transplantation.

PURPOSE: Enhanced engraftment and reduced viral complications may be achieved in bone marrow transplantation (BMT) by limiting homologous transfusions. We report on limiting donor exposures before and after BMT in a newborn with severe combined immunodeficiency (SCID) using dedicated whole blood and plateletpheresis donors as well as a sterile connecting device (SCD). PATIENTS AND METHODS: A 1-day-old neonate was admitted for an allogeneic, human leukocyte antigen-disparate, T-cell-depleted BMT performed on day 43 of hospitalization. All transfused red blood cells (RBCs) and platelets were cytomegalovirus negative, and were irradiated and leukodepleted (via a Pall filter). Using the SCD, tubing above the filter was connected to the product bag, and the distal tubing was connected to a transfer pack for collection of the filtered product. Additional transfer packs were connected to the filtered product using the SCD to separate small aliquots as needed. RBC aliquots were irradiated individually before each transfusion. RESULTS: During a total of 134 days of hospitalization, only four donor exposures occurred. Eleven RBC transfusions (mean volume 46.4 +/- 12.6 ml) from three donors and five plateletpheresis transfusions (mean volume 74.2 +/- 7.5 ml) from one donor constituted all the patients' transfusion requirements. Evidence of engraftment was seen on day 18 post-BMT with an absolute neutrophil count sustained at > 500 cells/mm3. The last transfusion was received on day 35 post-BMT. CONCLUSIONS: Current blood transfusion technology enables patients undergoing bone marrow transplantation to have limited donor exposures. This practice should decrease viral complications without effecting bone marrow engraftment.

Analysis of a linear peristaltic infusion device for the transfusion of red cells to pediatric patients.

A linear peristaltic infusion device was evaluated for red cell (RBC) transfusion in the pediatric and neonatal setting. CPDA-1 RBC units (n = 24) divided into six groups of 4 units each underwent simulated transfusion. Blood was infused by using manufacturer-provided administration sets with either a 21-gauge needle or a 24-gauge catheter. Filters were used in two groups to evaluate the effect of negative pressure on filter function. Two groups of RBCs less than 1 week old were washed, irradiated, and infused at 5 mL per hour, by using a standard administration set, or at 10 mL per hour, by using a syringe set. Four-week-old RBCs (washed and irradiated, irradiated and filtered, filtered only, or unmanipulated) were infused at 100 mL per hour. Paired samples from 0 and 2 hours before and after infusion were analyzed for hemoglobin, hematocrit, RBC count, plasma hemoglobin, lactate dehydrogenase, potassium, alanine aminotransferase, and aspartate aminotransferase. Hausser and Nageotte hemocytometers were used to perform white cell (WBC) counts when a filter was used. By analysis of variance and percentage of change, data from 0 and 2 hours before and after infusion were compared. No clinically or statistically significant differences were seen for hemoglobin, hematocrit, or RBC count. The difference in preinfusion and postinfusion plasma hemoglobin levels in washed RBCs at 2 hours was statistically but not clinically significant (14.5 +/- 6.8 vs. 19.3 +/- 7.1 mg/dL). No clinically significant differences were noted for the remaining analytes.(ABSTRACT TRUNCATED AT 250 WORDS)

The preparation of fibrinogen concentrate for use as fibrin glue by four different methods.

Fibrinogen concentrates for use as fibrin glue were prepared by modification of a cryoprecipitate method. The goals were the optimization of a method for different centrifuges and anticoagulants and the assay of factors not previously analyzed. Following a -70 degrees C freeze and a 4 degrees C thaw, CPDA-1 and ACD plasma were centrifuged at 6500 x g for 5 minutes or, alternatively, at 5000 x g for 7 minutes. The supernatant plasma was expressed to a final volume of 15.5 +/- 3 mL, and concentrates were stored at -30 degrees C. Preconcentration and postconcentration samples were analyzed for fibrinogen, fibronectin, factor XIII, and plasminogen content. Fibrinogen in CPDA-1 plasma was significantly higher than that in ACD plasma both before and after concentration at both centrifugation speeds. Fibronectin, factor XIII, and plasminogen concentrations were not significantly affected by centrifugation speed or the type of anticoagulant used. Fibronectin and plasminogen concentrations were significantly increased in components that were held for 5 to 6 days, as compared to those held for 0 to 1 day before freezing. Storage for up to 20 days in CPDA-1 and up to 5 months in ACD did not affect analyte concentration. It is concluded that ACD plasma centrifuged at 5000 x g yields a significantly low concentration of fibrinogen, while CPDA-1 plasma centrifuged at 6500 x g yields the highest amount. Acceptable yields were obtained from centrifugation of ACD plasma at 6500 x g and of CPDA-1 plasma at 5000 x g for use as fibrin glue.

Performance of reticulocyte counts in stored blood specimens in a pediatric population utilizing new methylene blue.

Although reticulocyte counts can be reliably performed for up to 48 h after storage in EDTA, it is unclear whether this is applicable to the pediatric age group. In order to evaluate this, manual reticulocyte counts were performed on 20 specimens from pediatric patients stored at 4 degrees C for up to 24 h post collection. Samples were evaluated at 1-3, 6, 12, 18, and 24 h after storage in EDTA vacutainer tubes at 4 degrees C. The age of the subjects ranged from 1 day to 9 years with a median age of 3 years. Patients' reticulocyte counts ranged from 0 to 27% (5.89 +/- 7.21). No clinically significant changes were evident in the reticulocyte count over 24 h after specimen collection. The mean of the 20 specimens at 1-3 h was 5.50 and at 24 h was 5.40 (P > .05). The standard deviation of the mean values ranged from 7.03 to 7.26 (P > .05). The results indicate that reticulocyte counts may be performed on previously drawn blood held at 4 degrees C for up to 24 h post collection in a pediatric population without significant difference from baseline values.

Pericardial extramedullary hematopoiesis in a neonate with congenital heart disease. A case report.

A case of pericardial extramedullary hematopoiesis in a neonate with congenital heart disease was diagnosed by fine needle aspiration cytology. Undifferentiated blasts, promyelocytes, metamyelocytes and nucleated red blood cells were evident in the pericardial fluid specimen. The differential diagnosis of bone marrow contamination of pericardial fluid secondary to inadvertent sampling of neonatal hypodense bone tissue is also discussed. To our knowledge, this is the first reported case of neonatal pericardial extramedullary hematopoiesis associated with congenital heart disease.