Are Bradycardic Donors More Likely to Have Adverse Outcomes During Blood Donation?

INTRODUCTION: In order to decrease adverse donor reactions during blood donation, volunteers are screened to safely donate according to the U.S. Food and Drug Administration standards. Volunteers must be normocardic, with a pulse between 50 and 100 beats per minute. Bradycardic volunteers with a pulse lower than 50 beats per minute who otherwise meet requirements may donate with physician approval. Blood donors in military settings tend to be younger and more physically fit than the average donor population, resulting in a higher percentage of bradycardic donors. The relationship between bradycardia and adverse donor reactions has not been well studied. Herein, we aim to compare post-donation adverse reactions and the ability to complete donation between normocardic and bradycardic donors. MATERIALS AND METHODS: Institutional review board approval was obtained. Records from a single blood donor center located on a large military installation in 2019 were retrospectively reviewed for vital signs, demographics, hemoglobin, and donor reactions. Donors were categorized as normocardic or bradycardic. The two groups were statistically compared using a χ2 test. RESULTS: Of the 1,601 donors in the study period, 1,514 qualified for donation. Mean age was 26.6 years (range, 17-72 years), with a male to female ratio of 2.1:1. Of these, 1,478 were normocardic and 26 were bradycardic. There was no significant difference in adverse reactions between the two groups (5.6% in bradycardic donors versus 3.6% in normocardic donors, n = 1,514, χ21 = 0.39, P = .53) or percentage of incomplete donations (5.9% in bradycardic and 5.65% in normocardic, n = 1,514, χ21 = 0.003, P = .96). CONCLUSIONS: Donors with bradycardia are as safe to donate as normocardic donors. In the absence of comorbidities, blood donor centers should ensure their policies consider donation for volunteers with bradycardia.

Development and Validation of Ultra-Rapid Periodic Acid-Schiff Stain for Use in Identifying Fungus on Frozen Section.

CONTEXT.­: There is no standardized process for utilization of periodic acid-Schiff during intraoperative frozen sections to identify fungal organisms. OBJECTIVE.­: To develop a rapid staining process for fresh tissue with periodic acid-Schiff during intraoperative consultation and develop an appropriate control block. DESIGN.­: Muscle tissue was inoculated with 2 species of fungus (Aspergillus fumigatus and Paecilomyces spp) and grown at 3 different temperatures for 72 hours. Inoculated tissue was embedded in optimal cutting temperature compound, cut, and stained using a modified periodic acid-Schiff stain. The optimal control was determined for future use as the standard control. Multiple control slides were cut and stained, using successively shorter time intervals for each step. The staining process that provided accurate results in the shortest amount of time was deemed ultra-rapid periodic acid-Schiff. This method was validated by carryover studies and clinical specimens. RESULTS.­: Paecilomyces spp incubated at 30°C for 72 hours was the most optimal positive control, with numerous yeast and hyphal forms. The fastest staining process involved 2 minutes of periodic acid and Schiff reagent and 10 dips of light green solution. Tap water was as effective as distilled water. Validation was successfully achieved. Clinical cases all stained identical to formalin-fixed, paraffin-embedded tissue stained with hematoxylin-eosin and periodic acid-Schiff. CONCLUSIONS.­: Ultra-rapid periodic acid-Schiff provides fast and reliable identification of fungal organisms on fresh tissue. Development of a concurrent positive control allows for quality control and validation.

Intravascular Large B-Cell Lymphoma.

CONTEXT.­: Intravascular large B-cell lymphoma (IVLBCL) is a rare hematopathologic entity, posing both a clinical and histologic challenge for diagnosis. Numerous pitfalls can hinder making the diagnosis. OBJECTIVE.­: To summarize recent developments in literature pertaining to IVLBCL and point out key pitfalls pathologists should be prepared to encounter. DATA SOURCES.­: Literature review via PubMed search and hospital (Darnall Medical Library) resources. CONCLUSIONS.­: The 3 primary pitfalls of IVLBCL include masking of IVLBCL, mimicry by IVLBCL, and mimicry of IVLBCL. These scenarios illustrate the importance of histologic pattern recognition and subsequent usage of immunohistochemistry, especially in context of a clinical history that may be noncharacteristic.

CMV Ileitis: To Treat or Not to Treat? Implications of Initiating Biologic Therapy for Concurrent Crohn's Disease.

Cytomegalovirus (CMV) enteritis is traditionally thought to be a self-limited infection in immunocompetent individuals. Consequently, current guidelines recommend against treating nonimmunocompromised patients with antiviral therapy. Conversely, recent data suggests that spontaneous resolution occurs less frequently than previously believed; furthermore, mortality rate in immunocompetent individuals is similar to that of the immunosuppressed. We present a case of a 43-year-old male who was simultaneously diagnosed with CMV ileitis and Crohn's Disease. When discovered concomitantly, there is no guidance in the current medical literature regarding the benefit of antiviral treatment of the CMV infection prior to initiating biologic therapy versus the risks of withholding treatment, as is currently recommended for nonimmunosuppressed individuals.

The Utility of Phosphohistone H3 (PHH3) in Follicular Lymphoma Grading: A Comparative Study With Ki-67 and H&E Mitotic Count.

OBJECTIVES: To determine the utility of phosphohistone H3 (PHH3) mitotic count (MC) in grading follicular lymphoma (FL). METHODS: FL cases were identified (2005-2017). Three hematopathologists recorded their average Ki-67 proliferation index, MC/high-power field (hpf) using PHH3 and H&E stains, and number of centroblasts/hpf. Results were assessed for correlations and interobserver variability. RESULTS: Forty-three cases of FL were studied. PHH3 MC resulted in the strongest correlation to grade (r = 0.701, P < .0001) compared with Ki-67 proliferation index (PI) (r = 0.681, P < .0001) and H&E MC (r = 0.536, P = .0002) and the strongest linear relationship to centroblast count (R2 = 0.453). Agreement among pathologists was strongest for PHH3 (intraclass correlation coefficient [ICC] = 0.86) followed by Ki-67 PI (ICC = 0.85) and H&E MC (ICC = 0.78). CONCLUSIONS: PHH3 correlates best to histologic grade and has less interobserver variability compared with Ki-67 PI and H&E MC. These results support using PHH3 as an adjunct in FL grading.

Adenovirus-Associated Acute Appendicitis: An Under-Recognized Relationship?

OBJECTIVE: Acute appendicitis (AA) is one of the most common causes of a surgical abdomen worldwide, occurring most frequently in those age 10 to 29 years. Adenovirus (ADV) is a rare but reported cause of AA in children and a well-recognized cause of intussusception in infants and young children. Annually, about 36,000 basic military trainees (BMTs) undergo initial training at Joint Base San Antonio Lackland, Texas. Before reintroduction of the ADV 4/7 vaccine in November 2011, one-third of BMTs developed an adenoviral upper respiratory tract infection (URI) during the 8.5 weeks of training. We hypothesized that ADV may be a common cause of AA in the BMT population given their young age and high incidence of adenoviral URIs. The objective of this study was to determine the frequency with which ADV, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and enterovirus were associated with AA in a population of young adults. MATERIALS AND METHODS: This study was a retrospective review of patient charts and existing pathological tissue specimens of all BMTs who underwent appendectomy at the Wilford Hall Medical Center from January 1, 2003, to August 31, 2011. Pathological tissue samples from 112 BMTs were assayed by quantitative polymerase chain reaction (qPCR) and immunohistochemistry (IHC) for viral targets. RESULTS: ADV DNA was detected in 16 of 112 samples (14%) via qPCR: ADV 4 in 13 cases, ADV B14 in 1 case, and nontypable ADV in 2 cases. IHC was positive in only the ADV B14 case (0.9%). All cases were negative for CMV, EBV, and enterovirus. CONCLUSION: By using qPCR, this study demonstrated an association between ADV and AA higher than has been previously reported: ADV was detected in 14% of AA cases in this series versus in only 0.23% of AA cases in previous studies (p < 0.01). There was no evidence of CMV, EBV, or enterovirus association with AA in this study. Comparison of qPCR to IHC shows that histologic analysis may overlook evidence of ADV in appendiceal tissue: qPCR is significantly more sensitive than light microscopy and IHC for detecting ADV in this setting. Because ADV 4 was detected in 81% of those with positive qPCR, the recently licensed live oral ADV vaccine might be useful for primary prevention against AA. Prospective studies evaluating young adults presenting with AA for evidence of infection with ADV are needed to determine if a causal relationship exists.

Improved Diagnosis of Prosthetic Joint Infection by Culturing Periprosthetic Tissue Specimens in Blood Culture Bottles.

UNLABELLED: Despite known low sensitivity, culture of periprosthetic tissue specimens on agars and in broths is routine. Culture of periprosthetic tissue samples in blood culture bottles (BCBs) is potentially more convenient, but it has been evaluated in a limited way and has not been widely adopted. The aim of this study was to compare the sensitivity and specificity of inoculation of periprosthetic tissue specimens into blood culture bottles with standard agar and thioglycolate broth culture, applying Bayesian latent class modeling (LCM) in addition to applying the Infectious Diseases Society of America (IDSA) criteria for prosthetic joint infection. This prospective cohort study was conducted over a 9-month period (August 2013 to April 2014) at the Mayo Clinic, Rochester, MN, and included all consecutive patients undergoing revision arthroplasty. Overall, 369 subjects were studied; 117 (32%) met IDSA criteria for prosthetic joint infection, and 82% had late chronic infection. Applying LCM, inoculation of tissues into BCBs was associated with a 47% improvement in sensitivity compared to the sensitivity of conventional agar and broth cultures (92.1 versus 62.6%, respectively); this magnitude of change was similar when IDSA criteria were applied (60.7 versus 44.4%, respectively; P = 0.003). The time to microorganism detection was shorter with BCBs than with standard media (P < 0.0001), with aerobic and anaerobic BCBs yielding positive results within a median of 21 and 23 h, respectively. Results of our study demonstrate that the semiautomated method of periprosthetic tissue culture in blood culture bottles is more sensitive than and as specific as agar and thioglycolate broth cultures and yields results faster. IMPORTANCE: Prosthetic joint infections are a devastating complication of arthroplasty surgery. Despite this, current microbiological techniques to detect and diagnose infections are imperfect. This study examined a new approach to diagnosing infections, through the inoculation of tissue samples from around the prosthetic joint into blood culture bottles. This study demonstrated that, compared to current laboratory practices, this new technique increased the detection of infection. These findings are important for patient care to allow timely and accurate diagnosis of infection.

Usefulness of sonication of cardiovascular implantable electronic devices to enhance microbial detection.

The cardiovascular implantable electronic device (CIED) infection rate is rising disproportionately to the rate of device implantation. Identification of microorganisms that cause CIED infections is not always achieved using present laboratory techniques. We conducted a prospective study to determine whether device vortexing-sonication followed by culture of the resulting sonicate fluid would enhance microbial detection compared with traditional swab or pocket tissue cultures. Forty-two subjects with noninfected and 35 with infected CIEDs were prospectively enrolled over 12 months. One swab each from the device pocket and device surface, pocket tissue, and the CIED were collected from each patient. Swabs and tissues were cultured using routine methods. The CIED was processed in Ringer's solution using vortexing-sonication and the resultant fluid semiquantitatively cultured. Tissue and swab growth was considered significant when colonies grew on ≥2 quadrants of the culture plate and device was considered significant when ≥20 colonies were isolated from 10 ml of sonicate fluid. In noninfected group, 5% of sonicate fluids yielded significant bacterial growth, compared with 5% of tissue cultures (p = 1.00) and 2% of both pocket and device swab cultures (p = 0.317 each). In infected group, significant bacterial growth was observed in 54% of sonicate fluids, significantly greater than the sensitivities of pocket swab (20%, p = 0.001), device swab (9%, p <0.001), or tissue (9%, p <0.001) culture. In conclusion, vortexing-sonication of CIEDs with semiquantitative culture of the resultant sonicate fluid results in a significant increase in the sensitivity of culture results, compared with swab or tissue cultures.

An analysis and report of custodial deaths in Nebraska, USA: Part II.

All medico-legal cases investigated by the Nebraska Institute of Forensic Sciences, Inc. in Lincoln, Nebraska, USA, between 2003 and 2009, were reviewed for deaths which occurred in custody (n = 38). The causes of death, in ranked order, were natural causes 37% (14/38), followed by homicide 21% (8/38), accident 21% (8/38), and suicide 21% (8/38). Each cause of death was then subdivided by age, race, and sex. The findings of this investigation are a continuation of a previous study of the same population from 1991 to 1996 (n = 51). This article also provided five case studies: two natural deaths, two suicides, and one homicide.

In vivo stable tumor-specific painting in various colors using dehalogenase-based protein-tag fluorescent ligands.

In vivo fluorescence cancer imaging is an important tool in understanding tumor growth and therapeutic monitoring and can be performed either with endogenously produced fluorescent proteins or with exogenously introduced fluorescent probes bound to targeting molecules. However, endogenous fluorescence proteins cannot be altered after transfection, thus requiring rederivation of cell lines for each desired color, while exogenously targeted fluorescence probes are limited by the heterogeneous expression of naturally occurring cellular targets. In this study, we adapted the dehalogenase-based protein-Tag (HaloTag) system to in vivo cancer imaging, by introducing highly expressed HaloTag receptors (HaloTagR) in cancer cells coupled with a range of externally injected fluorophore-conjugated dehalogenase-reactive reactive linkers. Tumor nodules arising from a single transfected cell line were stably labeled with fluorescence varying in emission spectra from green to near-infrared. After establishing and validating a SHIN3 cell line stably transfected with HaloTagR (HaloTagR-SHIN3), in vivo spectral fluorescence imaging studies were performed in live animals using a peritoneal dissemination model. The tumor nodules arising from HaloTagR-SHIN3 could be successfully labeled by four different fluorophore-conjugated HaloTag-ligands each emitting light at different wavelengths. These fluorophores could be alternated on serial imaging sessions permitting assessment of interval growth. Fluorescence was retained in histological specimens after fixation. Thus, this tagging system proves versatile both for in vivo and in vitro imaging without requiring modification of the underlying cell line. Thus, this strategy can overcome some of the limitations associated with the use of endogenous fluorescent proteins and exogenous targeted optical agents in current use.

Erbb2 suppresses DNA damage-induced checkpoint activation and UV-induced mouse skin tumorigenesis.

The Erbb2 receptor is activated by UV irradiation, the primary cause of non-melanoma skin cancer. We hypothesized that Erbb2 activation contributes to UV-induced skin tumorigenesis by suppressing cell cycle arrest. Consistent with this hypothesis, inhibition of Erbb2 in v-ras(Ha) transgenic mice before UV exposure resulted in both 56% fewer skin tumors and tumors that were 70% smaller. Inhibition of the UV-induced activation of Erbb2 also resulted in milder epidermal hyperplasia, S-phase accumulation, and decreased levels of the cell cycle regulator Cdc25a, suggesting altered cell cycle regulation on inhibition of Erbb2. Further investigation using inhibition or genetic deletion of Erbb2 in vitro revealed reduced Cdc25a levels and increased S-phase arrest in UV-irradiated cells lacking Erbb2 activity. Ectopic expression of Cdc25a prevented UV-induced S-phase arrest in keratinocytes lacking Erbb2 activity, demonstrating that maintenance of Cdc25a by Erbb2 suppresses cell cycle arrest. Examination of checkpoint pathway activation upstream of Cdc25a revealed Erbb2 activation did not alter Ataxia Telangiectasia and Rad3-related/Ataxia Telangiectasia Mutated activity but increased inhibitory phosphorylation of Chk1-Ser(280). Since Akt phosphorylates Chk1-Ser(280), the effect of Erbb2 on phosphatidyl inositol-3-kinase (PI3K)/Akt signaling during UV-induced cell cycle arrest was determined. Erbb2 ablation reduced the UV-induced activation of PI3K while inhibition of PI3K/Akt increased UV-induced S-phase arrest. Thus, UV-induced Erbb2 activation increases skin tumorigenesis through inhibitory phosphorylation of Chk1, Cdc25a maintenance, and suppression of S-phase arrest via a PI3K/Akt-dependent mechanism.

Multiplexing with multispectral imaging: from mice to microscopy.

Increasing sophistication in the design and application of biological models as well as the advent of novel fluorescent probes have led to new demands on molecular imaging systems to deliver enhanced sensitivity, reliable quantitation, and the ability to resolve multiple simultaneous signals. Sensitivity is limited, especially in the visible spectral range, by the presence of ubiquitous autofluorescence signals (mostly arising from the skin and gut), which need to be separated from those of targeted fluorophores. Fluorescence-based imaging is also affected by absorbing and scattering properties of tissue in both the visible and to a lesser extent the near-infrared (NIR) regions. However, the small size of typical animal models (usually mice) often permits the detection of enough light arising even from relatively deep locations to allow the capture of signals with an acceptable signal-to-noise ratio. Multispectral imaging, through its ability to separate autofluorescence from label fluorescence, can increase sensitivity as much as 300 times compared to conventional approaches, and concomitantly improve quantitative accuracy. In the NIR region, autofluorescence, while still significant, poses less of a problem. However, the task of disentangling signals from multiple fluorophores remains. Multispectral imaging allows the separation of five or more fluorophores, with each signal quantitated and visualized separately. Preclinical small animal imaging is often accompanied by microscopic analysis, both before and after the in vivo phase. This can involve tissue culture manipulations and/or histological examination of fixed or frozen tissue. Due to the same advantages in sensitivity, quantitation, and multiplexing, microscopy-based multispectral techniques form an excellent complement to in vivo imaging.

Erbb2 regulates inflammation and proliferation in the skin after ultraviolet irradiation.

Exposure to ultraviolet (UV) irradiation is the major cause of nonmelanoma skin cancer, the most common form of cancer in the United States. UV irradiation has a variety of effects on the skin associated with carcinogenesis, including DNA damage and effects on signal transduction. The alterations in signaling caused by UV regulate inflammation, cell proliferation, and apoptosis. UV also activates the orphan receptor tyrosine kinase and proto-oncogene Erbb2 (HER2/neu). In this study, we demonstrate that the UV-induced activation of Erbb2 regulates the response of the skin to UV. Inhibition or knockdown of Erbb2 before UV irradiation suppressed cell proliferation, cell survival, and inflammation after UV. In addition, Erbb2 was necessary for the UV-induced expression of numerous proinflammatory genes that are regulated by the transcription factors nuclear factor-kappaB and Comp1, including interleukin-1beta, prostaglandin-endoperoxidase synthase 2 (Cyclooxygenase-2), and multiple chemokines. These results reveal the influence of Erbb2 on the UV response and suggest a role for Erbb2 in UV-induced pathologies such as skin cancer.

Epstein-Barr virus latent membrane protein 2B (LMP2B) co-localizes with LMP2A in perinuclear regions in transiently transfected cells.

Epstein-Barr virus is a human gammaherpesvirus that infects and establishes latency in B lymphocytes in vivo. The latent membrane protein 2 (LMP2) gene is expressed in latently infected B cells and encodes two protein isoforms, LMP2A and LMP2B, that are identical except for an additional N-terminal 119 aa cytoplasmic domain which is present in the LMP2A isoform. A panel of fusion proteins was constructed in which the fluorescent enhanced green fluorescent protein and DsRed protein domains were fused to the N- and C-termini of LMP2A and LMP2B. By fluorescence microscopy, LMP2B localized to perinuclear regions of both live and fixed transiently transfected cells. Co-localization was detected with markers for the endoplasmic reticulum and the trans-Golgi network. No evidence of co-localization of LMP2B with endosomes or surface expression was obtained. Transiently expressed LMP2B co-localized with transiently or constitutively expressed LMP2A. Confocal microscopy confirmed that LMP2A proteins localized to intracellular perinuclear compartments with markers for the trans-Golgi network. Only LMP2A proteins with C-terminal truncations were detected in the plasma membrane with extracellular loop1 epitope tags. These results indicate that the transmembrane domain of LMP2 proteins possess intracellular retention signals and suggest that LMP2A-mediated signalling effects are likely to be ectopic, originating from sites inside the cell close to the nucleus.