Extranodal lymphocyte predominance Hodgkin's disease. Clinical and pathologic features.

Although B-cell nodular lymphocyte predominance Hodgkin's disease (nodular paragranuloma, LPHD) typically presents at low stage, reported series have identified a minor population of patients with advanced disease. Clinicopathologic findings in 13 cases of LPHD are described that had extranodal manifestations. The B-cell immunophenotype was confirmed in all cases with paraffin-section immunostains. Nine patients presented with extranodal disease; distribution was in Waldeyer's ring (n = 2), spleen (n = 3), spleen and liver (n = 3), or bone marrow (n = 1). Three cases, clinically stage III/IV at presentation, had involvement of bone marrow (n = 2) or bone marrow, liver and spleen (n = 1) at relapse. One patient presented with clinical stage IIe disease and had involvement of spleen at relapse. Follow-up was available for 11 patients (range 4 months to 11 years; mean, 5 years). One patient died of disease and one died with disease because of therapeutic complications. Six patients were disease-free and three had persistent or recurrent LPHD. Microscopically, LPHD was difficult to recognize in extranodal sites and could easily be mistaken for low-grade non-Hodgkin's lymphoma or conventional Hodgkin's disease. Certain morphologic and immunophenotypic findings were effective in avoiding such diagnostic confusion. Thorough staging evaluation appears warranted for LPHD because it may be responsive to therapy, even in advanced stage or after relapse. Although LPHD is unexpected in extranodal samplings, the wary pathologist can suspect its presence on the basis of characteristic histopathologic features. Confirmation of the diagnosis may require paraffinsection immunostains.

Fine-needle aspiration cytology of mammary adenomyoepithelioma: report of a case with intranuclear cytoplasmic inclusions.

Adenomyoepithelioma of the breast is an uncommon lesion which may recur and rarely metastasizes. We report the fine-needle aspiration (FNA) findings in one case of mammary adenomyoepithelioma in which this tumor's unusual cytomorphology led to a cytologic diagnosis of malignancy, possible metastatic to the breast. Large, atypical, polygonal cells, some with intranuclear cytoplasmic inclusions, were most worrisome cytologically, but corresponded in the biopsied specimen to cells immunohistochemically documented to be of myoepithelial origin. Nests of epithelium and myoepithelial cells sometimes embedded in fibrous, stromal fragments were suggestive of an infiltrating pattern. Recognition of such unusual features in breast FNA is most important since definitive therapy may follow an FNA diagnosis of carcinoma in some clinical settings. In cases with unusual morphology, surgical biopsy should be recommended to clarify the nature of the lesion.

Hospital-based toxicology: patterns of use and abuse.

We examined 949 consecutive toxicology requests to determine (a) the identity and relative frequency of the most commonly detected drugs in our hospital population; (b) degree of concordance between clinical impression and laboratory analysis; (c) influence of age and sex upon the numbers and results of toxicologic analyses; (d) temporal pattern of our annual toxicology case-load; (e) temporal and sexual distribution of various common drugs; (f) drugs most often found together; and (g) frequency with which inappropriate toxicology request were received. Laboratory analysis agreed with clinical impression in only 17.4% of cases. Age and sex correlated with the detection of specific drugs. But for benzodiazepines, no consistent temporal pattern was present regarding either type or number of drugs detected. Certain days of the week demonstrated a statistically significant effect upon the number of toxicology requests received, while seasons, holidays, and lunar phases had no influence. Inappropriate requests comprised 9% of the total annual toxicology caseload.

Creatine kinase MB in cases of skeletal muscle trauma.

Fifty-eight patients admitted through our emergency room with severe skeletal muscle injury but no obvious cardiac contusions were evaluated for creatine kinase isoenzyme MB (CK-MB). When such patients show an above-normal value for total CK, it is a question of whether or not myocardial injury has been sustained along with skeletal muscle injury when (a) there are no obvious chest contusions or (b) the patient is unconscious and unable to complain of chest pain. Whenever there is doubt concerning the cardiac status of a patient, lactate dehydrogenase (LD) isoenzymes, serial electrocardiograms, and CK isoenzymes are ordered. Our study revealed that serum of 8.6% of the trauma victims had CK-MB values exceeding 5.0 EU/L (reflecting abnormal CK-MB concentrations) as part of their increased total CK. All patients had normal electrocardiographic patterns along with negative results for LD isoenzymes; none had sustained any demonstrable myocardial injury. The CK-MB value must be interpreted together with the total CK value for appropriate diagnosis in patients with skeletal muscle trauma.

Prolonged epicardial mapping in myocardial infarction: the effects of propranolol and intra-aortic balloon pumping following coronary artery occlusion.

A methods of prolonged epicardial surface mapping of myocardial infarction by serial epicardial ECG's is described. The progression of infarction following coronary artery ligation in dogs was monitored over a 4 day period and the early and late changes in the configuration of the epicardial ECG's associated with the underlying myocardial injury were defined. The determination of the infarct size by surface mapping in vivo correlated accurately with the final infarct size determined by dehydrogenase staining in vitro. Treatment with propranolol resulted in a significant reduction in the infarct size. Treatment with intra-aortic balloon pumping did not alter the size of the myocardial infarction induced in this experimental model.

The relationship between overdrive suppression and overdrive excitation in ventricular pacemakers in dogs.

We studied the excitatory and inhibitory effects of overdrive on idioventricular pacemakers in anesthetized dogs with recently induced complete atrioventricular block. The following results were obtained: (1) a slow driving rate may induce a temporary rhythm which may be reinstituted with additional stimuli; (2) the induced rhythm may appear as coupled extrasystoles which, on interruption of the drive, are found to be self-sustaining; (3) during continued slow driving, extrasystoles may appear and disappear in a cyclical manner; (4) a short period of fast driving may be followed by a fast new rhythm, the rate and duration of which are a function of the rate and duration of drive; (5) fast driving may induce a new rhythm at a rate below predrive control; (6) after a long period fast driving, only suppression follows; and (7) intermittent periods of fast driving lead to a summation of inhibition with each successive period. These results suggest the following conclusions: (1) under certain conditions, electrical driving instead of inducing suppression may induce a rhythm ("overdrive excitation") at a rate similar to, faster then, or slower ("inhibited excitation") than control; (2) the duration of diastole and the number of driven beats are major factors in the induction of new rhythms; and (3) overdrive excitation is counteracted by overdrive inhibition, with development of the former requiring fewer beats than the latter.

The effect of adrenergic enhancement on overdrive excitation.

The effect of adrenergic enhancement (stimulation of a stellate ganglion or administration of norepinephrine) on arrhythmias induced by ventricular overdrive ("overdirve excitation") was studied in dogs with complete atrioventricular block. The following results were obtained. (1) Adrenergic enhancement may lead to abnormal ventricular rhythms. (2) A brief drive during adrenergic enhancement induced or enhanced fast ventricular rhythms. (3) The induced rhythms were characterized by an abrupt onset, a fast rate of discharge, and a moderate degree of slowing before an abrupt cessation. (4) The induced rhythms were accelerated by further drive. (5) Increasing the duration of overdrive during adrenergic enhancement resulted in overdrive suppression and not in overdrive excitation. (6) Prolonged drive could induce a few beats (instead of suppression) but at a rate below control ("inhibited excitation"). (7) The arrhythmogenic effects of overdrive and adrenergic enhancement were potentiated by the simultaneous administration of calcium. It is concluded that interventions which increase the inward calcium current (overdrive, adrenergic enhancement and higher [Ca]o) favor the onset and the maintenance of overdrive excitation.

The effect of high cervical cordotomy on portal vein plasma serotonin and 5-hydroxyindoleacetic acid levels in dogs with and without superior mesenteric artery occlusion.

In ten dogs undergoing high cervical cardotomy, there was a statistically significant fall in plasma serotonin (5-HT) levels in portal vein blood; no further change in plasma 5-HT occurred after superior mesenteric artery (SMA) occlusion, which is an effective stimulus for 5-HT release. In five dogs undergoing high cervical corotomy with no SMA occlusion, there was a comparable fall in portal vein plasma 5-HT levels. The 5-hydroxyindoleacetic acid (5-HIAA) values in portal vein blood in the two groups of dogs above fell to comparable levels. These findings indicate (1) that maintenance of the normal plasma 5-HT level in portal vein blood in this experimental model is dependent on the integrity of the spinal cord and (2) that SMA occlusion in animals with a high cervical cordotomy does not result in further changes in the plasma 5-HT level in portal vein blood.