Correction to: Amanita Mushroom Toxin Poisoning in Los Angeles County

[This corrects the article DOI: 10.14309/crj.0000000000001246.].

Amanita Mushroom Toxin Poisoning in Los Angeles County

Mushroom (amatoxin) poisoning from ingestion is a rare but life-threatening medical emergency characterized by gastrointestinal symptoms before progression to multisystem organ failure in severe cases. Many therapies of amatoxin intoxication have been described, including supportive care, medical therapies, detoxification strategies, and liver transplant. The evidence supporting these therapies remains limited due to the rarity of amatoxin poisoning and challenge of a timely diagnosis. We report a case of amatoxin poisoning in Los Angeles causing severe liver injury without acute liver failure treated successfully using medical therapies, gallbladder drainage, and plasma exchange.

Durable remission of thrombotic thrombocytopenic purpura in the setting of pembrolizumab therapy

BACKGROUND

There is a small but growing number of thrombotic thrombocytopenic purpura (TTP) cases attributed to immune checkpoint inhibitor therapy, with nivolumab and ipilimumab therapy being the most frequently described in the literature.

STUDY DESIGN AND METHODS

This report evaluates the course of a patient with a history of metastatic adenocarcinoma of the lung who developed TTP following treatment with the PD-1 inhibitor Pembrolizumab. The patient was treated with six sessions of therapeutic plasma exchange and appeared to be in remission. Exacerbation occurred 4 days later, and seven more sessions of plasma exchange were performed along with four total doses of Rituximab, and a steroid taper with monitoring of platelet counts and ADAMTS13 activity.

RESULTS

His platelet count recovered to a peak of 318,000 UL with an ADAMTS13 activity of 77% at the time of discharge. The patient has been following up regularly for outpatient testing with no TTP relapse as of the completion of this report.

DISCUSSION

This is one of a few cases of Pembrolizumab-associated TTP reported in the literature with successful complete remission following treatment. Plasma exchange in this setting may be an especially beneficial therapeutic intervention because of the removal of both the anti-ADAMTS13 antibody as well as the immune system upregulating anti-PDL1 monoclonal antibody with replacement of ADAMTS13 from donor plasma. Longer duration of plasma exchange and monitoring for normalization of ADAMTS13 levels in addition to platelet count before cessation of treatment may improve durable remission rates in this entity.

Altered type 1 interferon responses in alloimmunized and nonalloimmunized patients with sickle cell disease

Patients with sickle cell disease (SCD) have a high prevalence of RBC alloimmunization. However, underlying mechanisms are poorly understood. Given that proinflammatory type 1 interferons (IFNα/β) and interferon stimulated genes (ISGs) promote alloimmunization in mice, we hypothesized that IFNα/β may contribute to the increased frequency of alloimmunization in patients with SCD. To investigate this, expression of ISGs in blood leukocytes and peripheral blood mononuclear cells (PBMCs) of previously transfused SCD patients with or without alloimmunization and race-matched healthy controls were quantified, and IFNα/β gene scores were calculated. IFNα/β gene scores of SCD leukocytes and plasma cytokines were elevated, compared to controls (gene score, p < 0.01). Upon stimulation with IFNβ, isolated PBMCs from patients with SCD had elevated ISGs and IFNα/β gene scores (p < 0.05), compared to stimulated PBMCs from controls. However, IFNβ-stimulated and unstimulated ISG expression did not significantly differ between alloimmunized and non-alloimmunized patients. These findings indicate that patients with SCD express an IFNα/β gene signature, and larger studies are needed to fully determine its role in alloimmunization. Further, illustration of altered IFNα/β responses in SCD has potential implications for IFNα/β-mediated viral immunity, responses to IFNα/β-based therapies, and other sequelae of SCD.

Blood group O convalescent plasma donations have significantly lower levels of SARS-CoV-2 IgG antibodies compared to blood group A donations

Background

COVID‐19 convalescent plasma (CCP) is plasma collected from individuals who have recovered from SARS‐CoV‐2 infection. The FDA Emergency Use Authorization restricts use of CCP to high‐titer units only. The purpose of this study was to determine if donor ABO blood group was associated with SARS‐CoV‐2 antibody response, and subsequent qualification as high‐titer CCP.

Methods

All CCP donations collected from April 21, 2020 to September 1, 2020 were included. The Abbott ARCHITECT semi‐quantitative chemiluminescent microparticle immunoassay was used to assess IgG antibodies to the nucleocapsid protein of SARS‐CoV‐2. Units with a S/C value ≥4.5 were considered high titer.

Results

A total of 232 CCP donations were evaluated. There were no significant differences in the distribution of sex, age, and interval from symptom resolution to donation by ABO blood group. The mean SARS‐CoV‐2 IgG antibody S/C value was significantly lower in blood group O donations (3.6), compared to blood group A (5.0) donations (p < .001). There was no difference in antibody response between the other blood group pairings. Blood group O donations resulted in a lower percentage of high‐titer units (35%), compared to blood group A (60%), B (58%), and AB (65%) donations.

Conclusion

Blood group O donations were found to have significantly lower levels of SARS‐CoV‐2 IgG nucleocapsid antibodies compared to blood group A donations and were less likely to produce CCP units that qualified as high titer. These findings may aid donor recruitment to promote availability of high‐titer CCP to meet patient needs.

SARS-CoV-2 specific antibody and neutralization assays reveal the wide range of the humoral immune response to virus

Development of antibody protection during SARS-CoV-2 infection is a pressing question for public health and for vaccine development. We developed highly sensitive SARS-CoV-2-specific antibody and neutralization assays. SARS-CoV-2 Spike protein or Nucleocapsid protein specific IgG antibodies at titers more than 1:100,000 were detectable in all PCR+ subjects (n = 115) and were absent in the negative controls. Other isotype antibodies (IgA, IgG1-4) were also detected. SARS-CoV-2 neutralization was determined in COVID-19 and convalescent plasma at up to 10,000-fold dilution, using Spike protein pseudotyped lentiviruses, which were also blocked by neutralizing antibodies (NAbs). Hospitalized patients had up to 3000-fold higher antibody and neutralization titers compared to outpatients or convalescent plasma donors. Interestingly, some COVID-19 patients also possessed NAbs against SARS-CoV Spike protein pseudovirus. Together these results demonstrate the high specificity and sensitivity of our assays, which may impact understanding the quality or duration of the antibody response during COVID-19 and in determining the effectiveness of potential vaccines.

Novel SARS-CoV-2 specific antibody and neutralization assays reveal wide range of humoral immune response during COVID-19

Development of antibody protection during SARS-CoV-2 infection is a pressing question for public health and for vaccine development. We developed highly sensitive SARS-CoV-2-specific antibody and neutralization assays. SARS-CoV-2 Spike protein or Nucleocapsid protein specific IgG antibodies at titers more than 1:100,000 were detectable in all PCR+ subjects (n=115) and were absent in the negative controls. Other isotype antibodies (IgA, IgG1-4) were also detected. SARS-CoV-2 neutralization was determined in COVID-19 and convalescent plasma at up to 10,000-fold dilution, using Spike protein pseudotyped lentiviruses, which were also blocked by neutralizing antibodies (NAbs). Hospitalized patients had up to 3000-fold higher antibody and neutralization titers compared to outpatients or convalescent plasma donors. Interestingly, some COVID-19 patients also possessed NAbs against SARS-CoV Spike protein pseudovirus. Together these results demonstrate the high specificity and sensitivity of our assays, which may impact understanding the quality or duration of the antibody response during COVID-19 and in determining the effectiveness of potential vaccines.

Comparison of the platelet activation status of single-donor platelets obtained with two different cell separator technologies

BACKGROUND

The microparticle content (MP%) of apheresis platelets-a marker of platelet activation-is influenced by donor factors and by external stressors during collection and storage. This study assessed the impact of apheresis technology and other factors on the activation status (MP%) of single-donor apheresis platelets.

STUDY DESIGN AND METHODS

Data from six US hospitals that screened platelets by measuring MP% through dynamic light scattering (ThromboLUX) were retrospectively analyzed. Relative risks (RRs) were derived from univariate and multivariable regression models, with activation rate (MP% ≥15% for plasma-stored platelets; ≥10% for platelet additive solution [PAS]-stored platelets) and MP% as outcomes. Apheresis platform (Trima Accel vs Amicus), storage medium (plasma vs PAS), pathogen reduction, storage time, and testing location were used as predictors.

RESULTS

Data were obtained from 7511 platelet units collected using Trima (from 16 suppliers, all stored in plasma, 20.0% were pathogen-reduced) and 2456 collected using Amicus (from four different collection facilities of one supplier, 65.0% plasma-stored, 35.0% PAS-stored, none pathogen-reduced). Overall, 30.0% of Trima platelets were activated compared to 45.6% of Amicus platelets (P < .0001). Multivariable analysis identified apheresis platform as significantly associated with platelet activation, with a lower activation rate for Trima than Amicus (RR: 0.641, 95% confidence interval [CI]: 0.578; 0.711, P < .0001) and a 6.901% (95% CI: 5.926; 7.876, P < .0001) absolute reduction in MP%, when adjusting for the other variables.

CONCLUSION

Trima-collected platelets were significantly less likely to be activated than Amicus-collected platelets, irrespective of the storage medium, the use of pathogen reduction, storage time, and testing site.

Critical developments of 2018: A review of the literature from selected topics in transfusion. A committee report from the AABB's Clinical Transfusion Medicine Committee

BACKGROUND

The AABB compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine. An abridged version of this work is being made available in TRANSFUSION, with the full-length report available as Appendix S1 (available as supporting information in the online version of this paper).

STUDY DESIGN AND METHODS

Papers published in late 2017 and 2018 are included, as well as earlier papers cited for background. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed.

RESULTS

The following topics are covered: "big data" and "omics" studies, emerging infections and testing, platelet transfusion and pathogen reduction, transfusion therapy and coagulation, transfusion approach to hemorrhagic shock and mass casualties, therapeutic apheresis, and chimeric antigen receptor T-cell therapy.

CONCLUSION

This synopsis may be a useful educational tool.

Cefotetan-Induced Hemolytic Anemia: Case Series and Review

PURPOSE

To raise awareness of cefotetan-induced hemolytic anemia, a known rare but serious side effect that occurred in 5 patients at our medical center.

SUMMARY

Five cases of cefotetan-induced hemolytic anemia, which presented over the period of a single year at our center, are described. In each case, hemolytic anemia was confirmed by testing for the presence of anti-cefotetan antibodies. Each case occurred approximately 1 to 2 weeks following exposure to the drug. All five patients survived. A brief review of drug-induced immune hemolytic anemia (DIIHA) is also discussed.

CONCLUSION

DIIHA may be difficult to distinguish from other causes of hemolytic anemia, but should be included in the differential in patients exposed to medications associated with DIIHA. Once suspected, antibody testing should be performed, and once diagnosed, further exposure should be avoided.

Neuroinvasive West Nile Virus Post-Heart Transplantation: A Case Report

First described in the United States in the late 1990s, West Nile virus (WNV) infection following solid organ transplantation is a rare but life-threatening complication. The many ways in which WNV may be acquired, patient specific risk factors, and variability in clinical severity present challenges to health care providers caring for these patients.

Critical developments of 2017: a review of the literature from selected topics in transfusion. A committee report from the AABB Clinical Transfusion Medicine Committee

BACKGROUND

The AABB compiles an annual synopsis of the published literature covering important developments in the field of Transfusion Medicine. For the first time, an abridged version of this work is being made available in TRANSFUSION, with the full-length report available as an Appendix S1 (available as supporting information in the online version of this paper).

STUDY DESIGN AND METHODS

Papers published in 2016 and early 2017 are included, as well as earlier papers cited for background. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed.

RESULTS

The following topics are covered: duration of red blood cell storage and clinical outcomes, blood donor characteristics and patient outcomes, reversal of bleeding in hemophilia and for patients on direct oral anticoagulants, transfusion approach to hemorrhagic shock, pathogen inactivation, pediatric transfusion medicine, therapeutic apheresis, and extracorporeal support.

CONCLUSION

This synopsis may be a useful educational tool.

Multi-Center Evaluation of the Automated Immunohematology Instrument, the ORTHO VISION Analyzer

BACKGROUND

ORTHO VISION Analyzer (Vision), is an immunohematology instrument using ID-MT gel card technology with digital image processing. It has a continuous, random sample access with STAT priority processing. The efficiency and ease of operation of Vision was evaluated at 5 medical centers.

METHODS

De-identified patient samples were tested on the ORTHO ProVue Analyzer (ProVue) and repeated on the Vision mimicking the daily workload pattern. Turnaround times (TAT) were collected and compared. Operators rated key features of the analyzer on a scale of 1 to 5.

RESULTS

A total of 507 samples were tested on both instruments at the 5 trial sites. The mean TAT (SD) were 31.6 minutes (5.5) with Vision and 35.7 minutes (8.4) with ProVue, which renders a 12% reduction. Type and screens were performed on 381 samples; the mean TAT (SD) was 32.2 minutes (4.5) with Vision and 37.0 minutes (7.4) with ProVue. Antibody identification with eleven panel cells was performed on 134 samples on Vision; TAT (SD) was 43.2 minutes (8.3). The installation, training, configuration, maintenance and validation processes are all streamlined to provide a short implementation time. The average rating of main functions by the operators was 4.1 to 4.8. Opportunities for improvement, such as flexibility with editing QC results, maintenance schedule, and printing options were identified. The capabilities to perform serial dilutions, to accept pediatric tubes, and review results by e-Connectivity are enhancements over the ProVue.

CONCLUSIONS

Vision provides shorter TAT compared to ProVue. Every site described a positive experience using Vision.

Extracorporeal photopheresis in heart transplant rejection

Up to 25% of heart transplant recipients develop rejection requiring intervention. While the majority respond to augmentation of immunomodulatory drug therapy, a subset of patients will remain refractory. Extracorporeal photopheresis (ECP) appears particularly useful in the management of select heart transplant recipients at risk of rejection, with recurrent rejection, or rejection associated with hemodynamic compromise. This chapter summarizes the current clinical experience of ECP in heart transplantation. ECP appears to favorably affect both the cellular and humoral arms of the immune response to the allograft and promote a tolerogenic profile. These immunomodulatory effects also appear to decrease development of cardiac allograft vasculopathy. ECP is generally well tolerated with few adverse effects and low infection risk.

Platelet-rich plasma for the replenishment of bone

This review examines the use of platelet-rich plasma (PRP) in the treatment of bone injuries and to stimulate bone formation. Studies examining both in vivo bone healing and in vitro actions of PRP on osteoblasts are reviewed. Overall, the available literature suggests that PRP does not appreciably impact bone healing or induce bone formation. However, there is some evidence to suggest that PRP might augment recruitment of osteoblast progenitors to injection sites or in sites expected to experience delayed healing. In this capacity PRP might be utilized to initiate repair of an otherwise poorly healing skeletal lesion. The demonstration that PRP is a viable therapy is hindered by a lack of standardized criteria for what constitutes PRP, and more studies are needed to compare the efficacy of PRP to that of transforming growth factor-β or platelet-derived growth factor used as sole agents.

Acute hemolysis after high-dose intravenous immunoglobulin therapy in highly HLA sensitized patients

BACKGROUND AND OBJECTIVES

Intravenous Ig (IVIG) is used in renal transplantation for desensitization and treatment of antibody-mediated rejection (AMR). The infusion of high-dose IVIG is generally well tolerated, but there are reports of hemolytic anemia induced by anti-blood group antibodies present in IVIG. Here, we report our experience with IVIG-induced hemolytic anemia (IH) in ESRD patients receiving IVIG for desensitization or treatment of AMR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All patients receiving IVIG for desensitization or for treatment of AMR were monitored for evidence of acute anemia and hemolysis. Markers of hemolysis, including direct antiglobulin tests, were recorded. Five different IVIG products were tested for isohemagglutinin titers.

RESULTS

There were 18 cases of IH in 16 patients. All identified cases received the IVIG product Gamunex, Gammagard liquid, or Privigen. All patients developing hemolysis were non-O blood types. Isohemagglutinin titers ranged from 1:2 to 1:64 in the various IVIG products, with higher titers noted in the liquid, nonlyophilized products.

CONCLUSIONS

Acute IH is a significant complication of high-dose IVIG infusion. Identified risk factors include non-O blood type of the recipient and administration of liquid IVIG preparations with high titer anti-A/B IgG antibodies. We recommend monitoring hemoglobin 48 to 72 h after IVIG infusion. If the hemoglobin decreases, a hemolytic work-up is recommended. Hemolysis could be avoided in at risk patients by choosing a low titer product. However, other complications such as acute renal failure or thrombosis may be seen because the low titer products are usually hyperosmotic.

Combination vincristine and plasma exchange as initial therapy in patients with thrombotic thrombocytopenic purpura: one institution's experience and review of the literature

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) was once a highly fatal disease with mortality reaching nearly 95 percent; however, application of therapeutic plasma exchange (TPE) has dramatically increased survival. Nevertheless, mortality remains substantial (10%-30% in many published reports), requiring the search for more efficacious treatments. Vincristine (VCR) has been generally reserved for refractory TTP. Despite its effectiveness in a salvage mode, VCR has not been widely advocated as first-line therapy in conjunction with TPE. We previously reported improved survival when VCR and TPE were administered at presentation in patients treated from 1979 to 1994. Utilizing this standardized approach, outcomes of an additional group of patients and the results of a literature review of VCR therapy for TTP are reported.

STUDY DESIGN AND METHODS

Medical records of all patients with a diagnosis of TTP treated between 1995 and 2002 at Cedars-Sinai Medical Center were reviewed. TPE was performed daily, exchanging 1.25 plasma volumes, until the platelet count normalized. Patients received VCR 1.4 mg/m2, (up to 2.0 mg total dose) after the first TPE. A literature review of all publications utilizing VCR in the management of TTP was performed with MEDLINE.

RESULTS

Twelve consecutive patients meeting the diagnostic criteria received treatment with VCR and TPE. All patients achieved durable remission. Patients tolerated VCR without significant complications.

CONCLUSION

Our 100 percent survival rate, as well as evidence garnered from the literature review, suggests that combination therapy with VCR and TPE at presentation might be more effective than TPE alone and therefore warrants consideration as first-line therapy for TTP patients.

A case-control study of the impact of WBC reduction on the cost of hospital care for patients undergoing coronary artery bypass graft surgery

BACKGROUND

WBC reduction of blood components may reduce the incidence of transfusion reactions. The cost of this intervention might be offset by a reduction in the incidence of postoperative infection, thereby reducing the length of hospital stay and thus the cost of care for patients receiving transfusion. Cedars-Sinai Medical Center provided WBC-reduced blood components to all patients for a period of 2 years, creating an opportunity to compare the incidence of postoperative infection, length of hospital stay, and total hospital costs for patients undergoing coronary artery bypass graft surgery, before, during, and after WBC reduction.

STUDY DESIGN AND METHODS

Data were obtained by examining hospital records of patients who received transfusion and control patients who did not receive transfusion for the years 1991 (before WBC reduction), 1992 to 1993 (during WBC reduction), and 1994 (following discontinuation of WBC reduction). Comparisons were made by use of ANOVA following log or square root transformation of the data.

RESULTS

Length of hospital stay for patients who received transfusion decreased over time. Mean hospital stays were 15.9, 14.1, and 12.1 days before, during, and after WBC reduction, respectively. A similar trend was seen in the patients who did not receive transfusion. There was no indication that WBC reduction functioned as an independent variable that was responsible for the observed decrease. The rate of postoperative infection stayed constant during WBC reduction and only dropped when WBC reduction was stopped. Mean hospital cost showed no significant change over time for either the transfusion group or the nontransfusion group.

CONCLUSION

The cost of providing a totally WBC-reduced blood supply may not be offset by immediate savings related to decreased postoperative infections, reduced length of hospital stay, and cost of hospital care.

A second case of post-transfusion purpura caused by HPA-5a antibodies: successful treatment with intravenous immunoglobulin

Post-transfusion purpura (PTP) is a rare disorder characterized by severe thrombocytopenia developing seven to 10 days following transfusion of platelet-containing blood components, in a person who was previously sensitized via transfusion or pregnancy. Although most cases of PTP are caused by alloantibodies directed against HPA-1a[(Pl(A1))], this case represents the second example of anti-HPA-5a-associated PTP. A 61-year-old female was diagnosed with acute myocardial infarction and gastrointestinal bleeding and, after receiving six units of packed red cells over 5 days, developed PTP as a result of HPA-5a [Br(b)] antibodies with severe thrombocytopenia (5000/microl). She was successfully treated with intravenous immunoglobulin (IVIG), suggesting that this is a highly effective mode of treatment for PTP, regardless of the antibody implicated.

Treatment of thrombotic thrombocytopenic purpura: a role for early vincristine administration

Plasma exchange (PE) is considered first-line treatment for thrombotic thrombocytopenic purpura (TTP) to the point that many clinicians regard it as definitive therapy. Studies have reported response rates to PE ranging from 39% to 78%. In our experience, a minority of patients have been cured solely by PE. While adjuvant therapies (e.g., vincristine, splenectomy) have proved effective in anecdotal reports, protocols using these therapies in the treatment of TTP have not been established. Management of TTP over a 15-year period was reviewed to evaluate (1) the rate of cure accomplished by PE alone, and (2) the potential benefit of additional therapies. The records of 29 consecutive patients with TTP treated by PE were reviewed and classified according to response to PE alone and the need for adjuvant therapy. Eight patients (28%) achieved remission and long-term survival with PE alone. With the addition of adjuvant therapy another 13 patients survived, bringing the total survival to 72%. Fifteen patients were treated with vincristine in addition to PE. Only three of seven patients receiving vincristine after failing to respond completely to PE survived, but survival increased to 88% (7 of 8) when vincristine was administered within 3 days of beginning PE. These data suggest that PE alone may not be sufficient therapy for most patients with TTP. Additional therapy is often needed to achieve long-term survival. While controlled trials will be necessary to prove the efficacy of vincristine, we believe that, given the minimal risk of vincristine toxicity and the grave consequences of ineffective therapy, routine administration of vincristine early in the course of PE should be considered.

Confirmation of the safety of autologous blood donation by patients awaiting heart or lung transplantation. A controlled study using hemodynamic monitoring

BACKGROUND

Though earlier investigations have demonstrated the efficacy of autologous blood transfusion in reducing allogeneic blood exposure in patients undergoing heart or lung transplantation, questions remain regarding the safety of blood donation by patients with severe heart or lung disease.

METHODS

Response to autologous blood donation by candidates for heart and lung transplantation and a group of age- and gender-matched control subjects was studied. Heart rate, blood pressure, oxygen saturation, and cardiac rhythm were examined before and after phlebotomy, and response to orthostatic challenge was evaluated. Patients were also questioned regarding impressions of changes in subjective sense of well being. Differences between patients and control subjects were evaluated by the paired t test and Fisher's exact test. An alpha of 0.05 was used in all testing to determine statistical significance.

RESULTS

Eighteen candidates for heart transplantation, 16 candidates for lung transplantation, and their matched control subjects were studied. Though patients and control subjects differed with respect to baseline hemodynamic measurements, significant differences between the groups' responses to phlebotomy were not observed. After whole blood donation, orthostatic challenge resulted in a mean change in mean arterial pressure of -2.1 mm Hg in candidates for heart transplantation compared with a mean of +3.6 mm Hg in their control subjects (p = 0.062). In candidates for lung transplantation there was a mean change of +2.2 mm Hg after orthostatic challenge versus a mean change of +8.5 mm Hg in their control subjects (p = 0.052). Furthermore, no changes in cardiac rhythm or arterial oxygen saturation were detected.

CONCLUSIONS

The hemodynamic effects of autologous blood donation in a group of patients with significant cardiac or pulmonary disease were not different from those observed in patients considered acceptable candidates for autologous blood collection. On the basis of these objective findings, we believe that patients with less severe degrees of heart or lung disease should not be excluded from participation in autologous blood donation programs.

Granular cell tumor of the biliary system

Granular cell tumors (GCT) are rare benign neoplasms of Schwann cell origin which have been found in virtually every location in the body. Their location in the biliary system is unusual, and typically occurs in black females during the fourth decade of life. Forty-eight cases have been reported since 1952. We present two patients treated for obstructive jaundice caused by GCT of the extrahepatic biliary tree. The literature on biliary GCT is reviewed and their management is outlined. Local excision with Roux-y-hepaticojejunostomy was performed in one patient with GCT obstructing the common bile duct at the level of the cystic duct. Pancreaticoduodenectomy was performed on one patient for GCT of the common bile duct involving the ampulla and adjacent pancreas. GCT of the extrahepatic biliary system are rare but should be considered in black females who present with obstructive jaundice in the fourth decade of life. Local excision with cholecystectomy and reconstruction of the biliary remnant is indicated. Primary biliary anastomosis is desired but choledochojejunostomy or hepaticojejunostomy may be necessary. Rarely, pancreaticoduodenectomy may be indicated in GCT of the distal common bile duct.

Safety and efficacy of preoperative donation of blood for autologous use by patients with end-stage heart or lung disease who are awaiting organ transplantation

Many patients are, perhaps inappropriately, denied the benefits of autologous blood transfusion, because they are thought to be too ill to donate blood safely. The safety and efficacy of autologous blood donation by selected patients with end-stage heart or lung disease who are awaiting organ transplantation were studied to determine if even these critically ill patients could be suitable candidates for autologous blood donation. Seventy-two adults awaiting heart or lung transplantation were evaluated for autologous blood donation in a hospital-based blood collection facility. Phlebotomy was performed if the patient met the required medical eligibility protocol, and if he or she consented to participate. Units of blood were separated into packed red cells and plasma and stored in a frozen state. Of 48 heart transplant candidates, 31 (65%) were each able to donate 1 to 8 units of blood. The median number of exposures to allogeneic components was 1 for patients who donated and 7 for nondonors (p = 0.0141). Among patients who donated, 54 percent required allogeneic components, as compared to 88 percent of nondonors (p = 0.0968). Of 24 lung transplant candidates, 15 (63%) made 1 to 6 donations each. The median number of exposures to allogeneic components was 0 for donors and 2 for nondonors (p = 0.1871), but only 45 percent of donors required allogeneic components, as compared to 100 percent of nondonors (p = 0.0418). No serious complications during or following phlebotomy were observed. It is concluded that autologous blood donation by patients with end-stage heart or lung disease may be safe.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of babesiosis by red blood cell exchange in an HIV-positive, splenectomized patient

Babesiosis is a malaria-like parasitic disease causing subclinical or mild illness in most cases. Splenectomized patients, however, may experience a more severe course. Although generally responsive to antibiotic therapy, several cases of severe babesiosis refractory to appropriate antibiotic therapy have been reported to respond promptly and dramatically to red blood cell (RBC) exchange transfusion. Although the role of HIV coinfection in babesiosis is uncertain, two previously reported cases raise a concern that it may predispose to a more severe clinical course. We report a third case of severe babesiosis in an HIV-positive splenectomized man, following travel to an endemic area. Antibiotic therapy, though initially effective, ultimately failed to prevent severe disease. RBC exchange transfusion resulted in prompt clinical improvement, which has been sustained during 26 months of follow-up. Although the patient has since developed various sequelae of HIV infection, including disseminated Kaposi's sarcoma, CMV retinitis, and enteritis, there has been no recurrence of observable parasitemia. In severe babesiosis, RBC exchange transfusion, combined with appropriate antibiotic therapy, appears to be a rapidly effective therapeutic modality which can induce sustained remissions.

Computerized classification of nuclear profiles in non-Hodgkin's lymphomas

The authors present experimental technics for the diagnosis of non-Hodgkin's lymphomas, based on instrumental classification of nuclear profiles using a video-based system for computerized interactive morphometry (CIM). In their system, the real time video image of a specimen is superimposed to a graphics overlay generated by a computer, consisting of a test area with four visual markers for random sampling of cells and a menu with several options to send direct commands to the system. Using a touch-sensitive screen mounted on a video monitor as an interactive peripheral, a trained observer traces 100 randomly selected lymphoid cells, counts mitoses in 25 microscopic fields, and categorizes the lesion as diffuse or nodular. Each cell is instrumentally classified into either small cell noncleaved, small cell cleaved, or large, based on the length of their nuclear profiles, their enclosed nuclear area, and a circularity factor. Thereafter the computer provides a "diagnosis," based on hierarchic analysis of the data. The morphometric data are also interpreted by alternate statistical methods of discriminatory classificatory analysis that provide a diagnosis and a probability statement derived from matching unknown cases with a data base. Forty-two lymphoid lesions have been categorized with the CIM system. Studies of interobserver and intraobserver variations in data collection are discussed. The potential advantages of CIM for the objective classification of non-Hodgkin's lymphomas are discussed.