Leukostasis aggravated by red blood cell transfusion in a chronic lymphocytic leukemia patient

Introduction/Objective

Leukostasis/symptomatic hyperleukocytosis is commonly seen in acute leukemias and is characterized by high blast counts and symptoms of decreased tissue perfusion with a one-week mortality of 20-40%, if left untreated. It is a rare complication in chronic lymphocytic leukemia (CLL) and is seen in CLL patients with white blood cell (WBC) counts > 500x10^9/L. Studies have shown that transfusion of blood products prior to decreasing the WBC count may lead to increased blood viscosity and worsen leukostasis. We report a CLL patient with a lower WBC count presenting with symptoms of leukostasis, further worsened by a red blood cell (RBC) transfusion prior to leukapheresis.

Methods/Case Report

A 73-year-old male with history of CLL for 5 years, hypertension and chronic kidney disease presented with acute dyspnea for 1 day. The WBC count was 208x10^9/L, hemoglobin was 6.5 g/dL, troponin I was 1.554 ng/mL, creatinine was 1.68 mg/dL and chest x-ray showed bilateral interstitial lung edema. The patient was diagnosed with acute hypoxic respiratory failure, acute kidney injury and myocardial infarction due to leukostasis. He received RBC transfusion, shortly after which his dyspnea worsened. There were no other signs or symptoms that could suggest a transfusion reaction. A single leukapheresis was performed following which there was a significant improvement in symptoms with a drop in WBC count to 123.1x10^9/L and creatinine to 1.3 mg/dL.

Results (if a Case Study enter NA)

NA

Conclusion

CLL may present with symptomatic hyperleukocytosis at lower leukocyte counts than has been described in the literature. Symptoms due to leukostasis can be precipitated/worsened by transfusion of blood products due to increased blood viscosity. It is critical to identify the signs and symptoms of this medical emergency as prompt diagnosis and management with leukapheresis significantly reduces the leukocyte count and blood products should be transfused slowly during or after leukapheresis.

Histology Slide Quality Improvement Project Utilizing DMAIC principle of Six Sigma Quality Improvement Methodology

Introduction/Objective

DMAIC (an acronym for Define, Measure, Analyze, Improve and Control) refers to a data- driven improvement cycle used for improving, optimizing, and stabilizing business processes and designs. Our goal was to utilize DMAIC principle of six sigma quality to improve histology slide quality.

Methods/Case Report

We “defined” the problem as suboptimal quality in endometrial biopsy slides (defects). Utilizing the DMAIC principle and adhering to a strict timeline, the defects found during baseline slide quality review were “measured” by linking the defects to specific histology competencies, which were addressed systematically for process improvement (PI). After PI, a follow up review (“improve” and “control” phases) was carried out to identify measurable outcomes as a testament to quality.

Results (if a Case Study enter NA)

During the problem “measurement” phase, the defects found in the baseline review of 175 slides were linked to four specific histology competencies (fixation, embedding, cutting, and staining). Processing was excluded as it is completely automated and standardized. Our analysis showed that 83.3 % of defects were linked to embedding (“tissue too dispersed”). As embedding competency depends on the size and nature of the tissue (e.g. mucus and blood admixed with tissue), grossing competency was also addressed along with embedding at the respective workstations. Recommendations were offered to the grosser, embedder, and cutter to reduce variables during the “improvement” phase. Follow up review was done on 196 slides. The number of defective slides decreased and the defects that linked to “tissue too dispersed” had an overall improvement of 91.3%. Once the PI is proven to be effective, in service to histotechnology personnel biannually were also offered during “control” phase.

Conclusion

We have demonstrated successful methods for improving histology slide quality utilizing DMAIC principle of quality improvement by six sigma methodology DMAIC principle can be creatively adapted in laboratory practice management to enhance quality.

Importance of timing of magnesium administration in the isolated ischemic-reperfused rat heart: role of K(ATP) channels

There is a growing interest for the beneficial effect of magnesium (Mg) in cardiovascular disorders. A number of cardiovascular disorders including myocardial infarction, arrhythmias and congestive heart failure have been associated with low extra- cellular or intracellular concentrations of Mg. The efficiency of the preconditioning effect of Mg on cardiac function and infarct size in the globally ischemic-reperfused isolated rat heart was studied together with the role of ATP-sensitive potassium (K(ATP)) channels in protection induced by Mg. Rat hearts were Langendorff perfused, subjected to 30 min of global ischemia and 90 min of reperfusion, including treatment groups which focused on different times of Mg (8 mmol/l) use. Infarct size was measured by triphenyltetrazolium chloride (TTC) method. The left ventricular function was assessed by left ventricular developed pressure (LVDP), heart rate (HR) and coronary flow (CF). The administration of Mg before ischemia had an anti-infarct effect in rat hearts and improved cardiac function. The protective effects of magnesium was abolished by the blocking of K(ATP) channels and suggests that K-ATP channel has an important role in the heart protection effect of Mg as a preconditioning agent.

Culture filtrate of Cryptococcus neoformans var. gattii (CneF) as a novel anti-inflammatory compound in the treatment of experimental septic arthritis

We examined the efficacy of the culture filtrate of Cryptococcus neoformans var. gattii (CneF) as a novel anti-inflammatory compound in experimental septic arthritis. Haematogenously infectious arthritis was induced in rats by a single intravenous injection of 109 CFU Staphylococcus aureus producing toxic shock syndrome toxin-1. CneF solution at two different doses (36 and 72 mg/kg, based on carbohydrate concentration) was administered intraperitoneally 2 h before bacterial inoculation in the prevention groups and simultaneously with the appearance of clinical signs in the therapeutic groups. CneF administration was continued at regular 48-h intervals for 10 injections. The results of clinical evaluation showed that CneF-treated rats were significantly protected from disease development compared with nontreated controls. This finding correlated with the results of histological and radiological assessments of the involved joints. Synovial hypertrophy, inflammatory cell infiltration, pannus formation and cartilage/bone destruction were found to be significantly decreased in the prevention and therapeutic groups compared with arthritic controls. The data suggest that CneF may have therapeutic potential in the treatment of septic arthritis.

Effect of granisetron on morphine-induced analgesia in mice by formalin test

1. In this investigation, the influence of a selective 5HT3 antagonist, granisetron, on morphine-induced antinociception in the formalin test has been studied. There is evidence that the 5HT3 receptor system takes part in analgesic response. 2. Male albino mice weighing 22-27 g were used in the experiments. All drugs were administered 30 min before formalin injection. Comparison between groups was made by analysis of variance and then Newman-Keuls test. 3. Different doses of morphine (1.5-9.0 mg/kg) subcutaneously induced antinociception in both phases of the formalin test. 4. Coadministration of granisetron (0.1-10.0 mg/kg) intraperitoneally had no effect on morphine analgesia, but granisetron injection alone induced dose-dependent analgesia in both phases of the formalin test. 5. Results of this study suggest a role for a new selective 5HT3 antagonist in analgesia.