A Synoptic Reporting System to Monitor Bone Marrow Aspirate and Biopsy Quality

Objectives:

Bone marrow evaluation plays a critical role in the diagnosis, staging, and monitoring of many diseases. Although there are standardized guidelines for assessing bone marrow specimen quality, there is a lack of evidence-based tools to perform such assessments. The objective was to monitor bone marrow sample quality in real time by standardizing the basic components of a synoptic report and incorporating it into a bone marrow report template.

Materials and Methods:

A relational database of bone marrow quality parameters was developed and incorporated into our laboratory information system bone marrow report template, with data entry completed during specimen sign out. Data from multiple reports created within a date range were extracted by Structured Query Language query, and summarized in tabular form. Reports generated from these data were utilized in quality improvement efforts.

Results:

The synoptic reporting system was routinely used to record the quality of bone marrow specimens from adult patients. Data from 3189 bone marrow aspirates, 3302 biopsies, and 3183 biopsy touch imprints identified hemodilution as the principal issue affecting bone marrow aspirate quality, whereas aspiration artifact and fragmentation affected bone marrow biopsy quality.

Conclusions:

The bone marrow synoptic reporting process was easy to use, readily adaptable, and has proved a useful component of the overall quality assurance process to optimize bone marrow quality.

Widely Used Types and Clinical Applications of D-Dimer Assay

D-dimers are formed by the breakdown of fibrinogen and fibrin during fibrinolysis. D-dimer analysis is critical for the diagnosis of deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation. Modern assays for D-dimer are monoclonal antibody based. The enzyme-linked immunosorbent assay (ELISA) is the reference method for D-dimer analysis in the central clinical laboratory, but is time consuming to perform. Recently, a number of rapid, point-of-care D-dimer assays have been developed for acute care settings that utilize a variety of methodologies. In view of the diversity of D-dimer assays used in central laboratory and point-of-care settings, several caveats must be taken to assure the proper interpretation and clinical application of the results. These include consideration of preanalytical variables and interfering substances, as well as patient drug therapy and underlying disease. D-dimer assays should also be validated in clinical studies, have established cut-off values, and reported according to the reagent manufacturers recommendations.

Bone marrow aspirate and biopsy: a pathologist's perspective. II. interpretation of the bone marrow aspirate and biopsy

Bone marrow examination has become increasingly important for the diagnosis and treatment of hematologic and other illnesses. Morphologic evaluation of the bone marrow aspirate and biopsy has recently been supplemented by increasingly sophisticated ancillary assays, including immunocytochemistry, cytogenetic analysis, flow cytometry, and molecular assays. With our rapidly expanding knowledge of the clinical and biologic diversity of leukemia and other hematologic neoplasms, and an increasing variety of therapeutic options, the bone marrow examination has became more critical for therapeutic monitoring and planning optimal therapy. Sensitive molecular techniques, in vitro drug sensitivity testing, and a number of other special assays are available to provide valuable data to assist these endeavors. Fortunately, improvements in bone marrow aspirate and needle technology has made the procurement of adequate specimens more reliable and efficient, while the use of conscious sedation has improved patient comfort. The procurement of bone marrow specimens was reviewed in the first part of this series. This paper specifically addresses the diagnostic interpretation of bone marrow specimens and the use of ancillary techniques.

Translocation-positive acute myeloid leukemia associated with valproic acid therapy

Valproic acid is an effective anti-epileptic medication often used for long-term control of seizure disorders that has been implicated in hematological toxicities, including rare reports of myelodysplasia and acute leukemia. Here, we report a case of valproic acid-related leukemia-like syndrome with a t(8;16) chromosomal translocation. After discontinuing valproic acid, the hematological findings completely resolved.

A New Alloantigen-Independent Control for Chronic Allograft Nephropathy Rat Models

BACKGROUND

Isografts are used as controls in many transplant experiments. Our laboratory and others have noticed histological changes in control isograft groups of rats similar to allograft groups, suggesting alloantigen-independent factors contributing to chronic allograft nephropathy. However, the isograft model as a nonalloantigen control is flawed because of the potential of unrecognized minor antigen differences between rats. We designed a study using autografts to isolate alloantigen-independent factors in the rat renal transplant allograft model.

MATERIALS AND METHODS

Male Lewis rats weighing 150-250 g underwent a procedure designed to mimic the injury of renal transplant, in which the left kidney was perfused with cold University of Wisconsin solution and subjected to similar cold and warm ischemic times as Lewis isograft rats undergoing renal transplanation.

RESULTS

Six autograft rats were compared to five isograft and three single nephrectomy rats. Autograft rats showed normal kidney function according to serum BUN, Cr, and urinary protein. At 360 days, four of six autografts displayed normal renal parenchymal histology, whereas the remaining two autografts displayed histological changes scored as Banff acute rejection 1a and 1b. At sacrifice time, four of five isografts showed histological changes scored as Banff chronic rejection 1 and the single nephrectomy group showed normal histology in the remaining native kidney.

CONCLUSIONS

Our data demonstrate that the chronic nephropathy observed in the isograft cannot be completely freed from suspicion of immunological origin. We propose that the autograft model for rat renal transplant research is a better nonimmunologic control than the isograft model for chronic allograft nephropathy.

Hematologic aspects of myeloablative therapy and bone marrow transplantation

The transplantation of bone marrow cells or isolated hematopoietic stem cells from the bone marrow or peripheral blood is a widely utilized form of therapy for patients with incurable diseases of the hematopoietic and immune systems. Successful engraftment of the transplanted stem cells in an adequately prepared recipient normally leads to bone marrow reconstitution over a period of several weeks, accompanied by more gradual reconstitution of the immune system. Since the recipient is profoundly ill during the initial treatment period, laboratory data is critical for monitoring engraftment, detecting residual/recurrent disease, and identifying problems that may delay bone marrow reconstitution or lead to other medical complications. Accurate blood cell counts are imperative, and most bone marrow transplantation patients undergo periodic monitoring with bone marrow aspirates and biopsies with cytogenetic, molecular, and multiparametric flow cytometric studies. The potential complications of bone marrow transplantation include engraftment failure and delayed engraftment, infection, residual bone marrow disease, acute and chronic graft versus host disease, myelofibrosis, therapy-related acute leukemia, post-transplant lympho-proliferative disorders, and toxic myelopathy.

Digital photography: a primer for pathologists

The computer and the digital camera provide a unique means for improving hematology education, research, and patient service. High quality photographic images of gross specimens can be rapidly and conveniently acquired with a high-resolution digital camera, and specialized digital cameras have been developed for photomicroscopy. Digital cameras utilize charge-coupled devices (CCD) or Complementary Metal Oxide Semiconductor (CMOS) image sensors to measure light energy and additional circuitry to convert the measured information into a digital signal. Since digital cameras do not utilize photographic film, images are immediately available for incorporation into web sites or digital publications, printing, transfer to other individuals by email, or other applications. Several excellent digital still cameras are now available for less than 2,500 dollars that capture high quality images comprised of more than 6 megapixels. These images are essentially indistinguishable from conventional film images when viewed on a quality color monitor or printed on a quality color or black and white printer at sizes up to 11x14 inches. Several recent dedicated digital photomicroscopy cameras provide an ultrahigh quality image output of more than 12 megapixels and have low noise circuit designs permitting the direct capture of darkfield and fluorescence images. There are many applications of digital images of pathologic specimens. Since pathology is a visual science, the inclusion of quality digital images into lectures, teaching handouts, and electronic documents is essential. A few institutions have gone beyond the basic application of digital images to developing large electronic hematology atlases, animated, audio-enhanced learning experiences, multidisciplinary Internet conferences, and other innovative applications. Digital images of single microscopic fields (single frame images) are the most widely utilized in hematology education at this time, but single images of many adjacent microscopic fields can be stitched together to prepare "zoomable" panoramas that encompass a large part of a microscope slide and closely simulate observation through a real microscope. With further advances in computer speed and Internet streaming technology, the virtual microscope could easily replace the real microscope in pathology education. Later in this decade, interactive immersive computer experiences may completely revolutionize hematology education and make the conventional lecture and laboratory format obsolete. Patient care is enhanced by the transmission of digital images to other individuals for consultation and education, and by the inclusion of these images in patient care documents. In research laboratories, digital cameras are widely used to document experimental results and to obtain experimental data.

A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination

The bone marrow aspirate and biopsy is an important medical procedure for the diagnosis of hematologic malignancies and other diseases, and for the follow-up evaluation of patients undergoing chemotherapy, bone marrow transplantation, and other forms of medical therapy. During the procedure, liquid bone marrow is aspirated from the posterior iliac crest or sternum with a special needle, smeared on glass microscope slides by one of several techniques, and stained by the Wright-Giemsa or other techniques for micro-scopic examination. The bone marrow core biopsy is obtained from the posterior iliac crest with a Jamshidi or similar needle and processed in the same manner as other surgical specimens. Flow cytometric examination, cytochemical stains, cytogenetic and molecular analysis, and other diagnostic procedures can be performed on bone marrow aspirate material, while sections prepared from the bone marrow biopsy can be stained by the immunoperoxidase or other techniques. The bone marrow procedure can be performed with a minimum of discomfort to the patient if adequate local anesthesia is utilized. Pain, bleeding, and infection are rare complications of the bone marrow procedure performed at the posterior iliac crest, while death from cardiac tamponade has rarely occurred from the sternal bone marrow aspiration. The recent development of bone marrow biopsy needles with specially sharpened cutting edges and core-securing devices has reduced the discomfort of the procedure and improved the quality of the specimens obtained.

Immunophenotypic analysis of acute lymphocytic leukemia

Acute lymphoblastic leukemia (ALL) is one of the most common hematologic malignancies. Flow cytometry is an integral part of ALL diagnosis and also provides significant patient prognostic information. This article is a practical review of the basic principles of the flow cytometric evaluation of acute leukemias, the interpretation of flow cytometric data, and the management of practical problems such as aberrant antigen, hematogones, bone marrow regeneration, and minimal residual disease.

Reticulocyte analysis by flow cytometry and other techniques

Enumeration of peripheral blood reticulocytes is an essential part of the diagnosis and management of anemic patients, since the number of reticulocytes in the peripheral blood reflects the erythrocytic activity of the bone marrow. Reticulocyte enumeration using flow cytometric methodology is rapidly replacing the inaccurate, imprecise manual counting technique used in the past. This article explores the pathophysiology of the reticulocyte, the various means of counting reticulocytes, and the diverse clinical applications of reticulocyte data.

The virtual blood film

The computer and the digital camera offer unprecedented possibilities for improving hematology education, research, and patient service. Peripheral blood smear images of exceptional quality can be acquired rapidly and conveniently from the peripheral blood smear with a modern, high-resolution digital camera and a quality microscope. Digital cameras use CCD or CMOS image sensors to measure light energy and additional circuitry to convert the measured information into a digital signal. Because digital cameras do not use photographic film, images are immediately available for incorporation into web sites or digital publications, printing, transfer to other individuals by e-mail, or other applications. Several excellent consumer digital still cameras are now available for less than $1000 that capture high-quality images comprised of more than three megapixels. These images are essentially indistinguishable from conventional film images when viewed on a quality color monitor or printed on a quality color or black and white printer at sizes up to 8 x 10 in. Several recent dedicated digital photomicroscopy cameras provide an ultrahigh quality image output of more than 12 megapixels and have low noise circuit designs permitting the direct capture of darkfield and fluorescence images. There are many applications of digital images of peripheral blood smears. Because hematology is a visual science, the inclusion of quality digital images into lectures, teaching handouts, and electronic documents is essential. A few institutions have gone beyond the basic application of digital images to develop large electronic hematology atlases; animated, audio-enhanced learning experiences; multidisciplinary Internet conferences; and other innovative applications. Digital images of single microscopic fields (single-frame images) are the most widely used in hematology education at this time, but single images of many adjacent microscopic fields can be stitched together to prepare zoomable panoramas that encompass a large part of a microscope slide and closely stimulate observation through a real microscope. With further advances in computer speed and Internet streaming technology, the virtual microscope could easily replace the real microscope in pathology education. Interactive, immersive computer experiences may completely revolutionize hematology education and make the conventional lecture and laboratory format obsolete later in this decade. Patient care is enhanced by the transmission of digital images to other individuals for consultation and education, and by the inclusion of these images in patient care documents. In research laboratories, digital cameras are widely used to document experimental results and obtain experimental data.

Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures

BACKGROUND

Deep-vein thrombosis is a common complication following pelvic and acetabular fractures. The hypothesis of this study was that pulsatile mechanical compression is superior to standard sequential mechanical compression for decreasing the prevalence of deep-vein thrombosis in patients with pelvic or acetabular fracture.

METHODS

A prospective, randomized, blinded study of two methods of mechanical prophylaxis against deep-vein thrombosis was conducted. One hundred and seven patients were randomized into either Group A (fifty-four patients), in which a thigh-calf low-pressure sequential-compression device was used, or Group B (fifty-three patients), in which a calf-foot high-pressure pulsatile-compression pump was used. All patients underwent duplex ultrasonography and magnetic resonance venography. The two groups were comparable with regard to demographics, fracture type, fracture treatment, time from the injury to the prophylaxis, and patient compliance.

RESULTS

Deep-vein thrombosis developed in ten patients (19%) in Group A, with seven (13%) having a large or occlusive clot and one (2%) having a documented pulmonary embolism. Deep-vein thrombosis developed in five patients (9%) in Group B, with two (4%) having a large or occlusive clot and none having a documented pulmonary embolism. Nine of the nineteen detected thromboses were in the deep pelvic veins. The difference in the prevalence of large or occlusive clots between the two groups demonstrated a trend but, with the numbers available, was not significant (p = 0.16). Increased patient age and the time elapsed from the injury to the surgery were found to be associated with higher rates of thrombosis.

CONCLUSIONS

Pulsatile compression was associated with fewer deep-vein thromboses than was standard compression, with the difference representing a trend but not reaching significance with the number of patients studied.

Platelet satellitism as presenting finding in mantle cell lymphoma. A case report

Platelet satellitism surrounding polymorphonuclear neutrophils has been observed almost exclusively in EDTA-treated blood at room temperature. The mechanism underlying this phenomenon is not understood fully. We report a case of platelet rosetting around atypical lymphocytes in peripheral blood smears made from EDTA-treated and untreated blood. Flow cytometry of the peripheral blood sample and immunohistochemical stains of the subsequent bone marrow biopsy specimen revealed a monoclonal B-cell population positive for CD5, CD20, and cyclin D1 and negative for CD3 and CD23; cytogenetic findings revealed a complex karyotype that included t(11;14). These findings were consistent with mantle cell lymphoma. To our knowledge, the finding of platelet satellitism involving mantle cell lymphoma cells in peripheral blood has not been reported previously.

Clinical utilization of the international normalized ratio (INR)

The prothrombin time (PT) is one of the most important laboratory tests to determine the functionality of the blood coagulation system. It is used in patient care to diagnose diseases of coagulation, assess the risk of bleeding in patients undergoing operative procedures, monitor patients being treated with oral anticoagulant (coumadin) therapy, and evaluate liver function. The PT is performed by measuring the clotting time of platelet-poor plasma after the addition of calcium and thromboplastin, a combination of tissue factor and phospholipid. Intra- and interlaboratory variation in the PT was a significant problem for clinical laboratories in the past, when crude extracts of rabbit brain or human placenta were the only source of thromboplastin. The international normalized ratio (INR), developed by the World Health Organization in the early 1980s, is designed to eliminate problems in oral anticoagulant therapy caused by variability in the sensitivity of different commercial sources and different lots of thromboplastin to blood coagulation factor VII. The INR is used worldwide by most laboratories performing oral anticoagulation monitoring, and is routinely incorporated into dosage planning for patients receiving warfarin. Although the recent availability of sensitive PT reagents prepared from recombinant human tissue factor (rHTF) and synthetic phospholipids eliminated many of the earlier problems associated with the use of crude thromboplastin preparations, local instrument variability in the INR still remains a problem. Presently, the use of plasma calibrants seems the best solution to this problem. Standardizing the point-of-care instruments for INR monitoring is another dilemma faced by the industry. Ultimately, new generations of anticoagulant drugs may eliminate the need for laboratory monitoring of anticoagulant therapy.

Rapid diagnosis of acute eosinophilic pneumonia (AEP) in a patient with respiratory failure using bronchoalveolar lavage (BAL) with calcofluor white (CW) staining

A diagnosis of exclusion, acute eosinophilic pneumonia (AEP) is an acute febrile illness with respiratory impairment, diffuse pulmonary infiltrates, and bronchoalveolar lavage (BAL) fluid eosinophilia. Whether pulmonary eosinophilia in AEP is primary or secondary remains undetermined. We report here a 22-year-old auto mechanic with severe AEP and acute respiratory failure who required intubation and ventilatory support. The patient's bronchoalveolar lavage (BAL) fluid was analyzed using cultures, cytology, Wright/Giemsa, Gram, Gomori-methenamine-silver (GMS), and calcofluor white (CW) stains (1). Despite extensive evaluation, no infectious etiology was found. CW staining helped us rapidly to exclude Pneumocystis carinii or fungal infection and to focus attention toward the diagnosis of AEP. Transbronchial biopsy was unnecessary and supportive therapy without systemic glucocorticoids was followed by recovery within a few weeks. In this case, bronchoalveolar lavage with CW staining was of great assistance in the rapid diagnosis and initial management of AEP. Our literature review found no prior article using CW staining for evaluation of AEP.

Antiphospholipid antibodies: standardization and testing

A phenomenon originally scorned as a laboratory nuisance has turned out to be an important cause of thromboembolism, fetal death, and other forms of human disease. Investigations of this inaptly named "lupus anticoagulant" has led to the discovery of at least two distinct types of autoimmune antibodies. In spite of recent discoveries regarding the pathophysiology of these antibodies, their clinical significance is still controversial.

Laboratory implementation of a rapid three-stain technique for detection of microorganisms from lower respiratory specimens

A rapid, cost-effective method for the evaluation of lower respiratory specimen has become increasingly important in the diagnosis of pulmonary diseases in immunocompromised patients. In the past, the technically demanding, time-consuming, and expensive Gomori-methenamine-silver (GMS) stain was the principal means for the evaluation of these specimens. In this study, we compared the GMS stain with a new rapid, three-stain protocol for the evaluation of lower respiratory specimens. Lower respiratory specimens were obtained by bronchoalveolar lavage (BAL). Conventional Wright/Giemsa and Gram stains were utilized, as well as a contemporary strain, calcofluor white (CW). A cell count was performed on the BAL specimens, and cytospins were stained by the three stains. The calcofluor white-stained slides were examined with an epi-fluorescent microscope, whereas the other stains were evaluated with a conventional light microscope. Gomorimethenamine-silver (GMS), acid-fast bacillus (AFB), and Papanicolaou (PAP) stains were performed as controls. Thirty-two BAL procedures were performed in 20 (63%) male patients and 12 (37%) female patients. The clinical diagnosis was pneumonia in 31% of the patients, malignant hematologic disease in 28%, acute respiratory distress syndrome (ARDS) in 9%, and acquired immunodeficiency syndrome (AIDS) in 28%. Of these specimens, 78% were adequate for interpretation and 22% were inadequate. Bacteria were found in 50% (16/32) of all BALs, fungi were found in 9% (3/32), and Pneumocystis carinii was found in 9% (3/32). Gram-positive bacteria were most frequently found in patients with pneumonia (80%, 4/5), whereas P. carinii was identified in patients with AIDS. There were no false-positive results. One CW stain was equivocal for P. carinii due to high fluorescent background. Laboratory implementation of the rapid, three-staining technique was accomplished without difficulty in microbiology and hematology laboratory sections. Specimen evaluation with the rapid staining protocol was technically easy to perform; however, experience in ultraviolet fluorescent microscopy was crucial for interpretation of CW stain. All results were available in 2 hr, cost was reduced by 30%, and the assays were available 7 days/week. Further studies are ongoing to substantiate the sensitivity, specificity, and predictive value of this technique, as well as clinical guidelines for its optimal utilization.

Variations associated with disaggregation methods in DNA flow cytometry

We investigated the variations in DNA ploidy by flow cytometry (FC) among cell suspensions acquired by different disaggregation methods from the same tumor specimens. Cell suspensions (n = 121) of 40 solid tumors were obtained by mechanical mincing (n = 33), enzymatic digestion (n = 19), in vitro fine needle aspiration (FNA) (n = 34) or scraping (n = 35) of the tumor tissues. Mechanical disaggregation gave the highest cell yield, whereas enzymatic digestion provided the best cell viability. The mean values for the G0/G1 coefficient of variation, DNA indices and percent S phase were not significantly different in cell suspensions obtained with the four methods. However, the yield of malignant cells ranged from 60.4 +/- 5.3% (SEM) (enzymatic) to 82.3 +/- 3.1% (scraping). Tissue aliquots of 32 tumors were disaggregated by three to four methods, and the combined results of DNA ploidy obtained from different cell preparations showed that 22 tumors were nondiploid, but concordance with an abnormal DNA peak was found in only 27.3% (6/22) of the DNA nondiploid tumors. Our results indicate that scraping tumor tissue appears to be the best method for DNA FC since it has the highest percentage (61.3) of DNA nondiploid clones. Also, we believe the multiple samplings may provide comprehensive information on the DNA ploidy of solid tumors.

Comparative DNA analysis of solid tumors by flow cytometric and image analyses of touch imprints and flow cell suspensions

Comparative DNA analysis by flow cytometric (FCM) and image analyses (IA) has shown a high concordance rate. When present, discordance has been attributed to the presence of aneuploid cell populations detected only by IA, yet missed by FCM. This phenomenon has been explained by loss of aneuploid cells during FCM cell processing, differences in sampling area, or misinterpretation of the DNA histograms. To determine which factors are responsible for the discordance between IA and FCM, 82 fresh solid tumors from various sites were examined. Flow cytometric analysis was performed on cell suspensions isolated from the tumors, whereas IA was performed on touch imprints (IAT) and on cytosmears of the same cell suspension used for FCM (IAF). Comparison between IAT and IAF (IAT/IAF) assessed cell processing and sampling area differences, whereas IAF/FCM comparison assessed differences in apparatus and methodology as possible contributing factors to discordance. Furthermore, DNA histograms of IAT, IAF, and FCM were analyzed in the discordant cases to determine whether the discordance was due primarily to different cell populations detected (true discordance) or due to differences in histogram interpretation of the same cell populations (false discordance). IAT/IAF and IAF/FCM concordance rates (90% and 88%) were not significantly different from that of IAT/FCM (87%). False discordance accounted for most of the discordant cases in IAT/FCM comparison (six cases, 67%), whereas true discordance was seen in three cases. In all three truly discordant cases, the DNA-aneuploid cell populations detected only by IAT yet missed by FCM were also detected by IAF. This study demonstrates that discordance between IA and FCM is probably not due to cell loss during FCM cell processing or sampling area differences, but may be due to differences in assessing DNA ploidy in the interpretation of IA histograms and/or dilution of aneuploid cells by normal diploid cells in FCM.

Cellular proliferation markers in the evaluation of human cancer

Our knowledge of normal growth regulatory mechanisms, and of the disordered growth that occurs during tumorigenesis, has greatly increased during the past decade. In particular, these studies have emphasized the importance of chromosomal alterations, genetic heterogeneity, and cell proliferation in tumorigenesis and metastasis. As a result, the early diagnosis and treatment of malignancy appear to be even more important than previously recognized. Clinical studies of tumor proliferative activity were first conducted by thymidine-labeling techniques and more recently by flow cytometric analysis of DNA content. This information appears to provide important information that directly relates to tumor behavior and is of great prognostic significance in many tumors. In contrast, total nuclear DNA content, as measured by flow cytometry or image analysis, appears to be an "epi-phenomenon," and its clinical significance varies in different tumors. The potential clinical value of this research is enormous, because a rapid, accurate nonradioisotopic flow cytometric determination of tumor kinetic parameters, simultaneously with DNA content and surface antigen expression, would provide information of great importance for determining patient prognosis and making therapeutic decisions. Under these circumstances, analysis of DNA content and proliferative activity should be applied cautiously to patient care. Stringent quality control should be exercised, and the potential significance and limitations of these data should be clearly provided to the requesting physician. Most importantly, additional research during the next few years will provide answers to the many questions that remain about the appropriate clinical role of this information. As Stanbridge and Nowell stated at the conclusion of a recent Cold Spring Harbor meeting on the Origins of Human Cancer, "We have come a long way. . . and we have a very long way to go."

Assessment of coronary flow reserve using digital angiography before and after successful percutaneous transluminal coronary angioplasty

Important alterations of coronary blood flow and coronary flow reserve occur during percutaneous transluminal coronary angioplasty (PTCA). This study evaluated these alterations using digital subtraction angiography. Coronary flow reserve was determined before and after successful PTCA in 20 patients with 1-vessel coronary artery disease (CAD). Ten other patients with angiographically normal coronary arteries, normal exercise electrocardiographic responses and normal cardiac structure also were evaluated. Coronary flow reserve was calculated as the ratio of papavarine-induced hyperemic flow to basal flow. Flow reserve for the stenotic artery in patients who underwent PTCA was 1.6 +/- 0.2 (mean +/- standard error of the mean) (range 0.9 to 3.9, n = 20). After successful PTCA, flow reserve for this artery increased to 3.1 +/- 0.2 (range 1.7 to 5.2, n = 20) (p less than 0.0001 vs before PTCA). Flow reserve for adjacent nonstenotic, nondilated arteries was 2.6 +/- 0.2 (range 1.4 to 4.5, n = 13). Coronary flow reserve in the stenotic arteries before PTCA was far below normal. In addition, both successfully dilated arteries and nondilated, nonstenotic arteries in these patients with CAD had flow reserve values smaller than those in the patients with normal arteries (4.8 +/- 0.6, range 2.3 to 12.6, n =22) (p less than 0.01). These findings suggest that digital angiographic determinations of coronary flow reserve can reveal important alterations of individual artery vasodilatory capacity. The data suggest that although an epicardial coronary in a patient with CAD may appear angiographically normal, flow reserve remains impaired due to abnormalities as yet undefined.

Coronary flow reserve provided by sequential internal mammary artery grafts

Although internal mammary artery bypass grafts have a high patency rate, the adequacy of blood flow through such conduits, particularly if used sequentially, has been questioned. To evaluate this issue, coronary flow reserve was studied in 20 patients after coronary bypass surgery. Nine patients had sequential internal mammary grafts to the diagonal and left anterior descending coronary arteries; five had a single internal mammary graft to the left anterior descending artery and six had sequential saphenous vein grafts. Fifteen additional single vein grafts were also placed in these patients. Coronary flow reserve was measured after contrast-induced hyperemia by a digital subtraction angiographic technique an average of 25 days after surgery. There was no difference in coronary flow reserve between the proximal and distal anastomotic regions in either the sequential internal mammary graft group (2.14 +/- 0.50 versus 2.29 +/- 0.68, n = 8, p = NS) or the sequential vein group (1.77 +/- 0.49 versus 2.08 +/- 0.78, n = 6, p = NS). In addition, the flow reserve provided to either vascular bed of the sequential internal mammary graft was not different from that provided by a single internal mammary graft (1.64 +/- 0.39, n = 5), a single vein graft (1.95 +/- 0.95, n = 15) or nonstenotic native coronary arteries (2.04 +/- 0.87, n = 34). No cases of intracoronary steal were observed. Although some patients had unequal flow reserves between the proximal and distal anastomotic zones, these occurred in the setting of residual coronary stenoses distal to the site of graft insertion or prior myocardial infarction in the grafted distribution.(ABSTRACT TRUNCATED AT 250 WORDS)

Postradiation biopsy and histological effects in early-stage prostatic cancer treated with 125iodine implants

One hundred twenty patients with adenocarcinoma of the prostate were treated with 125I irradiation to the prostate and pelvic lymphadenectomy. Clinical stages were A-2 (13 pts), B-1 (34 pts), B-2 (49 pts), and C-1 (24 pts). The tumors were well differentiated in 44%, moderately differentiated in 39% and poorly differentiated in 17%. Nineteen of 22 patients with positive lymph nodes had either moderately or poorly differentiated tumors. A total radiation dosage between 15,000 and 24,000 rads per year were given to all patients. Seventy-six patients had been rebiopsied at 1 year, and 26 were positive for malignancy (34%). Thirty-eight patients had rebiopsy at 2 years, and 16 were positive (42%). Forty-four percent of the postradiation biopsies were of a different histologic grade from the primary lesion. Radiation injury was identified in 95% of the posttreatment biopsies and were moderate or severe in 71%. One hundred one patients are living from 1 to 9 years. Eight patients have died of metastatic carcinoma, and 11 have died of cardiovascular problems.

Coronary circulatory dynamics before and after successful coronary angioplasty

The hypothesis that successful percutaneous transluminal coronary angioplasty restores normal coronary circulatory dynamics was tested. Regional coronary blood flow, myocardial oxygen consumption and lactate extraction were measured at rest and during sustained pacing tachycardia. Before angioplasty, tachycardia stress was associated with an attenuated blood flow and oxygen consumption response and the induction of anaerobic metabolism. After successful angioplasty, blood flow and myocardial oxygen consumption increased during tachycardia stress and aerobic metabolism was sustained. The influence of basal alpha-adrenergic tone in modifying the time course of blood flow response to abrupt pacing was also assessed. Patients with normal coronary arteries demonstrated delayed increase in blood flow after alpha-adrenergic blockade. Alpha-adrenergic blockade did not affect the time course of blood flow response in patients with coronary artery disease, suggesting that alpha-adrenergic tone was chronically withdrawn. In patients undergoing coronary angioplasty, flow response before angioplasty was delayed, consistent with withdrawal of basal alpha-adrenergic tone. After coronary angioplasty, a brisk flow response was observed, indicating that basal alpha-adrenergic tone had been restored. Thus, successful coronary angioplasty restores the normal responsiveness of the coronary circulation.

Echocardiographic features of aortic ball valve prosthesis malfunction

A case of aortic ball valve prosthesis malfunction is described in which the poppet became alternately stuck in the open and closed position. The patient experienced chest pain followed by pulmonary edema and cardiac arrest. Malfunction of prosthetic valve was diagnosed on echocardiogram and cardiopulmonary resuscitation was carried out until a Bjork-Shiley valve could be inserted in place of the faulty prosthesis. At the time of the operation, poppet migration had occurred and the poppet could not be found. Subsequent Bjork-Shiley aortic valve prosthesis dysfunction was suggested by variation in the intensity of the aortic opening sound and in the duration of the systolic ejection period. Fluoroscopy revealed the missing poppet in the left ventricle. Following surgical removal of the poppet, "normal" Bjork-Shiley valve function was restored.

Clinical results of early stage prostatic cancer treated by pelvic lymphadenectomy and 125iodine implants

Eighty patients with clinically early stage adenocarcinoma of the prostate were treated with pelvic lymphadenectomy and interstitial implantation of 125iodine seeds. A new applicator that permits greater accuracy in spacing the seeds has been developed. Postoperative complications were minimal, with urinary irritability being the most common. Multiple transrectal needle biopsies were performed 12 and 18 months after treatment in 46 patients. The prostatic biopsies were negative for carcinoma in 61 per cent and positive in 39 per cent of the patients. Long-term followup is needed to correlate post-treatment biopsies with survival and to determine if patients with positive biopsies should receive further treatment.

Percutaneous vs surgical placement of intra-aortic balloon assist

Fifty-three patients required IABP over a one-year period. The type of insertion (percutaneous vs surgical) was used randomly. The hemodynamic effect, complication rate, and inability to insert the balloon were similar in both groups. Besides less trauma and cost-effectiveness, the most important advantage of percutaneous over surgical balloon insertion is shorter time interval between decision and insertion which thus allows faster stabilization of ischemic heart patients.

Evaluation of the role of coronary angioplasty in patients with unstable angina pectoris

Seventeen patients presenting with unstable angina pectoris underwent percutaneous transluminal coronary angioplasty (PTCA). Despite vigorous medical therapy, all patients were disabled with 10 experiencing refractory in-hospital angina. PTCA was judged successful in 13 patients and resulted in decreased coronary diameter narrowing from 80 +/- 16% to 34 +/- 13% and reduced transstenotic pressure gradient from 69 +/- 13 to 23 +/- 12 mm Hg. Regional coronary blood flow (CBF) and myocardial metabolism were assessed at rest and during pacing tachycardia in six patients with left anterior descending coronary stenosis. Prior to PTCA, neither regional CBF increased nor coronary vascular resistance declined during rapid pacing; myocardial lactate extraction fell, indicating a shift from aerobic to anerobic metabolism. Following PTCA, however, rapid pacing resulted in increased regional CBF, decreased coronary vascular resistance, and preservation of aerobic metabolism. Following PTCA, successfully dilated patients demonstrated marked relief of angina symptoms, increase in functional capacity, and objective exercise ECG and thallium scintigraphic evidence of relief of previously ischemic myocardium. This investigation demonstrates that PTCA, when combined with medical therapy, can be performed safely and successfully in selected patients who present with otherwise refractory unstable angina, and indicates the procedure deserves further study as a therapeutic alternative in this condition.

Restoration of normal coronary hemodynamics and myocardial metabolism after percutaneous transluminal coronary angioplasty

Regional coronary blood flow and myocardial metabolism were evaluated in a patient who underwent percutaneous transluminal coronary angioplasty (PTCA). Angioplasty increased coronary luminal diameter and reduced trans-stenotic gradient. Before PTCA, angina pectoris developed during sustained rapid atrial pacing and was associated with abnormal lactate metabolism and a mild increase in coronary flow and myocardial oxygen consumption. After PTCA, angina was absent during pacing and lactate extraction was preserved. Coronary flow and oxygen consumption were increased to a greater degree than before PTCA. The temporal response of changes in coronary blood flow due to an abrupt increase in heart rate was also evaluated. Floow reached peak value more rapidly after PTCA. These observations suggest that PTCA may result in improved regional coronary blood flow and restoration of normal flow regulatory mechanism and myocardial metabolism.

Complete heart block as a cause of syncope in asymmetric septal hypertrophy

This case report presents a young adult with asymmetric septal hypertrophy (ASH) and syncope. Infranodal complete heart block was demonstrated as his cause for syncope. Therapy consisted of implantation of a A-V sequential pacemaker. Cardiac output determinations and systolic time intervals demonstrated the beneficial effects of properly timed atrial contractions.

Further studies on the activation of microsomal (Na+ + k+)-atpase by a leukocytic product

Previous studies showed that microsomal (Na+ + K+)ATPase (ATP phosphohydrolase, EC 3.6.1.3) is activated by a proteinaeous material released by polymorphonuclear leukocytes. Investigations on the mode of action of the activator have been conducted by the siolation of 32P-labeled phosphoenzyme intermediates formed in the reaction of ATP and (Na+ + K)-ATPase, which has been postulated to occur through the formation and hydrolysis of acyl phosphate intermediates. The activator caused a concentration-dependent decrease in the recovery of phosphoenzyme intermediates that was not quantitatively altered by the Na+ or K+ concentration of the reaction mixture of by the presence of 1 mM oubain. A decline in phosphoenzyme intermediate recovery was promoted by the addition of the activator to preformed phosphoenzyme intermediates but not by activator that had been pretreated with protease or phenol. In addition, the activator caused a concentration-dependent stimulation of the p-nitrophenyl phosphatase and acetyl phosphatase activities of microsomal (Na+ + K+)-ATPase. It was proposed that the activator stimulates the dephosphorylation step of the (Na+ + K+)-ATPase reaction sequence.

Activation of rabbit brain microsomal (Na+ plus K+)-dependent ATPase by a leukocytic product

The properties of a (Na+ plus K+)-dependent ATPase (ATP phosphohydrolase, EC 3.6.1.3) activator contained in leukocytic extracts was investigated. Intact polymorphonuclear leukocytes release the activator in a time- and temperature-dependent process. It is non-dialyzable through cellophane; inactivated by protease, trypsin, or phenol; contains essential sulfhydryl groups; and is heat and acid labile. Treatment of ATPase with the activator and subsequent removable of the activator from mixtures did not reverse the ATPase activation.