Predicting Vibrio cholerae infection and symptomatic disease: a systems serology study

BACKGROUND

Vibriocidal antibodies are currently the best characterised correlate of protection against cholera and are used to gauge immunogenicity in vaccine trials. Although other circulating antibody responses have been associated with a decreased risk of infection, the correlates of protection against cholera have not been comprehensively compared. We aimed to analyse antibody-mediated correlates of protection from both V cholerae infection and cholera-related diarrhoea.

METHODS

We conducted a systems serology study that analysed 58 serum antibody biomarkers as correlates of protection against V cholerae O1 infection or diarrhoea. We used serum samples from two cohorts: household contacts of people with confirmed cholera in Dhaka, Bangladesh, and cholera-naive volunteers who were recruited at three centres in the USA, vaccinated with a single dose of CVD 103-HgR live oral cholera vaccine, and then challenged with V cholerae O1 El Tor Inaba strain N16961. We measured antigen-specific immunoglobulin responses against antigens using a customised Luminex assay and used conditional random forest models to examine which baseline biomarkers were most important for classifying individuals who went on to develop infection versus those who remained uninfected or asymptomatic. V cholerae infection was defined as having a positive stool culture result on days 2-7 or day 30 after enrolment of the household's index cholera case and, in the vaccine challenge cohort, was the development of symptomatic diarrhoea (defined as two or more loose stools of ≥200 mL each, or a single loose stool of ≥300 mL over a 48-h period).

FINDINGS

In the household contact cohort (261 participants from 180 households), 20 (34%) of the 58 studied biomarkers were associated with protection against V cholerae infection. We identified serum antibody-dependent complement deposition targeting the O1 antigen as the most predictive correlate of protection from infection in the household contacts, whereas vibriocidal antibody titres ranked lower. A five-biomarker model predicted protection from V cholerae infection with a cross-validated area under the curve (cvAUC) of 79% (95% CI 73-85). This model also predicted protection against diarrhoea in unvaccinated volunteers challenged with V cholerae O1 after vaccination (n=67; area under the curve [AUC] 77%, 95% CI 64-90). Although a different five-biomarker model best predicted protection from the development of cholera diarrhoea in the challenged vaccinees (cvAUC 78%, 95% CI 66-91), this model did poorly at predicting protection against infection in the household contacts (AUC 60%, 52-67).

INTERPRETATION

Several biomarkers predict protection better than vibriocidal titres. A model based on protection against infection among household contacts was predictive of protection against both infection and diarrhoeal illness in challenged vaccinees, suggesting that models based on observed conditions in a cholera-endemic population might be more likely to identify broadly applicable correlates of protection than models trained on single experimental settings.

FUNDING

National Institute of Allergy and Infectious Diseases and National Institute of Child Health and Human Development, National Institutes of Health.

The VSV matrix protein inhibits NF-κB and the interferon response independently in mouse L929 cells

The matrix (M) protein of vesicular stomatitis virus (VSV) plays a key role in immune evasion. While VSV has been thought to suppress the interferon (IFN) response primarily by inhibiting host cell transcription and translation, our recent findings indicate that the M protein also targets NF-κB activation. Therefore, the M protein may utilize two distinct mechanisms to limit expression of antiviral genes, inhibiting both host gene expression and NF-κB activation. Here we characterize a recently reported mutation in the M protein [M(D52G)] of VSV isolate 22-20, which suppressed IFN mRNA and protein production despite activating NF-κB. 22-20 inhibited reporter gene expression from multiple promoters, suggesting that 22-20 suppressed the IFN response via M-mediated inhibition of host cell transcription. We propose that suppression of the IFN response and regulation of NF-κB are independent, genetically separable functions of the VSV M protein.

Vibriocidal Titer and Protection From Cholera in Children

Background

Vibrio cholerae, the causative agent of cholera, is a major cause of diarrhea worldwide. Children under the age of 5 have the highest disease burden of cholera. Vibriocidal antibody responses following natural infection and oral cholera vaccination (OCV) are associated with protective immunity, but whether this holds uniformly true in young children is not known.

Methods

Household contacts of cholera patients are at high risk of V cholerae infection. We measured the association between baseline vibriocidal titer and the subsequent risk of infection in 50 household contacts <5 years old, 228 contacts 5–15 years old, and 548 contacts 16–70 years old in Bangladesh to determine whether vibriocidal antibody responses predict protection from V cholerae infection equally in all age groups.

Results

We found that the vibriocidal titer predicted protection similarly in young children and other age strata. There was no interaction between age and vibriocidal titer. Mean baseline serum vibriocidal titers were higher in individuals in all age groups who remained uninfected compared with those who developed V cholerae infection during the follow-up period.

Conclusions

After OCV, children have comparable vibriocidal responses to adults but a shorter duration and magnitude of protection compared with adults. In persons exposed to natural infection, we found that the vibriocidal titer predicts protection uniformly in all age groups. The vibriocidal titer may not be the optimal marker to demonstrate protection after OCV, and improved markers for estimating OCV efficacy in children are needed.

Tibia Bone Microvascular Flow Dynamics as Compared to Anterior Tibial Artery Flow During Body Tilt

BACKGROUND

We compared microvascular and macrovascular blood flows of the tibia and anterior tibial artery during graded whole-body tilt. We hypothesized equal responses for bone microvascular and macrovascular blood flows during varying angles of tilt.

METHODS

There were 18 volunteers who were randomly positioned in the following postures: supine, 15° head-up tilt, 6° head-up tilt, 6° head-down tilt, and 15° head-down tilt using an inversion table with reference to seated posture (baseline control). Ultrasonography quantified anterior tibial arterial diameter and peak systolic velocity, enabling calculation of macrovascular blood flow to the tibia. Tibial bone microvascular blood flow was measured noninvasively using photoplethysmography in the same leg.

RESULTS

Transitioning from a seated position to a supine position, macrovascular blood flow did not change significantly (1.81 ± 1.18 to 2.80 ± 1.74cm 3 · s-1). However, bone microvascular flow increased significantly (0.36 ± 0.23 to 1.11 ± 0.79 V) from the seated to the supine position. Transitioning from a seated posture to 15° head-down tilt, both arterial macrovascular and bone microvascular flows increased significantly (1.81 ± 1.18 to 3.32 ± 2.08 cm3 · s-1 and 0.36 ± 0.23 V to 2.99 ± 2.71 V, respectively). The normalized flow for microvascular blood flow as a function of body tilt was significantly greater than that for macrovascular blood flow at 6° and 15° head-down tilt.

DISCUSSION

These data do not support our hypothesis that bone microvascular flow and arterial macrovascular flow share equal responses to altered body tilt. Therefore, for a given decrease in local blood pressure in the leg with head-down body tilt, the magnitude of increase in blood flow is greater in the microcirculation as compared to the feeding artery.Becker RL, Siamwala JH, Macias BR, Hargens AR. Tibia bone microvascular flow dynamics as compared to anterior tibial artery flow during body tilt. Aerosp Med Hum Perform. 2018; 89(4):357-364.

Aging Decreases Hand Volume Expansion with Water Immersion

Hands may show early signs of aging with altered skin texture, skin permeability and vascular properties. In clinics, a hand volumeter is used to measure swelling of hands due to edema, carpal tunnel syndrome or drug interventions. The hand volume measurements are generally taken without taking age into consideration. We hypothesized that age affects hand volumeter measurements and that the younger age group (≤40 years) records a greater change in hand volume as compared to the older group (>40 years). Four volumetric measurements were taken at 5 min intervals during 20 min of water immersion using a clinically-approved hand volumeter. After 20 min of immersion, the hand volume changes of the younger age group were significantly higher than the older age group (p < 0.001). Specifically, the right-hand volume of the younger age group (≤40 years, n = 30) increased by 4.3 ± 2%, and the left hand increased by 3.4 ± 2.1%. Conversely, the right-hand volume of the older age group (>40 years, n = 10) increased by 2.2 ± 2.0%, and the left hand decreased by 0.6 ± 2.4% after 20 min of water immersion. The data are presented as Mean ± SD. Hand volume changes were not correlated with body mass index (BMI) or gender, and furthermore, neither of these two variables affected the relationship between age and hand volume changes with water immersion. We conclude that the younger age group has a higher increase in hand volume with water immersion as compared to the older age group.

A national treasure goes online: the Armed Forces Institute of Pathology

With the advent of the 21st century, the Armed Forces Institute of Pathology is delivering online medical consultation to the global health care community. By incorporating widely available open system technology into the paradigm of telepathology, the AFIP is providing world class expertise in pathology and access to a wealth of information for physicians and the general public. The national treasure known as the Armed Forces Institute of Pathology has more than a glorious history; it has a pretty bright future, too.

Three-dimensional modeling of renal glomerular capillary networks

OBJECTIVE

To quantitatively characterize three-dimensional (3D) vascular patterns based on the path length distribution in networks.

STUDY DESIGN

Volume data were stacks of confocal fluorescence images of renal glomeruli, obtained using a confocal laser scanning microscope and spanning 60-130 microns in the z axis. After manual editing to remove nonglomerular components, transverse sections of glomerular capillary lumens were segmented automatically using two-dimensional morphologic filters. The center points and the overlap (between adjacent sections) of lumens segmented in the x vs. y plane were used to derive a graph (i.e., a multiply connected network) for each glomerulus. The average degree and the distance between connected nodes were used to derive the number of graph edges and the overall length of the capillary network.

RESULTS

Renderings of the 3D reconstructions demonstrated well the lobular structure of the glomerular tufts. Mean capillary length ranged from 53 to 180 microns in 10 glomeruli. Total capillary length ranged from 3,500 to 9,500 microns (mean 5,833).

CONCLUSION

Structural measurements based on confocal data require less effort than do measurements based on serial sections and make detailed study of diseased glomerular populations practical.

Uveal melanoma: the importance of large nucleoli in predicting patient outcome--an automated image analysis study

BACKGROUND

Automated image capture and analysis (AICA) has not previously been used to measure the size of nucleoli in uveal melanoma. In this study, the measurements were tested for a possible association with patient outcome.

METHODS

Sections from 63 uveal melanomas were stained using the silver stain for nucleolar organizing regions (AgNOR). AICA was used to measure the following five nucleolar features in ten microscopic fields of the tumor: area, circularity, maximum diameter, width, and length of the perimeter. For each tumor, the mean and standard deviation of each of the features were calculated based on all the nucleoli and on subsets of nucleoli with larger areas. For the five nucleolar features the mean of the largest value (MLV) in each of the ten fields was calculated. For comparison, a related visually measured nucleolar feature (MLN) was obtained from hematoxylin and eosin stained sections using a filar micrometer.

RESULTS

Thirty-four patients died with metastatic disease and 29 patients survived at least 5 years without metastasis. A greater proportion of nucleoli larger than 3 mm2 in greatest dimension were from patients who died of their disease. The means of the nucleolar features were less significant outcome discriminators than the standard deviations. Means and standard deviations based on subgroups of nucleoli larger than 3 or 3.5 mm2 in greatest dimension were better discriminators. The MLVs were as effective discriminators as the corresponding standard deviations of the larger nucleoli and were better discriminators than MLN.

CONCLUSIONS

AICA of AgNOR stained sections of uveal melanoma provides an excellent method for predicting the outcome of patients with uveal melanoma.

Differential diagnosis of Hürthle cell neoplasms on fine needle aspirates. Can we do any better with morphometry?

OBJECTIVE

To determine the value of computerized interactive morphometry in the preoperative prediction of malignancy in fine needle aspirates of Hürthle cell neoplasms.

STUDY DESIGN

Alcohol-fixed, Papanicolaou-stained fine needle aspiration smears of histologically proven Hürthle cell adenomas (HCA) (n = 10) and Hürthle cell carcinomas (HCC) (n = 9) were studied by interactive computerized morphometry. The measured features included the areas, perimeters and shape factors of individual cells, nuclei and nucleoli; the nucleocytoplasmic and nucleolonuclear ratios; and the eccentricities of nuclei and nucleoli.

RESULTS

Only nucleolar features showed statistically significant differences between HCA and HCC. These features were the nucleolar area and its standard deviation, the nucleolar form factor and circularity, and the nucleolonuclear ratio. The most effective, albeit imperfect, discrimination was achieved by the nucleolar form factor.

CONCLUSION

Nucleolar features, such as size, variation in size and roundness, may be more effective than cellular or nuclear features in differentiating between HCA and HCC in fine needle aspiration smears.

Enumeration of interphase chromosomes. Comparison of visual in situ hybridization and confocal fluorescence in situ hybridization

OBJECTIVE

To compare two visual enumeration methods to determine whether the confocal approach yielded better counts of chromosome-specific hybridization sites.

STUDY DESIGN

Brightfield microscopy was used to count in situ hybridization (ISH) sites in 4-microns tissue sections. Confocal microscopy was used to collect three-dimensional (3D) data sets from fluorescence in situ hybridization (FISH) preparations made with sections of various thicknesses. Analysis of the confocal images relied on custom-built interactive visualization software.

RESULTS

The confocal method yielded higher average counts of hybridization sites per nucleus due to fewer truncated nuclei in thicker sections and to visual exclusion of the truncated nuclei that remained. Optimal section thickness was 8-12 microns. Limited penetration by FISH reagents restricted the use of thicker sections.

CONCLUSION

Analysis of intact nuclei visualized in three dimensions was more sensitive in demonstrating high centromere number than was brightfield ISH analysis of 4-microns sections. Improvements in semiautomated interactive software may make the confocal approach practical for accurate evaluation of chromosome number in precise histologic contexts.

Applications of neural networks in histopathology

ANN methods are one of several nonparametric approaches to classification. They are based on an adaptive, connectionist model of information storage and processing and learn by example rather than explicitly programmed classification rules. Their greatest strength probably is the ease with which they capture nonlinear and interactive feature effects during training, though at a higher risk of overtraining then is found with traditional classifiers. ANN can be used to process image data, but so far not to classify complex natural images directly. Instead, image dimensionality is reduced to a set of extracted features for ANN input. ANN finds growing use in time series signal processing and radiology. In anatomic pathology, ANN pilot studies are published for tumor classification. Pap smear analysis, and chromosome identification. Each application requires proper sampling technique, minimising bias in training and testing to assure the ANN classifier will perform prospectively as expected. With careful arrangement of input features, ANN can be used for prognostic as well as diagnostic models.

Adult medulloblastoma: review of 13 cases with emphasis on MRI

Medulloblastomas are generally associated with childhood, but 14-30% occur in adults, accounting for 1% of adult central nervous system tumors. While approximately one third of adult medulloblastomas present as vermian tumors similar to those seen in childhood, the majority differ substantially from the childhood variety. In this series of 13 patients, 5 had lateral, seemingly extra-axial masses in the cerebellopontine angle or at the tentorium, simulating meningiomas or acoustic neuromas, but angiographic hypovascularity in 2 of the latter suggested a diagnosis other than meningioma. Of 4 paramedian tumors, 3 diffusely infiltrated the cerebellar white matter, showed little or no gadolinium enhancement and were not associated with hydrocephalus. Hydrocephalus was present in less than half of our patients; in childhood the reported incidence is 85-100%. A possible association with pregnancy was noted.

Computerized nuclear morphometry and survival in renal cell carcinoma: comparison with other prognostic indicators

Morphometric nuclear parameters were compared with patient survival for a series of 174 renal cell carcinomas (RCC) collected over a 30 yr period. Stepdown regression showed long diameter, average feret diameter, form factor and the ratio of average feret diameter to equivalent diameter to be significantly associated with survival. Nuclear area, nuclear perimeter, equivalent diameter, ratio of long diameter to average feret diameter and coefficients of variation of nuclear area and nuclear perimeter were not significantly correlated with survival. All parameters were correlated with a 3 division nuclear grading classification using analysis of variance. Multivariate analysis showed nuclear form factor, tumor stage, silver staining nucleolar organizer region numbers and proliferating cell nuclear antigen expression to be independently associated with survival. The results of this study indicate that form factor is the most discriminate morphometric parameter for RCC, providing survival data additional to that derived from tumor staging and from markers of tumor proliferation.

An alternative health-care reimbursement system--application of arthroscopy and financial warranty: results of a 2-year pilot study

The results of a 2-year pilot study on an alternative health-care reimbursement system are presented. This innovative system includes a 2-year warranty by the providers to protect the insured and insurer from additional expenses. It is based on the advantages of arthroscopy. This system provided access, choice, and affordability for 111 patients from a managed care environment who were predetermined to be orthopedic surgical candidates. The unique features included unlimited free consultations and office radiographs. Payment was made only if a patient had surgery. This single fee included all related physician and hospital charges for surgery and any subsequent service for the next 2 years under the warranty. The profit margin for the providers was based on the application of arthroscopy, which anticipated reduction in the customary hospitalization. Accountability was provided by reporting of surgical indications and incidence. The surgical incidence of 42% was less than what was projected. The health maintenance organization insurer saved in excess of $125,000.00. Both the hospital and the surgeon earned more than under existing reimbursement systems.

Computer-assisted image classification: use of neural networks in anatomic pathology

Artificial neural networks (ANN) implemented on digital computers have received much attention for interpretation of images in pathology and cytology. Most such images are too complex for current ANN to interpret directly; instead, ANN usually classify the images according to numeric features extracted from them. In experiments on three distinct image classification problems, ANN classifiers performed as well or better than multivariate linear discriminant analysis (a traditional parametric statistical classifier). ANN empirically define non-linear multivariate decision boundaries, and can combine non-contiguous feature areas in mapping a classification. However, many training cases are required in order to map complex area boundaries precisely and with a low risk of 'overtraining.' Careful problem selection and attention to data dimensionality and format are important for efficient ANN use.

Domestic partner abuse treatment programs and cultural competence: the results of a national survey

Partner abuse literature reveals that treatment is less effective with minorities than with their white counterparts. Our survey of partner abuse programs (N = 142) indicates that, for the most part, little or no special effort is being made to understand or accommodate the needs of minority populations. This colorblind approach lacks the effectiveness of a culturally competent approach, which fosters an environment that helps minority groups succeed in treatment. Do partner abuse programs make efforts to be culturally competent? The major characteristics of an organizational transformation towards cultural competence occur when these programs do the following: (a) network with the minority community, (b) locate outside consultants with expertise in working with minority clients, (c) obtain information concerning service delivery and programming for minority clients, and (d) have at least one bilingual counselor. These four characteristics accounted for .58 of the variance in the minority-focused activities.

Flow cytometric and quantitative histological parameters to predict occult disease in clinical stage I nonseminomatous testicular germ cell tumors

The goal of this study was to determine if deoxyribonucleic acid (DNA) flow cytometric and quantitative histological parameters could predict occult metastases in clinical stage I nonseminomatous testicular cancer. Archival paraffin primary tumor tissue was available from 36 clinical stage I nonseminomatous germ cell testicular cancer patients who all had retroperitoneal lymphadenectomy and followup defining 2 groups: pathological stage I (23) and occult pathological stage II (13). Archival blocks were microdissected and individual histological components were subjected to flow cytometry. In addition, the primary histology was reevaluated for vascular invasion and per cent composition of histological components of embryonal carcinoma and other histologies. For flow cytometry parameters, no tumor was uniformly diploid, and the DNA index and per cent S phase cells were not useful in differentiating stages. Although mean per cent S phase for the aneuploid cell population and proliferative index were significantly greater for stage II cases by univariate logistic regression analysis, they are approximately 70% accurate in predicting occult disease as single tests and were not significant by multivariate analysis. The calculation of per cent embryonal carcinoma was also significantly greater in stage II cancer by univariate logistic regression testing and remained significant by multivariate analysis. Vascular invasion was marginally predictive of occult disease but was also not significant by multivariate analysis. Calculating the percentage of embryonal carcinoma of a primary testicular tumor may be a useful method to assess clinical stage I cancer patients for risk of occult disease. A larger study is needed to confirm the importance of per cent embryonal carcinoma and to clarify further if flow cytometry in combination is useful.

Use of remote video microscopy (telepathology) as an adjunct to neurosurgical frozen section consultation

We investigated the use of remote video microscopy (telepathology) to assist in the diagnosis of 52 neurosurgical frozen section cases. The TelMed system (Discovery Medical Systems, Overland Park, KS), in which the referring pathologist selects appropriate fields for transmission to the consultant, was used for the study. There was a high degree of concordance between the diagnosis rendered on the basis of transmitted video images and that rendered on the basis of direct evaluation of frozen sections; however, in seven cases there was substantial disagreement. Remote evaluation was associated with a more rapid consultation from the standpoint of the consultant, who spent approximately 2 minutes less per case when using remote microscopy; this was achieved at the expense of considerably greater effort on the part of the referring pathologist, who spent approximately 16 minutes per case selecting an average of 4.5 images for transmission to the consultant. The use of remote video microscopy for pathology consultation is associated with a complex series of tradeoffs involving cost, information loss, and timeliness of consultation.

Standardization and quality control of quantitative microscopy in pathology

Standardization and quality control of quantitative microscopy techniques are distinct but related concerns. The first deals with the great variety of quantitative methods, measured features, and even response variables used in investigation of biological or clinical processes. The latter deals with reproducibility of results from those investigations across time and test performance sites. Though distinct, efforts for standardization and quality control are inherently interactive. Consensus on standard methods, instrumentation, and data analysis is hard to achieve in fields developing as rapidly as quantitative microscopy. Consensus is possible, however, on the issues that affect test performance and interpretation. For example, issues of specimen type, fixation, processing, and staining affect image cytometry just as they do flow cytometry. Raw data acquisition issues include area sampling rules and fidelity of optical and sensor systems (light wavelength, glare/stray light, lens aberrations, numerical aperture, depth of focus, scan precision, pixel spacing and depth, sensor linearity, and stability). Intermediate data issues are primarily related to image foreground/background segmentation techniques--automated versus manual, object-specific versus field-based. Data reduction and interpretation procedures also provide many roads for divergence from uniformity. Each of these issues must be considered in terms of its effect on comparability and utility of quantitative microscopy results. Quality control for quantitative microscopy is as important as standardization for its use in research programs and with clinical specimens. The sine qua non of quality control is comparison of experimental results against a known "correct" value to estimate accuracy, and against other experimental results to estimate precision.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphometric distinction of sclerosing adenosis from tubular carcinoma of the breast

Objective features have been identified that assist in distinguishing sclerosing adenosis from tubular carcinoma of the breast. Hematoxylin and eosin stained paraffin sections of 18 sclerosing adenoses and 18 tubular carcinomas were studied using a TAS Plus image analysis system. Histological measurements from lumens and glands included stereologic features of architecture and morphometry of size and shape (the latter by Fourier coefficients). Cytological measurements included nuclear area, perimeter, diameter and formfactor. Initial analysis suggested utility for several individual features. However, after a modified Bonferroni procedure only two of the features were statistically significant, i.e. the coefficient of variation of luminal form factor and the surface density of glands. Multivariate discriminant analysis using these two variables correctly classified 86% of the cases, with three adenoses and two carcinomas misclassified. Validity of the discriminant rules was supported by classification using measurements from a separate, independent set of cases (ten sclerosing adenoses and nine tubular carcinomas). The classification function computed from the first set misclassified only one case from the second set, a tubular carcinoma, leaving 95% of the cases successfully categorized. Chi square test for 2 x 2 contingency tables gave a p-value < 0.001 for both sets of cases. The results suggest that morphometric features are helpful in distinguishing tubular carcinoma from sclerosing adenosis and point out the need for conservative analysis of high-dimensional data sets.

Computer-assisted image interpretation: use of a neural network to differentiate tubular carcinoma from sclerosing adenosis

Measurement of nuclear and glandular size and shape features was carried out on 18 cases of sclerosing adenosis and 18 cases of tubular carcinoma. Modified Bonferroni analysis showed that glandular surface density and the coefficient of variation of luminal form factor were significant in discriminating between these two lesions. These two histologic features, together with the diagnosis, were used to train a neural network implementing a backpropagation algorithm. Following training, the network correctly classified 33 of the 36 cases in the training set (92%). Furthermore, the network correctly classified 19 of 19 cases in a test set consisting of cases that were not used to train the network. These results suggest that neural networks may be useful to assist in the differential diagnosis of histologically similar lesions.

Toxicosis in horses after ingestion of hoary alyssum

Fever, limb edema, and laminitis were observed in horses 18 to 36 hours after they consumed hoary alyssum (Berteroa incana) under field and experimental conditions. Clinical signs were not observed in all horses that had ingested the plant. Diagnosis in the field cases was limited to observation of clinical signs and evidence of plant ingestion in hay or on pasture. In most cases, clinical remission was observed 2 to 4 days after empirical treatment, removal of the plant source, or both.

Prediction of prognosis in untreated stage A2 prostatic carcinoma

Carcinoma is found unexpectedly in approximately 10% or more of the 400,000 prostatectomies performed annually in the United States. Patients with Stage A2 carcinoma die of their disease in only 35% of the cases. To alter the course of disease in these patients, 65% of Stage A2 patients may be treated unnecessarily by radical prostatectomy, radiation therapy, or hormonal therapy. An accurate method to predict the outcome of patients with Stage A2 carcinoma is needed. Histologic sections from 18 patients with Stage A2 prostatic carcinoma followed without further treatment until progression, or followed without progression, were evaluated by several investigators who did not have knowledge of patient outcomes and who employed standard pathologic grading systems as well as morphometric, cytophotometric, flow cytometric, and immunohistochemical techniques. Outcome was predicted correctly by random sampled absolute (17 of 18 cases) and relative (16 of 18) nuclear roundness factor (NRF), tumor volume expressed as percent of specimen (13 of 16), primary (13 of 18), secondary (14 of 18), sum (15 of 18), and worse (14 of 18) Gleason grades and prostate-specific antigen immunohistochemical findings (13 of 18) that produced statistically significant separation of the two groups. Significant separation was not obtained with Mostofi's pattern, nuclear, sum, and worse grades, Johns Hopkins' grade, absolute tumor volume, nuclear DNA content measured by image cytophotometric study of Feulgen-stained histologic sections and flow cytometric study of propidium iodide-labeled suspensions of nuclei obtained from paraffin blocks, nonrandom sampled NRF of worse and most prevalent neoplastic areas, and prostatic acid phosphatase and peanut agglutinin immunohistochemical study. NRF measured by a random technique best predicted outcome in these patients with A2 prostatic carcinoma and should be evaluated prospectively as a means for selecting patients who require therapy.

Antibody responses to Haemophilus influenzae type B vaccines in men with human immunodeficiency virus infection

BACKGROUND

Persons with human immunodeficiency virus (HIV) infection are at increased risk for serious infections caused by Haemophilus influenzae, yet there are few data on their antibody responses to the H. influenzae type b vaccines.

METHODS

We evaluated antibody responses in 248 men who were randomly assigned to receive a single dose of either the H. influenzae type b polysaccharide (PRP) vaccine or the polysaccharide-mutant diphtheria toxoid conjugate vaccine (PRP-CRM). The subjects were stratified into four groups: seronegative men (67 subjects), men with asymptomatic HIV infection (79), men with symptomatic HIV infection (47), and men with the acquired immunodeficiency syndrome (AIDS) (55).

RESULTS

Before immunization, the subjects with AIDS had the lowest PRP-antibody titers; 40 percent had titers below the putative protective level (less than 0.15 micrograms per milliliter). In the seronegative subjects, those with asymptomatic HIV infection, and those with symptomatic HIV infection, the PRP-CRM vaccine led to a threefold greater increase in geometric mean antibody titers than did the PRP vaccine (P less than 0.01). However, the subjects with AIDS had a greater antibody response to the PRP vaccine. The antibody response of HIV-seropositive men to the PRP-CRM vaccine correlated significantly with the number of CD4 lymphocytes (r = 0.47, P less than 0.0001, as compared with r = -0.01 for the PRP vaccine). In these HIV-infected men, both vaccines elicited the dominant anti-PRP idiotype described previously in populations not infected with HIV.

CONCLUSIONS

Immunization with the PRP-CRM conjugate vaccine early in the course of HIV infection is likely to confer protection against disease caused by H. influenzae type b.

Cytometry and morphometry of malignant fibrous histiocytoma of the extremities. Prediction of metastasis and mortality

Flow cytometry and nuclear morphometry were compared with traditional pathologic grading techniques for predicting the course of malignant fibrous histiocytoma of the extremities. Clinical, pathologic, and flow/morphometric variables from 53 cases were tested by Cox regression for prediction of distant recurrence and mortality. Tumor grading based on extent of tumor necrosis was a significant predictor for both disease-free survival (p = .014) and overall survival (p = .003). The fraction of nuclei in the S + G2M segment of DNA histograms was significant for disease-free survival (p = .007), and remained significant (p = .033) in a joint Cox model with necrosis-based grade (p = .004 for the bivariate model). Relative risk for recurrence varied nearly 10x between the 10th and 90th percentiles of grade and (S + G2M)1/2. Overall survival was predicted by a nuclear shape feature termed "R" (p = .000008), the casewise difference (residual) between expected and observed nuclear perimeter as a function of average Feret diameter. In a bivariate Cox model, relative risk of mortality varied 35x between the 10th and 90th percentiles of grade and R. Cytometric and morphometric data contain information about recurrence-free and overall survival beyond that available from more usual clinical and pathologic features. It seems likely that nuclear morphometry, in particular, will prove to be a useful aid for estimating the prognosis of patients with malignant fibrous histiocytoma of the extremities.

A comparative study of quantitative stains for DNA in image cytometry

In this study we examined the reproducibility of several stains used to measure nuclear DNA by image cytometry. The specimens were touch preparations of liver and testis from mouse and liver, intestine and brain from rat, fixed in either neutral formalin or Carnoy's solution. The tested stains included four Feulgen methods (pararosaniline, azure-A, thionin and acriflavine), the gallocyanine-chromalum stain and two fluorescent stains (acridine orange and propidium iodide). Absorbance measurements employed a video image analysis system; fluorescence measurements were from a scanning microspectrophotometer. The acriflavine-Feulgen stain was analyzed for both absorbance and fluorescence. All seven stains were quantitative for DNA and gave reproducible results. The absorbance measurements had a lower coefficient of variation (CV) than the fluorescence values. In a nested analysis of variance of the pararosaniline Feulgen stains, cell-to-cell variability accounted for 67% of the total variance; slide-to-slide, 9%; and batch-to-batch, 24%. These values did not change significantly when the staining was performed in an automatic staining machine. For DNA analysis using image cytometry, we conclude that the Feulgen staining technique is the most useful. In particular, acriflavine-Feulgen-stained cells fixed in Carnoy's fluid give the least variation between measurement values and the most accurate ratios between the separate ploidy groups. For fluorescence cytometry we recommend Carnoy's fixation and the acriflavine-Feulgen stain because of its narrow CV as compared to acridine orange and propidium iodide.

DNA analysis of cardiac myxomas: flow cytometry and image analysis

Cardiac myxoma is the most common primary tumor of heart, but there is a longstanding controversy over whether it is a true neoplasm or a reactive lesion. We analyzed 24 cardiac myxomas from 22 patients: 22 by DNA flow cytometry and five by image analysis. Two myxomas were aneuploid; one of those analyzed by flow cytometry, and the other by image analysis. Proliferative fractions (S + G2/M) were high in three tumors from patients with multiple myxomas (mean, 15.9%; SD, 4.0%) as compared with 12 solitary uncomplicated myxomas (mean, 7.7%; SD, 6.0%). S-phase and proliferative fractions were low in embolic, recurrent, and solitary myxomas. The presence of aneuploidy in some myxomas supports a neoplastic origin for this tumor.

A comparative study of morphometric measurements of nucleoli in uveal melanomas from electron micrographs and plastic-embedded and paraffin-embedded sections

Morphometric measurements of nucleoli were done on uveal melanomas from surviving and nonsurviving patients. The melanomas were embedded in paraffin and plastic, and measurement data from Papanicolaou-stained paraffin-embedded sections, toluidine blue-stained plastic-embedded sections and scanning transmission electron micrographs (STEM) of plastic-embedded sections were compared. The results showed that one parameter, the coefficient of variation (CV) of nucleolar area, correctly classified 80% of the cases as to survival when plastic-embedded material was used and 70% of the cases when paraffin-embedded material or STEM micrographs were used. The inverse standard deviation of the nucleolar area was a better predictor of outcome than was the CV of nucleolar area only in the paraffin-embedded sections. The nucleolar measurements were most easily and rapidly performed in the plastic-embedded sections.

A comparative morphometric and cytophotometric study of endometrial hyperplasia, atypical hyperplasia, and endometrial carcinoma

The DNA content and nuclear measurements of five groups of endometrial proliferations--proliferative endometrium (PE), simple hyperplasia (SH), atypical hyperplasia (AH), well-differentiated carcinoma (WDC), and poorly differentiated carcinoma (PDC)--were compared using 14 descriptors in a stepwise discriminant analysis. Classification using the discriminant rules agreed with the pathologic interpretation for 78% of the specimens. All PEs were assigned to the correct group, and 97% of benign endometria and carcinomas were correctly classified as benign or malignant. Only two of 39 hyperplasias (5%) were misclassified as malignant, and only one of 36 carcinomas was classified as benign. In the difficult distinction between AH and WDC, using all descriptors for the five groups, only 68% of the AH and 60% of the WDC classifications were in agreement with the pathologist of record. However, when discriminant rules addressing only AH and WDC were used, 37 of 39 AHs and WDCs were in concordance. This suggests that a morphometric distinction between AH and WDC is feasible.

Potential applications for digital image processing at the Armed Forces Institute of Pathology

Digital image processing systems are fast becoming valuable tools in the quantitative study of visual images. These systems not only enhance image features, but provide the investigator with information about those features expressed in numeric form. Now, statistical analyses can be performed on information that was formerly only qualitative. At the Armed Forces Institute of Pathology (AFIP), we are studying the potential applications of digital image processing systems to a variety of problems including morphological analysis of cell, tissue, and organ samples; reconstruction and enhancement of photographic images; three-dimensional reconstruction of organ systems; analysis of terrain, material, and human remains involved in aircraft accidents; and the archiving of histological images and pathological records. This report outlines the basic characteristics of image processing systems and discusses their potential applications in pathological studies at the AFIP. Information was collected from interviews with the AFIP professional staff.

MR imaging in patients with intracranial aneurysm clips

Four patients with intracranial aneurysm clips made from a variety of alloys were studied without incidence by MR imaging at field strengths ranging from 0.35 to 0.6 T. Knowledge of the type of alloy used in the manufacturing of an aneurysm clip is important in determining whether the clip will or will not deflect in a magnetic field. Ferromagnetic clips show deflection and torque in a magnetic field and have the potential to dislodge from the aneurysm. Nonferromagnetic or weakly ferromagnetic aneurysm clips such as the Sugita (Elgiloy), Yasargil (316 LVM stainless steel), Heifetz (Elgiloy), Yasargil (Phynox), and Vari-Angle McFadden (MP35N) do not deflect or deflect weakly in the magnetic field and therefore would not be expected to dislodge during MR. The option of imaging many patients with intracranial aneurysm clips with MR extends the usefulness of the technique to a previously excluded population.

Pulmonary nodules resembling bronchioloalveolar carcinoma in adolescent cancer patients

Pulmonary nodules morphologically indistinguishable from bronchioloalveolar carcinoma (BAC) were found in two adolescent cancer patients postchemotherapy. A solitary nodule was noted at thoracotomy for a single computerized tomography (CT) scan lesion in a 16-yr-old male, 6 yr after diagnosis of Ewing's sarcoma. A similar nodule was found in a 19-yr-old male coincident with resection of multiple lung metastases of a testicular germ cell tumor. Both lesions were discrete nodular masses (1 cm and 0.5 cm) consisting of atypical epithelial cells with a papillary and lepidic growth pattern and surrounded by histologically normal appearing lung. Immunohistochemistry of both cases was positive for laminoorganel (LO) antigen, which is found in normal type II pneumocytes, and one nodule showed carcinoembryonic antigen (CEA) staining. Quantitative DNA analysis in one case indicated aneuploidy. Thus the morphology, immunohistochemistry, and DNA content of these lesions suggest that they may represent early lung cancers despite the highly unusual clinical context. The extreme rarity of BAC in this age group makes this report significant in light of heightening concern about second malignancies in pediatric cancer patients and reports of chemically induced pulmonary adenomas in mice. It also underscores the importance of basing therapeutic decisions on a histologic diagnosis of lung nodules in cancer patients rather than assuming the presence of metastatic disease.

Cytophotometric determination of DNA in mesotheliomas and reactive mesothelial cells

Cytophotometry was used to study the nuclear DNA content of cells in Feulgen-stained effusion specimens from 18 patients with mesothelioma and 14 patients with reactive mesothelial proliferations. The mean DNA content (MDNA) of mesothelioma cells was significantly higher than that of reactive mesothelial cells (P less than .001). Other parameters reflecting the DNA content also differed significantly between the two kinds of cells, including (1) the ratio of mean mesothelial DNA to mean lymphocyte DNA, (2) the percentage of mesothelial cells with DNA content exceeding three times the lymphocyte MDNA and (3) the coefficient of variation of the DNA content. Since these parameters were highly correlated, only one was accepted in a stepwise linear discriminant model for distinguishing reactive from mesotheliomatous effusions. The model correctly classified all of the reactive effusions studied and 89% of the mesotheliomatous effusions. These results indicate that DNA analysis, using the Feulgen stain and cytophotometry, yields criteria that may be useful in distinguishing benign reactive mesothelial cells from malignant mesothelioma in effusions when used in conjunction with other traditional parameters.

Extravascular hemolysis following the administration of cefamandole

Hemolytic anemia occurred in a 70-year-old female after a five-day course of intravenous cefamandole. The patient's serum contained an IgG antibody which was reactive with red blood cells which had been coated in vitro with cefamandole but not with uncoated cells. An in vitro assay of allogeneic mononuclear phagocytosis of cefamandole-coated red cells sensitized with the patient's anti-cefamandole indicated that the anti-cefamandole could induce significant phagocytosis. The anti-cefamandole was easily inhibited in vitro by cefamandole as well as by a variety of related cephalosporins indicating broad cross-reactivity, with the antigenic site primarily the 7-amino-cephalosporanic acid nucleus. Penicillins could inhibit the anti-cefamandole but only when using concentrations 3-10 X those of cephalosporins. Eleven examples of anti-penicillin tested failed to react with cefamandole-coated red cells. Screening of 344 random sera from hospitalized patients found only five (1.5%) reactive with cefamandole-coated red cells; three of these sera were also reactive with penicillin-coated red cells. The patient's hemolysis subsided following cessation of the drug. This is the first report of anti-cefamandole-induced hemolytic anemia.

CT patterns in histopathologically complex cavernous hemangiomas

Computed tomographic (CT) studies were correlated with microscopic findings in 10 histologically verified cavernous hemangiomas in nine patients. In four of the 10 lesions, two or more distinct types of cerebrovascular malformations were identified histopathologically. These included arteriovenous malformations, venous malformations, and telangiectasis. Such coexistence of various types of cerebrovascular malformations has been reported rarely. In each of the four combined lesions, there was evidence of recent or old hemorrhage. The CT findings were nonspecific and were similar to those seen in a variety of intracranial pathologic conditions.