Biological time and in vivo research: a field guide to pitfalls

Biological rhythmicity is a fundamental characteristic of all life forms, from primitive bacteria to man. The molecular biology, genetics, and the neurobiology of the biological clock(s) are being elucidated. Daily (circadian) statistically significant fluctuations occur in all of the normal biological variables studied in the experimental animal and the human. Many researchers, however, are not aware of the negative impact biological rhythmicity can have on experimental design and/or data interpretation. This article serves not as a review, but as a "field guide" to the pitfalls that can occur when research is performed in the absence of an understanding of biological rhythmicity. The major topics discussed are: 1) data transfer from the diurnally in-active/resting/sleeping lab animal to the diurnally active human, 2) frequency of sampling, 3) free-running vs. synchronization, 4) alternating periods of resistance and susceptibility, 5) phase shifting of a rhythm, 6) the assumption that one mean +/- S.E. from control animals can be "stretched" across an experimental time span, and 7) plotting data on an "hours after treatment" format vs. a "time of day" format. The hope is that by avoiding the pitfalls, biological time will become an ally in the endeavor to understand human biology.

Diagnosis of the hemolytic state using serum levels of erythrocyte adenylate kinase

Red cell hemolysis is classically diagnosed by a combination of nonspecific laboratory tests, including serum bilirubin, LDH, and the reticulocyte count. None of these tests alone or in combination has the specificity to reliably ascertain the presence of hemolysis. We have previously demonstrated that erythrocyte adenylate kinase (EAK) is a red cell specific enzyme released from damaged red cells. Its activity can be measured in serum by rapid electrophoresis or immunological methods and correlates linearly with the degree of hemolysis in vitro. We now report on a clinical study comparing EAK levels in patients with and without hemolysis. The clinical diagnosis of hemolysis was established in hospitalized patients with anemia by the combined elevation of the bilirubin, LDH, and reticulocyte count in the absence of liver disease and demonstrable blood loss. The normal range of serum EAK was determined in 30 healthy nonanemic voluntary blood donors and was 0-3.5 Units (mean = 0.5). In 25 patients with hemolytic anemia due to sickle cell disease, hemolytic transfusion reactions, or TTP, the mean EAK level was 62.4 with a range 0-298 Units (P < 0.001 compared to normals). Levels of EAK exceeded the normal range in 24 of 25 patients (96%). In a control group of 44 hospitalized patients with liver disease or myocardial infarction and no clinical evidence of hemolysis, the mean EAK level was 0.12 with a range of 0-3.2 (P = 0.1, NS compared to normals and P < 0.001 compared to patients with hemolysis). None of the control patients had EAK levels that exceeded the normal range. The diagnostic sensitivity of the EAK assay for hemolysis, as calculated according to Baye's algorithm, was 96%, with a specificity and accuracy of 97%. Measurement of serum EAK represents a highly sensitive and specific test for the diagnosis of hemolytic anemia.

Differentiation and resolution of erythrocyte and muscle adenylate kinase activities in serum by electrophoresis

Adenylate kinase activity originating from erythrocytes has been shown to be distinct from muscle adenylate kinase or myokinase activity, until now considered to be identical enzyme activities. The two activities can be differentiated by electrophoretic fractionation, thus making it possible to quantify the erythrocyte adenylate kinase activity present in serum.

Renal vein thrombosis treated with thrombolytic therapy: case report and brief review

Renal vein thrombosis (RVT) can occur as a complication of the nephrotic syndrome. We present the case of a young woman with systemic lupus erythematosus with nephrotic syndrome and bilateral RVT with extension of the thrombus into the vena cava to the level of the right atrium and multiple pulmonary emboli. She was treated acutely with streptokinase, with complete resolution of the thrombi. In general, anticoagulation is the mainstay of therapy for RVT. Review of the literature reveals that thrombolytic therapy can be used safely and appears to have been reserved for those patients with the most severe disease or the more grave prognosis. we feel that thrombolytic therapy is warranted in the presence of bilateral RVT with acute renal failure, massive clot size with high risk of acute embolic events, or recurrent pulmonary emboli, in the absence of overriding contraindications.

Detection of undiagnosed coagulopathies using routine rapid heparin neutralization

OBJECTIVE

To determine the most frequent clinical causes of a prolonged activated partial thromboplastin time (APTT) result, and to determine whether a new heparin-removal device (the Hepchek, Pall Biomedical, Glen Cove, NY 11542) is capable of efficiently detecting the causes of these values.

DESIGN

A combination of chart review and laboratory testing comparing the criterion standard--the heparin chromogenic substrate assay--with the Hepchek. Laboratory investigations were blinded and controlled.

SETTING

Inpatient, acute-care hospital.

PATIENTS

A total of 1,000 hospital patients with a variety of hemostatic disorders.

MAIN OUTCOME MEASURE

The extent to which the Hepchek accurately identified the etiology of a prolonged APTT result.

RESULTS

The APTT was prolonged in 25.2% of samples. The presence of heparin in the sample was confirmed by chromogenic assay or by using the Hepchek heparin-removal filter. The presence of heparin was confirmed in 12.8% of all samples and in more than 50% of all abnormal samples. The cause of the abnormal APTT was often unappreciated by the clinician. Bayesian analysis of the Hepchek's ability to diagnose heparin correctly as the cause of the abnormal APTT showed a sensitivity of 100% and specificity of 99.9%.

CONCLUSION

Use of the Hepchek in the routine clinical laboratory is an efficient and rapid method of detecting heparin as a cause of isolated prolonged APTT results, and should reduce demands for unwarranted coagulation analyses and inappropriate treatment with blood products.

Clinical impact of chemotherapy-induced thrombocytopenia in patients with gynecologic cancer

PURPOSE AND METHODS

This retrospective analysis of 501 patients with gynecologic cancer treated with chemotherapy evaluates the relationship between platelet count and clinical bleeding, as well as the clinical effects of platelet transfusion therapy. Thrombocytopenic patients were divided into six groups according to platelet counts, and major or minor bleeding manifestations were documented. Thrombocytopenia was defined as a platelet count less than 100,000/microL.

RESULTS

Thrombocytopenia occurred in 182 (36.3%) patients over 808 of 1,546 chemotherapy cycles (52%). No intracranial or life-threatening bleeding occurred in any patient. The majority of patients (139 [76.4%]) had no clinical bleeding. Minor bleeding, such as purpura, occurred in 34 patients (18.7%) and 44 cycles (5.4%). Major bleeding occurred in nine patients (4.9%) and 10 cycles (1.3%). Five major bleeding events occurred in 49 patients with platelet counts between 0 and 10,000/microL. Forty-three of these patients received platelet transfusions. Thirty-eight of 43 transfused patients (88.3%) had no bleeding. Of the remaining five patients, two were transfused prophylactically with no effect. Three major bleeding events occurred in patients with platelet counts that ranged from 11,000 to 20,000/microL, but these were due to chronic instrumentation or trauma. In patients with platelet counts more than 20,000/microL, major bleeding occurred only from necrotic metastatic lesions. Random-donor platelet transfusions provided inconsistent increments in platelet counts. Overall, 27.5% of patients achieved the expected increase in platelet number based on units of platelet concentrate transfused. The use of single-donor or human leukocyte antigen (HLA)-matched platelets did not provide greater increments in those patients who were refractory to random-donor platelets.

CONCLUSION

Platelet counts > or = 10,000/microL are not associated with spontaneous major bleeding. Prophylactic platelet transfusions in patients with gynecologic malignancies and chemotherapy-induced thrombocytopenia should be limited to those with platelet counts < or = 10,000/microL, provided they are not bleeding and have no major anatomic or pathophysiologic precursors of bleeding.

The temporal relationships of synthesis and phosphorylation in stress proteins 70 and 90 in aged caloric restricted rats exposed to bleomycin

A single intraperitoneal injection of the human therapeutic drug bleomycin (BL) was administered to three groups of male Fischer 344 rats at time 0, and the incorporation of [35S]methionine ("synthesis") and phosphorylation patterns of stress proteins (sps/hsps) from bone marrow cells were analyzed over time by two-dimensional electrophoresis and fluorography. Two groups of rats, young ad libitum (Y/AL--3 months) and old ad libitum (O/AL--28 months), had free access to rat chow, and a third group of old rats (O/CR--28 months) were maintained on a caloric restricted intake (60% of the AL diet). The administration of BL in Y/AL, O/AL and O/CR animals activated the 35S-labeling of sp 90 which reached a peak at 4 hours. Labeling of sp 90 was significantly greater in Y/AL compared to O/AL, and the incorporation pattern of O/CR was intermediate to Y/AL and O/AL animals. All labeling of sp 90 in each group had disappeared by 10 hours after BL administration. Stress protein 70x (inducible form) in these three animal groups displayed a similar pattern of 35S-incorporation, but the amount of labeling was less than that of sp 90. No labeling of sp 70x remained by 13 hours after BL administration. Phosphorylation ([32P] phosphate incorporation) of sp 90 reached a maximum level at 2 hours in all animals, and 32P-labeling in Y/AL was significantly increased over O/AL and O/CR with an intermediate level found in O/CR animals. The turnover rate (phosphorylation/dephosphorylation) of sp 90 induced by BL was significantly suppressed and temporarily extended in O/AL as compared with O/CR, which implied that CR not only increased incorporation of sp 90, but also enhanced a utilization of the phosphate pool very similar to that seen in Y/AL animals.

Circadian variations of gastrointestinal peptides and cell proliferation in rats: effects of adrenalectomy

The hypothalamo-pituitary-adrenal axis appears to play an important role in regulating the circadian fluctuations of brain-gut peptides, as well as the cell cycle of the gastrointestinal mucosa. Since dexamethasone treatment tended to restore circadian fluctuations lost to adren-x, the influence of adrenal glucocorticoids in the coordination of the rhythms of regulatory peptides and cell cycle kinetics appears to be substantial.

Paradoxic effect of multiple mild coagulation factor deficiencies on the prothrombin time and activated partial thromboplastin time

Single coagulation factor deficiencies predictably prolong the prothrombin time (PT) and activated partial thromboplastin time (APTT) at levels below 35% of normal activity. Acquired coagulopathies generally are characterized by multiple coagulation factor deficiencies. The effect was studied of such combined deficiencies on the PT/APTT using plasma from patients congenitally deficient in specific factors and pooled normal plasma. The PT begins to lengthen when individual factor levels fall below 25%. The APTT becomes prolonged when the levels of Factor V fall below 45%; the levels of Factors II and XI fall below 40%; and the levels of Factors I, V, VII, VIII, IX, and XII fall below 25% of normal. When plasma samples containing 50% activity of a single factor and 100% of all other factors were prepared by mixing the congenitally deficient plasma samples with the normal pool, the resulting mixtures had normal PT and APTT values. However, when two of these 50% factor-deficient plasmas were combined so that the mixture contained 75% activity of two coagulation factors and 100% of all other factors, the resulting PT and APTT were prolonged over the clotting times of either 50% factor-deficient plasma. Similar findings were obtained in patients with mild factor reductions caused by warfarin treatment. These data indicate that prolongations of the PT and APTT in disorders of coagulation affecting multiple factors represent less of a reduction in factor levels than is generally appreciated. This may explain the poor clinical correlation between abnormalities in these test results and clinical bleeding in acquired disorders of hemostasis.

Comparative studies of synthesis, phosphorylation, DNA binding and proteolytic characteristics of a novel protein during phases of the mouse spleen cell cycle

1. Cultured mouse spleen cells were exposed to the mitogen Concanavalin A followed by isoproterenol, and nuclei were electronically sorted from seven partitions of the cell cycle. 2. Several nuclear proteins, including stress proteins, which were cell-cycle-stage specific, were elicited by isoproterenol as determined by micro-electrophoresis and fluorography. 3. Two novel S-phase proteins (X0 and X') demonstrated differing synthesis and phosphorylation patterns during the cell-cycle phases. 4. X' showed DNA binding characteristics and proteolytic properties (hydrolyzing X0 or beta-galactosidase); both proteins were cell-cycle regulated.

A nuclear protein associated with lethal heat shock of HL-60 cells

The responses to stress in living cells are well known. Thermal stress causes decreased protein synthesis as well as rapid induction of heat shock proteins (hsps), or alternately termed stress proteins (sps). The exposure of cultured promyelocytic leukemia cells (HL-60) to a 45 degrees C lethal heat shock for 1 h elicited synthesis and phosphorylation of a polypeptide M(r) 48,000 and pI 7.5 (p 48) as visualized by two-dimensional polyacrylamide gel ultra-microelectrophoresis. p 48, which was not observed at sublethal temperatures (39 and 41 degrees C), was synthesized during all phases of the cell cycle but was phosphorylated only in G0 + G1 and S-phases. The appearance of p 48 was marked by a concomitant and reciprocal reduction in hsps or sps 70 and 90. Distinct protease V8 fragment maps of p 48, hsps 70 and 90 in conjunction with immunochemical determination indicated vast differences in their primary structures. These facts suggest that p 48 was not formed from coalesced breakdown products of hsps 70 or 90. Western blotting showed that p 48 possessed the same immunochemical determinants as two other proteins with the same molecular mass but different isoelectric points. In an association assay, p 48 was shown to bind with actins and hsp 90 from HL-60 nuclei.

Prevention of growth of Yersinia enterocolitica in blood by polyester fiber filtration

The ability of polyester white cell-reduction blood filters to prevent the growth of Yersinia enterocolitica in units of donated blood was studied. Sixteen units of freshly drawn blood were inoculated with 10, 50, 100, or 150 colony-forming units (CFU) per mL of a clinical isolate of Y. enterocolitica (serotype O:3). The units were subsequently fractionated into red cell concentrate and resuspended in AS-1 or AS-3 solution. One-half of the red cell concentrates in each solution were filtered within 15 hours of phlebotomy and stored for 42 days. The remaining units served as unfiltered controls. Bacterial growth was monitored by weekly cultures and, on the last storage day, by the presence of endotoxin and the formation of methemoglobin. One hundred twelve primary cultures (560 plates) were performed. Units collected in AS-1 and filtered remained sterile when initially inoculated with 50 CFU or less. Filtered units spiked with 100 CFU or less and collected in AS-3 remained sterile throughout their shelf life. All unfiltered units supported bacterial growth and the formation of endotoxin and methemoglobin. The filtration of freshly donated blood proves to limit the growth of Y. enterocolitica in red cell components.

Performance characteristics of state-of-the-art hematology analyzers

Data were obtained from four state-of-the-art automated hematology analyzers and compared with those obtained from microscopic reference procedures. The instruments evaluated were the Technicon's H*1, Sysmex's NE-8000, Coulter's STKR, and Coulter's STKS. Accuracy was assessed by comparing machine-generated white blood cell and red blood cell profiles with those obtained manually by experienced laboratorians. Specimens used were actual clinical samples submitted for routine analysis. The precision of the instruments in counting and sizing blood cells was not significantly different at the clinical decision-making level and consistently exceeded that of the microscopic method. Significant shifts in the leukocyte population were detected with relatively similar sensitivity by all instruments. As expected, the oldest model's clinical efficiency was exceeded by that of the newer analyzers. None of the analyzers performed with an accuracy that permits the laboratory to completely eliminate a microscopic scan of a stained blood film obtained from a patient's initial specimen.

Preoperative laboratory assessment of hemostasis for orthognathic surgery

Platelet count, prothrombin time, and activated partial thromboplastin time provide a baseline to evaluate patients with known coagulopathy, as well as present an opportunity to diagnose disease in previously symptom free patients. Current hematologic management of patients with Von Willebrand's disease uses heated Factor VIII that allows patients to undergo orthognathic surgery without significant risk of disease transmission from banked blood products.

The high mobility group of nuclear proteins as biomarkers of age and caloric restriction in rats

The quantitative levels and phosphorylation states of the high mobility group (HMG) of proteins were investigated in bone marrow, brain, heart, kidney, liver, pancreas, spleen, testis and thymus of three groups of male Fischer 344 rats. Two groups of rats, young ad libitum (Y/AL - 1 1/2 mo.) and old ad libitum (O/AL - 28 mo.), had free access to rat chow, and a third group of old rats were maintained on a caloric restricted intake (O/CR - 28 mo.). The quantities of HMGs 1,2,14 and 17 were significantly reduced in O/AL rats compared with Y/AL rats in all tissues examined, and in many cases, the amount of HMGs of O/CR rats were increased by varying degrees from O/AL animals. In G2-phase nuclei of bone marrow, spleen and testis, phosphorylation of HMG proteins was reduced significantly in O/AL rats, but was enhanced in O/CR animals (especially HMG14). These levels of HMGs in O/CR animals, altered by age and diet dependent factors, reflect a condition which is more reminiscent of Y/AL than O/AL animals.

Treatment of septic thrombocytopenia with immune globulin

Thrombocytopenia frequently complicates systemic infection and results from multiple possible mechanisms. We and others have demonstrated that platelet-associated IgG (PAIgG) levels are elevated in the majority of patients with septic thrombocytopenia. Corticosteroids may be undesirable as a treatment for thrombocytopenia for patients with severe infection because of their potential for suppressing the immune response. We hypothesized that septic thrombocytopenia is, in most cases, an immune disorder analogous to idiopathic thrombocytopenic purpura (ITP) which might respond to intravenous gamma-globulin as a treatment for increasing the platelet count in this disorder. Intravenous immune globulin (IVIG), 400 mg/kg daily for 3 days, was administered in a randomized double-blind placebo-controlled trial. Twenty-nine patients who developed thrombocytopenia during a documented, septic episode were studied. Patients with disseminated intravascular coagulation (DIC), hypersplenism, or drugs known to cause thrombocytopenia were excluded. Elevated PAIgG levels were documented in 52% of evaluable patients. Mean platelet counts in the IVIG group rose from 43K at study entry to 178K (411% rise) by Day 9. In the placebo group platelets rose from 51K to 125K (261% rise; P = 0.02). Seventy-seven percent of the IVIG group had a minimum peak rise of 35K, vs 56% of the placebo group. Three patients in the placebo group had a serious bleeding episode, vs one in the IVIG group. The use of IVIG to treat septic thrombocytopenia not associated with DIC leads to a more rapid, more sustained, and greater increase in platelet count than placebo. Its use is recommended in the septic patient who is bleeding or is likely to need invasive or surgical procedures.

Phenotypic characterization of white cells in white cell-reduced red cell concentrate using flow cytometry

The residual white cell (WBC) content of donated units of red cell concentrate rendered WBC-reduced by filtration through commercially available polyester filters was quantified and phenotypically analyzed. All studies were performed by flow cytometery. Quantification studies were performed with a DNA/RNA fluorophore, propidium iodide. WBC subset analyses were performed with fluorescence-labeled monoclonal antibodies directed against various cluster differentiation (CD) loci. The results indicate that the filter removes in excess of 3 log10 total WBCs from the red cell components and depletes granulocytes to or beyond the specific assay's sensitivity of 3 log10. Total T and B cells, T4 and T8 lymphocytes, and monocytes are reduced by approximately 4 log10. These analyses provide plausible explanations for the clinical success of the filter and suggest other potential applications.

Rapid removal of heparin from plasma by affinity filtration

Coagulation test abnormalities caused by the presence of heparin are not uncommon and frequently result in additional laboratory investigation and unwarranted therapy. Methods to neutralize the effect of heparin include the addition of polyanions, enzymes, or resins to the clinical samples. These techniques are time consuming and cumbersome and produce inconsistent results. As an alternative, use of a positively charged porous filtration medium to remove heparin from the sample is described. The filtration procedure requires less than one minute and provides a consistent and total removal of heparin at plasma concentrations in excess of therapeutic levels. Chromogenic substrate analysis for residual heparin activity confirms total removal of the drug at levels greater than one unit/mL of plasma. In clinical trials, filtration normalized the activated partial thromboplastin time (APTT) of all patient specimens containing heparin (n = 41). Filtration did not shorten the coagulation assay times of patients receiving warfarin (n = 36) or of those with a variety of acquired coagulopathies (n = 14). The level of coagulation factors adsorbed to the filter medium compares favorably to that adsorbed by other commercially available heparin-binding resins. Routine use of the filter in the clinical laboratory allows for the rapid and definitive identification of heparin in specimens with prolonged coagulation times and provides clinically meaningful data.

Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practice

A new patient and blood unit identification system designed to confirm the identity of crossmatched blood products and that of the intended recipient was evaluated. Six hundred seventy-two red cell concentrates were transfused to 312 patients. Participating hospital personnel and patients were interviewed regarding the use and benefit of this unique system, which incorporates a "lock-box" approach to the identification process. The product and procedure were accepted unanimously and enthusiastically, and three potential mistransfusions were avoided by use of the system during the limited period of observation. This type of approach to the identification process affords greater security than conventional practices and minimally burdens staff.

Synergistic effects of endothelin-1 (ET-1) and transforming growth factor alpha (TGF-alpha) or epidermal growth factor (EGF) on DNA replication and G1 to S phase transition

The cooperative cell kinetic actions of ET-1 with TGF-alpha or EGF in normal rat kidney fibroblasts (NRK-49F) and KNRK cells (Kirsten MSV transformed) were analyzed by [3H]-thymidine incorporation assay and flow cytometry. A marked synergistic effect of TGF-alpha and ET-1 (or EGF and ET-1) on DNA synthesis and G1 to S transition was observed in NRK cells; 15-20% S for TGF-alpha and 12% S for ET-1 alone but 45-50% S in combination. There was no detectable effect on cell cycle kinetics by TGF-alpha (1 ng/ml) or EGF (1 ng/ml) plus ET-1 (1 ng/ml) in KNRK cells treated for 22 hours. Insulin, insulin-like growth factor I (IGF-I), fibroblast growth factor (FGF), platelet derived growth factor (PDGF), and transforming growth factor beta (TGF-beta) were also tested and found to have no significant synergistic effects on ET-1 actions. Our findings suggest that the combination of TGF-alpha (EGF) and ET-1 is an important part of an intricate network which coordinates progression of G1 to S phase in normal cells.

Platelet-associated IgG in pediatric HIV infection

Hematologic abnormalities, including thrombocytopenia, are seen in HIV infection. We have previously reported elevated platelet-associated IgG (PAIgG) in thrombocytopenia in children associated with human immunodeficiency virus (HIV). In this study we prospectively monitored 40 HIV-infected infants and children to determine the significance of elevated PAIgG levels as they relate to thrombocytopenia. We also examined platelet eluates for the presence of HIV antibody and antigen. Of 16 patients with thrombocytopenia, 15 (93.7%) had elevated PAIgG. Of 24 patients with normal platelet counts, 21 (87.5%) had elevated PAIgG. On follow-up, none of the children with normal platelet counts and elevated PAIgG levels developed thrombocytopenia. Examination of the platelet eluates was negative for HIV antibody or P24 antigen. Although the sensitivity of an elevated PAIgG level in predicting thrombocytopenia is 93%, its specificity is only 13%. Elevated PAIgG levels are therefore not causally related to the development of thrombocytopenia in children.

A rare-event analysis model for quantifying white cells in white cell-depleted blood

An analysis model to detect and quantify white cells (WBCs) in red cell concentrates (RBCC) drawn from units of blood that are highly depleted of WBCs is described. WBC detection is performed by fluorescence analysis of 50 microL of RBCC labeled with propidium iodide, a DNA/RNA fluorophore. Quantification is performed by regression analysis of standard dilutions of RBCC in substantially WBC-free red cells. This RBCC diluent is obtained by filtration of blood through a new medium. The method proves to be precise (CV = 7%), efficient (+/- 30 min/aliquot), and linear (r = 0.99) to 6 log10 WBC depletion of the native product. The current technique is preferable to those suggested previously, such as ficoll concentration, which requires the sacrifice of the unit of blood for counting purposes, and to earlier fluorescence analysis techniques that do not employ WBC-free red cell diluents. The latter do not monitor extremely low concentrations of WBCs because they lack adequate signal-to-noise discrimination. The sensitivity of the described method allows for monitoring of WBC depletion procedures with greater efficiency than is currently available commercially.

Platelet studies in the pathogenesis of thrombocytopenia in May-Hegglin anomaly

Thrombocytopenia has a variable incidence in the May-Hegglin anomaly, a rare congenital syndrome characterized by inclusions resembling Dohle bodies within leukocytes, thrombocytopenia, and giant platelets. We studied a 16-year-old girl and three relatives with the syndrome to elucidate the pathogenesis of the thrombocytopenia and the degree of impaired hemostasis. On confirmation of automated platelet counts by manual techniques we found that both aperture-impedence and light-scatter instruments tended to undercount the actual number of platelets by 30-50%. An enzyme immunoassay for platelet-associated IgG showed elevated levels in all patients (mean of 2.3 +/- 0.6 ng/10(6) platelets versus 0.8 +/- 0.6 in normals, p less than 0.0001). Bleeding time and platelet aggregation in response to adenosine diphosphate, arachidonic acid, epinephrine, ristocetin, and collagen were all normal. No clinical bleeding was observed in any of the patients in the face of major surgery or childbirth. The findings suggest the possibility of a peripheral destructive and perhaps an immune pathogenesis of the thrombocytopenia of May-Hegglin anomaly and confirm that clinical bleeding may not accompany the severe thrombocytopenia seen in this disorder.

Enhanced platelet adherence and aggregation in Chagas' disease: a potential pathogenic mechanism for cardiomyopathy

Spasm and thrombosis of the coronary microcirculation has been implicated in the pathogenesis of the cardiomyopathy of Chagas' disease. We demonstrate that increases in platelet adherence and aggregation accompany Trypanosoma cruzi infection and may contribute to the observed microvascular pathology. Scanning electron microscopy and radiolabeled platelets studies revealed that platelet adherence to T. cruzi-infected human endothelial cells was significantly increased when compared to controls (P = 0.024). In in vitro experiments, we determined the influence of infection on prostacyclin production, a marker of endothelial cell perturbation. The basal levels of 6-keto-prostaglandin F1 alpha was significantly greater in the supernatant of infected endothelial cells than in those of uninfected endothelial cells (P less than 0.05). The influence of infection was assessed on platelet aggregation at days 5 and 12 post-infection in A/J mice. Platelets from T. cruzi-infected mice were 2-6-fold more sensitive to aggregation induced by adenosine diphosphate and sodium arachidonate than controls. Thromboxane B2 levels in the plasma of infected mice were greater than controls. These data support the hypothesis that heightened platelet reactivity and endothelial cell dysfunction are associated with acute Chagas' disease and may cause coronary microvascular spasm and/or occlusion.

Flow cytometric DNA analysis of corneal epithelium

We have modified an existing technique in order to perform DNA analysis by flow cytometry (FCM) of corneal epithelium from the mouse, rat, chicken, rabbit, and human. This protocol permitted an investigation of human corneal scrapings from several categories: normal, aphakic bullous keratopathy (ABK), keratoconus (KC), Fuch's dystrophy, edema, epithelial dysplasia, and lipid degeneration. No abnormal characteristic cell-kinetic profile was detected when averaged DNA histograms were compared statistically between the normal and either ABK, KC, edema, or Fuch's dystrophy groups. Abnormal DNA histograms were recorded for cell samples that were taken 1) from three individuals who had epithelial dysplasia and 2) from one individual diagnosed with lipid degeneration. The former condition was characterized by histograms that had a subpopulation of cells with an aneuploid amount of DNA or had higher than normal percentages of cells in the S and G2 + M phases of the cell cycle. Corneal cells from the patient who had lipid degeneration had an abnormally high percentage of cells in the G2 + M phases of the cell cycle. The availability of accurate DNA flow cytometric analysis of corneal epithelium allows further studies on this issue from both experimental and clinical situations.

Clinical utility of serum tests for iron deficiency in hospitalized patients

Serum iron and ferritin measurements lack the requisite sensitivity and/or specificity to accurately diagnose iron deficiency. To determine their utility in hospitalized patients, the authors compared the results of these tests with the presence of stainable iron in bone marrow aspirates of 301 patients. Forty (13.3%) had absent marrow iron. The serum diagnosis of iron deficiency was accepted on the basis of the following: iron less than 11 mumol/L, total iron-binding capacity (TIBC) greater than 45 mumol/L, transferrin saturation (%Sat) less than 0.20, and ferritin less than 13 micrograms/L for females and less than 25 micrograms/L for males. Using these criteria, iron deficiency was correctly diagnosed by serum iron in 41%, TIBC in 84%, %Sat in 50%, and ferritin in 90% of the patients. The serum ferritin is clearly the only useful serum test for diagnosing iron deficiency in hospitalized patients but is limited by a low sensitivity. The bone marrow examination is the most sensitive test for diagnosing iron deficiency in hospitalized patients.

Hematologic manifestations in pediatric HIV infection: severe anemia as a prognostic factor

The hematologic profile of 100 symptomatic children infected by the human immunodeficiency virus (HIV) was evaluated and compared to HIV uninfected infants with transplacentally acquired maternal anti-HIV antibodies, and to HIV-negative infants born to i.v. drug-abusing HIV uninfected mothers. Anemia was present in 94% of HIV-infected infants and was a major predictor of disease progression. In 91% of patients having a hematocrit (HcT) less than 25%, the disease course was rapidly fatal. Leukopenia and thrombocytopenia occurred in 47 and 33% of HIV infected patients, respectively. Neutropenia was most severe in children with opportunistic infections. There was no evidence of suppression of any component of hematopoiesis by passively acquired antibodies to HIV.

Bleeding time. A guide to its diagnostic and clinical utility

Although the bleeding time is the most widely used clinical test employed to assess platelet function, its indications are poorly defined. The test is commonly used as a preoperative screen to predict hemorrhage, but the data supporting this indication are contradictory at best. In this review we highlight the physiologic basis for the bleeding time and survey the literature for data supporting the valid indications for its use. The bleeding time is a useful test for assessing platelet function in patients with hemorrhagic disorders. Its utility in providing helpful clinical information in patients who do not have a known bleeding diathesis by history is minimal. Specific recommendations regarding the rational use of the bleeding time for the preoperative evaluation of patients are presented.

A human adult Wilms' tumor. Histologic, ultrastructural, and cytogenetic analysis

The cytogenetic, histologic, and electron microscopic studies of an adult patient with Wilms' tumor are presented. Wilms' tumor (nephroblastoma) is a common renal tumor of childhood but is extremely rare in people over 15 years old. The histologic analysis of the patient's tumor, including both light and electron microscopic analysis, indicated that this tumor satisfies the histologic criteria for an adult Wilms' tumor, namely, blastemic cells that are immature renal parenchymal cells, embryonic tubular structures, and a scanty stromal component consisting of loosely arranged spindle cells. The tumor showed several ultrastructural features characteristic of adult Wilms' tumor, namely, markedly elongated mitochondria, autophagic vacuoles, and intracytoplasmic filaments. Karyotypic analysis was performed on the patient's peripheral leukocytes and tumor cells. The leukocytes showed no significant increase in gaps and breaks, and the patient appears to have a normal male karyotype. Some interesting chromosomal anomalies were observed in the cultured tumor cells: at least one chromosome 13, both chromosomes 22, and the X chromosome are missing, three markers are present, and there is a possible deletion of 12p.

In vitro antiproliferative activity of 4-substituted 2-(2-hydroxyphenyl)thiazolines on murine leukemia cells

Two previously synthesized and two structurally novel thiazoline iron chelators are described. N4-Benzyl-N1,N8-bis[[2-(2-hydroxyphenyl)thiazolin-4-yl]carbonyl] homospermidine (5) proved to be the most potent antiproliferative and cytocidal compound in the series with in vitro IC50 values of 3 and 1 microM on L1210 and P388 murine cell lines. The N4-acetyl analogue 7 was considerably less active than 5 with IC50 and cell viability values that were similar to those of the structurally simple thiazolines 2 and 3. The antiproliferative activity of 3 and 7 could be substantially reduced or ablated by delivery to cell suspensions as a 1:1 molar mixture with FeCl3, while the activity of 5 was unaffected by Fe(III) chelation. As expected, 3 induced a G1/S cell cycle block at the 100 microM block consistent with interference with DNA synthesis while 10 microM 5 did not affect L1210 cell cycle distribution. Tritiated thymidine incorporation studies confirmed that 5 was incapable of interfering with DNA synthesis at concentrations below 40 microM. Alkaline elution studies indicate that 5 does not cause DNA strand breaks in vitro at concentrations of 10 microM. The N4-benzyl group of 5 appears to impart in vitro potency as the N4-acetyl analogue 7 lacks comparable in vitro antiproliferative and cytocidal activity.

Modification of a trypsin-detergent method for DNA flow cytometry of human epidermis

An existing technique (Vindelov et al. Cytometry 3:323, 1983) has been modified for DNA flow cytometry of human epidermis obtained from 2 to 3 mm punch biopsies. By varying the length of time of digestion of the epidermal disc by trypsin from 5 to 70 min a controlled release of keratinocytes occurred beginning with the stratum basale and proceeding toward, but not including, the superficial layer of the epidermis, the stratum corneum.

Thrombocytopenia and human immunodeficiency virus in children

Thrombocytopenia occurs in 13% of children with symptomatic human immunodeficiency virus (HIV) infection. The clinical and laboratory course of 19 children infected with HIV with thrombocytopenia is described. Bone marrow aspirates showed normal to increased numbers of megakaryocytes. Levels of antiplatelet antibodies were increased in 80% of the children and circulating immune complexes were found in 74%. Clinically significant hemorrhage leading to anemia occurred in five patients, and CNS bleeding led to a fatal outcome in an additional three children. Spontaneous remission of thrombocytopenia occurred in three of the 19 subjects. High-dose IV gamma-globulin was effective in increasing the platelet counts of six of 15 patients (40%) but resulted in a sustained remission in only one subject. Oral prednisone was effective in increasing the platelet count of two thirds of those whose platelet counts could not be controlled by IV gamma-globulin. Bleeding manifestations were eliminated in all patients whose platelet counts increased significantly. Of the 11 children whose counts increased either spontaneously or as a result of therapy, eight remain alive (72%). In contrast, all of the eight patients whose platelet counts did not improve have died. Thrombocytopenia in children with HIV disease is engendered by immune mechanisms and is a major cause of morbidity and mortality. High-dose IV gamma-globulin and/or corticosteroids are temporarily effective in increasing the platelet count and reducing bleeding in about half of thrombocytopenic patients and are recommended for use. The ability to respond to therapy correlates with improved survival.

Acquired circulating anticoagulants in children with acquired immunodeficiency syndrome

The mechanism underlying the prolonged activated partial thromboplastin time (APTT) seen in some pediatric patients with acquired immunodeficiency syndrome (AIDS) and opportunistic infections was studied. A circulating inhibitor of coagulation was demonstrated in three patients. The inhibitor appears to be an immunoglobulin that interferes with some of the phospolipid-dependent coagulation reactions of the intrinsic pathway. This "AIDS anticoagulant" does not predispose the patient to clinical bleeding despite its ability to cause a marked prolongation of the APTT. As such, careful laboratory diagnosis of the cause of abnormal coagulation test results is necessary for children with AIDS.

In vitro antiproliferative activity of 2'-(2-hydroxyphenyl)-2'-thiazoline-4'-carboxylic acid and its methyl ester on L1210 and P388 murine neoplasms

The activity of three iron chelators, methyl [2'-(2-hydroxyphenyl)-2'-thiazoline-4'-carboxylate] (MTL); 2'-(2-hydroxyphenyl)-2'-thiazoline-4'-carboxylic acid (TFAL); and 2-hydroxyphenyl-imido-ethyl-ether (Imidate), regarding antiproliferative, cytocidal, and cell-cycle effects are reported and compared with hydroxyurea (HU). In vitro, against L1210 and P388 murine neoplasms, MTL and TFAL displayed substantially greater antiproliferative activity than HU, although Imidate displayed no appreciable activity. MTL also induced a statistically more complete G1/S cell-boundary block than did HU at equimolar concentrations (100 microM). The IC50 values produced by MTL and TFAL were low enough (less than or equal to 20 microM) to warrant further testing of these chelators as potential antineoplastic agents.

P. falciparum infected erythrocytes are capable of endocytosis

P. falciparum, an intraerythrocytic parasite, obtains nourishment primarily through phagocytosis of the host cytosol but also through the incorporation of extracellular small molecules which enter through the parasitized red cell's membrane via pores. Normal mature erythrocytes are incapable of endocytosis. Several lines of evidence suggest that extracellular large molecules may be taken up when the mature red cell is parasitized by P. falciparum, but direct evidence has been lacking. We now report the use of ferritin, an electron dense protein, to demonstrate endocytosis in P. falciparum infected red cells. Parasitized red cells incubated with ferritin internalize that macromolecule as demonstrated by electron microscopy. While normal red cells incubated with ferritin took up none of the tracer molecule, parasitized red cells internalized substantial amounts. In addition both ferritin and apoferritin inhibited the growth of P. falciparum in a dose dependent fashion, again indicating endocytosis of a macromolecule. These data indicate that P. falciparum can somehow stimulate the mature erythrocyte to engage in endocytosis. We also note that both infected and non-infected red cells in a culture in which P. falciparum is growing become abnormally sticky for ferritin. Moreover, parasitized red cells bind I125-transferrin while non-parasitized erythrocytes do not. These observations suggest that a soluble parasite product alters the red cell membrane in a non-global manner, causing selective effects in relation to different proteins.

Comparative immunochemical and structural similarities of five stress proteins from various tissue types

1. Incorporation of radioactive phosphate or leucine by stress proteins from rodent lymphoma, submaxillary and liver nuclei were observed in two-dimensional gels following chemical and environmental stress. 2. The stress proteins were isolated from second-dimension gels and their similarities compared. Mol. wt determinations, immunochemical blotting and protease V8 peptide mapping confirmed the identical nature of the stress proteins possessing identical Mr, but from diverse tissue types. 3. These data imply that highly similar stress proteins exist in diverse tissues, are conserved during evolution, and possess some elemental and essential function.

The turnover of radiolabeled nuclear proteins in rats exposed to environmental and chemical stress

Exposure to a 12 h light/12 h dark (L/D) cycle for 1 month, followed by reversal to a 12 h D/12 h L (D/L) cycle stimulated within 18 h the incorporation of [3H]leucine and [32P]orthophosphoric acid into new proteins (130-25 kDa) in the G0 phase of the cell cycle of the non-regenerating and regenerating rat liver as observed in two-dimensional gel autoradiograms. Six additional proteins from the rat submaxillary gland (130-20 kDa) revealed labeling with 32P within 3 h following combined administration of isoproterenol and sodium arsenite. Labeling disappeared within 7 days for all stressed proteins.

A new assay for quantifying human reticulocytes

The authors describe a new method for quantitative reticulocyte analysis. The assay uses a conventional clinical blood cell analyzer to size a patient's red blood cell neocyte population, which relates to the reticulocyte fraction in a linear fashion. Blood is layered atop Stractan (arabino-galactan polysaccharide) and centrifuged for 30 minutes at 1,500 X g. This density medium fractionation process enriches the Stractan layer with neocytes by up to 20-fold as determined by G6PD enzyme analysis. The mean corpuscular volume (MCV) of the red blood cells partitioning in the Stractan layer and the starting whole blood is then measured. The ratio of the two MCV measurements is then related to the reticulocyte percentage by a standard curve. In 93 patients, the derived MCV ratio was linearly correlated with manual reticulocyte counts (r = 0.96/slope = 0.99). Agreement of results obtained for single samples was within 0.2%. The assay's within-run and between-run precision is excellent (coefficient of variation less than 1%). The assay provides data on the percentage of reticulocytes in whole blood with an accuracy and precision that is at least 20 times greater than conventional microscopic technics.

Biological time and the effects of hydroxyurea on DNA synthetic activity of bone marrow and tumor cells in mice bearing the Ehrlich ascites carcinoma

The objective of this experiment was to attempt to induce, with hydroxyurea (HU), significant quantitative differences in the level of DNA-synthetic activity (DNA-SA) between a neoplastic cell population (the Ehrlich ascites carcinoma or EAC) and bone marrow in the same animal. Mice bearing a 5-day-old EAC were standardized to and kept on an LD 12:12 cycle (light 0600-1800 hr). They were treated with 500 mg/kg HU at 0500 hr (23 hr after lights on, or HALO) or at 1700 hr (11 HALO). DNA-SA was determined by liquid scintillation counting of 3H-thymidine incorporation into chemically isolated DNA. DNA-SA in bone marrow and EAC cells was monitored over the next 60 hr with subgroups of ten mice each killed every 3 hr beginning 3 hr after treatment with HU. The circadian system of the host influenced the response of the bone marrow to HU; i.e., the response to HU administered at 0500 hr was different both qualitatively and quantitatively from that for HU given at 1700 hr. Comparisons of DNA-SA in bone marrow and EAC from the same animal revealed time points after treatment with HU when DNA-SA in the EAC was high, but DNA-SA in bone marrow was low. These differences in the level of DNA-SA between a tumor cell population and bone marrow should be of therapeutic value; i.e., executor doses of anti-DNA-SA drugs such as cytosine arabinoside could be given at that point in time after treatment with HU when DNA-SA in the tumor was high, but DNA-SA in the bone marrow was low.

The H*1 hematology analyzer. Its performance characteristics and value in the diagnosis of infectious disease

The performance characteristics and the value of data provided by the H*1 Automated Blood Cell Analyzer in the diagnosis of infectious disease are assessed. Data produced by the machine are precise over a wide range of complete blood cell counts and differential white blood cell (WBC) parameters. It is capable of accurately quantifying WBCs greater than 4000/mm3 (4 X 10(9)/L); red blood cells (RBCs), greater than 2.5 X 10(6)/mm3 (2.5 X 10(12)/L); and platelets greater than 1 X 10(3)/mm3 (1 X 10(9)/L). There is good agreement between the neutrophils and lymphocytes quantified by the standard microscopic count and the automated system; however, cells that are generally present in low incidence, namely, monocytes, basophils, and eosinophils, are less well correlated. The microscopic band cell count provides the greatest test efficiency in the diagnosis of infection. None of the unique parameters generated by the H*1 differential analyzer proved to have neither a test efficiency nor a diagnostic index greater than that of the absolute WBC count in the diagnosis of infection. The "left shift" in the leukocyte differential count as detected by the H*1 relates poorly to the presence of band neutrophils in the specimen. It is concluded that the state-of-the-art automated leukocyte differential count can dramatically reduce workload, but offers no advantage over the traditional differential WBC count in the diagnosis of infectious disease. Its potential value in the diagnosis of other conditions, particularly hematologic diseases, and in the sequential monitoring of infections in individual patients were not addressed by the present study.

Retinoic acid induction of stress proteins in fetal mouse limb buds

Retinoic acid (RA) is teratogenic in rodent embryos. Several teratogens have been shown to induce the synthesis of a subset of heat shock proteins (stress proteins) in Drosophila. To determine if RA induces the synthesis of these proteins in rodent embryos, pregnant ICR mice were dosed with 100 mg/kg RA on Day 11 of gestation. Forelimb buds were removed from embryos 2.5 hr post-RA-treatment and nuclei were isolated, stained, and sorted from stages of the cell cycle. Nuclear proteins were extracted and analyzed by two-dimensional polyacrylamide gel electrophoresis. Nuclear proteins with molecular weights of approximately 84 and 25 kDa were synthesized in embryos in the G0 + G1 phase after pregnant dams were treated with RA. Isoelectric points, molecular weights, immunochemical blotting, and polypeptide mapping demonstrated that these proteins are indistinguishable from stress proteins isolated under a variety of conditions from rat submaxillary glands and mouse lymphoma cells. These results suggest that treatment with RA induces the synthesis of a subset of stress proteins; the role of these proteins in the teratogenic effects of RA is not known.

Stimulation by cAMP of erythropoietin secretion by an established human renal carcinoma cell line

We used our recently reported stable, transformed human renal carcinoma cell line as a model system to study the role of 3',5'-adenosine monophosphate (cAMP) in erythropoietin secretion. The erythropoietin produced by these cells is both biologically active and immunologically cross-reactive with purified native human hormone in our radioimmunoassay. Erythropoietin release by these renal carcinoma cells appears to be stimulated by cAMP as well as by the phosphodiesterase inhibitor 3-isobutyl-1-methyl-xanthine (MIX). The response to cAMP involves a rapid and enhanced release of hormone, which occurred within 30 minutes of exposure of the cells to the effector and continued for at least 4 hours. Intracellular erythropoietin was higher in the control cultures than in the cells treated with cAMP, suggesting that cAMP stimulates the release of a storage pool of hormone. The ability of cAMP and MIX to elicit the release of erythropoietin suggests that a cAMP-mediated mechanism is involved in the release of this hormone.

Cell cycle-specific effects of sodium arsenite and hyperthermic exposure on incorporation of radioactive leucine and phosphate by stress proteins from mouse lymphoma cell nuclei

Cultured mouse lymphoma cells incorporated [3H]leucine and [32P]phosphate into nuclear stress proteins within 3 h after exposure to either elevated temperature (45 degrees C) or sodium arsenite. Radiolabeled proteins were detected by autoradiography after two-dimensional polyacrylamide gel electrophoresis. To determine the cell cycle stage specificity of labeling, nuclei were isolated and sorted into two cell cycle phases using a fluorescent activated cell sorter. After either heat shock or sodium arsenite treatment, the majority of [3H]leucine incorporation into stress proteins occurred during the G0 + G1 phase with minimal labeling in the G2 phase. On the other hand, 32P labeling of stress proteins occurred in both the G0 + G1 and G2 phases after exposure to sodium arsenite, while incorporation of 32P was limited after heat stress. Following sodium arsenite treatment, a distinct set of four stress proteins (80-84 kDa) was detected with [3H]leucine only in G0 + G1 phase, but with [32P]phosphate these stress proteins were labeled in both G0 + G1 and G2. There was differential [32P]phosphate labeling between proteins of the 80-84 kDa set during cell cycling. Individual proteins of this set were isolated from gel plugs after sodium arsenite or heat-shock treatment. Coelectrophoresis of proteins from the two treatment groups showed that they had similar electrophoretic mobilities. All four proteins of the 80-84 kDa set (sodium arsenite induced) possessed similar polypeptide maps after digestion with V8 protease. Cytofluorometric analysis demonstrated a reduction in the number of nuclei in both S and G2 phases of the cell cycle two h after heat shock, but not following sodium arsenite treatment. However, there was a significant depression in the number of nuclei in S and G2 4 h after exposure to sodium arsenite and very modest labeling with 32P of stress proteins was observed at this time.

The clinical utility of the leukocyte differential in emergency medicine

Leukocyte differentials from 468 emergency room patients were assessed for clinical value by determining their associations with diagnosis, disposition, therapy, and prognosis. The test efficiency of an elevated band count as an indicator of infectious or inflammatory disease is 86%. However, all but 2 of the 99 patients in this disease category had additional indicators of inflammation, including elevated temperatures and/or white blood cell (WBC) counts. The band count lacks utility beyond this limited function. The remaining parameters of the differential count correlate poorly with all diagnostic subsets. The use of antibiotics correlates well with fever and WBC count (r = 0.95) and less well with the differential count, bands (r = 0.85), and granulocytes (r = 0.5). Elevations in the total WBC count and the band count are each associated with an increased likelihood of hospitalization. However, in the absence of leukocytosis, an elevated band count was instrumental in suggesting admission for only one patient. The patient's outcome correlates poorly with the total WBC and differential count. It is concluded that most leukocyte differentials performed for emergency room patients provide information that is no more clinically significant than that obtained from the medical history, physical examination, and absolute leukocyte count.

The preoperative bleeding time as a predictor of postoperative hemorrhage after cardiopulmonary bypass

To determine whether the preoperative bleeding time, the most reliable indicator of in vivo platelet dysfunction, can prognosticate excessive postoperative hemorrhage and, hence, the need for infusion of platelet concentrations, we studied blood loss versus bleeding time in 43 patients undergoing coronary bypass grafting. There was no correlation between bleeding time and either fall in hemoglobin level (r = 0.04) or chest tube drainage (r = 0.004). In addition, bleeding time did not correlate with the number of units of platelet concentrate (r = 0.12) or packed red cells (r = 0.2) infused. The bleeding time, which has been recommended as an essential screening test before all cardiopulmonary bypass procedures, need not be performed as a preoperative screen in otherwise healthy patients with no history of bleeding abnormalities and a normal coagulation profile.

Volumetric erythrocyte macrocytosis induced by hydroxyurea

An atypical form of macrocytosis termed volumetric macrocytosis is described. In contrast to the macrocyte associated with megaloblastic anemia and the pseudomacrocyte caused by viscoelastic defects, the volumetric macrocyte is characterized by an increased mean corpuscular volume and a normal cell diameter. The volumetric macrocyte proves to be thicker than the normocytic red blood cell. This large erythrocyte is overhydrated and contains an increased quantity of hemoglobin. The cell has many characteristics in common with the red blood cells of neonates. Volumetric macrocytosis accompanies sustained hydroxyurea therapy and may represent a drug-induced dyserythropoiesis.