Occasional Red Blood Cell Research Articles

Luspatercept in patients with non-transfusion dependent β-thalassaemia

Ineffective erythropoiesis leads to the development of chronic anaemia and iron overload in patients with non-transfusion dependent β-thalassemia, which is associated with significant morbidity, risk of mortality, and loss of health-related quality of life (HRQoL) especially in patients who have haemoglobin concentrations lower than 10 g/dL.1 There are no approved drugs directed at the management of anaemia in patients with non-transfusion dependent β-thalassemia, leaving supportive care with occasional red blood cell transfusions and iron chelation as the only approved therapeutic options for these patients.

Giant circulating malignant cells spotted in feathered edge of blood film.

A 20-year-old male presented with a 4-week history of dry cough, night sweats, weight loss, and fever. Blood tests showed normocytic anemia (hemoglobin 71 g/L) and severe thrombocytopenia (platelets 17 × 109/L). His blood film demonstrated leukoerythroblastosis, occasional red blood cell fragments, and giant cells in the feathered edge (Figure 1, panel A; Wright–Giemsa stain, original magnification ×400). Imaging revealed a large anterior mediastinal mass. Bone marrow biopsy revealed a hypercellular marrow with extensive involvement by high-grade malignant cells (Figure 1, panel B—aspirate; Wright–Giemsa stain, original magnification ×400; panel C—trephine biopsy; hematoxylin and eosin stain, original magnification ×200). Immunohistochemical staining only revealed CD43+, pankeratin+, and weak CD30 (Figure 1, panels D–F). The mediastinal mass was biopsied and showed similar results, as well as positivity for Sal-like protein 4 (SALL4; Figure 1, panel G) and epithelial membrane antigen (EMA). Serum alphafetoprotein was also elevated. Karyotype and metaphase Fluorescence In Situ Hybridization (FISH) from the bone marrow showed two isochromosome 12p (Figure 1, panels H–I). The final diagnosis was nonseminomatous germ cell tumor, not further classified. This case illustrates the importance of scanning the feathered edge of blood films to check for circulating metastatic cells. While often discussed in theory and seldom seen in practice, it is rare cases like this that reaffirm the importance of checking the feathered edge. We would like to thank Dr. Brian F. Skinnider, Anatomical Pathology at Vancouver General Hospital, for signing out the surgical report for the anterior mediastinal biopsy and arranging for the appropriate immunohistochemical stains. The authors declare no conflict of interest. Robert Guo and Tyler Smith helped sign out the hematopathology report on the bone marrow specimen for this case, as well as in writing and editing this manuscript.

Cost per Responder Analysis for Pegcetacoplan and Eculizumab in the Treatment of Adults with Paroxysmal Nocturnal Hemoglobinuria

Background: In the absence of clinical guidelines for paroxysmal nocturnal hemoglobinuria (PNH), the European Society for Blood and Marrow Transplantation (EBMT) developed categories for classifying hematological response to complement inhibitor treatment (per Risitano AM, et al. Front Immunol. 2019;10:1157). These categories are: complete (no transfusions, normal stable Hb, and no evidence of hemolysis); major (no transfusions, normal Hb, but evidence of residual intravascular/extravascular hemolysis); good (no transfusions, but persistent chronic mild anemia); partial (persistent chronic moderate anemia and/or occasional red blood cell transfusions); minor (3-6 transfusions every 6 months); no response (>6 transfusions every 6 months). In the phase 3 PEGASUS trial (NCT03500549), 41 and 39 patients previously treated with C5 inhibitors with Hb<10.5 were randomized for treatment with pegcetacoplan or eculizumab, respectively. In a post hoc analysis of the 16-week PEGASUS data, patients were classified by EBMT category to compare hematologic responses of each treatment (per Risitano AM, et al. Blood. 2020; 136(Suppl1):44-5).Objectives: The objective of this study was to evaluate the number needed to treat (NNT) and treatment costs of pegcetacoplan and eculizumab using EBMT response criteria.Methods: The analysis used a United States payer perspective and included drug acquisition costs and associated intravenous or subcutaneous administration costs. Drug costs were calculated using dosages for each treatment as given in the PEGASUS trial, including dosage and frequency escalations. Weekly dosages were multiplied by each drug's wholesale acquisition costs from RedBook (2020 United States dollars). We calculated the following outcomes over 16 weeks and by treatment: NNT to achieve each level of response, mean cost per treated patient, total costs, mean cost per treated patient per week, cost per complete responder, cost per good responder, and cost spent on patients with partial/minor/no response.Additional analyses were conducted to calculate outcomes for treatment-naïve patients treated with pegcetacoplan using similar post hoc analyses of combined 16-week data from the phase 1b-2a PADDOCK/PALOMINO (NCT02588833 and NCT03593200) trials.Results: Results are summarized in Table 1. Based on response rates, patients with PNH treated with pegcetacoplan had a lower NNT (1.4) to achieve good-to-complete response compared with eculizumab (19.5). NNT to achieve complete response was 2.6 for pegcetacoplan; no patients treated with eculizumab achieved complete response at 16 weeks.For the PEGASUS trial, mean cost per treated patient was $182,762 (with C5 inhibitor loading dose) and $176,504 over 16 weeks for pegcetacoplan and eculizumab, respectively. Among the 41 pegcetacoplan-treated patients, the total costs were $7,493,256 over 16 weeks. Of 41 pegcetacoplan patients, 16 achieved a complete response, and their total costs were $2.9 million over the 16-week period ($468,328 per complete responder). The total 16-week costs were $2.6 million for 14 patients with good response ($535,233 per good responder). For the 39 eculizumab-treated patients, total 16-week costs were $6,883,637. Two of 39 patients achieved a good response, and their total costs were $353,007 ($3,441,818 per good responder). Of the 39 patients, 37 achieved partial, minor, or no response or discontinued treatment, for a total cost of $6.5 million. This resulted in 95% of total treatment costs being spent on inadequate or no response in the eculizumab arm compared with 27% in the pegcetacoplan arm.For treatment-naïve patients treated with pegcetacoplan, the mean cost per complete responder ($347,339) and per good responder ($496,198) over 16 weeks were both lower than the cost per responder for patients treated with either pegcetacoplan or eculizumab after previous C5 inhibitor treatment.Conclusion: Based on the treatment response observed in PEGASUS, the NNT and cost to achieve good or good-to-complete response was lower for pegcetacoplan-treated patients than eculizumab-treated patients, according to EBMT consensus-based hematological response categories. PNH treatment with pegcetacoplan allowed more patients to achieve EBMT defined good-to-complete response and better overall response and is a more efficient use of spending with lower cost per responder in all response categories. [Display omitted] DisclosuresAnderson: Apellis: Consultancy, Research Funding. Talbird: Apellis: Consultancy, Research Funding. Fishman: Apellis: Current Employment, Current equity holder in publicly-traded company.

Comparable Clinical Outcomes between Haploidentical Family Donor and Other Donor Types after Hematopoietic Stem Cell Transplantation for Rare Pediatric Rare non-Malignant Diseases

Introduction : Hematopoietic stem cell transplantation (HSCT) has been applied as the curative treatment for rare pediatric non-malignant diseases. However, these patients are at risk of transplant related morbidity and there are no established conditioning regimens, especially for children without matched sibling donors. We evaluate the outcome of 43 pediatric cases with rare non-malignant diseases treated with HSCT.Method : We performed a retrospective analysis of a total of 43 transplantations performed in 41 patients with rare non-malignant diseases between May 2002 and May 2017. The conditioning regimens were myeloablative (busulfan, cyclophosphamide) until the middle of 2011, and reduce intensity regimens were applied thereafter. Fanconi anemia patients received fludarabine, cyclophosphamide with or without ATG. In haploidentical hematopoietic stem cell transplantation (HHCT) before year 2016 a combination of fludarabine, cyclophosphamide and ATG was mostly used, while uniformed combination of fludarabine, thiotepa, treosulfan and ATG was used since 2016. Grafts for HHSCT were manipulated by ex vivo CD3 or αβ+ T-cell depletion.Results : This study included 14 patients with congenital immunodeficiency, 13 with congenital bone marrow failure syndrome, 5 with degenerative metabolic disease and 7 with familial hemophagocytic lymphohiotiocytosis (Table 1). By donor types, 8 patients received grafts from matched familial donor (MFD), 22 from matched unrelated donor (MUD), and 10 from haploidentical family donor(HFD), respectively.The median age at HSCT was 2.5 years (range, 0.65-13.5 years). Grafts for HHCTs were CD3-depleted in 2 patients and αβ+ T-cell depleted in 8. The median infused dose of CD34+ cells were 9.38 x 106/kg (range, 0.15-44.11). Among 41 patients, 39 patients reached neutrophil engraftment, with a median of 11 days (range, 9-21) with no significant difference in neutrophil engraftment between donor types (P value 0.355).Graft failure (GF) occurred in 4 patients (primary in 3 patients; Omenn syndrome, Kostmann syndrome, Thalassemia and secondary in 1 patient; Wiskott-Aldrich syndrome). One expired due to sepsis, and 1 patient diagnosed with thalassemia is alive with occasional red blood cell transfusion on an outpatient basis. The other two underwent second HHCT; one with secondary GF died due to pneumonia after engraftment, and the other experienced GF but alive with supportive care.Mixed chimerism was detected in 24 patients 1 month after HSCT (range, 1 - 100%) and in 10 patients 1 year after HSCT (range, 1 - 80%). Grade II-IV acute GVHD occurred in 12 patients (29%, 5 with Gr II, 5 with Gr III and 2 with Gr IV), while chronic GVHD occurred in 4 patients (10%, 1 MFD, 3 MUD and all extensive). There were 4 patients who developed cytomegalovirus (CMV) disease, and 2 with sinusoidal obstruction syndrome (SOS), but no post-transplant lymphoproliferative disorder. There was no mortality related to GVHD, CMV or SOS.As for survival results, a total of 6 patients died; one HFD recipient died of pneumonia on day +216 of second HHCT, 3 MUD recipients died of pulmonary hemorrhage and the other 1 MUD recipient died of sepsis. One MUD patient died due to sudden cardiac arrest 3 years after HSCT. The overall transplant-related mortality was 14.6%. At a median follow up 56 months (range, 0.3 - 182 months), the 5-year overall survival (OS) and event free survival (EFS) was 85.4% and 82.9%, respectively. There was no statistical difference in OS and EFS among HSCTs from 3 different donor types (OS - MFD : 100% vs MUD : 72.7% vs HFD : 90.0%, P=0.336, EFS-MFD : 100% vs MUD : 72.7% vs HFD : 80.0%, P=0.367). Patients who received HSCT at younger age (<500 days) had a worse outcome compared to the older age group (OS : 54.5% vs 96.7%, P=0.001, EFS : 63.6% vs 90.0%, P=0.038). Patients in the congenital immunodeficiency group tended to have a lower OS, although this showed no statistically significant difference (P=0.074).Conclusion : In this study, we presented a single center experience of HSCT in pediatric rare non-malignant diseases and showed that HHCT donors were comparable to HSCT from other donor types, with no statistically significant difference in neutrophil engraftment, OS and EFS. Since an HLA haploidentical relative is available in almost every patient, the improvement of this treatment modality will offer a better chance of cure in patients with a variety of pediatric rare non-malignant diseases. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Optimization of Clot Formation Under Blood Flow in a Tissue Engineered Blood Vessel

BackgroundHemostasis is a complex event relying on the intersection of coagulation and platelet plug formation at the damaged blood vessel wall. Blood flow is an important force during hemostasis that delivers and removes reactants and cells to the growing clot. Standard in vitro plasma-based clotting assays omit the influence of blood flow, blood cells, and the damaged vessel wall. To address this gap, we are developing a model of laser-induced clot formation under flow, in tissue engineered blood vessels, utilizing human proteins and cells. Our goal is to develop a system allowing the study of coagulation and platelet accumulation under physiological flow and cellular environments.MethodsBlood vessels (150 um in diameter) were formed in microfluidic devices by seeding endothelial cells in a tubular void within a collagen I matrix and culturing under flow conditions. A variety of human microvascular endothelial cells types were tested. Normal human donors provided blood with informed consent. To measure fibrin and platelet accumulation, blood was spiked with fluorescently-labelled fibrinogen and calcein-AM. Laser ablations were performed with a 532 nm pulse laser and time lapse images of clot formation were captured using widefield fluorescence microscopy.ResultsWhile most endothelial cell types tested could form blood vessels, only brain endothelial cells, with supporting brain pericytes seeded in the collagen I matrix, were able to reproducibly form blood vessels capable of supporting blood flow without leakage. Brain endothelial cell blood vessels could support blood flow for greater than 45 minutes. Upon laser ablation, and after occasional red blood cell leakage, fibrin(ogen) and platelet accumulation occurred at the site of injury. Clots began forming shortly after ablation (2.1 ± 1.2 minutes until platelet accumulation and 0.5 ± 0.4 minutes until fibrin(ogen) accumulation) and maximum platelet accumulation was reached 12.3 ± 3.2 minutes post-ablation. Overall clot architecture mirrors that reported with in vivo laser injury models where fibrin(ogen) accumulates at or outside the vessel wall and platelets form a primary plug with limited intravascular accumulation.ConclusionsTissue engineered blood vessels composed of brain endothelial cells with supporting pericytes in microfluidic devices can support blood flow and laser-induced clot formation. Clots that form have a similar architecture to clots formed in vivo . This model, which combines blood plasma and cells with blood flow and the damaged vessel wall, has the potential to facilitate investigation of the procoagulant activity of hemostatic drugs in a physiologic, all human system. DisclosuresKistanova:Bioverativ: Employment, Equity Ownership. Aleman:Bioverativ: Employment, Equity Ownership. Salas:Bioverativ: Employment, Equity Ownership.

Hematological Response to Eculizumab in Paroxysmal Nocturnal Hemoglobinuria: Application of a Novel Classification to Identify Unmet Clinical Needs and Future Clinical Goals

Hematological Response to Eculizumab in Paroxysmal Nocturnal Hemoglobinuria: Application of a Novel Classification to Identify Unmet Clinical Needs and Future Clinical Goals

Deferasirox for managing transfusional iron overload in people with sickle cell disease.

Sickle cell disease (SCD) is a group of genetic haemoglobin disorders, that occurs in about 2.2 per 1000 births worldwide. Increasingly, some people with SCD develop secondary iron overload due to occasional red blood cell transfusions or are on long-term transfusion programmes for e.g. secondary stroke prevention. Iron chelation therapy can prevent long-term complications.Deferoxamine and deferiprone have been found to be efficacious. However, questions exist about the effectiveness and safety of the newer oral chelator deferasirox. To assess the effectiveness and safety of oral deferasirox in people with SCD and secondary iron overload. We searched the Cystic Fibrosis &amp; Genetic Disorders Group's Haemoglobinopathies Trials Register: date of most recent search:13 March 2014.We searched MEDLINE, Embase, Biosis Previews, Web of Science, Derwent Drug File, XTOXLINE, EBMR and The Cochrane Library, respectively; date of most recent searches: 02 August 2013.We searched four trial registries: www.controlled-trials.com; www.clinicaltrials.gov; www.who.int./ictrp/en/; www.drks.de; date of most recent searches: 03 June 2013. Randomised controlled trials comparing deferasirox with no therapy or placebo or with another iron chelating treatment schedule. Two authors independently assessed risk of bias and extracted data. We contacted the corresponding study authors for additional information. Two studies (with 203 and 212 people) comparing the efficacy and safety of deferasirox and deferoxamine after 12 months and 24 weeks, respectively, were included. The overall quality, according to GRADE, for the main outcomes was moderate to low. Only limited data were available on mortality and end-organ damage, although one study did assess mortality, relative risk 1.26 (95% confidence interval 0.05 to 30.41), the 24-week follow up was too short to allow us to draw firm conclusions. One study reported a relative risk of 1.26 for the incidence of type 2 diabetes mellitus (95% confidence interval 0.05 to 30.41). Serum ferritin reduction was significantly greater with deferoxamine, mean difference of change of 440.69 µg/l (95% confidence interval 11.73 to 869.64). Liver iron concentration (reported in one study) measured by superconduction quantum interference device showed no significant difference for the overall group of patients adjusted for transfusion category, mean difference -0.20 mg Fe/g dry weight (95% confidence interval -3.15 to 2.75).The occurrence of serious adverse events did not differ between drugs. Nausea, diarrhoea and rash occurred significantly more often in people treated with deferasirox, while adverse events of any kind were more often reported for patients treated with deferoxamine (one study). The mean increase of creatinine was also significantly higher with deferasirox, mean difference 3.24 (95% confidence interval 0.45 to 6.03). Long-term adverse events could not be measured in the included studies (follow up 52 weeks and 24 weeks). Patient satisfaction and the likelihood of continuing treatment, were significantly better with deferasirox. Deferasirox appears to be of similar efficacy to deferoxamine depending on depending on the appropriate ratio of doses of deferoxamine and deferasirox being compared. However, only limited evidence is available assessing the efficacy regarding patient-important outcomes. The short-term safety of deferasirox seems to be acceptable, however, follow up in the available studies was too short to assess long-term side effects. Long-term safety and efficacy data are available from a non-controlled extension phase not included in our review; however, no valid comparative conclusions can be drawn and future studies should assess comparatively long-term outcomes both for safety and efficacy.

Quiz Page JUNE 2013: Graft Dysfunction After Kidney Transplantation in an Adolescent

A 15-year-old boy with no relevant medical or family history presented with nausea and fatigue. His blood pressure was 150/90 mm Hg, but the rest of the physical examination findings were normal. Laboratory investigations showed the following values: serum creatinine, 18.9 mg/dL (estimated glomerular filtration rate [GFR], 5 mL/min/1.73 m2 by the modified Schwartz formula); serum urea nitrogen, 549 mg/dL; parathyroid hormone, 496 (reference range, 9-55) pg/mL; and hemoglobin, 9.0 g/dL. Urinalysis showed hematuria (1+) and proteinuria (protein excretion, 930 mg/24 h), with occasional red blood cells on sediment evaluation.

A novel α0-thalassemia deletion in a Greek patient with HbH disease and β-thalassemia trait

To determine the molecular basis in a Greek child suspected of having HbH disease and β-thalassemia trait. Standard hematology, Hb electrophoresis, and HPLC. Multiplex ligation-dependent probe amplification (MLPA), direct sequencing, and breakpoint characterization by NimbleGen fine-tiling array analysis. The index patient showed a moderate microcytic hypochromic anemia with normal ZPP and elevated HbA(2) , indicative for β-thalassemia trait. However, the moderate microcytic hypochromic anemia along with the observation of HbH inclusions in occasional red blood cells suggested a coexisting α-thalassemia. Molecular analysis indicated that the propositus inherited the β(+) -thalassemia mutation IVS2-745 (c>g) and a novel α(0) -thalassemia deletion from the mother, and the common non-deletion α-thalassemia allele α(2) (-5nt)α from the father. The α(0) -thalassemia deletion, named - -(BGS) , is approximately 131.6 kb in length. It removes the major regulatory elements along with the functional α-globin genes but leaves the theta-gene intact. The compound interaction of a β-thalassemia defect along with a single functional α-globin gene is quite rare. Although patients with HbH/β-thal and simple HbH disease have comparable levels of Hb, the absence of free β-globin chains and thus detectable non-functional HbH means that in HbH/β-thal, the levels of functional Hb are higher, resulting in a better compensated functional anemia. Rare large deletions as the one described here remain undetected by gap-PCR in routine molecular screening. The introduction of MLPA as a diagnostic screening tool may improve laboratory diagnostics for these defects. The use of NimbleGen fine-tiling arrays may give additional information about the precise location of breakpoints.

Amylase secretion from isolated pure acinar cells

Isolation of pure acinar cells of the rat pancreas was achieved employing counterflow sedimentation filtration technique (CSFT). The preparation of purified acinar cells contained an occasional red blood cell (RBC, 200:1) with total absence of endocrine and duct cells. A significant stimulation of amylase secretion from isolated pure acinar cells was produced by octapeptide of cholecystokinin (CCK 8) and insulin produced potentiation of the effect of CCK 8. Synthetic glucagon inhibited basal and CCK 8 stimulated amylase secretion. Non-synthetic purified glucagon stimulated amylase secretion and potentiated the effect of CCK 8. Vasoactive intestinal polypeptide (VIP) did not stimulate amylase secretion but potentiated the effect of CCK 8. No leakage of lactic dehydrogenase (LDH) was detected from the cells in any of the secretion studies. Thus a highly purified preparation of isolated pure acinar cells of rat pancreas could be obtained with excellent morphologic and functional integrity.

Chronic glomerulonephritis: Nonimmunologic mechanisms of progressive glomerular damage

Patient]. A 66-year-old man was first evaluated in the Renal Clinic of the New England Medical Center (NEMC) at age 53. At age 9, he developed periorbital and peripheral edema, gross hematuria, cylindruria, and proteinuria. He was told he had acute glomerulonephritis and was confined to bed for one month; the edema and hematuria resolved. He remained asymptomatic for the next four decades although urinalyses performed during Army and insurance examinations consistently revealed trace to I + protein. At the age of 53, he noted intermittent pedal edema over a 3-month period. Physical examination revealed a blood pressure 130/90 mm Hg. The ocular fundi were normal. Cardiovascular examination was unremarkable. No abdominal organomegaly was present. There was 1 + pittingedema of the feet. Urinalysis revealed a specific gravity of 1.012, a pH of 5, no sugar, 1 + protein, 3 to 5 red blood cells per high-power field, no white blood cells, and rare granular casts. Twenty-four hour urine protein excretion measured on three occasions ranged between 400 and 900 mg; no significant postural component to the protein excretion was evident. Urine culture was sterile. The serum albumin was 4.5 ing/dI. The serum creatinine was 1.1 mg/dl and the BUN was 17 mg/dl. The patient was believed to have 'latent glomerulonephritis' for which no specific therapy was recommended. His edema resolved spontaneously during the next several weeks. During the ensuing 13 years, serial measurements of serum creatinine revealed a slowly progressive decline in renal function (Table I). During this period, urinalyses continued to reveal 1+ to 3+ protein and occasional red blood cells. The patient developed mild hypertension, treated initially with alpha-methyldopa, and later with propranolol. The latter drug was discontinued 2 years ago because of mild hyperkalemia (serum potassium 5.8 mEq/liter); however, the serum potassium concentration remained in the range of 5.0 to 5.4 mEq/liter subsequently. Because of recent increasing fatigue, intermittent nausea, and pruritus, plans are being made to initiate chronic hemodialysis. Patient 2. A 44-year-old woman was first admitted to NEMC 12 years ago because of acute renal failure. Three weeks earlier she had complained of a mild sore throat lasting only a few days. One week before admission she noted fever, palpitation, and painful erythematous lesions and swelling over the anterior lower legs. Physical examination at another hospital disclosed mild pharyngitis, erythema nodosum, and tachycardia. Blood pressure was 134/82 mm Hg. Neither a heart murmur nor edema was noted. An electrocardiogram revealed nonspecific T-wave abnormalities, and p-hemolytic streptococcus was recovered from a throat culture. The BUN was 12 mg/dl, and a urinalysis revealed no protein and 2 to 3 red blood cells per high-power field. Acute rheumatic fever was diagnosed, and treatment with erythromycin and aspirin was begun. Fever, tachycardia, and cardiac abnormalities improved, but edema developed. After 5 days, the urine output suddenly ceased. The BUN rose swiftly to 117 mg/dl and the serum creatinine increased to 4.7 mg/dl. The patient was transferred to NEMC for further evaluation and treatment. Her first pregnancy had been complicated by hypertension and postpartum hemorrhage 10 years earlier. She denied a history of renal disease, hypertension, diabetes, urinary tract infection, renal calculi, or hematuria. She was allergic to penicillin. Physical examination revealed a blood pressure of 120/70 mm Hg; mild periorbital, sacral, and ankle edema; and erythema nodosum. Urinalysis demonstrated 3+ protein, many red blood cells, and 3 to 4 red blood cell casts. Serum complement (C3) was subnormal; ANA and LE preps were negative. Nephrotomography demonstrated 15.5 cm kidneys. She was treated with peritoneal dialysis, oral Kayexalate,5 and a Giovanetti diet. An open renal biopsy 2 days later revealed diffuse, exudative, and proliferative glomerulonephritis typical of acute poststreptococcal glomerulonephritis. During the next 3 weeks, the patient remained anuric and required 2 peritoneal dialyses. Despite normal blood pressure (110 to 140/70 to 90 mm Hg), papilledema occurred. The neurologic examination was otherwise normal. One month after her illness began, urinary volume progressively increased and she noted less fatigue. Renal function improved and peritoneal dialysis was discontinued. Blood pressure rose to 150/115 mm Hg and therapy with alpha-methyldopa was begun. After another month, the BUN had fallen to 11 mg/dl and the serum creatinine to 1.1 mg/dl. During the next 2 months she continued to feel well, and her renal function remained normal. Hypertension persisted; the urinary sediment contained 50 to 75 red blood cells per high-power field and occasional red blood cell and granular casts. Urinary protein excretion declined from 4.7 to 2.3 g daily. A second renal biopsy revealed onethird of the glomeruli to be hyalinized, with more than one-half normal or only slightly sclerotic. No cellular proliferation or exudation remained. Hyaline droplet degeneration of proximal tubular cells and protein casts within tubules were evident. The biopsy was interpreted as revealing chronic, inactive proliferative glomerulonephritis.

Experimental angioplasty: lessons from the laboratory

To elucidate the pathophysiologic mechanisms of transluminal angioplasty, normal coronary arteries in dogs, atherosclerotic human coronary arteries, and atherosclerotic vessels in rabbits were studied after angioplasty. Normal canine coronary arteries showed desquamation of endothelium, exposure of subendothelial connective tissue elements, and deposition of a carpet of platelets, fibrin, and occasional red blood cells. Administration of low molecular weight dextran before angioplasty decreased platelet deposition. Atherosclerotic human coronary arteries studied postmortem showed enlargement of lumen size after angioplasty due to splitting and disruption of the plaque and the underlying media. Endothelial desquamation and splitting of the plaque were also seen in atherosclerotic vessels in rabbits after angioplasty. The amount of splitting seems to depend on the relative size of the stenotic vessel and the inflated angioplasty balloon. Animals studied sequentially showed retraction of the separated intimal plaque elements and further lumen enlargement after 1-2 weeks. Two mechanisms of successful angioplasty are suggested by these studies: (1) desquamation of superficial plaque elements and (2) splitting of the plaque with retraction of intimal flaps as healing occurs. These mechanisms have important implications for the treatment of patients undergoing percutaneous transluminal angioplasty.

Parenteral bacitracin in surgical infections

1. 1. Bacitracin was administered parenterally as the antibiotic in the fifty cases reported. 2. 2. In thirty-four or 68 per cent of these cases the clinical response to bacitracin was so favorable that in nineteen cases it was classified as excellent and in the remaining fifteen good. 3. 3. There were ten cases in which the infectious disease was not affected by bacitracin therapy. These are considered failures and comprise 20 per cent of the cases. 4. 4. In seven cases it was equivocal as to whether or not bacitracin influenced the clinical course. 5. 5. In sixteen or 32 per cent of the cases a toxic reaction developed. The toxic reactions consisted of albuminuria alone in six cases and albuminuria plus occasional red blood cell, cast of epithelial cell. As determined by blood chemical studies and urine analysis all signs of toxicity cleared when the drug was stopped. In one instance a patient showed an elevated blood urea nitrogen, which cleared with expectant therapy. Local reactions manifested by pain and induration at the site of infection were present in most of the cases. There was no correlation between toxicity and size of dose, duration of therapy, type of infection or lot of drug used. All toxic reactions were considered not to be severe enough to warrant discontinuing therapy in any case. 6. 6. Bacteriologic studies were made in thirty-three cases. In those infections with bacitracin-sensitive organisms 72 per cent of the twenty-five cases had an excellent to good result; whereas in those cases with resistant organisms, only three or 27.5 per cent could be so classified. In the sixteen cases which were unsuitable for or from which it was impossible to obtain material for bacteriologic study twelve or 75 per cent had good or excellent results. Most of these cases were cases of cellulitis or lymphangitis. Titrations of resistant strains might possibly have demonstrated that the organisms in these cases with excellent to good results were sensitive to bacitracin in higher concentration than those used in the test. The significance of this is all important and self-evident. Consequently, on all new cases the sensitivity of all bacteria recovered is determined by the titrations me thod. In this series one gram-negative bacillus, a chemogenic species, was sensitive to bacitracin. Eleven of thirteen strains of micrococci were bacitracin sensitive as were also eight of nine strains of hemolytic streptococci. Only six of eleven strains of staphylococcus were bacitracin sensitive.

TREATMENT OF LEAD ENCEPHALOPATHY WITH BAL (2.3-DIMERCAPTOPROPANOL)

TREATMENT OF LEAD ENCEPHALOPATHY WITH BAL (2.3-DIMERCAPTOPROPANOL)

The Structure of Unstained Reticulocytes

Brilliant cresyl blue and certain other basic dyes, if applied to fluid blood, bring out a reticulum in young red blood cells. This reticulum fails to appear if brilliant cresyl blue or other basic dyes are applied to dried and alcohol fixed blood smears. Moreover, no reticular structure could hitherto be demonstrated in the young red blood cells by microscopic examination of unstained blood with direct or oblique illumination, dark field illumination or in ultraviolet light.1While examining unstained wet blood films of albino mice with the phase microscope, we found that an occasional red blood cell showed a very delicate, hardly discernible reticulum. The cells showing this reticulum were fewer in number than the reticulocytes demonstrable by supravital staining with brilliant cresyl blue. However, when certain hypotonic salt solutions, preferably potassium oxalate 0.8% or ammonium oxalate 1.2% were mixed with the fresh blood, a larger number of cells, corresponding to the percentage of reticulocytes, s...

Congenital Solitary Pelvic Ectopic Kidney, with Report of a Case

A solitary pelvic or ectopic kidney is a rare anomaly if its frequency is to be judged by reported cases. Because the kidney is single, other abnormalities of form, such as a fused kidney, are not included in this classification. In 1937 Stevens (1) reviewed the literature and tabulated the findings in 27 cases including 2 of his own. He estimated that a single pelvic kidney occurred once in every 22,000 births. He also stressed the importance of urologic management of such cases and the frequent association with genital anomalies in women. Details of the cases reported since Stevens' publication are presented in Table I. Houtappel's (2) patient was sixty-eight years old. The oldest patient reported previously was forty-eight; the average age was sixteen. Houtappel pointed out the importance of excretory urography or retrograde pyelography before every kidney operation. Ockerblad's and Carlson's case (3) is interesting because the patient had two uneventful pregnancies and deliveries. In fact, the only time she was free from albuminuria was during these pregnancies. Mayers (4) reported an additional case and proposed a classification for renal anomalies. He also suggested that the designation “congenital solitary pelvic renal ectopia” be substituted for “pelvic single kidney.” Ogden and Maltry (5) added another case, briefly reviewed the embryology of the kidney, and presented an explanation for unilateral renal agenesis. Planas and Fablet's patient (6) had one delivery which required the aid of forceps and a second which was normal. Case Report A woman, aged twenty, came to the Cleveland Clinic in October 1939 because she had never menstruated. She had been happily married for three years. She had no symptoms referable to the urinary tract and felt perfectly well generally. Four sisters were normal. Examination showed a well developed, well nourished woman. The breasts were about average for a young adult female. The external genitalia were normal. The vagina admitted two fingers and appeared normal except that it was somewhat short and that no cervix could be palpated. On rectal examination a mass was felt, extending from the upper left to the lower right posterior pelvis and tapering to a small point at the lower end. The examiner thought that this might be the uterus and decided to do an exploratory laparotomy. If the mass were found to include the uterus and cervix, he was prepared to consider the possibility of connecting them to the vagina. On five urinalyses the specific gravity of the urine ranged from 1.020 to 1.032, and the pH from 5.0 to 7.5. Results of tests for sugar were negative. A trace of albumin was found twice, a few granular casts once, and an occasional red blood cell three times. The blood urea was 45 mg. per 100 c.c. The kidneys were obscured on a roentgenogram of the kidney, ureter, and bladder region. In January 1942 the patient was admitted to the Cleveland Clinic Hospital for operation.

ANGIONEUROTIC EDEMA AND DERMATITIS VENENATALIKE LESIONS DUE TO THE ORAL ADMINISTRATION OF SULFATHIAZOLE

very little pruritus and the mucous membranes were not involved. The urine at this time was amber ; specific gravity was 1.022; it was alkaline in reaction and negative for albumin, and sugar was 1 plus. Microscopic examination revealed many sulfaguanidine crystals, white blood cells and occasional red blood cells but no casts. The blood sulfaguanidine level was 2 mg. per hundred cubic centimeters on November 28. Otherwise the blood chemistry was unaltered. The patient looked extremely toxic. She felt nauseated and at 6 p. m. vomited a moderate amount of watery fluid. A record of the fluid intake and output for November 28 showed an oral intake of 2,600 cc. (reinforced by intravenous infusion of 1,000 cc. of 10 per cent dextrose in saline solution) with an output of only 130 cc. The following day, November 29, her pharynx was red and her tongue was coated but moist. She still had the generalized macular erythematous rash, which blanched on pressure. Under the continued regimen of forced fluids, her temperature dropped back to normal and by November 30 the cutaneous rash had practically disappeared. The red and white blood cells and crystals were no longer found in the urine and the patient was voiding adequately. There was no more nausea, vomiting or headache and the patient felt much better. COMMENT Sulfanilamide, sulfapyridine, sulfathiazole and, to some extent, sulfadiazine have all been exposed as to their toxic effects. Sulfaguanidine may be held under a similar indictment with the other members of the sulfonamide family. Despite its slow rate of absorption from the gastrointestinal tract, sulfaguanidine has produced its harmful side reactions and manifestations of irritation to organs. This seems to be the first noted instance of renal depression and irritation in human beings due to sulfaguanidine ; it was evidenced by the oliguria and by the presence of red and white blood cells in the urine. (Marshall and others have reported renal depression in experimental animals due to administration of sulfaguanidine.4)