Missed diagnosis in hematological patients—an autopsy study

Autopsy findings of missed diagnoses that would probably have changed management or prognosis occur in up to 29% of cases in general hospitals. Such proportions may be higher in subsets of patients with complex diseases. We reviewed 2908 consecutive autopsies performed over a period of 29 months in a large-volume hospital, analyzing 118 autopsies of patients with hematological malignancies or severe aplastic anemia. A review of macroscopic reports as well as microscopic examination of tissue samples was performed. Medical records were reviewed for clinical diagnoses. Discordances between clinical and autopsy diagnoses were classified using Goldmans criteria. Additionally, we searched for clinical parameters correlated with occurrence of class-I discrepancy using a multivariate method. Median age was 46.5 years, and 25.4% had received a hematopoietic stem-cell transplant. Overall, 11.9% (6.6–19.1%) of patients died before conclusion of the hematological diagnosis and 33% (24.6–42.3%) died with no active hematological disease. We found class-I discrepancy in 31.3% (23.1–40.5 %) of cases. The most common among these diagnoses were hematological disease, pneumonia and gastrointestinal bleeding. In a univariate analysis, being elderly (P=0.04) was positively correlated with the finding of class-I discrepancies; while, having received previous specific hematological treatment (P=0.0005) or hematopoietic stem-cell transplants (P=0.013), or being admitted to a specialized hematology unit (P=0.0006) were negatively correlated to the occurrence of such discrepancies. Multivariate analysis showed that care in a specialized hematology unit (OR 0.34, 0.12–0.93) was independently associated with lower occurrence of discrepancies. We concluded that critical diagnoses are often missed in highly complex hematological patients especially in the absence of admission to specialized hematology units.     

Molecular pathology of well-differentiated thyroid carcinomas

The newly discovered molecular features of well-differentiated thyroid carcinomas derived from follicular cells are reviewed, within the frame of the 2004 WHO classification of thyroid tumours, under the following headings: “Follicular carcinoma”, “Papillary carcinoma”, “Follicular variant of papillary carcinoma” and “Hürthle cell tumours”. A particular emphasis is put on the meaning of PAX8–PPARγ rearrangements, RAS and BRAF mutations, and deletions and mutations of mitochondrial genes and of nuclear genes encoding for mitochondrial enzymes, for thyroid tumorigenesis.     

Loss of lineage antigens is a common feature of apoptotic lymphocytes

The analysis of apoptosis in cell populations involves the detection of their specific lineage antigen (LAg) expression. This experimental approach relies on their assumed constant expression, but it is unclear whether such expression is actually maintained during cell death. We examined whether the loss of LAgs is a common feature of apoptotic lymphocytes and whether some might completely lose their LAgs. The changes in the expression of CD3, CD5, CD8, CD4, CD28, CD56, and CD19 were monitored in highly purified lymphocyte populations obtained by negative selection in a fluorescence-activated cell sorter. These were cultured for 24 h with or without phytohemagglutinin or staurosporin. For each LAg-positive subset studied, apoptosis was consistently more common among cells showing partial or total loss of LAg expression compared with cells maintaining their initial LAg levels. The kinetics of expression loss was rapid for CD8, CD56, and CD28, and more than 80% of initial expression was lost in the early stages of apoptosis but was slower for CD3, CD5, and CD4. For CD3 and CD5, expression was dependent on the apoptotic stimulus used. It is interesting that loss of antigen expression was independent of cell size. This phenomenon was also found in nonmanipulated, highly pure CD19 B lymphocytes of peripheral blood mononuclear cells from B chronic lymphocytic leukemia patients. Loss of LAg expression appeared to be a common feature of apoptotic lymphocytes under all the conditions assayed. The different kinetic patterns of LAg loss suggest apoptotic cells might actively regulate this process.     

Spermiogenesis in the proteocephalidean cestode<Emphasis Type="Italic"> Proteocephalus torulosus</Emphasis> (Batsch, 1786)

Spermiogenesis of the proteocephalidean cestode Proteocephalus torulosus (Batsch, 1786) was examined for the first time using transmission electron microscopy. Spermiogenesis begins with the formation of a distal cytoplasmic protrusion, a differentiation zone, at the periphery of the early spermatid. This differentiation zone is lined with cortical microtubules and contains two centrioles aligned along the same axis. Subsequently, each centriole is associated with the striated root and the intercentriolar body appears between them. A flagellar bud arises from each centriole, growing later as a free flagellum. Simultaneously, a median cytoplasmic process (MCP) develops distally to the flagella. The two flagella, which are of unequal length, become longer and rotate towards the MCP. At this stage, two arching membranes appear at the base of the differentiation zone. The nucleus elongates and when both flagella are fused with the MCP, the nucleus subsequently migrates into the MCP. Finally, the advanced spermatids detach from a condensing residual cytoplasm at the level of the arching membranes.     

Yq deletion with short stature, abnormal male development, and schizoid character disorder.

A 33-year-old male with short stature, abnormal male sexual differentiation, aspermia, and schizoid character disorder is described, who had a Y chromosome with a deleted long arm. The correlation of the symptoms, including the psychotic abnormality, with the cytogenetic finding is discussed.     

The effect of long-term stimulation of fast muscles on their blood flow,metabolism and ability to withstand fatigue

Chronic stimulation of fast rabbit muscles (tibialis anterior, extensor digitorum longus and the peroneal muscle group) at a frequency naturally occurring in nerves to slow muscles increased their ability to withstand fatigue. Isometric tension decreased during a 10-min period of contractions at 4 Hz by 75% in control muscles, but only 55% in muscles chronically stimulated for 4 days, and 23% in muscles stimulated for 28 days. Chronic stimulation had little effect on resting blood flow, oxygen or glucose consumption. The output or consumption of lactate and free fatty acids (FFA) at rest were also unaffected. The glycogen content was regularly increased, and was apparent after only 2 days of stimulation. The activity of fatty acid activating enzyme was increased after 28 days. During a 10-min period of isometric contractions at 4 Hz, there was a markedly greater increase in blood flow and oxygen consumption in muscles stimulated for 14-28 days than in control muscles; lactic acid output was lower in muscles stimulated for 28 days, and the uptake of FFA was significantly higher. It is therefore suggested that muscles chronically stimulated for 14-28 days use fats as the main source of energy during isometric contractions. The predominantly oxidative metabolism is probably facilitated by the higher density of capillaries. The latter also enables more efficient delivery of oxygen, and therefore smaller fatiguability, already after 4 days of chronic stimulation.     

Neuronal expression of Raf protooncogene in the brain stem of adult guinea pig

The Raf protooncogenes encode for cytoplasmic serine/threonine-specific protein kinases which can be activated via growth factor receptors by phosphorylation. Immunohistochemical and Western blotting studies have proven the existence of Raf protein kinases in neurons of the cerebral cortex of rats and guinea pigs. The aim of the present study was to map the immunohistochemical distribution of Raf kinase-like staining in the brain stem of guinea pig. Polyclonal antibodies were used that were raised against a recombinant viral protein in combination with the avidin-biotin-peroxidase system for detection of immunoreactivity. Specificity of the antibodies was tested in Western blotting experiments. Cytoplasmic immunostaining was observed in motor nuclei of hypoglossal, accessory, vagus, facial, trigeminal, abducent, oculomotor and trochlear nerves, and in the nucleus ambiguus, nucleus retroambigualis, lateral vestibular nucleus, mesencephalic nucleus of the trigeminal nerve, the red nucleus, raphe nuclei and reticular formation. Scattered neurons were stained in other sensory nuclei, such as solitary tract nuclei, medial, dorsal and ventral vestibular nuclei and cochlear nuclei. The spinal trigeminal nucleus and the main sensory nucleus of the trigeminal nerve contained few medium-sized immunoreactive cells. In general, staining was mainly somatodendritic; the axonal plexus was not positive. It is concluded, that the widespread neuronal appearance of cytoplasmic Raf kinase suggests an important role in transmission of trophic and growth factor signals in these neurons.