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The upcoming ultra-low-NOx (oxides of nitrogen) emissions standard and in-use NOx emissions requirement requires engine manufacturers to further reduce tailpipe NOx emissions by over 90% from the current United States Environmental Protection Agency 2010 heavy-duty emissions standard. To meet ultra-low NOx standards, significant improvements to the NOx reduction capability of the Selective Catalytic Reduction (SCR) system is required. Low-temperature exhaust conditions and the associated fuel penalty in increasing the exhaust temperatures for improving catalyst activity is an engineering challenge to balance lowering NOx emissions while lowering fuel consumption. Cylinder Deactivation (CDA) in diesel engines has shown the ability to increase exhaust temperatures while maintaining a zero-fuel penalty. This study details the results of the performance of a CDA hardware installed in a modern heavy-duty diesel engine. The study was aimed at developing steady-state engine calibrations to maximize exhaust temperatures while realizing a zero-fuel penalty or improved BTE operation during low-load engine operating conditions for an on-road heavy-duty diesel engine. In addition, the study demonstrated the effect of CDA on lowering aftertreatment cooldown during motoring operation. The results of the study showed close to a 100°C increase in turbine out temperatures (TOT) at idle, 1,000 rpm and 1,200 rpm engine speeds with engine load at 10 and 20% of rated torque. The results also showed that deactivating three of the six cylinders during motoring operation of the low-load cycle delayed after treatment cool down and maintained exhaust temperatures above the SCR activity threshold for a longer duration.

Biospecimens acquired during routine medical practice are the primary sources of molecular information about patients and their diseases that underlies precision medicine and translational research. In cancer care, molecular analysis of biospecimens is especially common because it often determines treatment choices and may be used to monitor therapy in real time. However, patient specimens are collected, handled, and processed according to routine clinical procedures during which they are subjected to factors that may alter their molecular quality and composition. Such artefactual alteration may skew data from molecular analyses, render analysis data uninterpretable, or even preclude analysis altogether if the integrity of a specimen is severely compromised. As a result, patient care and safety may be affected, and medical research dependent on patient samples may be compromised. Despite these issues, there is currently no requirement to control or record preanalytical variables in clinical practice with the single exception of breast cancer tissue handled according to the guideline jointly developed by the American Society of Clinical Oncology and College of American Pathologists (CAP) and enforced through the CAP Laboratory Accreditation Program. Recognizing the importance of molecular data derived from patient specimens, the CAP Personalized Healthcare Committee established the Preanalytics for Precision Medicine Project Team to develop a basic set of evidence-based recommendations for key preanalytics for tissue and blood specimens. If used for biospecimens from patients, these preanalytical recommendations would ensure the fitness of those specimens for molecular analysis and help to assure the quality and reliability of the analysis data.

The College of American Pathologists (CAP) developed the Biorepository Accreditation Program (BAP) in 2012. This program integrates best practices from the International Society for Biological and Environmental Biorepositories, the National Cancer Institute, the Organisation for Economic Cooperation and Development, the Center for Medicare and Medicaid Services, and the CAP Laboratory Accreditation Program. The goal of this elective program is to provide requirements for standardization in biorepository processes that will result in high-quality specimens that can be used to support research, drug discovery, and personalized medicine. CAP uses a peer inspection model to ensure the inspectors have proper expertise and to promote educational efforts through information sharing. Lead inspectors are comprised of pathologists, PhDs, and managers of biorepositories and they are often supported by CAP staff inspectors. Accreditation is a 3-year continuous cycle of quality with a peer inspection occurring at the start of year 1 and a self-inspection and CAP desk assessment at the start of year 2 and 3. At this time 53 biorepositories are fully CAP BAP accredited and 13 are in the process of obtaining accreditation. There are currently 273 established standards with requirement lists customized based on the scope of activities performed by a biorepository. A total of 90 inspections were completed between May 2012 and December 2016. Sixty-one were initial inspections and 29 were reinspections. A total of 527 deficiencies were identified in the areas of Equipment/Instrumentation (22%), Information Technology (18%), Specimen Handling and QC (15%), Quality Management (16%), Personnel (11%), Safety (10%), Facilities (6%), and Regulatory (2%). Assessment of common deficiencies identifies areas of focus for continuous improvement and educational opportunities. Overall success of the program is high based on the current enrollment of 66 biorepositories, anecdotal participant feedback and increasing national recognition of the BAP in federal documents.

Context: Biospecimens must have appropriate clinical annotation (data) to ensure optimal quality for both patient care and research. Additional clinical preanalytic variables are the focus of this continuing study., Objective: To complete the identification of the essential preanalytic variables (data fields) that can, and in some instances should, be attached to every collected biospecimen by adding the additional specific variables for clinical chemistry and microbiology to our original 170 variables., Design: The College of American Pathologists Diagnostic Intelligence and Health Information Technology Committee sponsored a second Biorepository Working Group to complete the list of preanalytic variables for annotating biospecimens. Members of the second Biorepository Working Group are experts in clinical pathology and microbiology. Additional preanalytic area-specific variables were identified and ranked along with definitions and potential negative impacts if the variable is not attached to the biospecimen. The draft manuscript was reviewed by additional national and international stakeholders., Results: Four additional required preanalytic variables were identified specifically for clinical chemistry and microbiology biospecimens that can be used as a guide for site-specific implementation into patient care and research biorepository processes., Conclusions: In our collective experience, selecting which of the many preanalytic variables to attach to any specific set of biospecimens used for patient care and/or research is often difficult. The additional ranked list should be of practical benefit when selecting preanalytic variables for a given biospecimen collection.

Context: Biospecimens must have appropriate clinical annotation (data) to ensure optimal quality for both patient care and research. Clinical preanalytic variables are the focus of this study., Objective: To define the essential preanalytic variables (data fields) that should be attached to every collected biospecimen and to provide a complete list of such variables, along with their relative importance, which can vary, depending on downstream use, institutional needs, and information technology capabilities., Design: The College of American Pathologists Diagnostic Intelligence and Health Information Technology Committee sponsored a Biorepository Working Group to develop a ranked list of the preanalytic variables for annotating biospecimens. Members of the working group were experts in anatomic, clinical, and molecular pathology; biobanking; medical informatics; and accreditation. Several members had experience with federal government programs, such as the National Cancer Institute's Biospecimens and Biorepository Branch and the National Cancer Institute's Community Cancer Center Program. Potential preanalytic variables were identified and ranked along with available supporting evidence, definitions, and potential negative effects if the variable was not attached to the biospecimen. Additional national and international stakeholders reviewed the draft manuscript., Results: The ranked listing of 170 preanalytic variables produced can be used as a guide for site-specific implementation into patient care and/or research biorepository processes. Conclusions.-In our collective experience, it is often difficult to choose which of the many preanalytic variables to attach to any specific set of biospecimens used for patient care and/or research. The provided ranked list should aid in the selection of preanalytic variables for a given biospecimen collection.

The 1st Puerto Rico Biobanking Workshop took place on August 20st, 2014 in the Auditorium of the Comprehensive Cancer Center of the University of Puerto Rico, Medical Sciences Campus in San Juan Puerto Rico. The program for this 1-day, live workshop included lectures by three biobanking experts, followed by presentations from existing biobanks in Puerto Rico and audience discussion. The need for increasing biobanking expertise in Puerto Rico stems from the fact that Hispanics in general are underrepresented in the biobanks in existence in the US, which limits the research conducted specifically to understand the molecular differences in cancer cells compared to other better studied populations. In turn, this lack of information impairs the development of better diagnostic and therapeutic approaches for our population. Dr. James Robb, M.D., F.C.A.P., consulting pathologist to the National Cancer Institute (NCI) and the Office of Biorepositories and Biospecimen Research (OBBR), opened the workshop with a discussion on the basic aspects of the science of biobanking (e.g., what is a biobank; its goals and objectives; protocols and procedures) in his talk addressing the importance of banking tissues for advancing biomedical research. Next, Dr. Gustavo Stefanoff, from the Cancer Institutes Network of Latin America (RINC by its name in Spanish), explained the mission, objectives, and structure of the Network of Latin-American and Caribbean Biobanks (REBLAC by its name in Spanish), which despite limited resources and many challenges, currently accrue high quality human tissue specimens and data to support cancer research in the region. Dr. Robert Hunter-Mellado, Professor of Internal Medicine, Universidad Central del Caribe, followed with an examination of the ethical and regulatory aspects of biobanking tissues for future research, including informed consent of subjects; protection of human subjects rights; and balancing risks and benefit ratios. In the afternoon, the directors of existing biobanks in Puerto Rico (the Puerto Rico Biobank, the Comprehensive Cancer Center biobank, and an HIV-focused biobank at Universidad Central del Caribe) presented their experiences and challenges with establishing biobanks for research in Puerto Rico. In sum, this workshop presented opportunities to share knowledge in the science of biobanking, for further training, and of networking among the participants (34 from 4 different institutions), which will strengthen the collaborative links between investigators studying cancer in Latin America, the Caribbean, and the US.

This article provides a thorough discussion of the proposed DSM-5 changes and their implications for current and future approaches to assessment, identification, and service delivery for children and adolescents with ADHD. Educational and clinical implications are discussed with special attention to the individual impact of the changes, diagnostic prevalence rates, and associated societal costs. Developmental period is considered as an important factor in the potential impact of the DSM-5 changes. The authors conclude that the DSM-5 proposed revisions may improve diagnostic sensitivity and specificity; yet the overall impact of these changes remains largely unknown as many were not empirically validated. The authors suggest that the cumulative impact of the set of changes be considered when finalizing the DSM-5 revisions.

Pathologists have long served as custodians of human biospecimens collected for diagnostic purposes. Rapid advancements in diagnostic technologies require that pathologists change their practices to optimize patient care. The proper handling of biospecimens creates opportunities for pathologists to improve their diagnoses while assessing prognosis and treatment. In addition, the growing need for high-quality biorepositories represents an opportunity for community pathologists to strengthen their role within the health care team, ensuring that clinical care is not compromised while facilitating research. This article provides a resource to community pathologists learning how to create high-quality biorepositories and participating in emerging opportunities in the biorepository field. While a variety of topics are covered to provide breadth of information, the intent is to facilitate a level of understanding that permits community pathologists to make more informed choices in identifying how best their skills and practice may be augmented to address developments in this field.

The purpose of this study was to examine and monetize the educational outcomes of students with ADHD. Data were examined from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of children diagnosed with ADHD in childhood and recontacted for follow-up in adolescence and young adulthood. A comprehensive educational history was obtained for all participants from Kindergarten through 12 th grade. Annual economic impact was derived from costs incurred through special education placement, grade retention, and disciplinary incidents. Results indicated that, as compared to students without ADHD, students with ADHD incurred a higher annual cost to the U.S. Education system. Specifically, a student with ADHD incurred an average annual incremental cost to society of $5,007, as compared to $318 for students in the comparison group. These results suggest that prevention and intervention strategies are greatly needed to offset the large financial impact of educating youth with ADHD.

Objective: To characterize the late adolescent and young adult outcomes of girls diagnosed with ADHD in childhood., Method: The study included 58 women from a larger longitudinal study of ADHD. A total of 34 (M = 19.97 years old) met DSM criteria for ADHD in childhood, whereas the remaining 24 (M = 19.83 years old) did not. Self- and parent-reports of psychopathology, delinquency, interpersonal relationships, academic achievement, job performance, and substance use were collected., Results: The findings suggest that girls with ADHD experience difficulties in late adolescence and young adulthood, such as more conflict with their mothers, being involved in fewer romantic relationships, and experiencing more depressive symptoms than comparison women. However, differences did not emerge in all domains, such as job performance, substance use, and self-reported ADHD symptomatology., Conclusion: The findings of this study add to the literature on the negative late adolescent and young adult outcomes associated with childhood ADHD in women.

The current study examined treatment preferences of 183 parents of young (average age = 5.8 years, SD = 0.6), medication naive children with ADHD. Preferences were evaluated using a discrete choice experiment in which parents made choices between different combinations of treatment characteristics, outcomes, and costs. Latent class analysis yielded two segments of parents: (a) medication avoidant parents constituted 70.5% of the sample whose treatment decisions were strongly influenced by a desire to avoid medication, and (b) outcome oriented parents constituted 29.5% of the sample whose treatment decisions were most influenced by a desire for positive treatment outcomes. Parents in the outcome oriented segment were more stressed and depressed, had lower socioeconomic status and education, were more likely to be single parents, and had more disruptive and impaired children. Simulations predicted that parents would prefer treatments with behavior therapy over treatments with stimulant medication only.

Objectives: This study examines the tolerability and efficacy of methylphenidate (MPH) and behavior modification therapy (BMOD) in children with attention-deficity/hyperactivity disorder (ADHD) and severe mood dysregulation (SMD)., Methods: Children (ages 5-12) from a summer program for ADHD were screened for SMD and additional manic-like symptoms using structured assessments and direct clinical interview with the Young Mania Rating Scale (YMRS). The SMD group was comprised of 33 subjects with SMD and elevated YMRS scores (mean = 23.7). They underwent weekly mood assessments plus the daily ADHD measures that are part of the program. The comparison group (n = 68) was comprised of the rest of the program participants. Using a crossover design, all subjects in both groups were treated with three varying intensities of BMOD (no, low, high) each lasting 3 weeks, with MPH dose (placebo, 0.15 mg/kg t.i.d., 0.3mg/kg t.i.d., and 0.6 mg/kg t.i.d.) varying daily within each behavioral treatment., Results: Groups had comparable ADHD symptoms at baseline, with the SMD group manifesting more oppositional defiant disorder/conduct disorder (ODD/CD) symptoms (p < 0.001). Both groups showed robust improvement in externalizing symptoms (p < 0.001). There was no evidence of differential treatment efficacy or tolerability. Treatment produced a 34% reduction in YMRS ratings in SMD subjects (p - 0.001). However, they still exhibited elevated YMRS ratings, more ODD/CD symptoms (p < 0.001), and were more likely to remain significantly impaired at home than non-SMD subjects (p < 0.05)., Conclusions: MPH and BMOD are tolerable and effective treatments for children with ADHD and SMD, but additional treatments may be needed to optimize their functioning.

Using a cost of illness (COI) framework, this article examines the economic impact of attention-deficit/hyperactivity disorder (ADHD) in childhood and adolescence. Our review of published literature identified 13 studies, most conducted on existing databases by using diagnostic and medical procedure codes and focused on health care costs. Two were longitudinal studies of identified children with ADHD followed into adolescence. Costs were examined for ADHD treatment-related and other health care costs (all but 1 study addressed some aspect of health care), education (special education, 2 studies; disciplinary costs: 1 study), parental work loss (2 studies), and juvenile justice (2 studies). Based on this small and as yet incomplete evidence base, we estimated annual COI of ADHD in children and adolescents at $14,576 per individual (2005 dollars). Given the variability of estimates across studies on which that number is based, a reasonable range is between $12,005 and $17,458 per individual. Using a prevalence rate of 5%, a conservative estimate of the annual societal COI for ADHD in childhood and adolescence is $42.5 billion, with a range between $36 billion and $52.4 billion. Estimates are preliminary because the literature is incomplete; many potential costs have not been assessed in extant studies. Limitations of the review and suggestions for future research on COI of ADHD are provided.

First-hand knowledge of the detection of the first bioweapon in modern United States history is described in this article. The method by which the presumptive diagnosis of anthrax meningitis was made within 13 hours of the patient presenting to the emergency department is described using pre-analytic, analytic, and post-analytic phases. The lessons learned from this process are briefly presented so that other laboratories may learn from our experience: how to prepare; how to quickly analyze a potential bioweapon; how to communicate with staff and local, regional, and national authorities; and how to deal with disruptive media attention.

This study determined whether the interval from estrus to ovulation was altered by giving P.G. 600 to sows at weaning. Mixed-parity sows received P.G. 600 i.m. (n = 72) or no treatment (n = 65) at weaning (d 0). Beginning on d 0, sows were observed for estrus twice daily. At the onset of estrus and thereafter, ultrasound was performed twice daily to determine the average size of the largest follicles and time of ovulation. Weaning age (20.1+/-0.4 d) did not differ (P > 0.10) between treatments. More P.G. 600 sows expressed estrus within 8 d (P < 0.01) than controls (94.4% vs 78.4%, respectively). Parity was associated with expression of estrus (P < 0.02), with 78% of first-parity and 93% of later-parity sows exhibiting estrus. However, no treatment x parity effect was observed (P > 0.10). The interval from weaning to estrus was reduced (P < 0.0001) by P.G. 600 compared with controls (3.8+/-0.1 d vs 4.9+/-0.1 d). Follicle size at estrus was not affected by treatment (P > 0.10). The percentage of sows that ovulated did not differ (P > 0.10) for P.G. 600 and control sows (90.3% vs 81.5%, respectively). Time of ovulation after estrus was not affected by treatment and averaged 44.8 h. However, univariate analysis indicated that the interval from weaning to estrus influenced the interval from estrus to ovulation (r = 0.43, P < 0.0001). Further, multivariate analysis showed an effect of treatment on the intervals from weaning to estrus, weaning to ovulation (P < 0.0001), and estrus to ovulation (P < 0.04). Within 4 d after weaning, 81% of the P.G. 600 sows had expressed estrus compared with 33% of controls. However, this trend reversed for ovulation, with only 35% of P.G. 600 sows ovulating by 36 h after estrus compared with 40% of controls. The estrus-to-ovulation interval was also longer for control and P.G. 600 sows expressing estrus < or = 3 d of weaning (45 h and 58 h, respectively) than for sows expressing estrus after 5 d (39 h and 32 h, respectively). Farrowing rate and litter size were not influenced by treatment. However, the interval from last insemination to ovulation (P < 0.02) indicated that more sows farrowed (80%) when the last insemination occurred at < or = 23 to > or = 0 h before ovulation compared with insemination > or = 24 h before ovulation (55%). In summary, P.G. 600 enhanced the expression of estrus and ovulation in weaned sows but, breeding protocols may need to be optimized for time of ovulation based on the interval from weaning to estrus.

The effects of s.c. and i.m. administration of P.G. 600 on estrual and ovulatory responses of prepubertal gilts were investigated. One hundred eighty-four crossbred gilts between 159 and 174 d of age were assigned to receive P.G. 600 s.c. (s.c. P.G. 600) in the flank, P.G. 600 i.m. in the neck (i.m. P.G. 600), or no treatment (control). At the beginning of the study (d 0), animals were selected from a modified, open-front barn, regrouped, relocated to new pens, and exposed once daily to a mature boar to check for estrus. On d 17, ovaries were collected from all gilts and analyzed for the presence of corpora lutea (CL), cystic follicles, and cystic CL. A higher proportion of gilts expressed estrus with s.c. P.G. 600 (76%) than with i.m. P.G. 600 (52%, P < .01) or controls (15%, P < .01). The interval from initiation of treatment on d 0 to estrus was reduced (P < .01) by P.G. 600 (4.6 d) compared to controls (5.9 d), but there was no significant difference between P.G. 600 treatments. Both s.c. P.G. 600 (86%) and i.m. P.G. 600 (77%) induced more gilts to ovulate (P < .01) than controls (18%), but there was no significant difference between P.G. 600 treatments. No significant effect of treatment was detected on number of CL (17.9), number of cystic follicles (1.5), or number of cystic CL (2.1). Proportions of gilts that developed cystic follicles or cystic CL were not influenced by treatment. Results of this study indicated that s.c. administration of P.G. 600 significantly improved the induction of estrus in prepubertal gilts compared to i.m. administration.

Precise quantitation of apoptotic cells in solid tumors is necessary to determine the role of apoptosis in cancer growth, prognosis, and treatment. In this study, the intensity of apoptotic death was determined in 91 breast carcinomas with a novel cellular marker of apoptosis based on the staining of histological sections with a monoclonal antibody (MAb) to single-stranded DNA. Staining of apoptotic cells with the MAb reflected the decreased thermal stability of DNA induced by the digestion of nuclear proteins, as demonstrated by the elimination of staining in sections reconstituted with histones before heating. The high sensitivity and specificity of apoptosis analysis with the MAb is based on the central role of protease activation in the mechanism and control of apoptosis. Apoptotic indexes (AIs) in breast carcinomas ranged between 0 and 46%. Most of the carcinomas had relatively low AIs, whereas 29 cases were classified as carcinomas with intensive apoptosis (AI >/= 10%). The high level of apoptotic cell death was associated with negative immunostaining for bcl-2 protein, the loss of estrogen and progesterone receptors, high proportion of cells in S-phase, and increased risk of lymph node metastases. There was no correlation between AI and tumor size or p53 immunostaining. Lymph node metastases were detected in 59% of patients with high levels of apoptosis in primary carcinomas and in only 21% of patients with AIs below 10% in primary carcinomas. Thus, the high sensitivity of the MAb assay made it possible to identify a subset of breast carcinomas with intensive apoptosis and markers of poor prognosis. These results demonstrate that the measurement of apoptosis in breast carcinomas provides valuable prognostic information.

The most widely used histochemical marker of apoptosis (in situ end labeling, TUNEL) detects both apoptotic and necrotic cells and evaluates only late stages of apoptosis. Hence, a specific and sensitive cellular marker of apoptosis is needed to determine the role of apoptotic death in biology and pathology. The present study describes a novel immunohistochemical procedure for the staining of apoptotic cells using a monoclonal antibody (MAb) to single-stranded DNA. This MAb stained all cells with the morphology typical of apoptosis in etoposide-treated HL-60, MOLT-4, and R9 cell cultures, in which apoptosis was accompanied by high, moderate, and low levels of internucleosomal DNA fragmentation, respectively. TUNEL stained all apoptotic cells in HL-60 cultures, nearly 60% of apoptotic cells in MOLT-4 cultures, and only 14% of apoptotic cells in R9 cultures. Apoptotic R9 cells, which progressed into secondary necrosis, retained MAb staining and became TUNEL-positive. Necrotic cells in MOLT-4 cultures treated with sodium azide were stained by TUNEL, but were negative for MAb staining. All floating cells at a late stage of apoptosis in MDA-MB-468 cultures treated with cisplatin were stained by both MAb and TUNEL. However, among adherent cells in the early stages of apoptosis, MAb stained nearly 20 times more cells than TUNEL. In histological sections of human tumor xenografts, MAb detected clusters of apoptotic cells in viable tumor tissue, but did not stain cells in areas of central ischemic necrosis. In contrast, TUNEL stained nuclei in necrotic areas. Thus, MAb to single-stranded DNA is a specific and sensitive cellular marker of apoptosis, which differentiates between apoptosis and necrosis and detects cells in the early stages of apoptosis.

We report application of a novel immunohistochemical procedure for the staining of apoptotic (AP) cells in paraffin sections using monoclonal antibody (MAb) to single-stranded DNA. MAb differentiated between apoptosis and necrosis and in contrast to in situ end labelling specifically stained only AP cells. AP carcinoma cells stained with the antibody were detected in 32 of 58 infiltrating human breast carcinomas and in 9 of 15 colon adenocarcinomas. Stromal cells stained with the MAb were observed in all carcinomas, including those in which no AP carcinoma cells were detected. There was a strong positive correlation between the presence of AP cells, loss of hormone receptors and a high proliferation rate in breast carcinomas. AP cells were present in 80-87% of receptor-negative carcinomas, while most of receptor-positive breast carcinomas did not contain AP cells. Apoptosis in tumor cells was detected significantly more frequently among breast carcinomas with high, than among carcinomas with low S-phase fraction. AP cells were present in 93-95% of breast carcinomas which were receptor-negative and had a high S-phase fraction. Immunostaining demonstrated a strong positive correlation between the loss of bcl-2 protein and intensive apoptosis in breast carcinomas. Association between apoptosis and markers of poor prognosis in breast cancer (loss of hormone receptors, intensive proliferation, loss of bcl-2 protein) indicates that apoptotic cell death is typical of more aggressive carcinomas.

Objective: To evaluate current laboratory practices and rates for atypical squamous cells of undetermined significance (ASCUS), a category of epithelial cell abnormality in the Bethesda System., Design: Questionnaire surveys were mailed in December 1993 and March 1994., Setting: Cytopathology laboratory participants in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology (PAP)., Results: Most responding laboratories (82.5%) limited the use of "atypia" terminology to abnormalities of undetermined significance. Nearly half of the laboratories employed only the term ASCUS for squamous epithelial changes in this category. The median rate of ASCUS in 1993 was 2.8%, with 10% of laboratories reporting rates greater than 9.0%. The median squamous intraepithelial lesion rate was 2.0%, with a median ASCUS-squamous intraepithelial lesion ratio of 1.3. The majority of laboratories qualified a portion of ASCUS cases and issued recommendations for follow-up when appropriate. Fifty-six percent of laboratories surveyed included patients diagnosed with ASCUS in follow-up programs. Laboratories estimated that about 20% (median response) of patients with ASCUS smears had a squamous intraepithelial lesion or equivalent diagnosis made within a year's follow-up., Conclusions: The ASCUS category is used by the majority of laboratories as recommended by the Bethesda System, but reporting rates vary. The results of this survey and associated surveys provide laboratories with useful benchmark figures for interlaboratory comparison of ASCUS practices.

Breast cancer cells are relatively resistant to the induction of apoptosis (AP) and drug regimens which readily activate apoptotic death, may enhance the antitumor effect. Rapid and intensive induction of apoptosis was observed in estrogen receptor positive and negative breast cancer cell cultures treated with tamoxifen (TMX) combined with the calmodulin antagonists trifluoperazine (TFP) or W7. TMX (1-5 microM) alone or calmodulin antagonists alone did not induce apoptosis. Importantly, intensive apoptosis was also induced by TMX and TFP in the cells obtained from primary human breast carcinomas. Inhibition of the Ca2+ calmodulin signaling pathway is an effective way to activate apoptotic death in epithelial cells. Combination of TMX with non-toxic calmodulin inhibitors may increase the preventive and therapeutic effects of TMX.

Various reports draw attention to the deficiency of services available for critically ill children. In December 1993 the British Paediatric Association published a report by a multidisciplinary working party on intensive care. The Minister of Health has apparently promised to act on the recommendations the working party made. In fact, purchasers are being encouraged to act and ask questions about the provision of paediatric intensive care--but no extra funding is available to provide it. However, this will all take time and until more resources are available children are still being cared for on adult intensive care units by nurses who may not be experienced in caring for sick children. One of the main areas of concern nurses have when caring for children is the physiological differences between an adult and a child. This paper is designed to assist in identifying the differences and consequent nursing implications. In an attempt to prioritize the nursing care a systems/modified model has been used over 2 papers. The review of the systems demonstrates the differences between adults and children and, where possible, highlights the nursing care and medical treatment a child requires. All aspects of care have been included as well as the psychological problems (see Part 2 which will be published in the next issue) encountered by the family of a critically ill child. Where possible easy reference tables have been included and the author hopes to introduce the package into the existing orientation programme for established staff and staff new to the unit in the hopes of decreasing the stress when a child is admitted. Paediatric resuscitation has not been covered intentionally, as the information on the physiological differences seemed to grow like 'Jack's beanstalk'. Therefore, a flow chart for basic and advanced life support is included as an appendix in Part I. It is hoped this will stimulate readers' interest for more in-depth study.

The antigen reactive with murine monoclonal antibody (MAb) KS1/4 is expressed on epithelial malignancies and some normal epithelial tissues. Studies were undertaken to evaluate KS1/4-methotrexate (KS1/4-MTX) immunoconjugate in patients with advanced non-small cell carcinoma of the lung. Eleven patients in two different groups received KS1/4-MTX in two different escalating dose infusion schedules with a maximal tolerated dose of 1,750 mg/M2 and a cumulative dose of MTX of 40 mg/M2. Toxicities were similar in both groups and included fever, anorexia, nausea, vomiting, diarrhea, abdominal pain, guaiac positive stool, and hypoalbuminemia. Two patients had an associated aseptic meningitis. One patient had a 50% decrease in two lung nodules without a change in lymphangitic infiltrates. This patient received a second course of treatment and developed an immune complex-mediated arthritis and serum sickness. Four patients mounted a human antimouse antibody response. Post-treatment tumor biopsies documented binding of MAb KS1/4. These studies document the feasibility and potential usefulness of a MAb directed against tumor-associated antigens with the targeting of chemotherapeutic drugs in patients with non-small cell lung carcinoma.

Nursing staff new to intensive care can often be apprehensive when observing, recording and interpreting ventilator observations. This review of ventilation and the necessary observations involved offers a description of the observations performed, with a problem-solving approach to cause, rationale and possible action that may be required. Calculations related to spontaneous and mechanical respiratory function are discussed, with recommendations for individual requirements. Explanation of available settings, demonstrating the functions and delivery methods of different ventilators is included, and a discussion on alarm settings and rationale. For the purpose of assessing the ventilatory support in use there is a guide to interpretation of arterial blood gases with suggestions and rationale for necessary changes of parameters.

Histological analysis remains the primary method of distinguishing between small cell (SCLC) and non-small cell lung cancer (NSCLC). This distinction has significant impact therapeutically because of their relative difference in chemoresponsiveness (J.D. Minna et al., Principles and Practice of Oncology, pp. 396-474, 1981). Yet for at least 10% of lung tumors, pathologists will disagree upon the classification (A.R. Feinstein et al., Am. Rev. Respir. Dis., 101: 671-684, 1970). Furthermore, current neuroendocrine markers lack specificity for SCLC although the presence of these markers may help predict chemosensitivity (S.L. Graziano et al., J. Clin. Oncol., 7: 1375-1376, 1989; S.B. Baylin, J. Clin. Oncol., 7: 1375-1376, 1989; C.L. Berger et al., J. Clin. Endocrinol. Metab., 53: 422-429, 1981; A.F. Gazdar et al., Cancer Res., 45: 2924-2930, 1985). In vitro growth characteristics may more accurately reflect biological properties of aggressiveness and susceptibility to chemotherapy. In this study, 3-dimensional gel-histoculture was used to retrospectively distinguish between NSCLC and SCLC. Tumor explants from 78 patients with NSCLC and 13 patients with SCLC were grown in gel-supported histocultures with an overall success rate of 92%. These 2 tumor types were distinguishable by their 3-dimensional in vitro tissue architecture. In addition, proliferation rates were measured by histological autoradiography after 4-day incorporation of [3H]dThd. The percentage of cells labeled in the most proliferatively active regions of the autoradiograms was termed the growth fraction index (A.F. Gazdar et al., Cancer Res., 45: 2924-2930, 1985; R.A. Vescio et al., Proc. Natl. Acad. Sci. U.S.A., 84: 5029-5033, 1987; R.M. Hoffman et al., Proc. Natl. Acad. Sci. U.S.A., 86: 2013-2017, 1989). The mean growth fraction index for pure small cell lung cancer was 79 +/- 10%, differing markedly from that of 35 +/- 19% for mixed small cell/large cell tumors, adenocarcinoma (38 +/- 16%), large cell undifferentiated carcinoma (40 +/- 18%), and squamous cell carcinoma (33 +/- 15%) (P less than 0.001 in each case). We therefore conclude that 3-dimensional gel-histoculture is a useful means of distinguishing pure SCLC from NSCLC, which may improve treatment decision making.

Molecular biology provides analytical tools for the study of human disease. These clinical assays can help make a diagnosis, predict a prognosis, or elucidate the pathogenesis of poorly understood diseases. The detection and/or quantitation of specific genes, messenger RNA's, and their protein products provide diagnostic and prognostic information for physicians. Illustrative applications of some of these techniques in human virus infection and breast cancer will suggest the future direction that an anatomic pathology laboratory should consider if it is to provide optimal and competitive service to physicians.

A Phase Ia clinical trial was undertaken to evaluate and compare murine monoclonal antibody KS1/4 and KS1/4-methotrexate immunoconjugate in patients with Stage IIIB or IV non-small cell carcinoma of the lung. Six patients received KS1/4 alone and five patients received KS1/4-methotrexate conjugate. The maximal total dose received per patient in both groups was 1661 mg. Mild to moderate side effects in both groups included fever, chills, anorexia, nausea, vomiting, diarrhea, anemia, and brief transaminasemia. One patient who received antibody alone had an apparent acute immune complex-mediated reaction. Ten of 11 patients had a human anti-mouse response. Posttreatment carcinoma biopsies revealed binding of monoclonal antibody KS1/4 and deposition of C3d and C4c complement fragments. Monoclonal antibody binding and complement deposition correlated with increasing doses of infused antibody. There was one possible clinical response.

There is a need for individualization of all aspects of cancer therapy. Because of significant heterogeneity within a tumor class, there is a need to develop an in vitro test to accurately gauge tumor aggressiveness. Such a measurement would greatly aid treatment decision making. Current methodologies such as flow cytometry, which lacks unambiguous interpretation of cell-proliferative data, and determination of the thymidine-labeling index, which measures nucleotide uptake in a nonphysiological state, have not reproducibly attained this goal. We have developed an in vitro native-state three-dimensional gel-supported histoculture system that allows the growth of all human solid tumor types for relatively long time periods. The native-state system was used to identify the percent of cells capable of incorporating [3H]thymidine over a 4-day period, which we term the growth fraction index (GFI). We have compared the ability of cancer tissue to proliferate in native-state culture to the stage and histological grade of four major types of human carcinomas: breast, ovarian, colon, and lung. Eighty percent of tumor explants could be evaluated, even when sent from across the country. We have determined that the GFI correlates with tumor stage and grade for breast and ovarian carcinoma. In colon carcinoma, there is a trend toward higher GFIs in tumors of more advanced stage and grade. In non-small cell lung carcinomas, GFI, stage, and grade do not correlate. These results suggest the applicability of gel-supported three-dimensional native-state histoculture for prognostic purposes in patients with breast and ovarian cancers and demonstrate the clinical relevance of the native-state histoculture system.

Two cases of lethal carcinoid neoplasia that involved unusual polypoid intraperitoneal metastases rather than the usual flat, sclerotic foci are reported. This type of intraperitoneal polypoid carcinomatosis should alert both the surgeon and pathologist to the possibility of carcinoid neoplasia.

Simian virus 40 (SV40) induces cell division in microcultures of sparsely plated nongrowing mouse BALB/3T3 cells during acute infection at moderate multiplicities of infection (MOI = 10-100). The infected cells are killed when a MOI of 1,000 is used. SV40 tumor (T) antigen is synthesized in the infected cells, but viral DNA, virion antigen, and progeny virions are not synthesized (abortive infection). The addition of exogenous dibutyryl adenosine 3'-5'-monophosphate (dbcAMP) at the time of infection stimulates the SV40-induced cell division at all MOI and inhibits SV40-induced cell death at high MOI. The percentage of T antigen-positive cells, as monitored by immunofluorescence, is also increased by the addition of dbcAMP at the time of infection. This regulation of SV40-induced cell division and T antigen formation by exogenous dbcAMP occurs within the first 6 hr after infection at 37 degrees C and is dependent upon both the MOI and the concentration of added dbcAMP. The addition of dbcAMP to productively infected TC7 monkey cells has litte effect on the SV40-induced cell death or T antigen formation.

We have used immunofluorescence in parallel with transmission and scanning electron microscopy to characterize the unusual cytoplasmic and nucleolar accumulation of Simian virus 40 (SV40) virion protein (C antigen) at restrictive temperatures (39 to 41 C) in monkey cells infected with a temperature-sensitive mutant of SV40 defective in virion assembly, tsB11. Cytoplasmic and nucleolar accumulation of C antigen did not occur in wild-type-infected cells at any temperature. Wild-type- and tsBll-infected cells were not distinguishable at 33 C by immunofluorescence or electron microscopy. Temperature-shift experiments using metabolic inhibitors of DNA (cytosine arabinonucleoside, 20 mug/ml), RNA (actinomycin D, 5 mug/ml), and protein synthesis (cycloheximide, 2 x 10(-4) to 10 x 10(-4) M) were used to investigate the requirements for ongoing DNA, RNA, and protein synthesis in the distribution of virion protein between the nucleus, nucleolus, and cytoplasm. The transport of C antigen from the nucleolus and cytoplasm into the nucleus was complete after a temperature shift-down (41 and 39 to 33 C). Limited virus particle formation occurred after the shift-down in the presence of actinomycin D and cycloheximide, indicating some of the 39 to 41 C synthesized virion protein could be used for capsid assembly at 33 C in the absence of further virion protein synthesis. Nucleolar and cytoplasmic accumulations of C antigen occurred in the absence of drugs after a shift-up (33 to 39 C and 41 C) indicating a continuous requirement for the tsB11 mutant function. Furthermore, the virion protein synthesized at 33 C remained confined to the nucleus when the cells were shifted to 39 and 41 C in the presence of actinomycin D or cycloheximide. In the presence of cytosine arabinonucleoside, however, the virion protein accumulated in large aggregates in the nucleus and nucleolus after the shift-up, but did not migrate into the cytoplasm as it did in drug-free tsB11-infected control cells. Colchicine (10(-3) M) had no effect on the abnormal accumulation of C antigen during shift-up or shift-down experiments suggesting that microtubular transport plays little if any role in the abnormal transport of tsB11 virion protein from cytoplasm to nucleus. Although virus particles were never observed by electron microscopy and V antigen was not detected by immunofluorescence at 39 or 41 C in tsB11-infected cells, dense amorphous accumulations were formed in the nucleoli and cytoplasm. We suggest that the tsB11 function is continuously required for the normal transport of SV40 virion protein between the cytoplasm, nucleolus, and nucleus and for the assembly of capsids and virions. Several possible mechanisms for the altered tsB11 function or protein are discussed. One of the virion proteins may also be involved in some presently undetermined nucleolar function during SV40 productive infection.