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Complement activation by Cuprophan hemodialysis membranes has been linked to a variety of pathological sequelae (neutropenia and various cardiopulmonary manifestations) seen in the clinical setting. The modification of reactive surface hydroxyl groups on regenerated cellulose with various dicarboxylic-acid anhydrides has been found to significantly limit the complement-activating potential of these materials. Of the anhydrides tested, maleic anhydride appears to display the most dramatic and consistent diminution of complement activation compared to unmodified cellulose (0-10% of control values for C3b deposition and C3a/C5a production). Current evidence suggests that this maleated derivative facilitates the factor-H control of C3 and C5 convertase activity and thus may help limit complement activation by normal regulatory mechanisms. In addition, this modification may help limit the production of other inflammatory mediators that may result in diminished levels of cellular activation.

The kinetics of formation of granulocytic colonies on macrophage-coated cellulose acetate membranes (CAM) were investigated in Sl/Sld mice, which have a genetic defect in their hematopoietic microenvironment. CAM were left in the peritoneal cavity of mice for 7 days to become coated with peritoneal cells. The mice were then sublethally irradiated to suppress endogenously derived granulocytic colonies, and bone marrow cells were injected i.p. within 1--2 hr irradiation. During the next 7 days, peroxidase-positive granulocytic colonies appeared on CAM. The number of colonies on CAM in Sl/Sld mice at 7 days was consistently less than that from littermate +/+ mice. Since it appeared that the CAM in the Sl/Sld provided an inferior microenvironment to that of the +/+, the effect of raising a CAM in one genotype and transferring it to another was investigated. CAM raised in +/+ or in Sl/Sld were transferred to an irradiated +/+ or Sl/Sld following which cells were injected into the secondary host and colonies determined subsequently. The number of granulocytic colonies on CAM was influenced primarily by the type of secondary host. Colony number was consistently less in the secondary Sl/Sld host than in the +/+ host whether the primary host was a Sl/Sld or a +/+. These observations confirm the concept of a microenvironmental defect in Sl/Sld mice. In addition, the studies indicate that the microenvironment on a CAM can be modified by a secondary host and suggest that "remodeling" of CAM may be a continuous, kinetic process.

Human leukemias and related diseases appear to be clonal in nature. In certain diseases, the initial cell involved is most likely the totipotential hematopoietic stem cell (HSC), i.e., the stem cell capable of giving rise to all hematopoietic cells, lymphoid as well as myeloid. In other diseases, an HSC of more restricted potentiality may be the primary cell producing the disease but, alternatively, all could arise from the totipotential cell. Cells in the clone are often identifiable by the presence of morphologic or chromosomal abnormalities, but in a given clone all cells may not express the abnormalities. In some but not in all patients who have been studied, residual normal HSC have been detected that are not part of the clone. Our current therapeutic attempts designed to cure at least some of these diseases are based on the concept of "total cell kill.' In order to achieve this goal, the clone of tumor cells must be eradicated. To monitor this attempt and carry out therapy in a more scientific fashion, better means of identifying all cells in the clone are needed. If the disease involves the totipotential HSC, for which we assume there is no precursor cell in postfetal life, then there must be residual, normal HSC or the disease cannot be eradicated in this manner without also eradicating the patient.

Hospitalized patients were studied prospectively in an attempt to determine whether idiopathic eosinopenia in the absence of other major changes in blood cells is rare or is more frequent than is commonly recognized. Strict criteria for eosinopenia were used; patients with more than 10.0 X 10(9)/liter total leukocyte count, or less than 4.0, as well as those with any form of hematologic cancer, or those receiving any form of cancer chemotherapy, were excluded from the study. With those criteria and exclusions, only 24 patients with eosinopenia were found among 24,300. Twenty were receiving some form of adrenal glucocorticosteroid (steroid) and of the other four, three had serious organic diseases for which they were receiving various drugs. The remaining patient, whose primary problem was depression, could have had drug-induced eosinopenia. Thus, unexpected eosinopenia appears to be a very rare event or syndrome. A normal range for eosinophils was defined from studies of 740 medical students, which was 0.015 to 0.65 X 10(9)/liter and was quite similar to previously reported values. The effect of acute or chronic steroid administration on eosinophils in normal human subjects was studied. Confirming studies reported for man and many other mammals, eosinopenia developed promptly, but disappeared within hours unless repeated doses were given. Literature on various types of eosinopenia was reviewed.

A patient with fairly typical chronic neutrophilic leukemia, as represented by some two dozen such reported cases, had been given Thorotrast more than 20 years before. Typical myeloblastic crisis developed with remarkable terminal leukocytosis. Mature blood neutrophils had normal function with respect to phagocytosis, bacterial killing, metabolic activation, and chemotactic response. The number of cells producing colonies of neutrophils and monocytes in in vitro semisolid cultures was normal in the blood and increased in marrow. Colony size was smaller than is usually observed in normal patients or in typical patients with chronic myeloid leukemia. Termination in blast crisis, also seen in a few other patients with chronic neutrophilic leukemia, indicates that this is indeed a form of leukemia and not a "leukemoid" reaction of obscure cause. The differential diagnosis of extreme neutrophilia is discussed.

Hematocrits were studied in 471 children aged 11, 12, or 13 years who resided in an affluent suburb of Pittsburgh. It was found that different microhematocrit machines gave slightly different results, so all values were corrected to a reading that would have been obtained using a Wintrobe hematocrit tube. A true Gaussian curve was obtained, suggesting that these children are a valid source of "normal" values. Mean hematocrit was 43%, with 95% confidence limits of 39 to 47%, and was the same for boys and girls. These are slightly higher values than usually are accepted as normal for this age group, and for the girls, values are comparable to those of women. A group of 220 black children of the same age who participated in a sickle-cell screening program had comparable mean hematocrits, but the distribution curve was skewed, suggesting that a small but significant number were anemic.

This study was designed to determine the effect of methylcellulose (MC)-induced reticuloendothelial (RE) hypertrophy on neutrophils and hematopoietic stem cells and to contrast its overall hematologic effect in the mouse to the more frequently studied rat model. Mice were given MC 3 times/wk and studies were done at 2, 3, and 4 wk, with maximal hematologic change by 2 wk. A stable, but incompletely compensated hemolytic anemia developed which was accompanied by a significant shift of erythropoiesis from marrow to spleen. Thrombocytopenia developed as did neutrophilia, accompanied by an increased number of marrow neutrophil precursors. Extramedullary hematopoiesis was observed in the liver. The number of cells forming spleen colonies in irradiated recipients increased in the spleen but not in marrow. The number of cells producing granulocyte and macrophage colonies in semisolid media increased in spleen and marrow. Splenectomized mice, treated with MC, developed changes very similar to intact mice. Thus, it appears that all three major hematopoietic lines may be destroyed by the MC-hypertrophied RE system. The mouse differs from the rat in its hematologic response to MC by destroying cells in organs other than the spleen, by increasing neutrophil production, by developing hepatic hematopoiesis, and by developing all changes more rapidly.

Differences were seen in the relative importance of spleen and marrow in early erythroid regeneration of lethally irradiated mice given spleen or marrow cell transplants compared with that in sublethally irradiated mice with surviving endogenous hematopoietic cells. Radioactive iron uptake was predominantly in the spleen of mice with transplants and in the marrow of endogenously recovering mice. Visable spleen colony counts increased from day 4 to day 7 and plateaued through day 10 in the transplant system, but shoed a small abortive rise with a 5-day peak, followed by a steady increase from days 6 to 10 in the endogenous system. Comparisons of peroxidase-positive cells (granulocytes) in the marrow of femurs and humeri and iron uptake in marrow and spleen suggested that repopulation of the marrow and spleen were independent, while that of different areas of the marrow was interrelated. The interrelationship of the rate of marrow regeneration was closer in the endogenous than in the transplant system.

The marginal granulocyte pool (MGP) was measured by epinephrine infusion in normal and neutropenic subjects. Neutrophil response curves to doses of 0.025 to 0.3 mg. in three normal subjects indicated that maximal neutrophil response was achieved by 0.1 mg. In 21 normal subjects, absolute neutrophils increased from 700 to 3,100 per microliter. The percentage increase ranged from 18 to 107 per cent of baseline. The per cent increase tended to be greater with low-normal baseline neutrophils than with high-normal neutrophils, although this relationship was not observed when increase was determined in absolute values. In neutropenic patients mean per cent increase of neutrophils was greater than observed in normal subjects, 121 vs. 50 per cent. Although the increase expressed in absolute neutrophil numbers was less in subjects with lower baseline neutrophil concentrations, there was an inverse correlation between the baseline neutrophil concentrations, there was an inverse correlation between the baseline neutrophils and the per cent increment following epinephrine. Mean increase was 200 per cent in patients with less than 200 neutrophils per microliter, compared with 61 per cent in patients with 1,000 to 1,500 neutrophils per microliter. These results indicate that circulating granulocyte pool (CGP) size may be misleading with respect to total blood neutrophils and in a sense confirm the concept of shift neutropenia, a decreased CGP and MGP as neutropenia becomes more profound suggests that shift neutropenia may be a normal physiologic methanism rather than a distinct neutropenic syndrome.

Whether the hematocrit normally declines in the aged or whether such a decline represents inapparent disease in addition to aging is a matter of dispute. Female B6D2f1 mice were studied at ages 3, 13, or 27-28 months, and there was no difference in hematocrit between the younger groups. The hematocrit of 45 aged mice was slightly lower than that of 66 younger mice; mean 43% vs 49% (p less than .001). However, rather unexpectedly, the total red cell mass was not decreased in the aged; rather, the plasma volume was expanded. Survival of mature red blood cells did not differ significantly between young and aged mice. Mice were bled 0.4 ml from the orbital sinus for 4 days, reducing the hematocrit of all groups to a nadir of 20-25%. Recovery of hematocrit began more slowly in aged than in young mice. That this reflected a difference in erythropoiesis rather than a difference in plasma volume equilibration was suggested by studies with 59Fe. 59Fe was given following the second bleed, and 1 day later RBC 59Fe was more than twice as high in young mice than in groups of aged mice. Aged mice that did not appear healthy had been excluded. Aged mice were divided into a group with significant amounts of gray hair and/or patches of hair loss and two groups with normal-appearing hair; the latter was subdivided into those weighing less (25-26 g) or more (30-34 g) than most aged mice. Neither hair condition nor weight influenced hematocrit or response to bleeding. These results suggest, but do not prove, that a mild "dilutional" anemia and a blunted erythropoietic response to hemorrhage may be an expected part of the murine aging process.

A patient with idiopathic myelofibrosis of some 20 yr duration developed esophageal varices and ascites. No explanation for increased portal pressure other than hepatic hematopoiesis was found. Consequently, a trial of cobalt irradiation to the liver was undertaken with definite but transient decrease in ascites. Subsequently, two courses of radioactive colloidal gold were given, again with definite but transient beneficial effects on the degree of ascites. This latter benefit occurred without suppression of marrow function.

Extensive hepatic erythropoiesis, granulocytopoiesis and megakaryocytopoiesis occur in adult mice given methylcellulose (MC). This appears to be a compensatory response to MC induced hemolytic anemia and thrombocytopenia. The present study was undertaken to evaluate the effects of whole body irradiation (WBI) upon established hepatic hematopoiesis (HH) as well as its effect when given before the induction of HH. Established hepatic erythroid and granulocytic foci were significantly decreased 24 hours after 100 or 300 rads. The DO for erythroid and granulocytic foci was 107 +/- 10 rads and 95 +/- 20 rads respectively, similar to those reported for murine marrow and spleen cell CFUS. Megakaryocytes were more radioresistant, gradually declining over 7 days to 50% of control values following 100 rads and with a DO of 347 +/- 7 rads; suggesting a differential radiation sensitivity compared to erythroid and granulocytic foci. WBI, 100 and 300 rads, given before MC failed to prevent subsequent development of HH although both marrow and spleen responses were reduced. Hepatic granulocytic foci and marrow peroxidase positive cells were reduced by such treatment while erythroid and megakaryocytic foci were similar to controls. This suggests that irradiation damaged stem cells responded to MC with increased erythropoiesis and megakaryocytopoiesis at the expense of granulopoiesis.

The percentage of donor-host chimerism was determined 4-6 weeks or six months after injection of normal bone marrow cells into normal syngeneic or coisogeneic recipient mice. Donor-recipient pairs had chromosome markers that provided easy identification of metaphase cells. The percentage of donor cells in marrow or spleen ranged from 0 to 16% and this percentage was independent of the age of recipient or attempts to stimulate hematopoiesis in donor and/or host mice. In adult C57BL/6 mice there was a roughly linear dose-response relationship between cell dose and percentage of chimerism. There was no apparent dose-response relationship for AKR mice. The percentage of donor cells in the spleen was correlated to that seen in the marrow of recipients. Neonatal mice given the same intraperitoneal marrow cell dose as weanlings, but a larger number of cells relative to their own marrow mass, did not show a larger percentage of chimerism than weanlings. Similarly, weanlings given the same intravenous dose as adults showed no greater degree of chimerism than adults. Temporary anemia, induced by bleeding donors prior to cell collection, or more chronic hemopoietic stimulus (produced by injecting recipients with phenylhydrazine prior to cell injection with subsequent bleeding at intervals) did not result in an increased percentage of chimerism. These results indicate that there are "empty" sites in bone marrow of normal mice in which injected hematopoietic stem cells can lodge and grow.

Ten patients with diverse forms of carcinoma (six patients) and of cancer in the lymphoid system (four patients) presented with or subsequently had a syndrome resembling idiopathic thrombocytopenic purpura (ITP). These patients were older than patients who had ITP alone. ITP was coincident with a diagnosis of cancer (three patients), preceded a diagnosis of cancer (three patients) or followed a diagnosis of cancer (four patients). No patients responded to steroid therapy permanently. Therefore, the course of our patients was fairly typical of ITP in the adult. Since we found nine patients with cancer in a survey of 52 consecutive patients with ITP in the adult population admitted to one hospital, this diagnosis may be missed with some frequency; the development of thrombocytopenia being attributed to other causes.

Prescriptions for ferrous sulfate, 300 mg, were filled with eight different preparations by 15 pharmacies. Only three types of pills had a reasonably rapid dissolution time in acid media and these were all obtained from university-associated pharmacies. Some form of "slow release" or "enteric coat" feature was present in the pills and capsule supplied by private pharmacies and the Veterans Administration Hospital pharmacy. Adding the phrase "not enteric-coated" to the prescription effected no change in the type of pill supplied. Prices were highly variable, even for the same preparation, and although all generic pills were cheaper than brand-name pills, the "supermarket" type pharmacies charged as much or more for the pills as individually owned pharmacies.

Neutrophil production and distribution were studied in two families with autosomal dominantly inherited neutropenia to distinguish their illness from other neutropenic disorders. In addition to a reduced post-mitotic pool of bone-marrow neutrophils and neutrophil precursors, mitotic pool size was also reduced, ranging from 1.1 to 2.9 X 10(9) cells per kilogram (normal, 3.8 +/- 0.4 X 10(9) per kilogram). In vitro committed stem cells were reduced as well, ranging from 2 to 12/10(5) marrow cells (normal, 30 to 120/10(5)). In three patients neutrophil counts were observed to return to normal when they were adults. In one such subject studied, however, both the mitotic pool of neutrophil precursors and marrow committed stem cells were reduced. These abnormalities were in contrast to studies of a patient with chronic benign neutropenia of childhood and an infant with Kostmann-type congenital neutropenia, both of whom had increased marrow committed stem cells. These studies demonstrate several different mechanisms for production of neutropenia in these syndromes.

A macrophage cell coating covering a cellulose acetate disk was an effective microenvironment for the production of peroxidase-positive hematopoietic colonies. These developed after intraperitoneal injection of marrow cells with a linear cell relationship of dose to colonies formed. One colony formed for every 2,000 nucleated marrow cells injected. Observation of colony formation daily showed a steady increase in number and size until seven days after cell inoculation. X-irradiation (400 rads) eliminated intrinsic colony formation in BALB/c mice. Irradiation of the donor of the ip marrow cells resulted in a d0 of 95 rads. Treatment of the marrow donor with cytosine arabinoside had a suppressive effect on colony formation as did treatment of the host animal after receipt of the ip marrow. These results indicate that the precursor of the granulocytic colonies seen in the macrophage layers are more similar to committed granulocytic precursors than to the pluripotential stem cell.

Longitudinal studies of hematocrits were done in aging B6D2F1 female mice at 54, 64, 91, 105 and 115 weeks of age. A modest decline in hematocrit was observed in 41/42 mice; we have previously shown that the decreased hematocrit of aged as compared to young mice is due to an expansion of plasma volume. Mice which died spontaneously after 91 weeks had lower hematocrits at 91 weeks and 105 weeks than did those which survived to 115 weeks. At each time interval, a sub-group of mice was killed and uptake of 59Fe into blood, foreleg, spleen and liver was studied and total nucleated cells per humerus was determined. The results were generally compatible with the thesis that aging mice maintain normal rates of erythropoiesis under basal conditions. Thus, it would appear that a decrease in hematocrit can be considered an expected part of the aging process in this mouse.

Three patients developed non-Hodgkin's lymphoma (NHL) 3-6 years after treatment for Hodgkin's disease (HD). In no instance was there evidence of recurrence of HD following the initial chemotherapy or radiotherapy. None of these patients had received both radiation therapy and chemotherapy. The histologic classification of the developing of the developing NHL for the three patients was (1) diffuse, poorly differentiated lymphocytic, (2) nodular histocytic, and (3) nodular, poorly differentiated lymphocytic. In no instance was there any histologic similarity to the original HD. Perhaps most important with respect to histology was the easily demonstrable presence of Reed-Sternberg cells at the time of original diagnosis and their absence with onset of NHL. All patients responded well to conventional chemotherapy for NHL and are alive at 23+, 37+, and 65+ months after that secondary diagnosis. This report, when coupled with at least ten other such reported patients, suggests that NHL may be a relatively uncommon but significant complication of therapy for HD and must be distinguished for recurrence of HD.

Urinary iron excretion was measured in patients with sickle cell anemia and relateddiseases. Iron concentration in urine was determined by atomic absorption spectrophotometry and daily total iron excretion was calculated from this and total daily urine volume. Normal subjects excreted a mean of 88 pg Fe per day (95 per cent confidence limitsof 0 to 120 pg). Nine persons with sickle cell trait had normal Fe excretion rates.However, abnormally high iron excretion was present in the first urine sample obtainedfrom 27/31 patients with SS, 3/7 with SC, 1/2 with CC, and 1 with S-thalassemia. Iron excretion varied very significantly from day-to-day in individual patients. The results of studies attemting to relate this to increase excretion during activityas compared to rest were negative. No clear relationship of iron excretion to painfulcrisis could be shown, but remarkable rises in urine iron occurred in two patients who developed a hyperhemolytic crisis. These studies suggest that urinary iron reflects intravascular hemolysis primarily. No correlation was evident between urine iron and the patients' age, transfusion history, or serum iron values suggesting increased urinary iron excretion cannot be attributed to iron overload in sickle cell anemia.

The MGR, the pool of band and segmented neutrophils from which sudden demands for extra blood neutrophils are met, has been studied by measuring blood neutrophil increments following administration of endotoxin, corticosteroids, or etiocholanolone. Alternatively its size may be estimated from marrow differential counts with or without estimates of marrow mass. In 34 studies of 31 patients with diverse causes of neutropenia, measurements were made of the MGR comparing endotoxin response and differential counts of marrow aspirates coupled with estimates of absolute marrow mass derived from EIT rate. Responses to endotoxin were normal in 10 studies and subnormal in 24. The factor which best predicted endotoxin response was the percent of marrow neutrophils and neutrophil precursors which were band and segmented forms. All responders to endotoxin had greater than 25% marrow neutrophils and neutrophil precursors that were band and segmented; 20 to 21 subjects with less than a normal response to endotoxin had less than 25%. These studies suggest that no further information is gained by measuring endotoxin response in neutropenic patients who have a reduced percent of band forms and segmented neutrophils in marrow aspirates.

Chronic lymphocytic leukemia (CLL) is a very common form of leukemia among middle-aged and elderly persons in Western countries. In the Japanese, or in those with Japanese ancestry born and living in the USA, CLL is rather rare. It is also rare in China, but convincing data to support this statement are found primarily in the Chinese literature. We have reviewed previously unpublished data from Peking Union Medical College (PUMC) concerning the frequency of CLL among adult patients with the four common types of leukemia. Of 4,174 such patients (1952-1986), 4.6% had CLL; 22.9% chronic myeloid leukemia (CML); 50.3% acute myeloid leukemia (AML); and 22.3% acute lymphoblastic leukemia (ALL). This low frequency of CLL is none the less higher than that found in a multiinstitutional collection of Chinese patients with leukemia. Various clinical and laboratory aspects of a carefully studied, previously published group of patients with CLL from PUMC were compared to similar published findings in patients from the University of Utah. No differences in the overall nature of the disease were detected between these groups. However, not unexpectedly, the duration of symptoms before the diagnosis was made longer in Chinese than in USA patients and the proportion diagnosed at a time when no CLL related symptoms had been noted was less in Chinese. Neither differences in life span in the two populations nor an excess of CML, AML, and ALL at the expense of CLL were viable hypotheses to explain the rarity of CLL in China. We suggest that the dearth of CLL in Chinese is on a genetic basis, as it is thought to be in the Japanese.

This paper reviews ways by which growth of transplanted or surviving hematopoietic stem cells might be enhanced to improve survival in the case of autologous marrow transplantation. Most of the treatments known to have such effects have been used in isologous mouse models and improve animal survival by enhancing hematopoietic recovery after high doses of whole body irradiation or chemotherapy. Although some of these were studied 20 years ago, the use of such treatments in man has awaited the realization that some disseminated cancer can only be eliminated by use of various treatments where hematopoietic damage is the limiting factor. Although increasing the number of transplanted pluripotent stem cells is the most certain way to hasten return of needed blood cells in transplant patients, several of the treatments listed in the paper have growth enhancing effects on both surviving host stem cells and transplanted cells. There are recent studies which indicate that such priming treatments may also be effective in other normal tissues such as gut and bladder epithelium. At least one study in man has intentionally applied this approach with the expected benefit and others may have done so inadvertently. Much work remains to find new combinations to select the best priming treatments and intervals in man and to determine whether or not such treatments are effective against tumors.