Immunoflow cytometry and cell block immunohistochemistry in the FNA diagnosis of lymphoma: a review of 73 consecutive cases

AIMS

To review the results of 73 consecutive fine needle aspirations (FNAs) that were collected by a pathologist and analysed by immunoflow cytometry. Material for a cell block was also collected from some of these lesions.

METHODS

The setting was a large general hospital in rural New Zealand. The FNAs were performed by a pathologist, or a radiologist for image guided localisations. Material for immunoflow cytometry was collected into RPMI and, when required, material for a cell block was collected into formalin.

RESULTS

Of the 73 samples collected by FNA nine were inadequate. Light chain restriction could be demonstrated in most FNA samples from B cell lymphomas (28 of 30 adequate samples). The exceptions were two cases of T cell rich B cell lymphoma. Artefactual light chain restriction was seen occasionally in T cell lymphomas, presumably as a result of autoantibodies binding to the cell surfaces. It was possible to subtype most (18 of 30 adequate samples) B cell lymphomas as chronic lymphocytic leukaemia (CLL), follicle centre cell lymphoma (FCCL), or mantle cell lymphoma. The CD4 to CD8 ratio was not usually restricted in T cell lymphomas and coexpression of CD4 and CD8 was not usually found. Loss of pan-T cell antigens was seen in some T cell lymphomas. Four of the six T cell lymphomas and three of the four non-lymphoid malignacies were diagnosed with the aid of cell block immunohistochemistry. Only one of the four cases of Hodgkin's lymphoma showed Reed-Sternberg cells in the FNA smears.

CONCLUSIONS

It is not always possible to characterise lymphomas as fully with FNA and immunoflow cytometry as is possible with biopsy histology and a full battery of modern investigations. Nevertheless, in the setting of a large rural general hospital immunoflow cytometry on FNA samples is a highly effective method of diagnosing and typing B cell lymphomas. Immunoflow cytometry is of little use for T cell lymphomas or Hodgkin's lymphomas. We advocate the use of cell block immunohistochemistry in preference to immunoflow cytometry for cases in which the cytological appearance of the specimen is overtly malignant but the differential diagnosis includes non-lymphoid malignancy.

Identifying male college students' perceived health needs, barriers to seeking help, and recommendations to help men adopt healthier lifestyles

Seven focus groups at a university campus were formed to identify college men's health concerns, barriers to seeking help, and recommendations to help college men adopt healthier lifestyles. Content analysis was used to identify and organize primary patterns in the focus-group data. Results of the study revealed that the college men were aware that they had important health needs but took little action to address them. The participants identified both physical and emotional health concerns. Alcohol and substance abuse were rated as the most important issues for men. The greatest barrier to seeking services was the men's socialization to be independent and conceal vulnerability. The most frequently mentioned suggestions for helping men adopt healthier lifestyles were offering health classes, providing health information call-in service, and developing a men's center. Implications of the results are discussed.

Continuous Quality Improvement to an ELECTROCONVULSIVE THERAPY Delivery System

1. ECT is known to be highly effective in relieving severe depression; however, there are few published articles focusing on nursing care of patients receiving ECT. 2. Education is an important component of nursing care. Lack of information about ECT can cause a high level of anxiety and reluctance to consent to ECT. 3. Using the Continuous Quality Improvement Model, nurses can improve the quality of a whole system of care delivery.

Common trisomy mosaicism diagnosed in amniocytes involving chromosomes 13, 18, 20 and 21: karyotype-phenotype correlations

Karyotype-phenotype correlations of common trisomy mosaicism prenatally diagnosed via amniocentesis was reviewed in 305 new cases from a collaboration of North American cytogenetic laboratories. Abnormal outcome was noted in 10/25 (40%) cases of 47,+13/46, 17/31 (54%) cases of 47,+18/46, 10/152 (6.5%) cases of 47,+20/46, and in 49/97 (50%) cases of 47,+21/46 mosaicism. Risk of abnormal outcome in pregnancies with less than 50% trisomic cells and greater than 50% trisomic cells were: 26% (4/15) versus 60% (6/10) for 47,+13/46, 52% (11/21) versus 75% (6/8) for 47,+18/46, 4.5% (6/132) versus 20% (4/20) 47,+20/46, and 45% (27/60) versus 59% (22/37) for 47,+21/46. Phenotypically normal liveborns were observed with mean trisomic cell lines of 9.3% for 47,+13/46, 8.6% for 47,+18/46, 27% for 47, +20/46, and 17% for 47,+21/46. Cytogenetic confirmation rates were 46% (6/13 cases) for 47,+13/46 mosaicism, 66% (8/12 cases) for 47, +18/46, 10% (10/97 cases) for 47,+20/46, and 44% (24/54 cases) for 47,+21/46. There were higher confirmation rates in pregnancies with abnormal versus normal outcome: 50% versus 44% for 47,+13/46 mosaicism, 100% versus 33% for 47,+18/46, 66% versus 7% for 47, +20/46, and 55% versus 40% for 47,+21/46. Repeat amniocentesis is not helpful in predicting clinical outcome. It may be considered when there is insufficient number of cells or cultures to establish a diagnosis. Fetal blood sampling may have a role in mosaic trisomy 13, 18, and 21 as the risk for abnormal outcome increases with positive confirmation: 1/5 (20%) normal cases versus 5/8 (62%) abnormal cases. High resolution ultrasound examination(s) is recommended for clinical correlation and to facilitate genetic counselling.

The existence of geographical clusters of cases of inflammatory polyarthritis in a primary care based register

OBJECTIVES

To determine whether there is any evidence that there are spatial clusters of rheumatoid arthritis in particular, and inflammatory arthritis in general.

METHODS

Setting was a population based incidence register of inflammatory arthritis: the Norfolk Arthritis Register (NOAR). All cases identified between 1990-1995 were mapped to place of residence. Statistical evidence of clustering was determined by calculating Poisson probabilities in putative areas.

RESULTS

Three clusters were identified including one small area (population 85) where five unrelated cases developed during this time period. There was no obvious greater disease homogeneity within clusters and no common environmental factors were identified.

CONCLUSION

Rare clusters of inflammatory polyarthritis do occur. Their significance and cause remain to be elucidated.

The influence of HLA-DRB1 alleles and rheumatoid factor on disease outcome in an inception cohort of patients with early inflammatory arthritis

OBJECTIVE

There are conflicting data concerning the role of HLA-DRB1 alleles in disease outcome in early rheumatoid arthritis. The exact role of these alleles in short-term outcome is determined in this large, prospective, population-based study.

METHODS

We recruited 532 patients with inflammatory polyarthritis from the Norfolk Arthritis Register and typed their sera for HLA-DRB1 alleles using polymerase chain reaction-based methods. Disease outcome was assessed at 2 years in terms of persistent joint inflammation, functional disability, and radiologic erosions. Results are expressed as risk ratios (RR) with 95% confidence intervals (95% CI).

RESULTS

There was no influence of HLA-DRB1 alleles, in any combination, on the likelihood of disease persistence, and only a modest effect on functional disability (Health Assessment Questionnaire score > or = 1). The most obvious effect was on the development of erosions (RR 1.9, 95% CI 1.4-2.6 for those who carried at least 1 DRB1 shared epitope [SE] allele), with slightly greater effects for those who were homozygous for SE-bearing alleles (RR 2.5, 95% CI 1.8-3.6). This effect of HLA-DRB1 was restricted to patients whose sera were negative for rheumatoid factor. Among patients with erosions, HLA-DRB1 had no influence on the severity of radiologic damage (defined as the number of eroded joints, or total Larsen score).

CONCLUSION

These data do not support routine HLA-DRB1 screening of patients with early arthritis to identify those at risk for subsequent severe disease.

Preclinical antitumor activity of XK469 (NSC 656889)

XK469 (NSC 656889) is a water-soluble member of the novel quinoxaline family of antitumor agents. In vitro, XK469 demonstrated selective cytotoxicity for several murine solid tumors including colorectal and mammary adenocarcinoma cell lines, when compared to both leukemia and normal epithelial cells. In vivo, XK469 was active against 7/7 murine tumors tested, including pancreatic ductal carcinomas #02 and #03, colon adenocarcinomas #38 and #51/A, mammary adenocarcinoma #16/C and the Adriamycin resistant mammary adenocarcinomas #16/C/ADR and #17/ADR. XK469 was efficacious both intravenously and orally. Regardless of dosing schedule, conventional mice tolerated higher total doses than SCID or nu/nu mice did. Despite these reduced doses, XK469 was active against xenografts of 4/6 human tumor lines including mammary adenocarcinoma MX-1, the small cell lung cancer DMS 273, the prostate model LNCaP and the CNS tumor SF295. The lower doses in the xenograft studies were below curative levels. The dose-limiting toxicity appeared to be myelosuppression with rapid host recovery (5-8 days), and in vitro assays of XK469 toxicity to murine bone marrow neutrophil progenitors CFU-GM (colony forming unit-granulocyte/macrophage) demonstrated concentration-dependent toxicity from 0.5-30 microg/mL. The difference in drug tolerance between BDF1 and SCID mice was detected in vitro as a 3-fold difference in the IC90 for CFU-GM, despite similar IC50 values. Comparative in vitro hematotoxicology studies revealed that human bone marrow CFU-GM tolerated XK469 as well as their SCID counterparts (IC90 values 5.7 vs. 7.4 microg/mL). Based on comparison with previously tested anti-cancer agents, these data suggest that humans will be able to tolerate XK469 doses that are efficacious against human tumor xenografts.

Estimating the incidence of rheumatoid arthritis: trying to hit a moving target?

OBJECTIVE

To examine the effect of delay between symptom onset and notification to an arthritis register and the effect of application of the American College of Rheumatology (ACR; formerly, the American Rheumatism Association) 1987 criteria in a cumulative manner on estimates of the incidence of rheumatoid arthritis (RA).

METHODS

General practitioners and/or hospital consultants in the Norwich Health Authority, Norfolk, UK, notified the Norfolk Arthritis Register (NOAR) of all patients who had onset of inflammatory polyarthritis (swelling of > or =2 joints) during 1990. The patients were assessed within 2 weeks of notification and annually thereafter. The ACR 1987 criteria for RA were applied at each assessment. Age- and sex-specific incidence rates were calculated.

RESULTS

If up to 12 months elapsed from symptom onset to notification to NOAR and the ACR criteria were applied at the baseline assessment, RA incidence estimates, age-adjusted to the population of England and Wales, were 30.8/100,000 for women and 12.7/100,000 for men. If up to 5 years elapsed from symptom onset to notification, these estimates rose by 45% for women and 36% for men. If up to 5 years elapsed between symptom onset and notification and the criteria were applied cumulatively, the estimates rose by 75% and 93% for women and men, respectively, compared with the 1-year data, reaching 54.0/100,000 for women and 24.5 per 100,000 for men.

CONCLUSION

Accurate estimation of the incidence of RA requires long-term followup of patients who present with undifferentiated inflammatory polyarthritis. The highest age-adjusted estimates from this study are probably the best that are available.

An analysis of the causes of adverse events from the Quality in Australian Health Care Study

OBJECTIVE

To examine the causes of adverse events (AEs) resulting from healthcare to assist in developing strategies to minimise preventable patient injury.

DESIGN

Descriptions of the 2353 AEs previously reported by the Quality in Australian Health Care Study (QAHCS) were reviewed. A qualitative approach was used to develop categories for human error and for prevention strategies to minimise these errors. These categories were then used to classify the AEs identified in the QAHCS, and the results were analysed with previously reported preventability and outcome data.

RESULTS

34.6% of the causes of AEs were categorised as "a complication of, or the failure in, the technical performance of an indicated procedure or operation", 15.8% as "the failure to synthesise, decide and/or act on available information", 11.8% as "the failure to request or arrange an investigation, procedure or consultation", and 10.9% as "a lack of care and attention or failure to attend the patient". AEs in which the cause was cognitive failure were associated with higher preventability scores than those involving technical performance. The main prevention strategies identified were "new, better, or better implemented policies or protocols" (23.7% of strategies), "more or better formal quality monitoring or assurance processes" (21.2%), "better education and training" (19.2%), and "more consultation with other specialists or peers" (10.2%).

CONCLUSION

The causes of AEs or errors leading to AEs can be characterised, and human error is a prominent cause. Our study emphasises the need for designing safer systems for care which protect the patient from the inevitability of human error. These systems should provide new policies and protocols and technological support to aid the cognitive activities of clinicians.

Quantifying the exact role of HLA-DRB1 alleles in susceptibility to inflammatory polyarthritis: results from a large, population-based study

OBJECTIVE

To accurately determine the contributions of HLA-DRB1 alleles in explaining susceptibility to inflammatory polyarthritis in a large, true population-based cohort of new-onset cases.

METHODS

A cohort of 680 consecutive patients with inflammatory polyarthritis, of whom 404 satisfied the American College of Rheumatology (ACR) criteria for rheumatoid arthritis (RA), was recruited from the population-based Norfolk Arthritis Register. All cases were compared with 286 local population controls. A standardized clinical assessment was performed on all patients. HLA-DRB1 phenotypes, including DR4 subtypes, were determined using a semiautomated, reverse dot-blot method. Results were expressed as odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

There was only a modest association (OR 1.8, 95% CI 1.4-2.4) between inflammatory polyarthritis and the presence of any shared epitope (SE) allele; the strongest individual risk was with DRB1*0404 (OR 3.5, 95% CI 1.8-6.8). Comparison of the genotypes demonstrated that the effect of being SE homozygous (OR 2.1, 95% CI 1.5-3.0) was only moderately greater than the effect of being SE heterozygous (OR 1.3, 95% CI 1.1-1.6). The exception to this was genotypic combinations that included HLA-DRB1*0404, which exhibited ORs ranging up to 18.0. There were no differences between either the phenotype or genotype data when the patients were stratified by RA status (defined by the ACR criteria). In contrast, the associations were substantially stronger in patients who were positive for rheumatoid factor.

CONCLUSION

Previous studies had not been able to clarify whether the influence of HLA-DRB1 on RA was related to disease susceptibility or to disease severity and progression. These data on a unique population-based incident cohort suggest only weak effects on susceptibility, with the exception of the clearly distinct influence of HLA-DRB1*0404.

Cyclic polyketide peroxides and acyclic diol analogues from the sponge Plakortis lita

The sponge Plakortis lita from Papua New Guinea is a source of three cyclic peroxides-ethyl plakortide Z (3), ethyl didehydroplakortide Z (4), and methyl didehydroplakortide Z (5)-and three acyclic diol analogues-ethyl seco-plakortide Z (6), epi-ethyl seco-plakortide Z (7), and ethyl didehydro-seco-plakortide Z (8). The absolute stereochemistry at the three chiral sites of 3 was assigned by preparing 6, which was investigated using the refined Mosher's method. Compounds 4, 5, and 6 were also concluded to have the same absolute stereochemistry as 3. The cyclic peroxides were generally cytotoxic, while the acyclic analogues were devoid of activity. Compound 3 was equally active in vitro against solid tumor and L-1210 leukemia cell lines. Alternatively, 4 was observed in vitro to be moderately solid-tumor selective but did not exhibit in vivo activity against solid tumors in mice.

Repetitive pinching of the skin during lidocaine infiltration reduces patient discomfort

BACKGROUND

The administration of a local anesthetic is often painful.

OBJECTIVE

The purpose of this study was to determine whether rapidly shaking and pinching the skin during local anesthetic administration decreases pain perception.

METHODS

The skin at the intended site of lidocaine injection was rapidly pinched between the thumb and forefinger just before the injection. Control patients received no intervention. Patients reported their pain perception using a visual analog scale (0 to 10). In the feasibility phase, patients were assigned to receive the pinching technique or no intervention, then randomized in the second phase.

RESULTS

In phase 1, 34 patients received 42 excisions. Pain was significantly reduced (p=0.001) in the treatment group. In phase 2, 69 patients had 91 excisions. When adjusted for age and sex (data combined from phases 1 and 2), the treatment significantly reduced pain (p=0.03) when compared with no intervention.

CONCLUSION

We describe a simple, noninvasive technique that significantly lowered perceived pain during the administration of unbuffered lidocaine with epinephrine local anesthetic.

Current microbiological status of 'health foods' sold in Canada

A follow-up survey was conducted across Canada to evaluate the current status of 'health foods' sold in Canada. A total of 1239 sample units of 'health foods' were analysed for a variety of bacteria, including aerobic colony counts (ACC), coliforms, aerobic and anaerobic sporeformers, Escherichia coli and Bacillus cereus. Results presented indicate that 16.8-18.4% of the 'health foods' exceed ACC guidelines, 16.0-17.8% exceeded coliform guidelines, 35.7% exceeded aerobic sporeformer guidelines, 81.4% exceeded anaerobic sporeformer guidelines, and 9% exceeded B. cereus guidelines. Some ACC were further identified and found to be opportunistic pathogens, including the genera Bacillus, Enterococcus, and Staphylococcus. It was concluded that more extensive surveillance of this industry by health officials is needed.

Low frequency of recent parvovirus infection in a population-based cohort of patients with early inflammatory polyarthritis

OBJECTIVE

To determine the contribution of human parvovirus B19 infection in explaining the incidence of early inflammatory polyarthritis (IP) in a population.

SETTING

The Norfolk Arthritis Register (NOAR) is a community-based programme aiming to ascertain all new cases of IP arising in a population that lead to attendance at primary care.

SUBJECTS

147 newly ascertained subjects with IP with a disease duration of less than 16 weeks.

METHODS

Full clinical appraisal of all subjects who were followed up for three years. B19 IgM assayed with a third generation antibody capture enzyme immunoassay.

RESULTS

Only four (2.7%) patients had evidence of recent B19 infection, only one of whom did not satisfy criteria for rheumatoid arthritis (RA).

CONCLUSION

B19 infection does not explain more than a small proportion of either RA or undifferentiated IP cases occurring in the population.

Coronary artery bypass after single lung transplant: a case report

Chronic obstructive pulmonary disease (COPD) is the most common indication for adult single lung transplantation. These patients commonly have one or more risk factors for coronary artery disease. Traditionally previous lung transplantation has been considered a contraindication to coronary artery bypass grafting (CABG). This report describes a case of CABG 3 yr after single lung transplantation and briefly discusses the risks of cardiac surgery in lung transplant patients.