Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience.

PURPOSE: Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation. MATERIALS AND METHODS: Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days. RESULTS: The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses. CONCLUSION: Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.

The effect of DCIS grade on rate, type and time to recurrence after 15 years of follow-up of screen-detected DCIS.

BACKGROUND: The incidence of ductal carcinoma in situ (DCIS) rose rapidly when the NHS Breast Screening Programme (NHSBSP) started in 1988. Some authorities consider that this represents both over-diagnosis and over-treatment. We report long-term follow-up of DCIS diagnosed in the first 10 years (April 1988 to March 1999) of the West Midlands NHSBSP. METHODS: 840 noninvasive breast cancers were recorded on the national breast screening computer system. Following exclusions, and thorough case note and pathology review, 700 DCIS cases were identified for follow-up. RESULTS: After a median follow-up of 183 (range 133 to 259) months, 102 (14.6%) first local recurrences were identified, 49 (48%) were invasive. Median time to first noninvasive recurrence was 15 months, and 60 months for invasive recurrence. Median time to invasive recurrence was 76 months from initially high-grade DCIS, and 131 months from low/intermediate grade DCIS. For the seven women, presenting with metastasis as their first event, the median time was 82 (range 15 to 188) months. The cumulative proportion developing recurrence at 180 months was twice as high as at 60 months. INTERPRETATION: Short-term follow-up of patients diagnosed with DCIS will miss significant numbers of events, especially invasive local recurrences.

Radiological and pathological size estimations of pure ductal carcinoma in situ of the breast, specimen handling and the influence on the success of breast conservation surgery: a review of 2564 cases from the Sloane Project.

BACKGROUND: The Sloane Project, an audit of UK screen-detected non-invasive carcinomas and atypical hyperplasias of the breast, has accrued over 5000 cases in 5 years; with paired radiological and pathological data for 2564 ductal carcinoma in situ (DCIS) cases at the point of this analysis. We have compared the radiological estimate of DCIS size with the pathological estimate of DCIS size. We have correlated these sizes with histological grade, specimen-handling methods, particularly the use of specimen slice radiographs, and the success or failure of breast-conserving surgery (BCS). METHODS: The Sloane Project database was interrogated to extract information on all patients diagnosed with DCIS with complete radiological and pathological data on the size of DCIS, nuclear grade, specimen handling (with particular reference to specimen radiographs) and whether primary BCS was successful or whether the patient required further conservation surgery or a mastectomy. RESULTS: Of 2564 patients in the study, 2013 (79%) had attempted BCS and 1430 (71%) had a successful single operation. Of the 583 BCS patients who required further surgery, 65% had successful conservation and 97% of them after a single further operation. In successful one-operation BCS patients, there was a close agreement between radiological and pathological DCIS size with radiology tending to marginally overestimate the disease extent. In multiple-operation BCS, radiology underestimated DCIS size in 59% of cases. The agreement between pathological and radiological size of DCIS was poor in mastectomies but was improved by specimen slice radiography, suggesting specimen-handling techniques as a cause. CONCLUSION: In 30% of patients undergoing BCS for DCIS, preoperative imaging underestimates the extent of disease resulting in a requirement for further surgery. This has implications for the further improvement of preoperative imaging and non-operative diagnosis of DCIS so that second operations are reduced to a minimum.

The NHS breast screening programme (pathology) EQA: experience in recent years relating to issues involved in individual performance appraisal.

BACKGROUND: The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK. AIMS/METHODS: To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed. RESULTS/CONCLUSIONS: Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist's practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.

Impact of a national external quality assessment scheme for breast pathology in the UK.

BACKGROUND: This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology. AIMS/METHODS: The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics. RESULTS: Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming. CONCLUSIONS: These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.

Inhibition of human breast carcinoma growth by a soluble recombinant human CD40 ligand.

CD40 is present on B cells, monocytes, dendritic cells, and endothelial cells, as well as a variety of neoplastic cell types, including carcinomas. CD40 stimulation by an antibody has previously been demonstrated to induce activation-induced cell death in aggressive histology human B-cell lymphoma cell lines. Therefore, we wanted to assess the effects of a recombinant soluble human CD40 ligand (srhCD40L) on human breast carcinoma cell lines. Human breast carcinoma cell lines were examined for CD40 expression by flow cytometry. CD40 expression could be detected on several human breast cancer cell lines and this could be augmented with interferon-gamma. The cell lines were then incubated with a srhCD40L to assess effects on in vitro growth. srhCD40L significantly inhibited the proliferation of the CD40(+) human breast cancer cell lines. This inhibition could also be augmented with interferon-gamma. Viability was also affected and this was shown to be due to increased apoptosis of the cell lines in response to the ligand. Treatment of tumor-bearing mice was then performed to assess the in vivo efficacy of the ligand. Treatment of tumor-bearing SCID mice with the ligand resulted in significant increases in survival. Thus, CD40 stimulation by its ligand directly inhibits human breast carcinoma cells in vitro and in vivo. These results suggest that srhCD40L may be of clinical use to inhibit human breast carcinoma growth.

Germinal-center cell proliferation in response to T-independent antigens: a stathmokinetic, morphometric and immunohistochemical study in vivo.

Although the nature of the germinal center reaction during responses to T-dependent antigens has been well documented, much less is known regarding the relationship between germinal centers and T-independent antigens. In this study, germinal-center cell proliferation was determined at specific time points in spleens of C3H/HeN mice following immunization with either the type-1, T-independent antigen dinitrophenol-lipopolysaccharide (DNP-LPS), or the type-2, T-independent antigen DNP-Ficoll. A stathmokinetic technique was employed to assess proliferation in terms of germinal center cell birth rate and morphometry was used to measure actual growth and regression of the germinal center cell population. An estimate of the absolute rate of germinal-center (GC) cell proliferation was derived from these two values. In addition, immunohistochemistry was performed to correlate changes in GC cell proliferation with the presence or absence of antigen within GC. Following immunization with both antigens, there was an initial reduction of proliferation within pre-existing germinal centers which manifested as either GC dissociation (DNP-LPS) or a suppression of birth rates (DNP-Ficoll). This was followed by a period of increased GC cell proliferation in animals immunized with DNP-LPS, but not in those exposed to DNP-Ficoll. GC cell proliferation was then measured in mice treated with cyclosporin A from 1 day before to 2 days after immunization with DNP-LPS. In these animals, the expected increase in GC cell birth rates did not take place. Immunohistochemistry showed that DNP-Ficoll and DNP-LPS were present in GC from 1 day after immunization until the end of the experiment on day 7. Treatment with cyclosporin A did not affect the deposition of DNP-LPS in GC. These results show that only some T-independent antigens are able to stimulate GC cell proliferation, and we propose that this is related to their ability to recruit precursors of GC B cells into the GC reaction. In addition, the results indicate that GC proliferation seen in response to a so-called T-independent antigen is at least partly driven by T cell-derived cytokines.

Regulation of murine germinal centre cell proliferation in vivo: a stathmokinetic study examining the effect of differently timed doses of cyclosporin A.

Although studies have identified factors which affect germinal centre cell proliferation in vitro, their relative contributions in vivo remain largely undetermined. In this study, the proliferative rate of germinal centre cells was measured in sheep red blood cell-immunized C3H/HeN mice exposed to variously timed doses of cyclosporin A. Germinal centre (GC) cell proliferation was measured by a stathmokinetic technique to determine GC cell birth rates at specific time points after immunization. Changes in total GC volume were determined by morphometry in order to assess actual growth and regression of the GC cell population. An estimate of the absolute rate of GC cell proliferation was derived from these two values. Following exposure to antigen, there was an initial inhibition of proliferation within pre-existing germinal centres, followed by a rapid rise, then a sustained phase of increased GC cell proliferation. By comparing the effects of the different cyclosporin A treatment regimes, it was possible to deduce that the initial inhibition of proliferation was mediated by a T-cell-derived cytokine, as was the final sustained phase of the proliferative response. The intervening rise in GC cell proliferation, however, was attributable to a contact-dependent signalling mechanism.

Cell kinetics of the germinal center reaction--a stathmokinetic study.

The changes in splenic germinal center (GC) cell proliferation were measured during primary and secondary responses to a T-dependent antigen in vivo to examine the regulation of the GC reaction. Adult C3H/HeN mice were immunized with sheep red blood cells and boosted 7 or 21 days later. GC cell proliferation was assessed by measurement of GC cell birth rates using a stathmokinetic technique. Actual GC growth and regression were assessed in terms of total splenic volume and number. Pre-existing GC had a mean cell birth rate of 33 cells/1000 cells/h. The GC reactions following each immunization showed a biphasic pattern of changes in cell birth rate, comprising an initial fall immediately succeeded by a transient, but significant, increase. These fluctuations occurred earlier in secondary compared to primary responses. Significant increases in total GC volumes succeeded the peaks of cell birth rate following both primary and early secondary immunization. However, there was a substantially smaller increase following later secondary immunization. We propose that the initial cell birth rate reduction is due to inhibition of pre-existing GC clones and represents one component of the phenomenon of GC dissociation. The succeeding peak birth rate represents early, massive proliferation of newly activated antigen-specific clones. The different patterns of GC expansion, despite similar proliferative responses, may reflect different pathways of differentiation dependent on the timing of antigenic stimulation.

Reduced apoptotic cell death in follicular lymphoma.

It has been hypothesized that inhibition of germinal centre cell apoptosis may underlie the development of follicle centre cell lymphomas. We have performed a comparative, quantitative study of apoptotic cell death in germinal centres and in the neoplastic follicles of centroblastic-centrocytic, follicular, non-Hodgkin's lymphoma (Cb/Cc NHL). Ten cases each of reactive follicular hyperplasia and Cb/Cc NHL were analysed. One-micrometre-thick resin-embedded sections were examined at x 1000 magnification. The total numbers of cells, nuclear containing apoptotic bodies, and mitoses were counted in each follicle and the apoptotic and mitotic indices were derived. Transmission electron microscopy was performed on selected cases to confirm the typical features of apoptosis. The mean apoptotic (4.9 per cent) and mitotic indices (0.9 per cent) for the germinal centres were significantly higher (P much less than 0.001) than those for the neoplastic follicles (0.9 and 0.14 per cent). These results lend support to the recent proposal that reduced apoptotic cell death may be important in the pathogenesis of follicular lymphomas.

DNA flow cytometry of follicular non-Hodgkin's lymphoma.

S-phase fraction, an index of cellular proliferation, and DNA ploidy were measured by DNA flow cytometry in a retrospective study of lymph node biopsy specimens from 83 cases (before treatment) of follicular non-Hodgkin's lymphoma, Working Formulation categories B and C. The correlations between these measures and survival, clinical stage, symptoms and histopathological factors were investigated. Aneuploidy was rare (n = 16) and had no effect on length of survival or transformation to high grade lymphoma. The overall mean S-phase fraction was 3.6%; for the whole series increasing S-phase fraction was associated with decreased survival. A high S-phase fraction (more than 5%) in initial biopsy specimens was also associated with an increased risk of subsequent high grade transformation at relapse. There was no difference between the survival or proliferative activity of tumours composed of mainly small cleaved cells compared with those composed of mixed small and large cells. There was no difference in survival or proliferative activity between tumours showing a pure follicular growth pattern and those with a mixed follicular and diffuse growth pattern. Multifactorial analysis showed that an S-phase fraction of more than 5% and B symptoms were the most important factors determining survival in these follicular non-Hodgkin's lymphomas.

Cell kinetics of human gastric mucosa and gastric cancer in organ culture.

The cell kinetics of human gastric epithelium in organ culture have been measured using flash labelling with tritiated thymidine and the metaphase arrest technique to estimate cell birth rates. Normal gastric antral and body mucosa have been compared with mucosa showing gastritis and gastric carcinoma. Labelling indices with tritiated thymidine in normal gastric mucosa declined over a 48-h period suggesting that essential growth factors were lacking. Labelling indices and cell birth rates were higher in gastritis than in normal mucosa and highest in gastric carcinoma. Labelling indices were higher in intestinal-type gastric carcinoma than diffuse carcinoma. In metaphase arrest experiments carcinomas showed on average an eightfold increase in resistance to the metaphase-arresting properties of vincristine when compared with normal mucosa. The validity of using the metaphase arrest technique to measure cell birth rate in gastric cancers in view of this vincristine resistance is discussed.

Differential upregulation of intercellular adhesion molecule-1 in coeliac disease.

The expression of intercellular adhesion molecule-1 (ICAM-1) was studied on peroral jejunal biopsies from patients with coeliac disease. The biopsies from untreated patients exhibited greater staining of the superficial lamina propria cells compared with treated patients and controls. A gluten challenge in treated patients produced an altered staining pattern within 2 h. The results demonstrate the role of ICAM-1 expression in coeliac disease, providing further evidence for the role of lamina propria cells in the pathogenesis of this condition.

Adenoidal hypertrophy as the presenting feature of HIV infection.

A case of symptomatic recurrent adenoidal hypertrophy, as the presenting feature of HIV infection in a haemophiliac child, is reported. The incidence of non-malignant nasopharyngeal lymphoid hyperplasia in HIV infection is examined and the relevance of the histological appearance is discussed in relation to progression of disease.

Measurement of S-phase fractions in lymphoid tissue comparing fresh versus paraffin-embedded tissue and 4',6'-diamidino-2 phenylindole dihydrochloride versus propidium iodide staining.

S-phase fractions for 62 lymphoid biopsies were calculated, by means of flow cytometry, from both fresh and paraffin-embedded tissue. The purposes of this study were to determine whether significant differences were seen between S-phase estimates obtained from fresh and fixed tissue and to compare results obtained with two DNA dyes, namely 4'-6'-diamidino-2 phenylindole dihydrochloride (DAPI) and propidium iodide (PI). The 62 cases consisted of 38 cases of non-Hodgkin's lymphoma (NHL), 19 reactive samples, and 5 cases of Hodgkin's disease. Fifty-four of the samples showed DNA diploid profiles. A good agreement between S-phase results from fresh and fixed tissue was seen, with technical factors accounting for around 20% of the total variance. Using a paired t test, no significant difference was seen between fresh and fixed tissue for diploid cases, but there was a trend for S-phase estimates from fixed tissue to be higher. If all cases (including the eight DNA aneuploid samples) were included in the analysis this difference just reached statistical significance (P less than .05). In a subgroup of 19 of the cases, a comparison was performed on both fresh and fixed tissue of staining with DAPI and PI. A good agreement between results with both DNA stains was found on fresh and fixed tissue, with no significant differences being apparent, and stain-related factors accounted for only 10% of the total variance.

DNA flow cytometry of thymomas.

Forty-seven thymomas have been examined by DNA flow cytometry and results correlated with histology, stage, associated clinical features and survival. Twenty-five cases were DNA diploid, 14 were aneuploid and no results could be obtained for eight cases. The presence of aneuploidy correlated with more advanced (stage II and III) disease and the presence of myasthenia gravis and was more frequent in epithelial predominant thymomas. Tumour recurrence was more frequent in DNA aneuploid tumours, stage II/III disease and epithelial predominant neoplasms. Multifactorial analysis showed that DNA aneuploidy was predictive of tumour recurrence independent of the effects of stage and histology.

A comparison of in vitro and in vivo gastric mucosal cell kinetics.

In order to determine whether organ culture of gastric mucosa preserves in vivo kinetic alterations, a comparison of in vivo and in vitro measurements of cell proliferation was made on antral mucosa from rats treated with the carcinogen methyl-nitro-nitrosoguanidine, administered orally for up to 30 weeks. Morphologic, morphometric and cell kinetic features in gastric mucosa were observed in vivo in treated and control rats. Similar in vitro measurements were made on mucosa from treated and control rats after a further 24-hour organ culture. All carcinogen-treated stomachs showed erosions, with widespread areas of glandular architectural irregularity which were more widespread after 30 weeks carcinogen treatment. Organ cultures showed good preservation of these morphologic features. In areas of architecturally normal mucosa, the carcinogen caused an increase in antral pit vertical column counts. This alteration was preserved after organ culture of carcinogen-treated mucosa. Cell birth rates and [3H]thymidine flash labeling indices were raised in architecturally normal mucosa from carcinogen-treated animals. These kinetic indices continued to be elevated after organ culture, though the in vitro values were lower than in vivo. Cell birth rates in architecturally abnormal mucosa from carcinogen-treated animals did not differ significantly from adjacent morphologically normal mucosa. Despite evidence of epithelial cell loss with depression of kinetic activity on organ culture compared with in vivo results, organ culture gives consistent results which reflect methyl-nitroso-nitrosoguanidine-induced changes and is of value for further in vitro investigations.