HPV immunisation and cervical screening--confirmation of changed performance of cytology as a screening test in immunised women: a retrospective population-based cohort study.

BACKGROUND: To document the effect of bivalent HPV immunisation on cervical cytology as a screening test and assess the implications of any change, using a retrospective analysis of routinely collected data from the Scottish Cervical Screening Programme (SCSP). METHODS: Data were extracted from the Scottish Cervical Call Recall System (SCCRS), the Scottish Population Register and the Scottish Index of Multiple Deprivation. A total of 95 876 cytology records with 2226 linked histology records from women born between 1 January 1988 and 30 September 1993 were assessed. Women born in or after 1990 were eligible for the national catch-up programme of HPV immunisation. The performance of cervical cytology as a screening test was evaluated using the key performance indicators used routinely in the English and Scottish Cervical Screening Programmes (NHSCSP and SCSP), and related to vaccination status. RESULTS: Significant reductions in positive predictive value (16%) and abnormal predictive value (63%) for CIN2+ and the mean colposcopy score (18%) were observed. A significant increase (38%) in the number of women who had to be referred to colposcopy to detect one case of CIN2+ was shown. The negative predictive value of negative- or low-grade cytology for CIN2+ increased significantly (12%). Sensitivity and specificity, as used by the UK cervical screening programmes, were maintained. CONCLUSIONS: The lower incidence of disease in vaccinated women alters the key performance indicators of cervical cytology used to monitor the quality of the screening programme. These findings have implications for screening, colposcopy referral criteria, colposcopy practice and histology reporting.

HPV immunisation and increased uptake of cervical screening in Scottish women; observational study of routinely collected national data.

BACKGROUND: To measure the uptake of first invitation to cervical screening by vaccine status in a population-based cohort offered HPV immunisation in a national catch-up campaign. METHODS: A retrospective observational study of routinely collected data from the Scottish Cervical Screening Programme. Data were extracted and linked from the Scottish Cervical Call Recall System, the Scottish Population Register and the Scottish Index of Multiple Deprivation. Records from 201 023 women born between 1 January 1988 and 30 September 1993 were assessed. Women born in or after 1990 were eligible for the national catch-up programme of HPV immunisation. Attendance for screening was within 12 months of the first invitation at age 20 years. RESULTS: There was a significant decline in overall attendance from the 1988 cohort to the 1993 cohort with the adjusted attendance ratio of the 1988 cohort being 1.49 times (95% CI 1.46-1.52) that of the 1993 cohort. Immunisation compensated for this decrease in uptake with unvaccinated individuals having a reduced ratio of attendance compared with those fully vaccinated (RR=0.65, 95% CI 0.64-0.65). Not taking up the opportunity for HPV immunisation was associated with an attendance for screening below the trend line for all women before the availability of HPV immunisation. CONCLUSIONS: HPV immunisation is not associated with the reduced attendance for screening that had been feared. Immunised women in the catch-up cohorts appear to be more motivated to attend than unimmunised women, but this may be a result of a greater awareness of health issues. These results, while reassuring, may not be reproduced in routinely immunised women. Continued monitoring of attendance for the first smear and subsequent routine smears is needed.

Reduction of low- and high-grade cervical abnormalities associated with high uptake of the HPV bivalent vaccine in Scotland.

BACKGROUND: In Scotland, a national HPV immunisation programme began in 2008 for 12- to 13-year olds, with a catch-up campaign from 2008 to 2011 for those under the age of 18. To monitor the impact of HPV immunisation on cervical disease at the population level, a programme of national surveillance was established. METHODS: We analysed colposcopy data from a cohort of women born between 1988 and 1992 who entered the Scottish Cervical Screening Programme (SCSP) and were aged 20-21 in 2008-2012. RESULTS: By linking datasets from the SCSP and colposcopy services, we observed a significant reduction in diagnoses of cervical intraepithelial neoplasia 1 (CIN 1; RR 0.71, 95% CI 0.58 to 0.87; P=0.0008), CIN 2 (RR 0.5, 95% CI 0.4 to 0.63; P<0.0001) and CIN 3 (RR 0.45, 95% CI 0.35 to 0.58; P<0.0001) for women who received three doses of vaccine compared with unvaccinated women. CONCLUSIONS: To our knowledge, this is one of the first studies to show a reduction of low- and high-grade CIN associated with high uptake of the HPV bivalent vaccine at the population level. These data are very encouraging for countries that have achieved high HPV vaccine uptake.

Prospective parallel randomized trial of the MultiCyte™ ThinPrep(®) imaging system: the Scottish experience.

BACKGROUND: Computer-assisted screening of cervical liquid-based cytology (LBC) preparations using the ThinPrep® Imaging System (TIS) has shown improved qualitative and quantitative gains. The use of Multicyte™ has not been described in a well-established national screening programme with a low incidence of high-grade dyskaryosis. OBJECTIVES: To assess the impact of computer-assisted screening within the Scottish Cervical Screening Programme (SCSP). METHODS: Two groups of three laboratories, each sharing a ThinPrep® Imager, screened 79 366 slides randomized to test and 90 551 to control arms by laboratory accession. Screeners were not blinded. Standard laboratory reporting profiles of the SCSP, sensitivity, specificity and false-negative rates of all grades of LBC abnormalities with respect to final cytology reports, predictive value for cervical intraepithelial neoplasia grade 2 or worse (CIN2+) on histology; and screening rates were compared for both arms. RESULTS: Inadequate and negative reporting rates were significantly lower and low-grade reporting rates significantly higher in the imager arm. Imager-assisted screening showed significantly better specificity than manual screening with respect to the final cytology result. There was no evidence of a significant difference in the detection of CIN2+ or CIN3 +. Positive, abnormal and total predictive values (high-grade, low-grade and all abnormal cytology found to be CIN2+, respectively) were similar in both arms. Productivity was significantly higher in the imager arm. CONCLUSION: Computer-assisted screening in a well established screening programme showed significantly improved productivity without loss of quality. These findings should inform future policy for cervical screening programmes.

Cutaneous mycobacterial infection post intravesical BCG installation.

Disseminated tuberculous lesions post intravesical BCG therapy are rare but need to be identified and treated quickly. We report the first case of a tuberculous cutaneous lesion in a patient receiving the above treatment.

Haemosuccus pancreaticus due to mucinous cystadenocarcinoma: the significance of recurrent abdominal pain, hyperamylasaemia and a pancreatic cyst in association with recurrent gastrointestinal bleeding.

Haemosuccus pancreaticus is a rare cause of gastrointestinal haemorrhage, and when it presents in otherwise healthy people, can prove difficult to diagnose. The cardinal features are episodic epigastric pain associated with a raised serum amylase and the passage of melaena. Failure to make the connection between recurrent gastrointestinal bleeding and apparently unrelated symptoms attributable to pancreatitis may lead to a significant delay in diagnosis.

Negative pressure pulmonary edema after a tonsillectomy and adenoidectomy in a pediatric patient: case report and review.

Negative pressure pulmonary edema (NPPE) continues to be reported as a complication of upper airway obstructions seen by anesthesia providers during induction or emergence. The majority of patients reported to have experienced NPPE have been healthy, without underlying pulmonary or cardiac disease. Factors associated with the formation of NPPE include young male patients and patients with long periods of airway obstruction. Overzealous intraoperative fluid administration and preexisting heart and lung disease also have been implicated as predisposing factors. Negative pressure pulmonary edema is the result of a marked decrease in intrathoracic pressure caused by ventilatory efforts against a closed glottis resulting in a disruption of the normal intravascular Starling mechanism, ultimately leading to the transudation of intravascular proteins and fluid into the pulmonary interstitium. The onset of NPPE is usually rapid, and without prompt recognition and intervention, the outcome can be fatal. A case of NPPE in a pediatric patient after an otherwise uncomplicated surgical procedure was observed in our institution and is described in this report.

Fine needle aspiration cytology of head and neck lesions: an early experience.

Fine needle aspiration cytology (FNAC) was performed on 91 patients with lesions of salivary glands and cervical lymph nodes. The results were compared with histopathology in 58 patients who subsequently underwent surgery. Of a total of 105 aspirates, a definitive cytodiagnosis was possible in 88 (83.8%). An overall sensitivity of 77.7% and specificity of 93.3% were obtained when the cytological results were correlated with histopathology in 48 cases. The figures for salivary glands were 40.0 and 88.9%, and for cervical lymph nodes were 92.3 and 100.0% respectively. The incorrect diagnosis of some aspirates did not adversely affect the subsequent management of these cases. Fine needle aspiration cytology has a role in the diagnosis and management of a variety of head and neck lesions, although it should be used, along with other investigations, not as a substitute but as an adjunct to sound clinical judgement. The limitations of the procedure, including occasional errors of cytodiagnosis, should be borne in mind. The use of this technique by otolaryngologists has been limited, and we advocate that it becomes a more integral part of the diagnostic work-up in head and neck practice.

Mucous membrane plasmacytosis of the upper aerodigestive tract. A case report with effective treatment.

We present a case of plasmacytosis of the mucous membrane of the upper aerodigestive tract. This is a rare benign condition characterized by plasma cell infiltration of the mucosa, with only nine cases described previously (Ferreiro et al., 1994). The lesions, which have a cobblestone appearance, cause throat discomfort, dysphonia and mild dyspnoea. All the cases described previously failed to respond to antibiotics, systemic steroids, or to surgical resection. The present case has however responded favourably to intensive and prolonged treatment with beclamethasone oral spray and Corsodyl mouthwashes.

Exophthalmos and facial swelling: a case of limited Churg-Strauss syndrome.

We report a case of vasculitis causing facial swelling and exophthalmos which on clinical and histological grounds is thought to be limited Churg-Strauss syndrome. An excellent response was achieved to high doses of systemic steroids and cyclophosphamide.

The intraoperative use of Amicar to reduce bleeding associated with open heart surgery.

In an effort to reduce morbidity associated with transfusion of blood products, Amicar is used as a prophylactic inhibitor of hyperfibrinolysis associated with diffuse perioperative bleeding in patients undergoing open heart surgery. Previous studies indicate a significant reduction of intraoperative and postoperative bleeding in patients receiving Amicar during open heart surgery. Fifteen historical controls who did not receive Amicar were compared to 15 nonrandomized, prospective patients who received Amicar and who underwent open heart surgery by the same surgeon. The study found a significant reduction in postoperative chest tube output for the group receiving Amicar, as well as a reduction in perioperative blood product transfusion in patients who received Amicar. One patient in the Amicar group experienced a thrombotic event.

Echocardiographic diagnosis of infective endocarditis of all four cardiac valves.

Cross-sectional echocardiography in a 78-year-old woman with infective endocarditis demonstrated echogenic masses on all four cardiac valves. The echocardiographic diagnosis was confirmed at autopsy.

Oncocytic adenomas and oncocytic hyperplasia of salivary glands: a clinicopathological study of 26 cases.

Twenty-six benign oncocytic lesions of the salivary glands, excluding Warthin's tumours, have been reviewed and criteria for their classification as oncocytoma, multifocal nodular oncocytic hyperplasia, diffuse oncocytosis, pleomorphic adenoma with oncocytic change or oncocytic monomorphic adenoma have been proposed. The histological and clinical features of this heterogeneous group of lesions are discussed. This analysis suggests that the majority of lesions initially categorized as oncocytomas were, in fact, either non-neoplastic or, alternatively, oncocytic change in other types of adenoma.

Induction of pancreatic tumours by longterm duodenogastric reflux.

The incidence of pancreatic cancer is increased in patients who have undergone gastric surgery. An animal model is described in which pancreatic hyperplasia and adenoma formation developed within 56 weeks. The effects of a simple gastrojejunostomy were compared with those after a split gastrojejunostomy, in which the jejunum was transected and the two limbs implanted separately into the greater curvature of the glandular stomach 1 cm apart. After 56 weeks no animals in the simple gastrojejunostomy group had pancreatic hyperplasia whereas all 10 animals in the split gastrojejunostomy group had generalised pancreatic hyperplasia with macroscopic nodules. Microscopy of the nodules showed that in nine animals hyperplastic nodules had developed, and four of these also had adenomatous nodules. The remaining animal had enlarged lymph nodes. Pancreatic hyperplasia was associated with jejunal hyperplasia. Jejunal morphometry showed that the villus height was doubled and the villus height:crypt depth ratio was higher in the split gastrojejunostomy group compared with those animals with a simple gastrojejunostomy. This finding represents a new model for the investigation of pancreatic neoplastic change.

Tumours of the pancreas as a sequel to abdominal irradiation.

Two cases of tumours arising in or near the pancreatic head are reported in patients previously treated with abdominal irradiation for testicular tumours. These are only the third and fourth such cases to be reported and they suggest that second cancers may develop as a result of abdominal irradiation for malignant disease.

Distinctive epidermal atypia in immunosuppression-associated cutaneous malignancy.

The histopathological appearance of proliferative squamous lesions removed from the skin of iatrogenically immunosuppressed patients differs subtly from that of classical malignant and premalignant epidermal lesions. The majority of cases show 'Bowenoid' changes with a marked degree of cellular atypia including characteristic multinucleate cells.

Longterm pancreaticobiliary diversion stimulates hyperplastic and adenomatous nodules in the rat pancreas: a new model for spontaneous tumour formation.

A model for spontaneous tumour formation in the rat pancreas is described that requires neither cocarcinogens nor dietary manipulation. Short term hypercholecystokininaemia, when induced by raw soya flour feeding, induces benign and malignant tumours of the rat pancreas. Pancreaticobiliary diversion (PBD) results in hypercholecystokininaemia and in the short term, pancreatic hyperplasia. Longterm PBD was done to establish whether hypercholecystokininaemia thus produced would also lead to pancreatic neoplasia. After a period of 16-21 months hyperplastic and adenomatous nodules, one of the latter showing carcinoma in situ, were found in PBD rats but not in sham operated control rats.

Transduction of penicillinase production and other antibiotic-resistance markers in Staphylococcus epidermidis.

Transduction of resistance from a multiply antibiotic-resistant strain of Staphylococcus epidermidis sub-group II was studied using the typing phage 108. The effect of increasing doses of ultraviolet radiation on the transducing phage was used to indicate the chromosomal or plasmid nature of the genes. Tetracycline and chloramphenicol resistance behaved as plasmid genes and streptomycin resistance as a chromosomal marker. It was also possible to transduce penicillin resistance (Pc) due to penicillinase production (bla+) using a low level of benzylpenicillin (0.03 microgram ml-1) for recovery. Approximately 10(-5) transductant colonies per phage input were obtained and ultraviolet kinetics indicated that Pc was plasmid carried. Pc transductants fell into two categories. In one group PC was stable as in the donor strain and transductants had the same phage sensitivity as the recipient. In the other, Pc was unstable at 37 degrees C and the instability was enhanced by growth at approximately 43.5 degrees C; these transductants also gained genes for restriction and modification of certain phages. Transductants that subsequently lost bla+ also lost the restriction and modification characters.