Ethnicity as an independent predictive factor for the results of computed tomography pulmonary angiography and ultrasonography of the lower limbs.

BACKGROUND: Asians, Pacific Islanders and Maori have significantly lower rates of venous thromboembolism (VTE) compared to Europeans, but its clinic implication regarding diagnosis and prevention is unclear. AIMS: To investigate if ethnicity affects the yield of computed tomography pulmonary angiography (CTPA) and ultrasonography of the lower limbs. METHODS: Data previously collected for 523 patients from another study were used to analyse the effect of ethnicity on the results of CTPA; 1587 consecutive ultrasonography of lower limbs was retrospectively analysed according to ethnicity. The Wells score was retrospectively calculated to determine the pretest probability of VTE. RESULTS: The positive rates of CTPA were 23.3% for European patients and 9.3% for non-European patients. The rate ratio was 2.50 (confidence interval [CI] 1.27-4.95). European patients were 2.5 times more likely to have a positive scan result than non-Europeans, given same pretest probability. There was a larger difference among patients with low and moderate pretest probability with a rate ratio of 4.27 (CI 1.62-11.3). The positive rates of ultrasound scans (USS) among European patients were 16.6 and 9.0% for non-European patients. Rate ratio was 1.85 (CI 1.27-4.95). The difference was also more significant amongst patients with low and moderate pretest probability. The rate ratio was 2.31 (CI 1.38-3.86) for European patients compared to non-European patients. CONCLUSION: Given the same pretest probability according to the Wells score, European patients had significantly higher positive rates of CTPA and ultrasonography of the lower limbs than non-European patients. Further prospective studies are required to confirm our findings and establish an appropriate pretest assessment tool for non-European patients.

The utility of assessing the gross appearances of FNA specimens.

OBJECTIVE: Ideally, fine needle aspiration (FNA) cytology should be performed with near-patient assessment of the adequacy of the specimen by a cytopathologist. However, this is often not feasible. A cruder alternative is for the FNA practitioner to examine the gross appearances of the specimen and to try to predict the its quality. This study set out to determine the value of this approach. METHODS: The study was conducted in tertiary public hospitals in New Zealand and the UK. FNA gross material grading was performed by a variety of pathologists on FNA samples taken using manual guidance and image guidance. The FNA gross material grade was compared with the findings on microscopic examination. RESULTS: Nine out of 123 FNA samples were assessed as Grade 1 (unlikely to contain diagnostic material). All were subsequently reported as having insufficient diagnostic tissue on microscopic examination. Forty-two of the FNA samples were assessed as Grade 2 (possibly contains diagnostic material) and 46 as Grade 3 (probably contains diagnostic material). None from either of these grades was reported as showing insufficient diagnostic material on microscopic examination. Twenty-six cases were reported as Grade 4 (material suggesting a specific diagnosis). None of these was reported as showing insufficient diagnostic material on microscopic examination. The most common Grade 4 provisional diagnosis was that of a colloid cyst or colloid nodule of the thyroid (seven cases). Only two cases had misleading Grade 4 provisional diagnoses. Both were thought to be pus on gross examination but showed necrotic carcinoma on microscopic examination. CONCLUSIONS: The gross appearances of FNA samples can usually predict the adequacy of the samples and sometimes predict the final microscopic diagnosis. However, near-patient microscopic assessment of FNA specimens is preferable if available.

The gross appearances of fine needle aspiration cytology samples.

AIMS: This study set out to photograph and describe the gross appearances of fine needle aspiration (FNA) cytology samples of commonly encountered lesions. METHODS: During a 2 year period, a cytopathologist photographed the gross appearances of near patient FNA samples, concentrating on commonly encountered lesions. RESULTS: The gross appearances are described, accompanied by photographic illustrations. CONCLUSIONS: This paper describes and illustrates the gross appearances of FNA cytology samples of some commonly encountered lesions.

Evidence for secular change in Paget's disease.

Death certification data has shown that death rates due to Paget's disease of bone and osteosarcoma in older people (assumed to be attributable to Paget's) declined in the latter part of the 19th and in the early 20th century, suggesting that there may be a secular trend toward less severe disease. We have reviewed a 21 year experience in a clinic specializing in Paget's disease. Data from all 1041 patients attending the clinic in this period were reviewed. Despite an increase in the susceptible population and an increased rate of referral to the clinic over this time (p = 0.012), there was a fall in the absolute numbers of patients referred with severe disease, as judged by the initial plasma alkaline phosphatase activity at presentation. In the years 1973-1978 the initial plasma alkaline phosphatase was > 500 U/L in an average of 22 new patients per year and > 1000 U/L in 12 per year. In the years 1988-1993, the figures were 12 and 3 per year, respectively. During this period, there were no other facilities offering scintigraphy or intravenous treatment for Paget's disease in the Auckland region, making it unlikely that patients with severe disease were being seen and treated elsewhere. The average age of newly referred patients rose steadily from a mean 62 years, in 1971-1973 to 71 years in 1991-1993 (p < 0.001). 534 subjects had scintiscans (52%) from which the extent of skeletal involvement was calculated. Skeletal involvement showed a significant negative correlation with year of birth (p < 0.01) but not with age or year of presentation. The proportion of patients with > 20% skeletal involvement had fallen by a third in the cohort born after 1926, compared to the cohort born before 1915. Our data demonstrate that, on average, newly referred patients with Paget's disease have less severe disease and are significantly older at diagnosis than was the case two decades ago.

Immunoregulation in severe generalized periodontitis.

Severe generalized periodontitis (SGP) is an inflammatory disease which leads to extensive alveolar bone loss in young adults. Peripheral blood lymphocytes from SGP patients have been previously reported to exhibit an in vitro hyperproliferative response when exposed to B cell mitogens derived from Staphylococcus aureus and Actinomyces viscosus. Therefore hyperresponsiveness to B-cell mitogens could be an important pathogenic factor in the susceptibility to and progression of SGP. We have tested whether the hyperproliferative response of lymphocytes from SGP patients was due to (i) a functional deficiency of suppressor T cells, or (ii) to numerical alterations of lymphocytes. Supernatant fluids from concanavalin A-stimulated T cells from 14 SGP patients and 14 normal subjects were compared for their ability to suppress the IgM synthesis of B-cell mitogen-stimulated mouse splenocytes. No significant differences were noted in suppressor T-cell function between control subjects and SGP patients. However, SGP patients had significantly higher lymphocyte counts than control subjects, and there was a positive correlation between high lymphocyte counts and high mitogen-stimulated proliferation. SGP patients also had higher lymphocyte:monocyte ratios than control subjects, suggesting that a defect in macrophage-mediated suppression might be involved in the hyperproliferation phenomenon. Our data do not support the hypothesis that a suppressor T-cell defect is the cause of mitogen-induced hyperproliferative responsiveness of peripheral blood lymphocytes from SGP patients. Rather, hyperproliferation may be due to an expansion of the lymphocyte pool which responds to mitogens, or/and a regulatory disturbance which arises because of altered lymphocyte:macrophage ratios.