Pulmonary embolism at autopsy in a normal population: implications for air travel fatalities.

BACKGROUND: Much attention has been focused on the apparent risk to long-haul air travelers of venous thromboembolism [deep vein thrombosis (DVT) and pulmonary embolism (PE)], following a number of well-publicized cases. However, there is little epidemiological data to elucidate the problem. PE tends to be under-diagnosed as a cause of death in the general population. This study sets out to establish the level of risk of fatal PE among long-haul passengers arriving in the UK, on the basis of a reappraisal of the role of PE in mortality in the general population. METHODS: Autopsies carried out at Gloucester in 1996-2000 were reviewed to determine age-specific mortality rates for PE for West Gloucestershire. These rates were applied to long-haul air travelers arriving in the UK, for whom the number of passenger-years at risk were calculated, to estimate the expected numbers of deaths in this group. RESULTS: In 3764 autopsies, PE was the primary cause of death in 221 cases (5.9%), while in 304 (8.1%) it was present as an incidental finding. This suggests that PE was involved in approximately 13.9% of deaths, and is more common with age. Passenger years at risk per annum among long-haul passengers arriving in the UK were estimated (mid-range) at 21,830.482; it was anticipated that 6.55 deaths involving PEs, but not related to air travel, could be expected annually in this group. CONCLUSIONS: It appears that the risks of venous thromboembolism due to air travel are overstated. Some deaths are bound to occur inflight, but there is no evidence to suggest an increase, though clearly there are predisposing risk factors for DVT present on long journeys.

Gastric cancer below the age of 55: implications for screening patients with uncomplicated dyspepsia.

AIMS: To test the hypothesis that gastric cancer presenting with uncomplicated dyspepsia is rare below the age of 55. PATIENTS AND METHODS: The area studied was the postcode defined catchment area of a district general hospital (Gloucestershire Royal) serving a population of 280,500. An open access endoscopy service has been available in this district for more than 17 years. All cases of gastric cancer during a seven year period (1986-92) were drawn from the local pathology database. The database of the neighbouring hospital and the South West Cancer Registry were searched for missed cases from the postcoded area. Hospital and general practitioner records were retrospectively reviewed with respect to duration of symptoms, and previous consultation and investigation for dyspepsia; and alarming symptoms and signs suggestive of underlying malignancy (unexplained recent weight loss, dysphagia, haematemesis or melaena, anaemia, previous gastric surgery, palpable mass, and perforation). RESULTS: Twenty five of 319 cases of gastric cancer detected during the seven year period were aged less than 55. Twenty four of these 25 patients presented with one or more suspicious symptoms or signs. Only one patient (4%) aged less than 55 presented with uncomplicated dyspepsia. In two patients there was a delay in diagnosis of more than six months after first presenting to the general practitioner. Both these patients had significant symptoms at presentation. CONCLUSION: Gastric cancer is rare below the of 55 (7.8% of all cases) and, even in the presence of established open access endoscopy, presents with suspicious symptoms or signs in 96% of cases. The age limit for screening uncomplicated dyspepsia can be raised safely to 55.

Spontaneous graft-versus-host disease following autologous peripheral blood progenitor cell transplantation in chronic myeloid leukaemia.

Myeloablation followed by haemopoietic reconstitution using autologous peripheral blood progenitor cells (PBPC) is applicable to some patients with CML, particularly where there is no allogeneic stem cell donor available, and interferon alpha has failed to achieve a significant cytogenetic response. Cells lacking the Philadelphia (Ph) chromosome can be collected at the early phase of myeloid recovery after intensive chemotherapy, and reconstitution after autografting can be associated with prolonged suppression of the Ph positive clone. It is possible that mechanisms other than this "in vivo purge' may contribute to disease control, for example an autologous graft-versus-leukaemia effect. We report two patients in whom significant autologous graft-versus-host disease (auto-GVHD) has occurred, which has not previously been described as a spontaneous event after PBPC autograft for CML. We postulate that mononuclear cells collected in an early phase of recovery after intense myelosuppression have the capacity to produce self-reactivity after autografting. These cells, which may include autoreactive T lymphocytes or antigen-presenting dendritic cells, might mediate a useful graft-versus-leukaemia effect.

Histological examination of clots from cytological specimens: is this a worthwhile procedure?

A comparison of conventional cytology and clot histology was made on 174 serous fluids, fine needle aspirates (FNA) and other non-gynaecological specimens. In eight cases (4.5%) this clot material contained malignant cells or cells suspicious of malignancy despite the absence of suspicious or malignant cells in conventionally prepared smears from the same specimen. In 11 cases (6.3%) the clot was negative, although conventional smears contained malignant or suspicious cells. A chi 2 test showed that there was no statistically significant difference between the number of positive diagnostic scores in each group with chi 2 of 0.223 (degree of freedom = 1), P = 0.637. Examination of clot material from serous fluids and FNA-aspirates is as effective as examination of conventional cytological preparations. Processing of clots from cytological aspirates for histological examination should be more widely adopted, and is applicable in all cytopathology laboratories.

Efficacy and safety of large-loop excision of the transformation zone.

Large-loop excision of the transformation zone (LLETZ) has become a popular treatment for women with cervical intraepithelial neoplasia (CIN) before long-term effectiveness and safety have been fully evaluated. Women who took part in a 1990 study of the procedure have been followed-up by cervical cytology for longer than 2 years. The rate of recurrences and residual lesions was 5.0% in the first year and 0.6% in the second year. LLETZ was also effective when used as a repeat procedure, although the negative histology rate was much higher (4.7% for initial procedures and 20% for repeat procedures). 250 women from the original study group of 1000 answered a questionnaire on fertility and menstrual symptoms 3 years after LLETZ. We found no differences between these women and controls of the same age, living in the same geographical area, with a history of negative cervical smears. LLETZ is a safe and effective procedure with no effect on menstruation or fertility.

Results of a prospective randomized trial of the Angelchik prosthesis and of a consecutive series of 119 patients.

The results of a randomized multicentre trial comparing the Angelchik prosthesis with floppy Nissen fundoplication for gastro-oesophageal reflux were assessed 4-6 years after surgery. Of the original 52 patients 48 were traced. A good or excellent result (Visick grade 1 or 2) was obtained in 21 of 25 after insertion of the Angelchik prosthesis compared with 18 of 23 after fundoplication. Poor results were due to recurrent heartburn after fundoplication and to dysphagia after prosthesis insertion. In a separate consecutive series of 119 patients receiving Angelchik prostheses, results were good or excellent in 101 (85 per cent) and poor in 18 (15 per cent). Control of reflux with a correctly positioned prosthesis was good. Troublesome dysphagia (Visick grade 3 or 4) was experienced in eight of the 119 patients. There was no mortality and no incidence of splenectomy or gas-bloat syndrome.

The histology of 'stored' autologous ossicles.

Controversy still exists concerning the ultimate fate of transposed or transplanted ossicles in tympanoplasty. Histological studies on autologous and homologous ossicles removed at revision operations, or from animal studies, vary in their conclusions. The viability, of such materials used in the long-term is still uncertain. Whether this has any functional significance is also uncertain. This report contains a histological review of 10 ossicle remnants stored in the 'closed' mastoid cavity for 12 months, following closed cavity mastoidectomy (combined approach tympanoplasty).

Cancer registration by linking pathology and district PAS data.

The incompleteness and inaccuracy of cancer registries, with the resulting underestimation of cancer incidence and lack of confidence by clinicians in the information offered, have been noted by numerous studies throughout the world. We report attempts in one district to provide more accurate and timely information on cancer cases, both for local purposes and for expediting input to the Regional Registry and hence the National Registry. A semi-automatic link between the pathology system and the PAS system was developed to establish a histopathology-based dataset of cancer cases for the district. This software provides a basis for cancer registration and, combined with clinical staging and treatment ranges, could provide a timely and accurate picture of cancer for research, management, treatment and planning purposes.

Colposcopic diagnosis and treatment of cervical dysplasia at a single clinic visit. Experience of low-voltage diathermy loop in 1000 patients.

In a study of 1000 women referred over 20 months with abnormal smears and in whom the entire transformation zone could be seen the aim was to test the feasibility of colposcopic assessment and treatment at one visit to the clinic. 897 women needed only one visit. This was achieved by using a modification of the large loop diathermy excision technique and by careful attention to the timing of the clinic visit. 103 required further visits, for the following reasons: incomplete excision on histology and/or subsequently abnormal smear (85), secondary haemorrhage (6), microinvasion or invasive carcinoma (9), biopsy specimens unusable (3). Further treatment was given in 4.1% of the cervical dysplasias. All patients treated in a single visit preferred this approach to the alternative of colposcopic assessment and biopsy followed, after histological examination, by local ablation by laser, excision by loop biopsy technique, or cone biopsy.

Primary malignant lymphoma of the large intestine complicating chronic inflammatory bowel disease.

Ten cases of malignant lymphoma of the colon and rectum complicating chronic inflammatory bowel disease are presented. Seven patients had chronic ulcerative colitis with a history varying from 6 to 20 years. There was extensive colitis in six of these patients and left-sided colitis in one. All seven lymphomas showed the pathological and immunohistological features of primary B-cell tumours of the gastrointestinal tract with a predominance of high-grade tumours. Three patients had Crohn's disease of the large intestine complicated by malignant lymphoma of the sigmoid colon or rectum. The history of Crohn's disease varied from 30 months to 20 years and in each case there was fissuring and fistulae. There was extensive anal involvement in two cases. Histologically the three lymphomas were heterogeneous: one was of 'granulomatous' T-cell type and the other two were markedly polymorphic and of equivocal phenotype. They were also characterized by numerous multinucleate tumour giant cells. Primary colorectal malignant lymphoma should be regarded as a rare, but significant, complication of ulcerative colitis. Immunosuppression may be an additional factor in the genesis of intestinal lymphoma in Crohn's disease. The prognosis appears to be dependent on factors already known to be of prognostic significance in primary gut lymphomas: a predominance of high-grade tumours suggests that the outlook is generally worse than that for idiopathic primary large intestinal lymphoma.

Five year follow-up study of gastritis.

This paper describes a five year follow-up study of the incidence and course of gastritis affecting the antrum and body of the stomach of 50 patients, most of whom presented with non-ulcer dyspepsia and a few with peptic ulceration. We have shown that antral gastritis, like gastritis affecting the fundus, becomes more severe in a proportion of patients as time goes by. Perhaps more important is the increased severity and progression of atrophic and metaplastic change in the antrum compared with the fundus. The significance of these changes with regard to the development of peptic ulceration and malignancy is discussed.