Johne's disease in Irish dairy herds: considerations for an effective national control programme.

The Irish dairy industry has established a reputation for the production of safe and healthy dairy products and is seeking to further expand its export market for high value dairy products. To support its reputation, stakeholders aim to control Johne's disease. To assist decision-makers determine the most appropriate design for an Irish programme, a narrative review of the scientific literature on the epidemiology of Johne's disease, and selected control programmes throughout the world was undertaken. Two modelling studies specifically commissioned by Animal Health Ireland to assess testing methods used to demonstrate confidence of freedom in herds and to evaluate a range of possible surveillance strategies provided additional information. The majority of control programmes tend to be voluntary, because of the unique epidemiology of Johne's disease and limited support for traditional regulatory approaches. While acknowledging that test performance and sub-clinical sero-negative shedders contributes to the spread of infection, a range of socio-political issues also exist that influence programme activities. The paper provides a rationale for the inclusion of a Veterinary Risk Assessment and Management Plan (VRAMP), including voluntary whole herd testing to identify infected herds and to support assurance-based trading through repeated rounds of negative testing, national surveillance for herd-level case-detection, and improved understanding of biosecurity management practices. Identification and promotion of drivers for industry and producer engagement in Ireland is likely to guide the future evolution of the Irish Johne's Control Programme (IJCP) and further enhance its success. The provision of training, education and extension activities may encourage farmers to adopt relevant farm management practices and help them recognize that they are ultimately responsible for their herd's health and biosecurity.

Costs and utilization of intraoperative cholangiography.

BACKGROUND: Routine intraoperative cholangiography (IOC) has been advocated as a viable strategy to reduce common bile duct injury (CDI) during cholecystectomy. This is predicated, in part, on the low cost of IOC, making it a cost-effective preventive strategy. Using billed hospital charges as a proxy for costs, we sought to estimate costs associated with the performance of IOC. METHODS: The 2001 National Inpatient Survey (NIS) database was assessed for IOC utilization and associated charges. Average charges for hospital admission where the primary procedure was laparoscopic cholecystectomy were compared for those associated with and without the performance of IOC. RESULTS: Eighteen percent of cholecystectomies were performed in facilities that never perform IOC. Routine IOC (defined as >75% of cholecystectomies performed in any one hospital having a concomitant IOC) was performed in only 11% of hospitals. In the remaining 71% of hospitals, selective IOC was performed. IOCs were associated with US $706-739 in additional hospital charges when performed in conjunction with laparoscopic cholecystectomy. We project a cost of US $371,356 to prevent a single bile duct injury by using routine cholangiography. CONCLUSION: We conclude that only a minority of hospitals performs cholecystectomies with routine IOC. Because of the significant amount of hospital charges attributable to IOC, routine IOC is not cost-effective as a preventative measure against bile duct injury during cholecystectomy.

Indications for selective intraoperative cholangiography.

The indications for selective intraoperative cholangiography (IOC) include a clinical history of jaundice, pancreatitis, elevated bilirubin level, abnormal liver function test results, increased amylase levels, a high lipase level, or dilated common bile duct on preoperative ultrasonography. Although these clinical features are widely accepted as indications for IOC, they have not been tested for their ability to predict choledocholithiasis. Charts were reviewed for a 6-month time period in 2003 at Parkland Memorial Hospital for all patients undergoing cholecystectomy. Univariate analysis and logistic regression were used to determine which factors predicted choledocholithiasis. Of the 572 patients undergoing cholecystectomies during the study period, 189 underwent IOC and common bile duct stones were found in 57. Only preoperative hyperbilirubinemia or ultrasonograph identification of common bile duct dilation reliably predicted choledocholithiasis. There were 13 cases of choledocholithiasis that would not have been identified by preoperative hyperbilirubinemia or an enlarged common bile duct. However, common bile duct stones were clinically significant in only 2 of the 13 cases. One of these was treated with postoperative endoscopic retrograde cholangiopancreatography, and the other was treated with laparoscopic common bile duct exploration. Preoperative identification of a dilated common bile duct or elevated bilirubin levels can be the sole criteria for performing IOC on a selective basis in patients without malignancy. Reliance on a history of remote jaundice, pancreatitis, elevated liver function test values, or pancreatic enzymes results in unnecessary IOCs.

Health care access and poverty do not explain the higher esophageal cancer mortality in African Americans.

BACKGROUND: Esophageal cancer mortality is increased in African Americans relative to white patients. The reasons for this are unknown but are thought to be related to inadequate access to health care secondary to a higher poverty rate in African American populations. METHODS: The National Health Interview Survey database for years 1986 to 1994 were combined and linked to the National Death Index. Individuals who died from esophageal carcinoma were assessed in the combined database, thus enabling detailed analysis of their socioeconomic status, race, and health care access. RESULTS: Poverty was 4-fold more frequent in African Americans who died from esophageal carcinoma than whites. Despite poverty, African American patients' access to health care was good and was not statistically related to increased mortality. CONCLUSIONS: Although the esophageal carcinoma mortality rate is higher in African Americans than in whites, it is not clearly related to the presence of poverty or to limited health care access. The higher mortality may be related to lifestyle differences, environmental exposure, or difference in disease biology, but it is not related exclusively to socioeconomic factors.

Predictors of human papilloma virus in patients with keratinization.

Given the prevalence of human papilloma virus (HPV) infection, an attempt was made to determine whether certain factors such as keratinization and/or squamous atypia are associated with its development. Review of our gynecologic cytology files from 1989 yielded 1,615 specimens showing parakeratosis and/or hyperkeratosis, without cytologic evidence of HPV. Concomitant diagnoses included no atypia [keratinization only (KO)], inflammatory squamous atypia (ISA), and squamous atypia (SA). Morphologic follow-up including repeat cytology or biopsy was available for 916 cases, 92 (10.0%) of which possessed changes of HPV. For any case with both cytologic and biopsy evidence of HPV, only the biopsy result was tabulated. HPV on follow-up examination was detected in 52 (6.7%) of the 764 cases with KO; in 20 (20.8%) of the 96 cases with keratinization and ISA (KISA); and in 20 (35.7%) of the 56 cases with keratinization and SA (KSA). The definitive diagnosis of HPV was based on previously described features (Gupta, In: Comprehensive Cytopathology, Philadelphia: WB Saunders, 1991:133-140) including nuclear enlargement with nuclear membrane irregularities in combination with sharply demarcated paranuclear cytoplasmic clearing. Affected cells have rounded borders. Binucleated cells are not uncommon. The increasing percentage of HPV from KO to KISA to KSA is not necessarily surprising. However, mathematical analysis revealed statistically significant differences in the development of HPV in each of the 3 groups: KISA vs. KO (P < 0.001), KSA vs. KO (P < 0.001), and KSA vs. KISA (P < 0.05). Therefore, a cytologic diagnosis of keratinization with ISA or especially SA should warrant closer follow-up than that of KO.

Effusion cytology of desmoplastic small round cell tumor of the pleura. A case report.

Desmoplastic small round cell tumor is a recently described neoplasm with multidirectional differentiation. Although it occurs predominantly in adolescent males as an intraabdominal mass with multiple peritoneal implants, we report a case with primary pleural involvement. The cytologic features correspond to previously reported histologic findings and include tightly cohesive clusters of small round poorly differentiated malignant cells with accompanying desmoplastic stromal cells. Immunohistochemical studies revealed characteristic reactivity to epithelial markers, desmin and one neuroendocrine marker (chromogranin). We believe that together with clinical and immunohistochemical data, desmoplastic small round cell tumor can be diagnosed in effusion or aspiration cytology specimens.

Fine-needle aspiration of a periurethral Teflon-filled cyst following radical prostatectomy.

Periurethral Teflon injections are being used increasingly for the treatment of urinary incontinence after radical prostatectomy. We report a case of a man who developed increasing obstructive urinary symptoms and stress incontinence following radical retropubic prostatectomy. Six months earlier, he had undergone periurethral Teflon injections. On transrectal ultrasound and magnetic resonance imaging, a 3.2-cm cystic lesion was noted at the prostatic bed near the bladder neck where the Teflon had been injected. Ultrasound-guided transperineal fine-needle aspiration of the cyst yielded a specimen with numerous birefringent crystalline Teflon particles. Although previous reports have described granulomatous tissue reaction, no multinucleated giant cells were present to suggest granuloma formation. To our knowledge, this is the first reported case of Teflon cyst formation following periurethral Teflon injections. The patient's history, imaging studies, cytopathology, and review of the literature are presented in this report.

Needle aspiration cytology of the irradiated breast.

During a 3-year period (1987-1989), 60 fine-needle aspiration biopsies (FNAs) were obtained from new breast lesions in patients previously treated by radiation and surgery for breast carcinoma. The lesions occurred at or near the site of previous excision, 3-117 months after initiation of radiotherapy. FNAs were classified as follows: acellular (11); negative (29); atypical (13); suspicious (4); and positive (3). For statistical analysis, acellular, negative, and atypical diagnoses were considered negative findings, and suspicious and positive diagnoses were considered positive findings. On the basis of subsequent biopsy and/or patient follow-up, FNA yielded a sensitivity of 86%, a specificity of 98%, a positive predictive value of 86%, a negative predictive value of 98%, and an efficiency of 97%. Excluding cystic lesions, the most reliable criterion for distinguishing malignant from benign lesions was the abundance of epithelial cells, both singly and in large clusters. Cellular characteristics were less helpful, since nuclear atypia was seen in both benign and malignant lesions. It is concluded that (1) FNA is a reliable technique in the evaluation of the irradiated breast; (2) when performed by an experienced operator, an acellular aspirate may be interpreted as evidence against recurrent carcinoma; and (3) epithelial atypia must be interpreted with caution to avoid a false-positive diagnosis.

Detection of Chlamydia trachomatis in cervical smears from pregnant population.

Specimens were obtained for chlamydial cultures and for routine cytologic studies from 281 consecutive pregnant women who presented for their first prenatal visit. Forty patients (14%) had positive cultures for Chlamydia trachomatis. The cervical smears from all patients with positive cultures and from an equal number of age-matched patients with negative cultures were screened for cytologic features reported to be associated with Chlamydia infection. The following features were noted to be more common in the patients with positive cultures: squamous metaplasia, cytoplasmic vacuolation, nuclear abnormalities, human papillomavirus-associated changes, and a greater degree of inflammation. Cytoplasmic inclusions were present in only a single cell in each of 4 (10%) of the patients with positive cultures. None of the cytologic findings was considered to be specific enough to allow a diagnosis of Chlamydia infection. In our experience, the evaluation of cervical smears is of limited value in the detection of Chlamydia infection in pregnant women.

Reevaluation of pulmonary neoplasms resected as small cell carcinomas. Significance of distinguishing between well-differentiated and small cell neuroendocrine carcinomas.

The clinicopathologic features of 50 cases of surgically resected small cell carcinoma were reevaluated (doubly blinded). Two pulmonary carcinomas were excluded because neuroendocrine features could not be demonstrated; two additional cases also were excluded because the tumors grossly invaded the chest wall and their pulmonary origin was not substantiated. Thirty-four tumors were confirmed to be small cell neuroendocrine carcinoma (SCNC). Only seven of 11 (64%) patients with T1N0,T2N0 tumors survived more than 1 year; one of 11 (9%) patients survived more than 2 years. In 12 cases, the diagnosis was changed to well-differentiated neuroendocrine carcinoma (WDNC). Of these, nine of nine (100%) patients with T1N0,T2N0 tumors survived more than 1 year; six of eight (75%) patients survived more than 2 years. These observations strongly indicate that a significant number of long-term survivors with the diagnosis of small cell carcinoma may, in fact, have a distinctly less aggressive type of pulmonary neuroendocrine carcinoma. It was concluded that the distinction between small cell and well-differentiated types of neuroendocrine carcinomas has significant prognostic and therapeutic implications.

A novel monoclonal antibody, SCCL 175, with specificity for small cell neuroendocrine carcinoma of the lung.

The murine monoclonal antibody SCCL 175, which is one of several monoclonal antibodies directed against small cell neuroendocrine carcinoma developed by one of us (E.D.B.), was studied for its immunohistochemical reactivity against normal human tissues and a spectrum of bronchopulmonary and metastatic carcinomas using the avidin-biotin complex technique. SCCL 175 reacted with 40 of 44 small cell carcinomas including both primary and metastatic sites and was distributed both on the cell surface and intracytoplasmically. Staining was seen in fresh frozen tissues, cytology preparations, and in a limited number of paraffin-embedded tissue sections after trypsin pretreatment. It was nonreactive with all non-small cell lung carcinomas, neuroendocrine carcinomas from other primary sites, and nonpulmonary carcinomata studied to date. Its distribution in normal adult human tissues was limited to some hypothalamic neurons and the apical membranes of renal proximal tubular epithelium. Cytotrophoblastic and syncytotrophoblastic cells from placental tissue demonstrated variable SCCL 175 immunoreactivity. Of choriocarcinomas studied, one of three demonstrated focal staining. These findings demonstrate the diagnostic utility of SCCL 175 in phenotyping small cell carcinoma of lung, and its specificity suggests a potential role in the therapy of this disease.

The cytodiagnosis of well-differentiated neuroendocrine carcinoma. A distinct clinicopathologic entity.

Well-differentiated neuroendocrine carcinoma (WDNE) has been recognized as a distinct variant of pulmonary neuroendocrine carcinoma, with characteristic histopathologic and clinical features that separate it from both carcinoid and small-cell carcinoma (SCC). Histologic review of tumors in long-term survivors (greater than two years) with an initial diagnosis of SCC has shown that the majority of these cases are, in fact, better classified as WDNE; the distinction of WDNE from SCC has, therefore, important prognostic and therapeutic implications. A retrospective review of 200 cytologies originally diagnosed as SCC was undertaken in an attempt to characterize the cytomorphologic features of WDNE. The cytologic criteria that distinguished cases of WDNE included polygonal-to-fusiform cells with a variable amount of lacy cytoplasm, oval nuclei with coarsely dispersed chromatin and frequent chromocenters, and mild nuclear and cytoplasmic anisomorphism. The majority of malignant cells were arranged either in acinarlike clusters or in epithelial sheets with evidence of palisading. Twenty-two cases were reclassified cytologically as WDNE and were accurately distinguished from all other neoplastic and SCC cases on repeated double-blind review. Clinical and histologic data confirmed the diagnosis of WDNE in all cases; it can be concluded that SCC and SDNE are cytologically distinct entities.

Limitations and value of aspiration cytology.

The successes of aspiration cytology have enhanced its popularity over the past few years. Now the limitations of the technique are becoming apparent. This article reviews the uses and contraindications for the detection of benign and malignant lesions in various body sites.