No-biopsy strategy for coeliac disease is applicable in adult patients: a 'real-world' Scottish experience.

Objective: Emergency interim guidance from the British Society for Gastroenterology (BSG) states that a no-biopsy strategy is possible to diagnose coeliac disease (CD) in adults with elevated transglutaminase IgA antibody (TGA-IgA) levels. We aimed to determine if the suggested TGA-IgA ≥10× ULN is safe and robust in making the diagnosis in adult patients in Scotland. We also aimed to establish if any important co-diagnoses would be missed if no biopsy was performed. Method: All positive coeliac serology results for patients aged >15 years in Scotland in 2016 (Grampian 2019) were accessed. Data were collected on demographics, TGA-IgA titres, D1 sampling, histology and macroscopic findings at upper and lower gastrointestinal (GI) endoscopy. Results: 1037/1429 patients with positive serology proceeded to biopsy, of which 796/1037 (76.8%) were diagnosed as CD. A total of 320/322 (99.37%) patients with TGA-IgA ≥10× ULN were diagnosed as CD giving the cut-off a positive predictive value of 99.38%. No significant co-pathology was found at endoscopy in these patients. Conclusion: Our results show that a no-biopsy strategy using a cut-off of TGA-IgA ≥10× ULN is safe to diagnose CD and that no important pathology would be missed. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition 2020 and BSG COVID-19 interim guidelines are applicable to adult patients in Scotland.

Refractory Human Cutaneous Protothecosis.

A 67-year-old Scottish woman presented to her general practitioner with a subcentimeter lump between her shoulder blades. The lump was suspected to be an epidermal cyst and was excised. The patient had a history of controlled diabetes. Most summers, she spent a month near a beach resort in Mexico. The lump reappeared after 6 months within the scar area and was re- excised. Both skin excisions were performed in the primary care setting without histologic assessment.

Investigating Various Thresholds as Immunohistochemistry Cutoffs for Observer Agreement.

BACKGROUND: Clinical translation of immunohistochemistry (IHC) biomarkers requires reliable and reproducible cutoffs or thresholds for interpretation of immunostaining. Most IHC biomarker research focuses on the clinical relevance (diagnostic, prognostic, or predictive utility) of cutoffs, with less emphasis on observer agreement using these cutoffs. From the literature, we identified 3 commonly used cutoffs of 10% positive epithelial cells, 20% positive epithelial cells, and moderate to strong staining intensity (+2/+3 hereafter) to use for investigating observer agreement. MATERIALS AND METHODS: A series of 36 images of microarray cores stained for 4 different IHC biomarkers, with variable staining intensity and percentage of positive cells, was used for investigating interobserver and intraobserver agreement. Seven pathologists scored the immunostaining in each image using the 3 cutoffs for positive and negative staining. Kappa (κ) statistic was used to assess the strength of agreement for each cutoff. RESULTS: The interobserver agreement between all 7 pathologists using the 3 cutoffs was reasonably good, with mean κ scores of 0.64, 0.59, and 0.62, respectively, for 10%, 20%, and +2/+3 cutoffs. A good agreement was observed for experienced pathologists using the 10% cutoff, and their agreement was statistically higher than for junior pathologists (P=0.02). In addition, the mean intraobserver agreement for all 7 pathologists using the 3 cutoffs was reasonably good, with mean κ scores of 0.71, 0.60, and 0.73, respectively, for 10%, 20%, and +2/+3 cutoffs. For all 3 cutoffs, a positive correlation was observed with perceived ease of interpretation (P<0.003). Finally, cytoplasmic-only staining achieved higher agreement using all 3 cutoffs than mixed staining patterns. CONCLUSIONS: All 3 cutoffs investigated achieve reasonable strength of agreement, modestly decreasing interobserver and intraobserver variability in IHC interpretation. These cutoffs have previously been used in cancer pathology, and this study provides evidence that these cutoffs can be reproducible between practicing pathologists.

Primary invasive aspergillosis with disseminated intravascular coagulation as a presenting feature of non-Hodgkin's lymphoma.

Invasive aspergillosis (IA) is a life-threatening infection. IA is usually seen in severely immunocompromised patients. However, IA as a presenting feature of non-Hodgkin's lymphoma is rare. The patient we describe had no signs or symptoms of lymphoma prior to hospital admission. A. fumigatus was isolated from respiratory tract specimens on the day of admission and fungal elements were detected on autopsy. Isolation of Aspergillus in patients with severe sepsis should trigger a search haematological malignancy.

Primary nodal hemangioma.

Benign vascular tumors arising primarily in lymph nodes are rare. The importance of identifying these entities is to avoid misdiagnosing them as malignant vascular tumors, which occur more often in lymph nodes. Hemangioma is a benign nodal vascular tumor, but its occurrence in lymph nodes is extremely rare. Hemangiomas can occur at any age, mostly in females. It is usually asymptomatic, affects only one node, and does not recur. Four histologic types of hemangioma have been identified: capillary/cavernous, lobular capillary, cellular, and epithelioid. This review highlights the key features of previously reported cases and discusses the differential diagnosis.

Hyalinizing parathyroid adenoma and hyperplasia: report of 3 cases of an unusual histologic variant.

Fibrosis in the parathyroid glands can be seen in adenomas, in carcinomas, and after fine needle aspiration of the thyroid gland. Fibrosis occurs in approximately 10% of typical adenomas and in all atypical adenomas. This is usually in the form of fibrous bands or trabeculae that intersect the hypercellular parenchyma. However, widespread diffuse fibrosis or sclerosis in either parathyroid gland hyperplasia or adenoma has not been reported before in the English medical literature. We report 3 cases of hyperparathyroidism (2 adenomas and 1 hyperplasia) with an unusual pattern of sclerosis. The hyalinized, eosinophilic fibrous tissue was diffusely distributed within and around the parathyroid parenchyma, often isolating groups of cells and single cells.

Response of vitiligo to narrowband ultraviolet B and oral antioxidants.

Narrowband ultraviolet B phototherapy (NB-UVB) is the most widely and effective therapeutic option in vitiligo. Antioxidant supplementation has also been reported to be useful. The purpose of this study was to determine the efficacy of oral antioxidants with NB-UVB in the treatment of vitiligo. Twenty-four patients with stable vitiligo were recruited and divided randomly into 2 groups. They were treated with NB-UVB plus oral vitamin E in group A and with NB-UVB only in group B. Improvement was recorded according to the extent of repigmentation in the existing lesions. Both plasma malondialdehyde (MDA; product of lipid peroxidation) and reduced glutathione (GSH) were measured before and after treatment. Twenty patients completed the study. Marked to excellent repigmentation was noted in 72.7% and 55.6% of the patients in group A and group B, respectively. Of the patients, 70% in group A and 85% in group B experienced mild erythema. After treatment, there was a significant reduction in plasma MDA in group A than in group B, but the increase in plasma GSH was not significant. In conclusion, oral vitamin E may represent a valuable adjuvant therapy, preventing lipid peroxidation in the cellular membrane of melanocytes and increasing the effectiveness of NB-UVB.