Oncocytic mucoepidermoid carcinoma of the salivary glands.

Two parotid mucoepidermoid carcinomas with predominant oncocytic features were initially assessed on frozen section. Because of extensive oncocytic change, it was inferred that the lesions were most likely benign. Permanent sections revealed low-grade mucoepidermoid carcinoma with prominent oncocytic change (in more than 75% of the neoplasms) in both cases. Review of 48 additional consecutive cases of mucoepidermoid carcinoma of the salivary glands revealed prominent oncocytic change (accounting for 60% of the neoplasm) in one high-grade lesion. Phosphotungstic acid-hematoxylin stains revealed strong granular cytoplasmic staining in the oncocytic elements; immunohistochemical stains for antimitochondrial antibodies also showed intense immunoreactivity in these cells. Oncocytic change is not typically a prominent feature of mucoepidermoid carcinoma of the salivary glands, and to our knowledge, only three such cases have been reported previously. Because most salivary gland lesions with oncocytic change are benign, it is important to distinguish mucoepidermoid carcinoma from other entities that may show prominent oncocytic change. We report three additional examples of this rare lesion, two low-grade tumors and one high-grade tumor, and review our experience with oncocytic change in mucoepidermoid carcinoma of the salivary glands.

Screening for infection and disease as a tuberculosis control measure among indigents in New York City, 1994-1997.

SETTING: Several social service agencies in New York City, and the Chest Clinic of Bellevue Hospital, a large public hospital. OBJECTIVE: To determine the utility of screening as a preventive and control measure among persons at risk for tuberculosis. DESIGN: Persons seeking social services at several private agencies in New York City were screened, and those with a positive skin test or symptoms suggestive of active tuberculosis were referred to the Chest Clinic for evaluation. RESULTS: Of 3828 persons evaluated, 20 had active tuberculosis, and 33% of the screened cohort were tuberculin skin test positive. Of 466 persons with tuberculosis infection who were evaluated, only 55 persons were given isoniazid (INH), and only 20 completed preventive therapy. Most patients who were not given INH had taken it previously, were older than 35 years, or had continuing alcohol use which made physicians reluctant to prescribe isoniazid. CONCLUSION: Screening for tuberculosis may detect a significant number of cases of active disease when the background prevalence of the disease is very high. However, screening for infection as a means to prevent future cases is unlikely to be effective unless rates of administration and completion of isoniazid preventive therapy are increased.

Tuberculosis infection and disease among persons seeking social services in New York City.

SETTING: A large public hospital in New York City. OBJECTIVE: To determine the prevalence of tuberculosis infection and disease in a cohort of indigent persons in New York. DESIGN: Persons seeking social services at any of five community-based organizations in New York City were screened for tuberculosis infection using tuberculin skin testing and a symptom questionnaire. Skin test or symptom positive persons were referred to the Bellevue Hospital Chest Clinic for a chest radiograph and medical evaluation. After this evaluation, patients were classified into a diagnostic category (e.g. tuberculosis infection, tuberculosis disease, no evidence of tuberculosis infection or disease). RESULTS: Of 651 persons screened, 591 (91%) completed the initial evaluation. The tuberculosis infection prevalence for the entire cohort was 41% (95% Confidence Interval [CI], 37% to 45%). Risk factors for infection included residence in a congregate setting, drug use, and birth outside the United States. Human immunodeficiency virus (HIV) infection was not a risk factor for infection. Eleven cases of active tuberculosis were also detected (disease prevalence of 1.7%, 95% CI, 0.85% to 3%). Most of the patients with active tuberculosis had documented HIV infection or clear risk factors for HIV. CONCLUSION: We conclude that tuberculosis infection and disease remain common in populations characterized by poor housing conditions, drug use, and HIV infection. Linking a major medical provider with community-based organizations is an effective means to provide highly targeted screening services to a population at serious risk for disease acquisition and transmission.

Interobserver variation in the histopathological assessment of Helicobacter pylori gastritis.

The histopathologic detection of Helicobacter pylori in gastric biopsy specimens is considered the gold standard for the diagnosis of H pylori infection. However, few studies have addressed the pathologists' reliability to detect the organism and to assess the degree of the related inflammatory changes. The objectives of this study were to determine the degree of agreement among the findings of four gastrointestinal pathologists in the semiquantitative evaluation of H pylori infection and gastritis. Three slides from specified areas of the stomach of 99 patients with and without H pylori infection were stained with the triple stain, coded, and examined independently by four pathologists. For each specimen, a visual analogue scale graded from 0 (absent/normal) to 5 (maximal intensity) was used to score (1) H pylori (2) neutrophils, and (3) atrophy. Data were analyzed using kappa-statistics. The kappa-coefficient for the detection of H pylori (present vs absent) was approximately .9 (excellent); for the intensity of infection, it was considerably lower on the 6-point scale (approximately .61) and improved slightly on an amalgamated 4-point scale (approximately .71). The agreement on presence or absence of neutrophils was excellent (kappa = .8) in antral biopsies and good (kappa = .67) in corpus biopsies. The kappa for the semiquantitative scoring of neutrophils was poor on the 6-point scale (approximately .43) and fair on the amalgamated scale (approximately .54). The interobserver agreement was the poorest in the evaluation of atrophy (presence, absence, categories, or group categories) with kappa coefficients varying from .08 and .29. This group of pathologists had a high level of concordance on the diagnosis of H pylori infection in any particular patient and a high index in the assessment of the intensity of infection. The agreement was less in the semiquantitative evaluation of active inflammation. When the evaluation concerned a loosely defined feature, such as atrophy, there was essentially no agreement among the pathologists. This study suggests the need for further assessments of pathologists' ability to provide reproducible diagnoses. These results also indicate that more stringent criteria for the diagnosis of "soft" histopathologic features (such as atrophy) are urgently needed.

Bloodstream infections in neonatal intensive care unit patients: results of a multicenter study.

For identification of risk factors for bloodstream infection (BSI) among neonatal intensive care unit patients, prospective 6-month studies in three neonatal intensive care units were conducted. BSI was diagnosed in 42 of 376 (11.2%) enrolled infants. Pathogens included coagulase-negative staphylococci, Candida sp., Group B streptococci and Gram-negative species. Patients with BSIs were more likely to die during their neonatal intensive care unit stay than were patients who did not acquire BSIs (6 of 42 vs. 11 of 334, P = 0.007). BSI rate was highest in infants with birth weight < 1500 g (relative risk (RR) = 6.8, P < 0.001), those treated with H-2 blockers (RR = 4.2, P < 0.001) or theophylline (RR = 2.8, P < 0.001) and those with admission diagnoses referable to the respiratory tract (RR = 3.7, P < 0.001). Infants who developed BSI were more severely ill on admission than other infants (median physiologic stability index 13 vs. 10 (P < 0.001) and were of lower gestational age (28 vs. 35 weeks, P < 0.001). In logistic regression analysis, risk of BSI was independently associated only with very low birth weight, respiratory admission diagnoses and receipt of H-2 blockers. Risk of isolation of a pathogen from blood culture was independently associated with Broviac, umbilical vein or peripheral venous catheterization > 10, 7 or 3 days, respectively, at one insertion site. Rate of isolation of a pathogen was higher (9 of 59 (15%)) within 48 hours of a measurable serum interleukin 6 concentration than an interleukin 6 level of 0 pg/ml (10 of 159 (6%), P = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

The gastric cardia in Helicobacter pylori infection.

Helicobacter pylori gastritis is believed to be both more prevalent and more severe in the antrum than in the corpus. The mucosa of the cardia is architecturally similar to that of the antrum. This study was designed to test the hypothesis that intensity of H pylori infection and the associated inflammation are similar in the cardia and the antrum and are greater in these locations than in the corpus. A total of 445 gastric biopsy specimens were obtained from predetermined sites from 50 subjects (42 with demonstrated H pylori infection). Slides were stained with a combined stain to simultaneously visualize H pylori, mucosal morphology, and inflammatory infiltrate. Numbers of H pylori, inflammatory responses, and intestinal metaplasia were graded on a scale from 0 to 5. Helicobacter pylori was detected in the cardia of 40 of the 42 infected subjects (95%). Helicobacter pylori density was similar in the three gastric regions. The intensity of chronic active gastritis was similar in the antrum and the cardia, and was higher in these locations than in the corpus (P < .005). Lymphoid follicles were significantly less prevalent in the cardia and in the corpus than in the antrum (P < .05). Helicobacter pylori infection was as prevalent in the cardia as in the rest of the stomach and its density was similar in all sites of antrum, corpus, and cardia. The inflammatory responses characteristic of chronic active gastritis, except for lymphoid follicles, were similar in the antrum and the cardia and in both these locations were more intense than in the corpus. The significance of these findings is discussed with respect to the relationship between H pylori infection and the genesis of gastric adenocarcinoma and lymphoma.

Atypical Pneumocystis carinii pneumonia in homosexual men with unusual immunodeficiency.

Pneumocystis carinii pneumonia is a well known opportunistic infection whose radiographic presentation and association with cytomegalovirus (CMV) have been well described. Recently nine young homosexual men with chronic flulike illnesses were seen. Bronchoscopy in six cases demonstrated evidence of CMW infection with Pneumocystis pneumonia. The radiographic presentation was atypical. Immunologic evaluation revealed T-cell abnormalities. CMV infections altering immunologic mechanisms has been postulated as the underlying cause of this and other uncommon infections in homosexual men.

Benign molar pregnancies: pulmonary complications.

Cardiopulmonary dysfunction has been observed after the removal of benign hydatidiform mole. Of 60 cases reviewed with benign trophoblastic disease, five developed respiratory complications. Two patients developed pulmonary edema that progressed to adult respiratory distress syndrome. Autopsy of two patients showed no evidence of pulmonary trophoblastic emboli. Possible etiologies for the pulmonary findings, including trophoblastic emboli, hypervolemia, disseminated intravascular coagulation, and hyperthyroidism, are discussed.

Intralesional BCG injection of pulmonary neoplasms: radiographic findings.

A clinical trial has been established to evaluate the use of intralesional bacillus Calmette Guérin (BCG) immunotherapy as an adjunct to surgery in resectable pulmonary neoplasms. BCG was injected percutaneously under fluoroscopic guidance into a single nodule in each of 21 patients with resectable primary and metastatic pulmonary neoplasms. Eighteen of 21 infected nodules increased in size and nine became poorly defined in the 2-4 week interval between BCG administration and resection. There was no change in those nodules that were not injected. The changes in the injected nodules were due to BCG-induced granulomatous inflammation and necrosis. BCG can be administered intralesionally into pulmonary neoplasms without significant complications (pneumothorax in nine, intrapleural injection in one). Preliminary observations suggest an improvement in disease-free interval. A prospective, randomized trial is planned to determine whether BCG immunotherapy will result in significantly improved survival in patients with primary and metastatic pulmonary neoplasms.