The NHS breast screening programme (pathology) EQA: experience in recent years relating to issues involved in individual performance appraisal.

BACKGROUND: The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK. AIMS/METHODS: To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed. RESULTS/CONCLUSIONS: Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist's practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.

Impact of a national external quality assessment scheme for breast pathology in the UK.

BACKGROUND: This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology. AIMS/METHODS: The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics. RESULTS: Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming. CONCLUSIONS: These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.

Subungual pilonidal sinus of the hand in a dog groomer.

Interdigital pilonidal sinus of the hand is an occupational hazard in barbers, sheep shearers and cow milkers. We present a case of a subungual pilonidal sinus of the thumb of a dog groomer, complicated by the development of osteomyelitis in the distal phalanx.

Effects of low concentrations of ampicillin in feed on the intestinal Escherichia coli of chicks.

Ampicillin in low concentrations (1.7 and 5 g t-1) was incorporated in the feed given to 1-d-old chicks for 2 weeks. This was sufficient to select, in the intestinal contents, resistant Escherichia coli strains for which the minimum inhibitory concentration of ampicillin was > 100 micrograms ml-1. Different clones of E. coli were identified by their biotype, pattern of resistance to antibacterial agents and plasmid profile (designated P-P types). The experiment was repeated twice and the average proportion of ampicillin-resistant P-P types among 72 isolates of E. coli from chicks given feed containing 0, 1.7 and 5 g ampicillin t-1 were 10%, 31% and 46% respectively.

Comparison of liver histology with ultrasonography in assessing diffuse parenchymal liver disease.

To establish the accuracy of ultrasonography in assessing diffuse parenchymal liver disease we performed a prospective comparative study with histology in 50 patients with a wide range of liver disease. Liver biopsy was performed within 24 h of the ultrasound examination and ultrasonography was performed by a single operator who was unaware of clinical details of the patients. Histology was reviewed blind and the degree of steatosis graded mild, moderate or severe while increased portal fibrous tissue was graded mild, moderate or established cirrhosis. Thirty-six patients had steatosis and 31 patients had increased fibrous tissue on histology. Ultrasonography correctly identified steatosis in 32/36 (89%) patients including all patients with the severe grade. Increased fibrous tissue was correctly identified in 24/31 (77%) with a sensitivity of 100% in patients with moderate fibrosis and established cirrhosis. Specificity was 93% for steatosis and 89% for increased fibrous tissue. These results show that ultrasonography can provide a non-invasive prediction of liver histology which in moderate and severe steatosis and advanced fibrosis can be both highly sensitive and specific.

Malignant rhabdoid tumour of the bladder with immunohistochemical and ultrastructural evidence suggesting histiocytic origin.

A malignant rhabdoid tumour of the bladder is reported from a girl aged 6. Detailed immunohistochemical and ultrastructural investigations provide evidence which suggests a histiocytic origin for this controversial neoplasm.

Duplex scanning and plaque histology in cerebral ischaemia.

Twenty-seven patients undergoing carotid endarterectomy (21 M, 6 F), with a mean age of 62 years, were studied by carotid ultrasound imaging, angiography, and histological examination of endarterectomy specimens, including Perl's stain to detect haemorrhage more than a week old. Haemorrhage into a plaque was seen histologically in 21 patients (78%), compared with 19 (70%) diagnosed preoperatively as echolucent heterogeneous plaques on ultrasound imaging. The remainder were echogenic homogeneous, fibrous plaques. In only one case was the nature of the plaque diagnosed by contrast arteriography. Excised endarterectomy specimens were inspected independently of the ultrasound assessment to determine whether the site of haemorrhage communicated with the base of an atherosclerotic ulcer. Communicating haemorrhages were present in 9 of 11 with episodic symptoms and non-communicating haemorrhages in 7 of 10 patients with a single cerebrovascular event. Perl's stain showed recent haemorrhage in 7 of 11 patients with multiple symptoms, and old haemorrhage in 9 of 10 patients with a single event. These findings suggest that ultrasonically heterogeneous communicating carotid plaques are symptomatically more active than homogeneous non-communicating plaques.

Phenotypic expression of immune secretory function in focal pregnancy-like change of the human breast.

Fibrocystic disease of the breast in middle-aged women characteristically shows focal epithelial lesions of a very varied nature. The functional immunohistochemical changes in such lesions have been little studied. Focal Pregnancy-like Change in the breast has a striking morphological similarity to the secretory breast lobules in pregnancy and in lactation. We show that the epithelial cells in all the lesions of Focal Pregnancy-like Change studied simultaneously express secretory component, Ig A and J chain in their cytoplasm. Additionally these epithelial cells, unlike those in resting breast lobules, contain lysozyme and lactoferrin. All these phenotypic immunohistochemical changes in Focal Pregnancy-like Change resemble the breast lobules of late pregnancy and lactation. Possibly, the very focality of Focal Pregnancy-like Change reflects a peculiar and local sensitivity of 'resting' breast lobules to unidentified hormonal stimulation.