HIGHLIGHTS OF ADVANCES IN MEDICAL RETINA FROM THE VIRTUAL WORLD OPHTHALMOLOGY CONGRESS 2020

The World Ophthalmology Congress (WOC) is one of the largest international ophthalmology conferences, taking place every two years. The event this year was the first of its kind, held as a virtual summit due to the Covid-19 pandemic. There were over 2000 talks from world experts, a virtual industry exhibition including free papers, e-posters, live symposia and presentations. Medical retina is a subspecialty in which exciting and innovative advances in research were presented. The topics covered included the use of Conbercept for Polypoidal Choroidal Vasculopathy, Faricimab in Diabetic Macular Oedema and neovascular Age Related Macular Degeneration (nAMD), Brolucizumab, Aflibercept and Port Delivery Systems in nAMD, amongst many others. Medical retina continues to be a rapidly advancing field within ophthalmology with new research findings having great implications for treatment burden and service delivery. This report summaries the highlights of advances within the medical retina subspecialty from free papers in WOC 2020.

The transcriptional repressor REV-ERB as a novel target for disease

REV-ERB is a member of the nuclear receptor superfamily of transcription factors involved in the regulation of many physiological processes, from circadian rhythm, to immune function and metabolism. Accordingly, REV-ERB has been considered as a promising, but difficult drug target for the treatment of numerous diseases. Here, we concisely review current understanding of the function of REV-ERB, modulation by endogenous factors and synthetic ligands, and the involvement of REV-ERB in select human diseases. Particular focus is placed on the medicinal chemistry of synthetic REV-ERB ligands, which demonstrates the need for higher quality ligands to aid in robust validation of this exciting target.

Improving sputum collection processes to increase tuberculosis case finding among HIV-positive persons in Botswana

SETTING

Twenty-two human immunodeficiency virus (HIV) clinics in Botswana.

OBJECTIVE

To compare sputum collection rates, sputum quality and volume, and tuberculosis (TB) diagnosis rates before and after field efforts to improve sputum collection among individuals newly diagnosed with HIV with TB symptoms.

DESIGN

Newly diagnosed individuals living with HIV attending 22 HIV clinics in Botswana were screened for TB from August 2012 to March 2014. Starting in May 2013, a field intervention composed of the introduction of a tracking log for presumed TB patients, and patient instructions and sputum induction to improve sputum collection rates was implemented.

RESULTS

Prior to the intervention, sputum collection rates were 44.1% (384/870). Subsequently, sputum collection increased to 58.3% (579/993) (P < 0.001). Sputum quality and volume also improved. Although rates of TB diagnosis increased from 9.7% (84/870) to 12.5% (120/993), this difference was not significant (P = 0.143).

CONCLUSION

Sputum collection rates among presumptive TB cases, as well as sputum quality and volume improved after implementation of the field intervention. To improve sputum collection rates, efforts at the program level should be ongoing.

Assessment of routine screening of pediatric contacts of adults with tuberculosis disease in Tanzania

Setting

Ten selected healthcare facilities in Tanzania, March-April 2016.

Objective

To assess the implementation of screening among pediatric contacts of adults with tuberculosis (TB) disease.

Design

Using a mixed-methods approach, we conducted a questionnaire study among sputum smear-positive adult TB patients and abstracted data from their patient cards to assess the implementation of a child contact management (CCM) intervention. We also conducted in-depth interviews with healthcare workers (HCWs) to solicit their views on clinical practices and challenges in CCM.

Results

A total of 141 adult smear-positive TB patients reported 396 children living in households; detailed information on 346 (87.4%) was available. Only 37 (10.7%) children were clinically assessed for TB, 5 (13.5%) were diagnosed with TB, and 22 started on isoniazid preventive therapy (IPT) (59.0%). Of the 320 children whose caregivers responded to whether their children had undergone human immunodeficiency virus (HIV) testing, 55 (17.2%) had been tested and one (1.8%) was HIV-positive. Forty-one HCWs described passive CCM without use of contact or IPT registers.

Conclusion

We identified gaps in the implementation of TB screening, IPT provision, and HIV testing in pediatric contacts of adults with sputum smear-positive TB. Systematic efforts, including increasing HCW training and educating the community, may improve implementation.

Expanding human immunodeficiency virus testing and counseling to reach tuberculosis clients' partners and families

Recent years have shown important increases in human immunodeficiency virus (HIV) testing and counseling (HTC), diagnosis, and coverage of antiretroviral therapy (ART) among HIV-infected tuberculosis (TB) patients. Expansion of HTC for partners and families are critical next steps to increase earlier HIV diagnoses and access to ART, and to achieve international goals for reduced TB and HIV-related morbidity, mortality, transmission and costs. TB and HIV programs should develop and evaluate feasible and effective strategies to increase access to HTC among the partners and families of TB patients, and ensure that newly diagnosed people living with HIV and HIV-infected TB patients who complete anti-tuberculosis treatment are successfully linked to ongoing HIV clinical care.

Modular protein switches derived from antibody mimetic proteins

Protein switches have potential applications as biosensors and selective protein therapeutics. Protein switches built by fusion of proteins with the prerequisite input and output functions are currently developed using an ad hoc process. A modular switch platform in which existing switches could be readily adapted to respond to any ligand would be advantageous. We investigated the feasibility of a modular protein switch platform based on fusions of the enzyme TEM-1 β-lactamase (BLA) with two different antibody mimetic proteins: designed ankyrin repeat proteins (DARPins) and monobodies. We created libraries of random insertions of the gene encoding BLA into genes encoding a DARPin or a monobody designed to bind maltose-binding protein (MBP). From these libraries, we used a genetic selection system for β-lactamase activity to identify genes that conferred MBP-dependent ampicillin resistance to Escherichia coli. Some of these selected genes encoded switch proteins whose enzymatic activity increased up to 14-fold in the presence of MBP. We next introduced mutations into the antibody mimetic domain of these switches that were known to cause binding to different ligands. To different degrees, introduction of the mutations resulted in switches with the desired specificity, illustrating the potential modularity of these platforms.

Review of policy and status of implementation of collaborative HIV-TB activities in 23 high-burden countries

Issuance of national policy guidance is a critical step to ensure quality HIV-TB (human immunodeficiency virus-tuberculosis) coordination and programme implementation. From the database of the Joint United Nations Programme on HIV/AIDS (UNAIDS), we reviewed 62 national HIV and TB guidelines from 23 high-burden countries for recommendations on HIV testing for TB patients, criteria for initiating antiretroviral therapy (ART) and the Three I's for HIV/TB (isoniazid preventive treatment [IPT], intensified TB case finding and TB infection control). We used UNAIDS country-level programme data to determine the status of implementation of existing guidance. Of the 23 countries representing 89% of the global HIV-TB burden, Brazil recommends ART irrespective of CD4 count for all people living with HIV, and four (17%) countries recommend ART at the World Health Organization (WHO) 2013 guidelines level of CD4 count ⩿500 cells/mm(3) for asymptomatic persons. Nineteen (83%) countries are consistent with WHO 2013 guidelines and recommend ART for HIV-positive TB patients irrespective of CD4 count. IPT is recommended by 16 (70%) countries, representing 67% of the HIV-TB burden; 12 recommend symptom-based screening alone for IPT initiation. Guidelines from 15 (65%) countries with 79% of the world's HIV-TB burden include recommendations on HIV testing and counselling for TB patients. Although uptake of ART, HIV testing for TB patients, TB screening for people living with HIV and IPT have increased significantly, progress is still limited in many countries. There is considerable variance in the timing and content of national policies compared with WHO guidelines. Missed opportunities to implement new scientific evidence and delayed adaptation of existing WHO guidance remains a key challenge for many countries.

Cost-effectiveness of the Three I's for HIV/TB and ART to prevent TB among people living with HIV

OBJECTIVE

To evaluate the cost-effectiveness of the Three I's for HIV/TB (human immunodeficiency virus/tuberculosis): antiretroviral therapy (ART), intensified TB case finding (ICF), isoniazid preventive treatment (IPT), and TB infection control (IC).

METHODS

Using a 3-year decision-analytic model, we estimated the cost-effectiveness of a base scenario (55% ART coverage at CD4 count ⩿350 cells/mm(3)) and 19 strategies that included one or more of the following: 1) 90% ART coverage, 2) IC and 3) ICF using four-symptom screening and 6- or 36-month IPT. The TB diagnostic algorithm included 1) sputum smear microscopy with chest X-ray, and 2) Xpert® MTB/RIF.

RESULTS

In resource-constrained settings with a high burden of HIV and TB, the most cost-effective strategies under both diagnostic algorithms included 1) 55% ART coverage and IC, 2) 55% ART coverage, IC and 36-month IPT, and 3) expanded ART at 90% coverage with IC and 36-month IPT. The latter averted more TB cases than other scenarios with increased ART coverage, IC, 6-month IPT and/or IPT for tuberculin skin test positive individuals. The cost-effectiveness results did not change significantly under the sensitivity analyses.

CONCLUSION

Expanded ART to 90% coverage, IC and a 36-month IPT strategy averted most TB cases and is among the cost-effective strategies.

Coherent backscattering of ultracold atoms

We report on the direct observation of coherent backscattering (CBS) of ultracold atoms in a quasi-two-dimensional configuration. Launching atoms with a well-defined momentum in a laser speckle disordered potential, we follow the progressive build up of the momentum scattering pattern, consisting of a ring associated with multiple elastic scattering, and the CBS peak in the backward direction. Monitoring the depletion of the initial momentum component and the formation of the angular ring profile allows us to determine microscopic transport quantities. We also study the time evolution of the CBS peak and find it in fair agreement with predictions, at long times as well as at short times. The observation of CBS can be considered a direct signature of coherence in quantum transport of particles in disordered media. It is responsible for the so called weak localization phenomenon, which is the precursor of Anderson localization.

An analytical technique for measuring protein carbonyl in the stratum corneum using surface plasmon resonance

Protein carbonyl groups in the stratum corneum may be used as a biomarker for skin photo-stress. To evaluate the relationship between the protein carbonyl to total protein (TP) ratio (carbonylation ratio) and skin photo-stress, the authors established a methodology by which protein carbonyl can be easily and highly sensitively analysed using an optical technique based on surface plasmon resonance (SPR). To collect the stratum corneum, tape stripping was employed. Firstly, the protein carbonyl was reacted with 2,4-dinitrobenzenesulfonic acid dihydrate, and the quantity of dinitrophenylated (DNP)-protein carbonyl was determined using an anti-dinitrophenyl (anti-DNP) antibody. The mass of DNP-protein carbonyl was measured using SPR. A truncated sampling-reporting cycle of <5 min allowed speedy reporting of DNP-protein carbonyl levels. A significant difference was observed in the protein carbonyl/TP ratio (carbonylation ratio) between a sun-protected area (mid-ventral arm) and a sun-exposed area (upper cheek, P < 0.05). Additionally, the carbonylation ratio of the sun-exposed area showed a higher value than that of the sun-protected area. It was suggested that the carbonylation ratio might be a useful index of skin photo-stress.

Selenium intoxication with selenite broth resulting in acute renal failure and severe gastritis

Selenium (Se) is an essential trace element in human and animal nutrition. It is also widely utilized in industrial processes. Reports of acute selenium toxicity in humans are rare. We report a case of a 23-year-old female who consumed about 100 mL of liquid selenite broth and presented with severe nausea, vomiting, abdominal pain, hematemesis and acute renal failure (ARF). The serum selenium level was significantly increased. Gastro-duodenoscopy revealed severe corrosive gastritis. Renal biopsy showed features of acute tubular necrosis (ATN), affecting primarily the proximal tubules. The patient was managed with gastric lavage, blood transfusions, infusion of fresh frozen plasma (FFP) and platelet concentrates and hemo-dialysis. The patient was discharged five weeks after admission and her renal functions recovered completely by eight weeks after admission. She continues to be on regular follow-up for any possible sequelae of mucosal corrosive damage. This case highlights a case of selenium intoxication from selenite broth resulting in ARF and corrosive gastritis. The recovery was complete.

Tonsillar actinomycosis: a clinicopathological study

Actinomycosis has been known to involve virtually every anatomic site in the body. Although actinomycosis has been identified in resected tonsils, its possible role in adeno-tonsillar disease has received little attention. A clinicopathological study of 302 patients who had adeno-tonsillar surgery is presented. Tonsillar actinomycosis was present in 86 (28.5%) patients. The statistical analysis revealed a significant association (P<0.0001) of actinomycosis and tonsillar hypertrophy (56.8%) compared to only 10.3% in the recurrent tonsillitis group. A statistically significant association (P<0.0001) of tonsillar actinomycosis and sickle cell anaemia, beta thalassaemia, bronchial asthma and beta haemolytic streptococcal infections was also seen. This data supports a predisposition of the above conditions to tonsillar actinomycosis and adeno-tonsillar hypertrophy and a possible etiopathologic role of this organism in adeno-tonsillar hypertrophy and disease. Although the clinical association of actinomycosis and tonsillar hypertrophy and beta haemolytic streptococcal infection has been described before the association of actinomycosis with sickle cell anaemia, beta thalassaemia and bronchial asthma is being observed for the first time in literature.

Palatal presentation of scleroma

A case with palatal presentation of scleroma is presented due to its rarity and unusual manifestations. The patient presented with only palatal symptoms. Nasal endoscopy revealed signs of all three stages of scleroma: catarrhal, granulomatous and sclerotic stages. Histopathology was vital in the diagnosis. The patient was treated by medical therapy, and palatal symptoms were relieved by uvulopalatopharyngoplasty.

Schistosomiasis in patients in the Sultanate of Oman

BACKGROUND

Following an intensive public health eradication program, the focus of schistosomiasis mansoni at Salalah in Southern Oman (the only focus of schistosomiasis in Oman), appeared to have been eradicated in 1994. Since the vector snails for Schistosoma mansoni (and also for S. haematobium) were widely endemic in freshwater springs at Salalah, and reintroduction of infection (or introduction in the case of S. haematobium) was possible, we undertook a prospective study in 1995 for schistosomiasis in patients at the Sultan Qaboos University Hospital (SQUH), and to obtain evidence of visits by these patients to Salalah.

PATIENTS AND METHODS

From May 1995 to May 2000, Omani and expatriate patients presenting at SQUH were evaluated for possible schistosomiasis (residence in an endemic region, suggestive clinical features) by a search for ova in stool, urine, or in tissue biopsies, or when ova were absent, by serodiagnosis. A retrospective survey of schistosomiasis patients diagnosed in SQUH from 1990 to April 1995 was also performed. Ministry of Health (MOH) data on reports of schistosomiasis (a notifiable disease) in Oman from 1991 to 2000, were obtained.

RESULTS

Thirty patients with schistosomiasis were identified, 10 retrospectively and 20 in the prospective study. Patients were aged 9 to 60 years, and 25 of them (10 Omanis, 14 Egyptians, 1 Sudanese) contracted the infection in Africa, while 5 Omanis became infected in Salalah (3 in 1999). Twelve patients had schistosomiasis mansoni, 6 had schistosomiasis haematobia, and in the rest, infection by both parasites was confirmed or possible. The most common presentation (23%) was hepatosplenic schistosomiasis with portal hypertension. No patient admitted to contaminating freshwater with excreta in Salalah. MOH data revealed 3 to 14 cases of schistosomiasis were reported annually between 1991 and 2000, and that all schistosomiasis cases reported from 1994 to 1998 originated from Africa.

CONCLUSION

Schistosomiasis remains an important health problem in Oman. Many doctors are unfamiliar with the clinical features and methods of diagnosis, thereby frequently causing delays in diagnosis. Because vector snails are endemic in Salalah, schistosomiasis patients must be detected and treated early. At infested freshwater sites at Salalah, mollusciciding should continue indefinitely, and notices should warn visitors not to contaminate the spring water.

Glomerular injury induced in mice by intraperitoneal injection of Shiga-like toxins

BACKGROUND AND OBJECTIVES

Shiga-like toxins I and II (Stx1 and Stx2) play an important role in the pathogenesis of renal disease by causing renal microvascular injury. A murine model was used to study glomerular lesions produced by Stx1 and Stx2.

METHODS

Swiss albino mice of the Rockefeller strain were inoculated intraperitoneally with LD(50) doses of endotoxin-free Stx1 of Stx2 and observed for signs of disease. Samples of renal cortical tissue from mice were examined with the electron microscope.

RESULTS

the mice developed systemic and neurological symptoms including hind limb paralysis and generalised convulsions. Renal arteriolar damage and glomerular endothelial cytoplasmic swelling, vacuolation, lysis and intravascular coagulation were present and resembled the microangiopathy seen in renal biopsies from patients.

INTERPRETATION AND CONCLUSIONS

these experiments establish the role of Stx1 and Stx2 in glomerular vascular injury and provide a model for studying the pathogenesis of Shiga-like toxin related microangiopathy.

Eosinophilic cystitis--not that uncommon!

The clinical presentation, radiological manifestations and response to therapy of seven cases of biopsy-proven eosinophilic cystitis seen over an 8-year period were evaluated retrospectively. All of the five men and two women had symptoms of dysuria and frequency, with haematuria in two cases. One developed acute painful retention. The urine was sterile in all. Radiological findings included bladder mass lesions and upper tract dilatation. Cystoscopy showed papillary, erythematous and ulcerative mucosal lesions, and in one instance a large mass lesion. The various procedures carried out were cold cup biopsies, transurethral resections, or fulgration of lesions and partial cystectomy. Medical therapy included non-steroidal anti-inflammatory drugs and prophylactic antibiotics to cover the procedures carried out. There was excellent symptomatic improvement in all patients. This is the largest single-centre experience reported, and is unusual as the majority of the patients in this series were men.

Familial Lecithin:cholesterol acyltransferase deficiency with renal failure in two siblings. First case report from India

We encountered 2 siblings with corneal opacities, anemia, decreased concentration of plasma esterified cholesterol, chronic renal failure and markedly reduced levels of plasma lecithin:cholesterol acyltransferase. Renal biopsy in 1 patient showed clear lacunae containing characteristic dense bodies in the glomerular and tubular basement membranes and the interstitium. One of the 2 siblings received a kidney transplant and is doing well after 9 years. This is the first report of this rare metabolic disease from India.

Histological studies in primary neuritic leprosy: changes in the nasal mucosa

The nasal mucosae of 39 cases of primary neuritic leprosy (PNL) registered at Karigiri were studied histologically to determine nasal mucosal involvement in PNL and its relevance to the pathogenesis of the disease. Specific changes of leprosy were seen in 20 (51%) biopsies, ranging from macrophage granulomas with acid fast bacilli, to epithelioid granulomas and nerve inflammation. The remaining biopsies revealed chronic inflammatory changes of the mucosa or mild non-specific nerve changes. These findings show that there are widespread effects of the disease even in PNL patients in whom the disease is believed to be confined to the peripheral nerves. The findings also show that early leprosy involvement can be found in the nasal mucosa even before lesions become apparent in the skin or other parts of the body. The nasal mucosa could be one of the sites for the primary lesion in leprosy. Clinical and histological examination of the nasal mucosa may be useful and important in the early diagnosis of leprosy and especially in contacts.

Echinococcosis with concurrent phaeohyphomycosis

A double infection in the same organ, echinococcosis associated with phaeohyphomycosis in the lungs, is reported.

Evolutionary history and mechanism of the Drosophila cecropin gene family

Upon bacterial infection, insects secrete a set of synthesized antibacterial proteins into the hemolymph and initiate synergistic destruction of invaders. Cecropin is one such antibacterial protein which is also found in vertebrates. To study the evolutionary history and mechanism of the Cecropin gene family, we determined DNA sequences of one isogenic In(3R)C and six isofemale lines of Drosophila melanogaster as well as one line of D. simulans and of D. yakuba. The phylogenetic analysis of these sequences together with those published for D. virilis and Sarcophaga peregrina reveals frequent gene re-organization. It was also found that silent nucleotide differences within D. melanogaster are quite heterogeneous across the gene region of approximately 3 kilobases and the extent of polymorphism is unusually usually high. These data suggest that the Cecropin gene region of D. melanogaster underwent intragenic recombination as well as introgression from a closely related sibling species, D. simulans.

The effect on patient management of temporary non-availability of immunofluorescence for renal biopsy reporting

Delay in reporting the immunofluorescence findings on renal biopsies, owing to an interruption in supply of reagents, made possible a retrospective analysis of the effect of the lack of this information on patient management. Hospital case records of the 39 patients so affected were reviewed to determine what changes in their management took place after the immunofluorescence findings became available. The clinical, laboratory, and light microscopic findings in all except a case of pauci-immune crescentic glomerulonephritis allowed management decisions to be made that were not influenced by immunofluorescence findings. This was owing to correct prediction of the immunofluorescence findings, as in cases of IgA nephropathy presenting with recurrent haematuria; the adequacy of light microscopy in the interpretation of graft biopsies, in classifying lupus nephritis and in most cases of nephrotic syndrome; and the absence of entities identifiable only by immunofluorescence among these patients.

Leprosy and renal transplantation

Nine cases of leprosy in patients treated at a large renal transplant centre in South Asia are described. Three had leprosy diagnosed before transplantation and had either completed or were continuing chemotherapy at the time of transplantation. One showed exacerbation of undisclosed leprosy after transplantation. Five patients developed the disease for the first time 22 months to 12 years after transplantation. Immunosuppression did not adversely affect the treatment of leprosy in any of the patients though concurrent liver disease required cessation of rifampicin in one patient.

Inter- and intra-observer variation in the histopathological reporting of cervical squamous intraepithelial lesions using a modified Bethesda grading system

OBJECTIVE

1. To assess inter- and intra-observer variation in the histopathological reporting of cervical colposcopic biopsies using a histologic modification of the cytological Bethesda grading system; 2. to determine the histologic profile of those cases which resulted in diagnostic disagreement.

METHODS

Consecutive cervical colposcopic biopsies (n = 125) were assessed independently by six experienced histopathologists. Cases were classified as normal, low grade squamous intraepithelial lesion or high grade squamous intraepithelial lesion. Six months later the process was repeated. The degree of inter and intra-observer variation was assessed by kappa statistics. All cases in which there was less than perfect inter and intra-observer agreement were reviewed by the coordinator of the study.

RESULTS

In the first round of the study inter-observer agreement was generally poor, with unweighted and weighted kappa values ranging from 0.15 to 0.58 (average 0.30) and from 0.21 to 0.61 (average 0.36) respectively. In the second round inter-observer agreement was better, with unweighted and weighted kappa values ranging from 0.08 to 0.55 (average 0.33) and from 0.22 to 0.59 (average 0.42). Ten of the 15 pairs of observers achieved fair inter-observer agreement using weighted kappa analysis. The degree of intra-observer agreement was better, unweighted and weighted kappa values ranging from 0.26 to 0.61 (average 0.47) and from 0.34 to 0.62 (average 0.51) respectively. Two of the six participants achieved fair intra-observer agreement and two achieved good intra-observer agreement using weighted kappa analysis. There were marked difficulties in the separation of normal squamous epithelium from low grade squamous intraepithelial lesion and in the separation of low grade from high grade squamous intraepithelial lesions. Histopathological review revealed that many of the difficulties in the separation of normal and low grade squamous intraepithelial lesion were in the distinction between superficial vacuolated cells and true koilocytes. Difficulties also resulted in the separation of basal cell hyperplasia, inflammatory associated changes and immature squamous metaplasia from low grade squamous intraepithelial lesion. Conditions which resulted in difficulty in the separation of low grade and high grade squamous intraepithelial lesions included florid koilocytotic change and immature metaplastic squamous epithelium with atypia. In some cases, there was a full spectrum of diagnoses from normal to high grade squamous intraepithelial lesion. These were largely cases of immature metaplastic squamous epithelium with atypia and of thin or atrophic squamous epithelium with atypia.

CONCLUSIONS

Most pairs of observers can achieve fair inter-observer agreement in the reporting of cervical colposcopic biopsies using a modified Bethesda system. Intra-observer agreement is also generally fair to good using this system. It may be that a two tier grading system is more appropriate for the histopathological reporting of these biopsies than the traditional three-tier intraepithelial neoplasia (CIN) system.

Light and electron microscopic findings in rhinosporidiosis after dapsone therapy

Morphological findings in serial nasal mucosal biopsies from three cases of rhinosporidiosis on dapsone therapy were compared with biopsies from 33 patients taken before dapsone or surgical treatment was initiated. All biopsies were examined by light microscopy and five by electron microscopy. Counts of histologically intact and degenerated organisms showed a decreasing proportion of intact forms with treatment.

Personal Problem-Solving Scoring of TAT Responses: Known-Groups Validation

Two studies employed a known-groups validation strategy to evaluate a Thematic Apperception Test (TAT) scoring system purported to measure personal problem-solving skills, the Personal Problem-Solving System (PPSS). In Study 1 clinicians rated the records of 46 mental health outpatients for the presence of personal problem-solving skills deficits. Verbatim TAT transcripts from these patients were blindly scored using the PPSS. Participants predicted to demonstrate problem-solving deficits obtained lower PPSS scores. In Study 2 a psychiatric sample (n = 47) and a community-based comparison group (n = 47) completed a life history questionnaire, a checklist of problems currently experienced, a measure of psychiatric symptoms, and responded to 3 TAT cards. TAT responses were again blindly scored using the PPSS. In contrast to the comparison group, psychiatric patients checked a greater number of current problems, endorsed more psychiatric symptoms, and obtained lower scores on the PPSS. A discriminant function analysis using PPSS scores correctly classified 72% of these participants. PPSS scores predicted group membership even after controlling for differences in age, education, the number of problems experienced, and psychiatric symptoms. This combination of variables correctly classified 92% of the participants. Results of both studies are interpreted as supporting the discriminant validity of the PPSS.

Interobserver variation in the reporting of cervical colposcopic biopsy specimens: comparison of grading systems

AIMS

To assess interobserver variation in reporting cervical colposcopic biopsy specimens and to determine whether a modified Bethesda grading system results in better interobserver agreement than the traditional cervical intraepithelial neoplasia (CIN) grading system.

METHODS

One hundred and twenty five consecutive cervical colposcopic biopsy specimens were assessed independently by six histopathologists. Specimens were classified using the traditional CIN grading system as normal, koilocytosis, CIN I, CIN II, or CIN III. The specimens were also classified using a modified Bethesda grading system as either normal, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL). Participants were also asked to categorise biopsy specimens by the CIN system with the addition of the recently proposed category "basal abnormalities of uncertain significance (BAUS)". The degree of agreement between participants was assessed by kappa statistics.

RESULTS

Using the CIN system, interobserver agreement was generally poor: unweighted and weighted kappa values between individual pairs of observers ranging from 0.05 to 0.34 (average 0.20) and from 0.20 to 0.54 (average 0.36), respectively. With the modified Bethesda system, interobserver agreement was better but still poor: unweighted and weighted kappa values ranging from 0.15 to 0.58 (average 0.30) and from 0.21 to 0.61 (average 0.36), respectively. There was little or no agreement between observers in the diagnosis of BAUS.

CONCLUSIONS

Interobserver agreement in the reporting of cervical colposcopic biopsy specimens using the CIN grading system is poor. Agreement, while still poor, is better when a modified Bethesda grading system is used. There is little or no consensus in the diagnosis of BAUS.

Endometrial stromal sarcoma with sex cord-like areas and focal rhabdoid differentiation

An unusual uterine lesion is described in a patient with postmenopausal bleeding. Grossly, a yellow, polypoid mass projected into the uterine cavity. Histological examination showed a distinct biphasic pattern with areas of typical low-grade endometrial stromal sarcoma and areas where tumour cells were arranged in cords and trabeculae, resulting in a sex cord-like pattern. In these areas the cells assumed a rhabdoid morphology with eccentric vesicular nuclei, prominent nucleoli and eosinophilic hyaline cytoplasmic inclusions. Immunohistochemistry showed positive cytoplasmic staining of both components for vimentin, desmin and the cytokeratin marker CAM 5.2, but no staining for CEA and EMA. Electronmicroscopy revealed prominent paranuclear arrays of intermediate filaments. This is the second reported case of endometrial stromal sarcoma with rhabdoid differentiation and the first documented example of rhabdoid cells in sex cord-like areas. The report adds to the list of diverse neoplasms which may display a characteristic rhabdoid morphology and supports the hypothesis that extrarenal rhabdoid tumours are not a distinct clinicopathological entity. A diagnosis of malignant rhabdoid tumour of the uterus should be considered only when extensive sampling fails to disclose areas with an appearance typical of an endometrial stromal lesion.

Gastric aspiration for diagnosis of pulmonary tubercolosis in adult renal allograft recipients

Of 213 renal allgraft recipients suspected to have had pulmonary tuberculosis, 132 had sputum examinations and 14 showed acid-fast bacilli. Of the remaining 118 patients, 25 had gastric aspirations, 18 had bronchoalveolar lavage, and 75 did not require further investigation because of spontaneous improvement or confirmation of an alternative diagnosis. While 9 of the 25 patients' gastric aspirate examination was positive, all the 18 who had bronchoalveolar lavage were negative for acid-fast bacilli. Eighty-one patients without expectoration had gastric aspiration directly and 14 showed acid-fast bacilli. Of the remaining 67 patients only 17 had bronchoalveolar lavage, of which three were positive for AFB and the rest did not require further testing for tuberculosis. A total of 106 patients had gastric aspiration. Acid-fast bacillus positivity was significantly more (P<.01) in patients with abnormal chest radiographs as compared with patients with normal chest radiographs as compared with patients with normal chest radiograph results. We suggest gastric aspiration for AFB in all renal transplant recipients who have fever, scanty expectoration, and abnormal chest radiograph with clinical suspicion of pulmonary tuberculosis.

Saprophytic mycosis with pulmonary echinococcosis

Two patients with pulmonary echinococcal hydatid cysts and concurrent saprophytic mycosis histologically resembling aspergillosis are described.

Atypical copper cirrhosis in Indian children

In addition to ten children with Wilson's disease and one with Indian childhood cirrhosis, nine Indian children, aged from 4 to 15 years, with cryptogenic cirrhosis had significant deposits of stainable copper in their hepatocytes. These nine children had normal or elevated serum caeruloplasmin levels, absence of Kayser-Fleischer rings and a history of sibling death owing to liver disease in four cases. Histologically, fatty change was absent from all the biopsies but Mallory's hyaline, pericellular fibrosis and ballooning of hepatocytes were present in some. Since these children did not conform to the accepted clinical or histological definitions of either Indian childhood cirrhosis or Wilson's disease, they were designated as having atypical copper cirrhosis. The relationship of this group of cases to other types of copper cirrhosis is unknown.

Raised serum IgE levels in chronic inflammatory lung diseases

OBJECTIVE

To study the serum IgE response in nonallergic subjects with chronic inflammatory lung diseases.

SETTING

Christian Medical College Hospital, Vellore.

SUBJECTS

Twenty six patients with bronchiectasis, five with pulmonary mycosis referred from all over India and 30 healthy subjects.

MAIN OUTCOME MEASURES

Serum IgE value (determined by radioimmuno assay) above the upper limit of normal control range (136 to 948 iu/ml) was considered as raised level.

RESULTS

Of the 26 patients with bronchiectasis 13 had pyogenic infections, six had pulmonary tuberculosis; in six patients sputum culture was sterile while another patient had herpes zoster. Five cases of mycosis included one each of actinomycosis, aspergillosis, blastomycosis, cryptococcosis and nocardiasis. The serum IgE levels were raised in 20 (65%) of the 31 patients.

CONCLUSION

Associated bacterial, fungal and parasitic infections were probably responsible for inducing an hyper-IgE response in these non-allergic subjects.