We read with interest the British Andrology Society (BAS) guidelines
for the assessment of post vasectomy semen samples (2002).[1] The authors
have carried out a thorough and comprehensive review of the topic, and we
are convinced by their recommendation that assessment should be undertaken
16 weeks and at least 24 ejaculates after vasectomy. We are unconvinced
however, by the specific recommendations ab...
We read with interest the British Andrology Society (BAS) guidelines
for the assessment of post vasectomy semen samples (2002).[1] The authors
have carried out a thorough and comprehensive review of the topic, and we
are convinced by their recommendation that assessment should be undertaken
16 weeks and at least 24 ejaculates after vasectomy. We are unconvinced
however, by the specific recommendations about sample collection,
transport and examination.
First, no evidence is provided to support the need for samples to be
maintained at body temperature, delivered to the laboratory within one
hour, and examined within four hours. Since the presence of any
spermatozoa in the sample indicates a need for further samples, assessment
of motility and morphology is not essential. Secondly, the
recommendations for the use of a direct displacement pipette,
centrifugation of samples negative on direct microscopy and quantitation
of spermatozoa are excessive and potentially costly, and appear to have
been taken directly from methods used appropriately in assessment of
infertility. We would question the need for such sensitive methods in
determining whether or not a vasectomy has been successful. The majority
of patients undergoing vasectomy will have been previously fully fertile,
with sperm counts ³106/ml. The success of the operation can be judged on
the basis of the disappearance of sperms based on a simpler assessment of
sperm count.
For many years our method for assessment of post-vasectomy semen samples
has involved requesting samples at 10 and 12 weeks after 5 days of
abstinence. Samples are delivered on the day of collection via the
routine GP transport services and examined at the end of each working day.
We examine each specimen by direct light microscopy using an x40
objective. One drop of uncentrifuged sample is transferred to a slide
using a disposable Pasteur pipette for each sample. The presence of
motile and non-motile spermatozoa in one scan across the slide is reported
semi-quantitatively (+, ++, or +++. Samples are repeated until 2
consecutive negative samples have been reported. 4542 patients have been
assessed by this method between 1997 and 2002. We are not aware of any
unexpected pregnancies after reporting patients negative by our method,
excluding a small number clearly due to late recanalisation. The surgeons
or GPs who carried out vasectomies on 1781 of these patients were
contacted, again they were unaware of any unexpected pregnancies. We
estimate that with a median frequency of sexual intercourse of 4 in 4
weeks in males aged between 25 and 44 years,2 that there are likely to
have been over 3.5 million episodes of sexual intercourse in our cohort
over the last 5 years. These results support our contention that more
elaborate methods of semen analysis are not necessary. Our results are
consistent with those of Haldar et al who reviewed over 30,000 vasectomies
assessed without centrifugation and did not report any pregnancies which
were not attributable to late recanalisation.3
Guidelines from learned societies are always welcome, but must take into
account the opportunity costs of unnecessarily rigorous laboratory
methods. It is easy to suggest a more complex way of processing any
pathology specimen, but far more difficult to define the most cost-
effective method, while still maintaining high levels of sensitivity and
specificity.
References
(1) British Andrology Society. British Andrology Society guidelines
for the assessment of post vasectomy semen samples (2002). J Clin Pathol
2002;55:812-816.
(2) Johnson AM et al. Sexual behaviour in Britain:partnerships, practices,
and HIV risk behaviours. Lancet 2001;358:1835-42.
(3) Haldar N, Cranston D, Turner E, MacKenzie I, Guillebaud J. How reliable
is a vasectomy? Longterm follow-up of vasectomised men. Lancet 2000;356:43-44.
I read the contribution in Historical Perspectives, 'Molten gold was
poured down his throat until his bowels burst,'[1] with mounting horror
and incredulity. Though the subject atter was unusual and the animal model
dubious, I was most puzzled by the nature of the references. The second
and fourth references are to web pages. Investigation of these pages shows
that both are postings taken from books at lea...
I read the contribution in Historical Perspectives, 'Molten gold was
poured down his throat until his bowels burst,'[1] with mounting horror
and incredulity. Though the subject atter was unusual and the animal model
dubious, I was most puzzled by the nature of the references. The second
and fourth references are to web pages. Investigation of these pages shows
that both are postings taken from books at least one of which is in print
in English translation in several editions.[2,3] The third reference
appears to be a duplicate of the fourth and mistakenly attributes an
anthology of literature to the individual that put together the web page
rather than the compiler of the anthology. While it may be convenient for
readers to be able to find references on the Internet, web addresses can
be very ephemeral and a true historical perspective should require
quotation of the title and author of the original published work.
References
(1) Van de Goot FRE, ten Berge RL, Vos R. Historical Perspectives. J Clin Pathol 2003;56:157.
(2) Wylie JA. History or Protestantism. London: Cassell and Company, 1878.
It is a pleasure to read Professor Pileri’s recent article on Hodgkin
disease (HD).
Reflecting back, it took a long time and a lot of effort to identify
the cell of origin of the RS cell, which in 98% of cases is a follicular
center B-cell. It took a lot more time to recognize that in 2% of
classical HD (cHD) cases the RS cells are actually of T-cell origin.
Surprisingly, and rightly so (in...
It is a pleasure to read Professor Pileri’s recent article on Hodgkin
disease (HD).
Reflecting back, it took a long time and a lot of effort to identify
the cell of origin of the RS cell, which in 98% of cases is a follicular
center B-cell. It took a lot more time to recognize that in 2% of
classical HD (cHD) cases the RS cells are actually of T-cell origin.
Surprisingly, and rightly so (in my opinion), this has not hampered the
inclusion of cases of T-cell origin under the umbrella of cHD. In some
ways, this actually goes against the philosophy of the WHO classification
– “to identify and enumerate homogenous entities of lymphoid neoplasia”.
In contrast to such a flexible attitude towards cHD, the proponents
of the WHO classification have been a bit rigid in defining anaplastic
large cell lymphoma (ALCL), which excludes cases of B-cell phenotype. Even
after such exclusion, ALCL is heterogeneous not only on morphology, but
also with respect to ALK gene translocations.
With respect to the pathogenesis of HD, the aspect that has not been
explored fully is the uniform presence of endomitosis in the neoplastic
cells of HD. We need to address, not only of how endomitosis is induced,
but also of how the cell modulates the occurrence of normal mitosis after
several cycles of endomitosis. This is common to both cHD and HD-nodular
lymphocyte predominant type. To some extent the same phenomenon is also
seen among ALCLs and to a greater extent among giant-cell variants of
ALCLs. Apart form this and apart from the morphological and
immunohistochemical overlap, the other common feature to ALCL and cHD is
loss of lineage specific markers.
In broad terms, I believe HD and ALCL have similarities. However, HD
is predominantly a B-cell disease and an extreme minority of cases is of T
-cell origin. Similarly, a majority of ALCLs are of T-cell origin and a
minority is of B-cell origin.
Understanding the basis of endomitosis could be crucial to grasp the
underlying commonality.
Re: Unnecessary repeat requesting of tests in a university teaching
hospital immunology laboratory: an audit.
Unnecessary testing is not only a problem for teaching hospitals. We
were aware that the utility of many of the tests performed by our
department was low and undertook an audit assess this. Our standard was
that 90% of requests should be clinically appropriate. DNA antibodies
shou...
Re: Unnecessary repeat requesting of tests in a university teaching
hospital immunology laboratory: an audit.
Unnecessary testing is not only a problem for teaching hospitals. We
were aware that the utility of many of the tests performed by our
department was low and undertook an audit assess this. Our standard was
that 90% of requests should be clinically appropriate. DNA antibodies
should not be requested unless ANA was present. ENA should not be
requested in ANA-negative patients unless cutaneous lupus, Sjorgren’s
syndrome , myositis or pulmonary fibrosis was suspected: indicated on the
request form. For patients known to have RF, mitochondrial, gastric
parietal cell, smooth muscle antibodies, or rheumatoid patients with ANA
(on at least 2 occasions), repeated testing was considered unnecessary. In
addition to the above criteria, the clinical appropriateness of requests
was assessed (HJL). For example, requests for GBM in cases of chronic
renal failure where there was already a known cause, or requests for ANCA
in patients presenting with clear-cut infection were considered unlikely
to be useful. In a few cases there was no mechanism for test results to be
reviewed. For example, thyroid antibodies were requested for patients who
were subsequently discharged from A&E, without hospital follow up. In
our hospital, the senior scientist approving the reports forwards positive
results to the GP. However, this is time-consuming and we do not have the
resources to forward negative results, which are discarded.
We retrieved 100 consecutive request forms originating from MEHT
hospital doctors. Clinical information and the tests requested were
recorded and the patients’ computer results were reviewed. Of 99 requests
suitable for analysis, 227 tests were generated. 81 tests (35.7%) were
considered clinically unnecessary. (Table 1) 7 tests considered
appropriate, were not requested.
Test
Number
ANA
10
AIS
10
DNA
14
ENA
10
RF
24
ACA
2
EMA
1
TPO
2
GBM
3
ANCA
5
Table 1 Clinically unnecessary tests requested over a 3 day period
ANA, antinuclear antibodies; AIS autoimmune screen; DNA, DNA
antibodies; ENA, Antibodies to extractable nuclear antigens; RF,
rheumatoid factor; ACA anticardiolipin antibodies; EMA endomysial
antibodies; TPO thyroid peroxidase antibodies; GBM glomerular basement
membrane antibodies; ANCA antineutrophil cytoplasmic antibodies.
Unnecessary tests are expensive and, because sensitivity and
specificity declines with poor patient selection, may lead to diagnostic
confusion, unnecessary further investigation and risk of misdiagnosis.
Many of these tests could be prevented by a computer system that rejects
unnecessary requests and allows follow on testing. Follow on testing would
obviate the need for clinicians to request a panel of tests which would
only be required if the initial test was positive. Similar ‘request
management’ protocols work well elsewhere (Longhurst, Helbert, personal
communication) and we are currently discussing suitable protocols with
clinicians. Other tests, such as ANCA cannot be safely rejected by request
management protocols and in this situation, education; particularly of
junior staff, information and interpretative comments encouraging
appropriate requesting are necessary.
H J Longhurst
G C Clarke
Department of Immunology
Broomfield Hospital
MEHT
Court Road
Chelmsford
Essex CM1 7ET
UK
References
(1) Huissoon AP, Carlton SA. Unnecessary repeat requesting of tests in a
university teaching hospital immunology laboratory: an audit [letter]. J
Clin Pathol 2002; 55:78
Janet Shirley and colleagues [1] have made a useful contribution to the
costings of laboratory out of hours services. Their study is based on the
findings from 22 laboratories. Some of their results have been confirmed
in the latest annual report from the national Pathology Benchmarking
Study [2]. In this study 93 haematology departments participated and 86
provided details of their out of hours service...
Janet Shirley and colleagues [1] have made a useful contribution to the
costings of laboratory out of hours services. Their study is based on the
findings from 22 laboratories. Some of their results have been confirmed
in the latest annual report from the national Pathology Benchmarking
Study [2]. In this study 93 haematology departments participated and 86
provided details of their out of hours service. Only 1 department still
pays their staff on a standard Whitley Council contract. 53% of
departments now pay their staff a salary based on a fixed amount not
related to a notional number of calls. This has been an increasing trend
over the last 3 to 4 years with a move away from payment linked to a
notional number of calls.
10 haematology and blood transfusion departments operate either a
full or partial shift system covering the full 24 hour period. These
shifts have been implemented in all size of hospitals i.e. teaching
hospitals,large,medium and small district general hospitals. This compared
to only 3 departments that were operating shift systems in 1998 [3]. In
addition a separate analysis of combined biochemistry and haematology
departments shows that 2 out 9 departments operate a shift system [4].
Shirley and Wing draw attention to the implementation of the European
Working Time Directive [5] and they emphasise the importance of changing
working patterns so that laboratory staff can reduce their working hours
in order to comply with the directive. The analysis of working hours for
Medical Laboratory Scientific Officers (MLSOs) nationally shows a median
number of hours worked per week of 53 hours with a "worst case" of 93
hours [2]. This figure represents the MLSO with the longest weekly working
hours. The median figure of 53 hours has remained static over the last 2
years. This suggests that there has been little impact of the Working Time
Directive on the working hours of laboratory staff.
The national Pathology Benchmarking Study also analyses the costs of
the out of hours service by comparing the costs per request and costs per
test between departments. In a comparative analysis of 11 hospitals based
in London the costs of the haematology out of hours service as measured by
cost per request were lower in the London hospitals than for equivalent
hospitals outside London [6].This result appeared to be explained by the
observation that there was less floor space available from which the
London hospitals were provding their service. We note the addditional
analysis of cost per acute bed that has been used by Shirley and Wing.
Although this does introduce another variable into the equation i.e. the
number of acute beds and how these are defined, we will explore the
feasiblity of introducing this analysis into the national report with our
participants.
References
(1) Shirley J & Wing S. Workload,organisation and costs of haematology
out of hours services. J Clin Pathol 2001;54:647-649.
(2) Pathology Benchmarking Study,Haematology and Blood Transfusion report
1999/000.London:Newchurch Limited,2001.
(3) Pathology Feedback Report, Haematology and Blood Transfusion 1997/98.
London:Clinical Benchmarking Company,1999.
(4) Pathology Benchmarking Study for Combined Biochemistry and Haematology
and Blood Transfusion Departments 1999/00. London:Newchurch 2001.
(5) European Foundation for the Improvement of Living and Working
Conditions.Briefing Paper 98/18. The working time directive.1998.
(6) Pathology Benchmarking Review London Analysis 1998/99. Clinical
Benchmarking Company,2000.
After encountering 5 cases in our institution over an 8 year span and
reviewing the literature to find 15 more cases reported, we realized that
bread bag clip ingestion is an uncommon but not an exceptionally rare
event. We summarized these cases in a recent publication (1). Many of
the patients were elderly and wore dentures, suggesting that decreased
oral sensation may be a risk factor for ingestion. T...
After encountering 5 cases in our institution over an 8 year span and
reviewing the literature to find 15 more cases reported, we realized that
bread bag clip ingestion is an uncommon but not an exceptionally rare
event. We summarized these cases in a recent publication (1). Many of
the patients were elderly and wore dentures, suggesting that decreased
oral sensation may be a risk factor for ingestion. These clips remain
ubiquitous in North America and we suggest that re-design or elimination
of these devices should be considered to prevent further morbidity and
mortality.
1. Newell KJ, Taylor B, Walton JC, Tweedie EJ. Plastic bread-bag
clips in the gastrointestinal tract: report of 5 cases and review of the
literature. CMAJ 2000;162(4):527-9.
Dear Editor
We read with interest the British Andrology Society (BAS) guidelines for the assessment of post vasectomy semen samples (2002).[1] The authors have carried out a thorough and comprehensive review of the topic, and we are convinced by their recommendation that assessment should be undertaken 16 weeks and at least 24 ejaculates after vasectomy. We are unconvinced however, by the specific recommendations ab...
Dear Editor
I read the contribution in Historical Perspectives, 'Molten gold was poured down his throat until his bowels burst,'[1] with mounting horror and incredulity. Though the subject atter was unusual and the animal model dubious, I was most puzzled by the nature of the references. The second and fourth references are to web pages. Investigation of these pages shows that both are postings taken from books at lea...
Dear Editor
We enjoyed reading this poem. Certainly this reads much better than a drab 'tissue was fixed in 10 % formalin, routinely processed' etc.
Can we expect some more poems from Dr.Alexander for in situ hybridization, microarray et al.?
H.Shakila
V.D. Ramanathan
Dear Editor
It is a pleasure to read Professor Pileri’s recent article on Hodgkin disease (HD).
Reflecting back, it took a long time and a lot of effort to identify the cell of origin of the RS cell, which in 98% of cases is a follicular center B-cell. It took a lot more time to recognize that in 2% of classical HD (cHD) cases the RS cells are actually of T-cell origin. Surprisingly, and rightly so (in...
Dear Editor,
Re: Unnecessary repeat requesting of tests in a university teaching hospital immunology laboratory: an audit.
Unnecessary testing is not only a problem for teaching hospitals. We were aware that the utility of many of the tests performed by our department was low and undertook an audit assess this. Our standard was that 90% of requests should be clinically appropriate. DNA antibodies shou...
Dear Editor
Janet Shirley and colleagues [1] have made a useful contribution to the costings of laboratory out of hours services. Their study is based on the findings from 22 laboratories. Some of their results have been confirmed in the latest annual report from the national Pathology Benchmarking Study [2]. In this study 93 haematology departments participated and 86 provided details of their out of hours service...
Editor,
After encountering 5 cases in our institution over an 8 year span and reviewing the literature to find 15 more cases reported, we realized that bread bag clip ingestion is an uncommon but not an exceptionally rare event. We summarized these cases in a recent publication (1). Many of the patients were elderly and wore dentures, suggesting that decreased oral sensation may be a risk factor for ingestion. T...
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