We fully support the integrated approach to hematopathological
diagnostics, which has been advanced by the WHO 2008 classification and we
acknowledge the prominent role of immunophenotyping in this classification
(1). The integrated approach is still not fully applied even in the most
advanced countries. In some other countries, (hemato)pathologists still
struggle, having only bone marrow (BM) tissue...
We fully support the integrated approach to hematopathological
diagnostics, which has been advanced by the WHO 2008 classification and we
acknowledge the prominent role of immunophenotyping in this classification
(1). The integrated approach is still not fully applied even in the most
advanced countries. In some other countries, (hemato)pathologists still
struggle, having only bone marrow (BM) tissue core biopsies to work with.
In some centers and countries, there may be a partial redundancy in
immunophenotyping with both flow cytometry and immunohistochemistry (IHC)
methods available.
This is not universally the case and one must rely much more on one
or the other source of information. If the histopathologists are
restricted to histology, they need to be assured that the applied IHC
methodology is accurate.
Quality assurance (QA), quality control (QC), proficiency testing, reagent
documentation and validation are standard parts of everyday practice in
clinical laboratories (2). IHC is one area of laboratory practice where
such standardization and quality assurance procedures have been addressed
relatively late (2,3). The complexity of IHC presents challenging issues
within pre-analytical, analytical, and post-analytical components, which
still make true standardization difficult. However, optimization in this
area has become possible due to rapidly advancing technologies. Also, we
have increased our understanding of each of these components, which makes
it possible to start the standardization process (3,4).
Tissue processing has been recognized as an essential pre-analytical
component that greatly determines the outcome of IHC stains (5,6). When
very few IHC markers were employed in the evaluation of BM biopsies, there
was no emphasis on QA/QC issues. Currently we face a challenge in the
light of increasing number of applied markers and the variation in tissue
processing of the BM biopsies. The results of IHC testing in BM biopsies
are not exempt from the principles that apply for any other tissue biopsy.
This means that none of the components of the IHC testing can be
neglected. Even in the situation where one type of fixative is used and no
decalcification is applied, pre-analytical components must be subjected to
the standardization process. Analytic variables such as the antigen
retrieval protocol, the detection system, and the immunostaining platform
play an important role in the quality of IHC stains.
Our pilot study included only a fraction of European Bone Marrow
Working Group laboratories. However, it disclosed that even in this
limited number of laboratories, a large variety of tissue processing and
staining methods were in use. It clearly shows that a currently used
approach to external QA/proficiency testing is not possible for BM
biopsies. At the same time our study shows that there is a need of such
external QA/QC to assure reproducibility of the results.
BM biopsy remains excluded from the good practices of QC/QA, which are
already established in surgical pathology. This is important in the light
of the increase in number of tests applied to BM biopsy, which is
happening despite advances in other, possibly more sophisticated methods
of tissue analysis. Moreover, introducing class II tests to this type of
tissue, a new landmark in BM tissue biopsy IHC is approaching.
The priority must be given to stand-alone IHC tests. However, we
disagree with Dr.Orazi that standardization and external QA/QC should be
limited to class II tests. Many of the class I tests are equally complex
to perform and may have critical impact for the final diagnosis (5). If
any clinical test deserves to be done, it also deserves to be performed
optimally and interpreted correctly. The integrated approach of WHO 2008,
at least in our minds, was never constructed to support integration of
either false-negative or false-positive IHC results or to obscure
deficiencies of technically suboptimal results.
Sincerely yours,
Emina Emilia Torlakovic, MD, PhD,
Kikkeri Naresh, M.B.B.S.; D.C.P.; M.D.;F.R.C.Path.,
Marcus Kremer, MD,
Jon van der Walt, M.D., F.R.C.Path.,
Elizabeth Hyjek, MD, PhD
Anna Porwit, MD, PhD,
References:
1. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H,
Thiele J, Vardiman JW. WHO Classification of Tumours of Haematopoietic and
Lymphoid Tissues. WHO Press, Geneva, 2008.
2. Taylor CR. Editorial--a personal perspective. Appl Immunohistochem Mol
Morphol. 2007;15:121-3.
3. Taylor CR. Quality assurance and standardization in
immunohistochemistry. A proposal for the annual meeting of the Biological
Stain Commission, June, 1991. Biotech Histochem. 1992;67:110-7.
4. Bogen SA, Vani K, McGraw B, Federico V, Habib I, Zeheb R, Luther E,
Tristram C, Sompuram SR. Experimental validation of peptide
immunohistochemistry controls. Appl Immunohistochem Mol Morphol.
2009;17:239-46.
5. Goldstein NS, Hewitt SM, Taylor CR, Yaziji H, Hicks DG; Members of Ad-
Hoc Committee On Immunohistochemistry Standardization. Recommendations for
improved standardization of immunohistochemistry. Appl Immunohistochem Mol
Morphol. 2007;15:124-33.
6. Taylor CR, Shi S-R, Barr N, Wu N. Techniques of Immunohistochenmistry:
Principles, pitfalls, and standardization. In: Dabbs D. Diagnostic
Immunohistochemistry. Churchill Livingstone, Philadelphia, PA, USA, 2nd
Ed. 2006:17-19.
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.
We thank Drs Rotimi and Reall for their comments, but would suggest
that their criticisms have been framed by a perspective that is different
from our own. Their perspective is the “most striking result” was that
sessile serrated adenomas (SSAs) were predominantly right sided. They are
welcome to highlight this point, which is readily apparent from the data
presented.
We thank Drs Rotimi and Reall for their comments, but would suggest
that their criticisms have been framed by a perspective that is different
from our own. Their perspective is the “most striking result” was that
sessile serrated adenomas (SSAs) were predominantly right sided. They are
welcome to highlight this point, which is readily apparent from the data
presented.
Our perspective is that the right sided predominance of SSAs is well
known, and widely reported in the literature. Hence we did not highlight
this finding. Their perspective is that a frequency of 4% of all polyps is
not “common”. From our perspective, four in every 100 polyps is “common”,
and we believe this point is worth emphasising because in many practices
SSAs are reported rarely, if ever. Again, the quantitative information is
available to readers, who are welcome to interpret it as they see fit.
We would argue that although “common” is a relative and qualitative
term, it is misleading to propose that SSAs are not common in routine
practice. Finally, Drs Rotimi and Reall are concerned that our statistical
tests may have been inappropriate. We have the happy perspective of
knowing the age distribution of the groups in question (serrated and non-
serrated polyps). We can assure them that these distributions are normal,
and that the use of parametric tests is indeed appropriate in this case.
Nicholas J Hawkins, Norman J Carr, King L Tan, Hema Mahajan, Robyn L Ward,
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
A casual role for Human Papilloma virus-16 for the Head and
Neck Cancers word wide-and role of HPV vaccine altering the carriage rate
of oropharyngeal HPV16?
Dear Editor
Infection with Human Papilloma Virus (HPV) 16 and 18 mostly is well
established for development of cervical cancers in pre and post menopausal
women through out the world. Professor H. Zur Housen was awarded the Nobel
Prize for medicine an...
A casual role for Human Papilloma virus-16 for the Head and
Neck Cancers word wide-and role of HPV vaccine altering the carriage rate
of oropharyngeal HPV16?
Dear Editor
Infection with Human Papilloma Virus (HPV) 16 and 18 mostly is well
established for development of cervical cancers in pre and post menopausal
women through out the world. Professor H. Zur Housen was awarded the Nobel
Prize for medicine and physiology for establishing role of HPV in
development of cancer in 2008 instead of HSV2. But a pathogenic role for
this HPV in non ano- genital cancer has yet been unclear till now.
Tobacco and alcohol is considered today as important etiological
factor for Head and Neck Squamous cell cancers(HNSCC). Epidemiological and
laboratory evidences howevver now suggest this conclusion that in addition
to tobacco and alcohol, HPV may be also the causative agent for the head
and neck SCC. In our Institute at IPGME&R, Kolkata-20, West Bengal, India,
from Pathology department the major bulk of cancer are diagnosed in the
male population in any year is HNSCC and more then 95% of these sufferers
gives however history of either smoking cigarette or local made Bidi or
chewing Pan Parag products for long periods. These people are usually
older and middle aged male. What about those young people dignosed with
HNSCC? As with cervical cancer HNSCC is today a world wide public health
problem with more then 9-10 lacks population per year are diagnosed by the
Histopathologists having HNSCC. High risk HPV like HPV16 or HPV18 is
probably not necessary for development of HNSCC. In our laboratory, we
carried a work for 2 years on Role of HPV 16 and HNSCC mostly in younger
people particularly and found HPV type 16 DNA is present in primary[poorly
differentiated] and in metastatic cell nucleus in high copy numbers
frequently integrated and transcriptionaly active by ISH technique. We are
not sure whether these findings is casual association of HPV16 with HNSCC
or etiology. Researches over past several years had also shown a string
and consistent association between high risk HPV and distinct subset of
HNSCC . However in our study these HPV associated HNSCC are characterized
clinically by their location within the laryngeal and palatal tonsil of
oropharynx. Their poorly differentiated histopatholgy and their frequent
occurrence in nonsmoking and young patients then in HNSCC not associated
with HPV.
The proportion of HNSCC that is associated with HPV may be greater in a
nonsmoker. HPV positive cancer may also occur in smokers. However it is
unclear whether elevated risk of HNSCC for contamination of HPV
infection and tobacco addiction is synergistic or additive with HPV?
Thus screening for HPV in oral cavity and development of oral PAP smear
might lead to early diagnosis and treatment for HNSCC. The prevalence of
oral HPV infection presently a pre-requisite for HPV associated HNSCC was
around 7% in centers without cancer in the IARC study [1]
Another possibility for prevention of HPV associated HNSCC lies in HPV
vaccine as we consider. Systemic Immunization with a protective HPV16
vaccine will be highly effective no doubt in preventing persistence HPV 16
in female genital tract. It is however not known to us whether such a
vaccine will also alter the carriage rate of oropharyngial HPV16 and
HNSCC.
Professor Pranab kumar Bhattacharya MD(cal), FIC path(Ind.)
, Professor of Pathology, In charge of Histopathology Unit, in charge
Blood Bank &VCCTC, Cytogenetics. Institute of Post Graduate Medical
Education & Research, 244a AJC Bose Road, Kolkta-20, West Bengal,
India; **Mr. Ritwik Bhattacharya, B.Com(cal); ***Mr. Rupak Bhattacharya
BSc(Cal)MSc(JU) of 7/51 purbapalli, Sodepur Dist 24 parganas(North) Kol-
110, West Bengal, India; ****Mrs Dahlia Mukherjee BA(hons) Swamiji Road,
Habra N-24 parganas, W.B, India, *****Miss upasana Bhattacharya of
Mahamyatala, Garia kol-86,Daughter of Prof. Bhattacharya**** Dr Debasis
Bhattacharya Ms(cal) FRCS(eng). Associate Professor, dept. of Surgery
IPGME&R, Dr. Tarun Mandal MBBS(cal) , Dr. Ananya Pal MD(PGT) Pathology
Dept. Of Pathology Institute of Post Graduate Medical Education &
Research, 244a AJC Bose Road, Kolkta-20, West Bengal, India
Reference
1. Herrero R, Castellasaguex, Pawlita M etal “ Human Paplloma Virus and
Oral Cancer, The international gency for Research on Cancer-a multicenter
study J. Natl .cancer Institute 2003:95:1272-83
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.
I read the recent publication by Likhari et al with a great
interest [1]. Likhari et al concluded that "In subjects with similar
fasting and postprandial glycaemia on OGTT, those of South Asian origin
have higher HbA(1c) levels than white subjects. It is speculated that the
higher glycaemia-independent HBA1c levels in people of South Asian origin
could possibly contribute to their increase cardiovas...
I read the recent publication by Likhari et al with a great
interest [1]. Likhari et al concluded that "In subjects with similar
fasting and postprandial glycaemia on OGTT, those of South Asian origin
have higher HbA(1c) levels than white subjects. It is speculated that the
higher glycaemia-independent HBA1c levels in people of South Asian origin
could possibly contribute to their increase cardiovascular risk [1]." I
have some additional concerns on this work. First, the rather few subjects
in this work reduce the value of the research. It is questionable whether
the number of subjects in this work is statisticall acceptable or not.
Second, the concern on the performance of the analyzers for HBA1C should
be raised. In a recent publication, only a few analyzers are acceptable
for precision and accuracy [2].
References
1. Likhari T, Gama R. Ethnic differences in glycated haemoglobin between
white subjects and those of South Asian origin with normal glucose
tolerance. J Clin Pathol 2010; 63:278-280
2. Lenters-Westra E, Slingerland RJ. Six of eight hemoglobin A1c point-of-
care instruments do not meet the general accepted analytical performance
criteria. Clin Chem 2010;56:44-52
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.
We are astonished by Wiwanitkit's inaccurate remarks regarding the
number of subjects studied and analytical methodology in our study [1].
The data set was of more than sufficient size to be subjected to rigorous
statistical analyses. If Wiwanitkit had bothered to even casually read the
articles he cites [1,2], he should have immediately realised that firstly
the thrust of Lenters-Westra's and Sling...
We are astonished by Wiwanitkit's inaccurate remarks regarding the
number of subjects studied and analytical methodology in our study [1].
The data set was of more than sufficient size to be subjected to rigorous
statistical analyses. If Wiwanitkit had bothered to even casually read the
articles he cites [1,2], he should have immediately realised that firstly
the thrust of Lenters-Westra's and Slingerland's paper was to
highlight poor analytical performance of some HbA1c point-of- care (not
laboratory based) instruments and secondly that laboratory HbA1c analyser
used in our study (Tosoh G7, cation-exchange HPLC) was a reference method
for measurement of HbA1c in study of Lenters-Westra and Slingerland [1,2].
In addition our HbA1c assay, and indeed all our assays, are subject to
stringent internal quality control procedures and external quality
assurance. We had hoped our article would stimulate meaningful debate
rather than inane comment.
Dr Taruna Likhari,
Professor Rousseau Gama
References
1. Likhari T, Gama R. Ethnic differences in glycated haemoglobin
between white subjects and those of South Asian origin with normal glucose
tolerance. J Clin Pathol 2010; 63:278-280
2. Lenters-Westra E, Slingerland RJ. Six of eight hemoglobin A1c point-of-
care instruments do not meet the general accepted analytical performance
criteria. Clin Chem 2010;56:44-52
Dear Editor,
We fully support the integrated approach to hematopathological diagnostics, which has been advanced by the WHO 2008 classification and we acknowledge the prominent role of immunophenotyping in this classification (1). The integrated approach is still not fully applied even in the most advanced countries. In some other countries, (hemato)pathologists still struggle, having only bone marrow (BM) tissue...
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...
Dear Editor
We thank Drs Rotimi and Reall for their comments, but would suggest that their criticisms have been framed by a perspective that is different from our own. Their perspective is the “most striking result” was that sessile serrated adenomas (SSAs) were predominantly right sided. They are welcome to highlight this point, which is readily apparent from the data presented.
Our perspective is t...
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...
A casual role for Human Papilloma virus-16 for the Head and Neck Cancers word wide-and role of HPV vaccine altering the carriage rate of oropharyngeal HPV16?
Dear Editor
Infection with Human Papilloma Virus (HPV) 16 and 18 mostly is well established for development of cervical cancers in pre and post menopausal women through out the world. Professor H. Zur Housen was awarded the Nobel Prize for medicine an...
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
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,
I read the recent publication by Likhari et al with a great interest [1]. Likhari et al concluded that "In subjects with similar fasting and postprandial glycaemia on OGTT, those of South Asian origin have higher HbA(1c) levels than white subjects. It is speculated that the higher glycaemia-independent HBA1c levels in people of South Asian origin could possibly contribute to their increase cardiovas...
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 are astonished by Wiwanitkit's inaccurate remarks regarding the number of subjects studied and analytical methodology in our study [1]. The data set was of more than sufficient size to be subjected to rigorous statistical analyses. If Wiwanitkit had bothered to even casually read the articles he cites [1,2], he should have immediately realised that firstly the thrust of Lenters-Westra's and Sling...
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