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Letters to the Editor readily than microscopical examination of processed tissue,6 but this has not been systematically tested. These five cases of microsporidia represent 6 5% of the African HIV positive patients with intestinal symptoms that we saw. Three of the patients also had cryptosporidiosis (diagnosed on faecal smears, though not seen on histological examination). Irrespective of the degree of inflammation, no microsporidia have been identified in 36 small bowel biopsy specimens from HIV negative Ugandan and Zambian controls; no microsporidia have been seen in over 50 rectal biopsy specimens from HIV negative or HIV positive patients. More intestinal biopsy specimens from patients with AIDS should be examined for microsporidia. This group of parasites infects most phyla of invertebrates and all classes of vertebrates; yet E bieneusi has only been described in human enterocytes in association with HIV-1 infection.' It is unresolved whether they are genuine pathogens rather than mere passengers. The enterocytes containing microsporidia in our material and that of other workers do not show obvious damage by light or electron microscopy. The aetiology of the diarrhoea in AIDS is multifactorial, and microsporidia may be involved, possibly by affecting secretion.
5 Modigliani R, Borles C, Le Charpentier Y, et al. Diarrhoea and malabsorption in acquired immunodeficiency syndrome: a study of four cases with special emphasis on opportunistic protozoal infestations. Gut 1985;26:179-87. 6 Rijpstra AC, Canning EU, van Ketel, RJ, et al. Use of light microscopy to diagnose smallintestinal microsporidiosis in patients with AIDS. JInfect Dis 1988;157:827-31. 7 Sewankambo N, Goodgame R, Carswell WJ, et al. Enteropathic AIDS in Uganda: a
microbiological and histopathological study. AIDS 1987;1:9-13. 8 Nicholls G. Microsporidiosis in AIDS. Communicable Diseases Report CDR 86/21. London: PHLS, 1986:3-4. 9 Brandborg LL, Goldberg SB, Breidenbach WC. Human coccidiosis-a possible cause of malabsorption. The life cycle in small-bowel biopsies as a diagnostic feature. N Engl J Med 1970;283:1306-13.
Visual aid for quick assessment of coronary artery stenosis at necropsy
A chart was designed to give a quick visual assessment of the degree of coronary artery stenosis at necropsy. It was intended for routine cases in which coronary artery angiography and formal morphometric analysis of processed segments of vessel were not to be undertaken. The method described here is not the most accurate, but it is preferable to simple subjective categorisation into simple, moderate, and severe degrees of artery stenosis. Ischaemic heart disease is one of the leading causes of death in Great Britain. Quantification of coronary artery stenosis as part of the necropsy is necessary to estimate the functional importance of any atherosclerotic disease present. The cross sectional area of the vessel lumen, compared with that contained within the elastic lamina, expressed as a percentage, is a widely used method of estimating the degree of luminal area narrowing within a vessel.' A narrowing by 75% reduces coronary blood flow at times of stress and exertion; narrowing by 90% means that coronary blood flow is severely reduced at rest.2 Even in the absence of coronary thrombosis, cardiac death may occur if there is one segment of luminal area which has narrowed by more than 85%, although most of these patients have multiple foci of stenosis.3 Coronary angiography can be used routinely at necropsy4 to show the luminal diameter and it can also show all branches of the coronary vessels. Formal morphometry with the use of either point counting,5 or plan-
LUCIENNE PAPADAKI* C CONLONt
imetry of multiple cross sections of vessels that have been fixed, decalcified, and stained for elastin, give a good estimation of luminal area narrowing. Vessels that have been perfused and fixed at physiological pressures before dissection give the most meaningful results.6 An alternative, but the most routinely used method, is simple subjective assessment of a serially sliced vessel at the time of necropsy into categories of mild, moderate, and severe stenosis. The first two methods are obviously more accurate, and the merits and demerits ofeach have been discussed elsewhere.' The aim of our method is not to replace or compete with these methods but to make simple, immediate, subjective assessment more accurate and scientific. Examination ofcoronary arteries by serial transverse slicing at 3 mm intervals is widely practised. Most pathologists open the heart first and then slice the vessels while gripping the artery, with forefinger outside the heart and thumb inside. A sharp brain knife allows a "clean slice" to be made even with moderate vessel calcification. Once the vessels have been serially sliced, the cut surface is compared with the chart (figure). The vessels have been drawn with concentric round, eccentric round, and slit shaped lumina representing the three main patterns seen at necropsy. The diagrams have been photoreduced following the calculation of the areas on graph paper. Arteries that are distended at physiological pressure are almost circular in shape.' The
D SERWADDA4 *Department of Histopathology, University College and Middlesex Hospital School of Medicine, University Street, London WCJ tDepartment of Medicine, University Teaching Hospital, Lusaka, Zambia, ,Department of Medicine, Mulago Hospital, Kampala, Uganda.
I Canning EU, Hollister WS. Microsporidia of mammals-widespread pathogens or opportunistic curiosities? Parasitol Today
2 Desportes L, Le Charpentier Y, Galian A, et al. Occurrence of a new microsporidian: Enterocytozoon bieneusi n.g., n.sp., in the enterocytes of a human patient with AIDS. J Protozool 1985;32:250-4. 3 Dobbins WO, Weinstein WM. Electron microscopy of the intestine and rectum in acquired immunodefiency syndrome. Gastroenterol
-20% - (
Figure Schematic diagram representing a
4 Curry A, McWilliam LJ, Haboubi NY, Mandal BK. Microsporidiosis in a British patient with AIDS. J Clin Pathol 1988;41:477-8.
percentage reduction in cross sectional area of coronary artery vessels. The outer circle represents vessel exterior, inner circle
represents the elastic lamina, and black area represents the lumen.
Recent advances in histopathology 13. In experiments 8-13 coefficients of variation were obtained similar to those in experiments 1-7. Revitalising postmortem coronary angiography: J Clin Pathol 1983.Jc_ shows the coefficients of variation of the haematocrit of whole blood and of erythrocyte suspensions in plasma or buffer. Ann Intern Med -'. Coefficients of variation were assessed with whole blood anticoagulated with edetic acid or leucocyte poor erythrocyte suspensions in anticoagulated plasma or in buffer.91:350-6. problem. Isner JM. 4 Coghill SB.9:959-76. Bhagwandeen BS. This reflecting unit was provided with a screw driven fixation device for the microchematocrit tube so that the bottom of the red cell column could be gently adjusted to the zero line of the scale (figure). To avoid the parallax error.com 888 slit shapes of some lumina are artefactual due to collapse: the degree of stenosis at necropsy is therefore greater than in life. Coronary artery narrowing in coronary heart disease: Comparison of cineangiographic and necropsy findings. In experiment 1 the buffy layer was read in addition to the plasma and red cell layers and the cytocrit (sum of the red plus white cell columns divided by the length of the whole column) was also calculated and was 0-478 ± 0 001 and the coefficient of variation 0-21%. When observed by a magnifying glass. For those around 007. et al.bmj. some crowding also occurred (experiment 16) but could almost be suppressed when the instrument was in vertical position (experiment 17). a practical approach to the forensic Cliftonville.5:451-60. Matthew BM. 10 repeated readings of single capillaries were performed. Requests for a chart on A4 size paper can be made to Dr Champ. Redwood DR. In experiments 8-17.156:1 11-17. After centrifugation they were kept in vertical position until the reading. the real and reflected cell and plasma layers can be adjusted to a common level. Zardawi IM. A transparent scale was mounted on a surface mirror and covered by a glass layer. Kettering. In experiments 8-17 repeated readings of single capillaries were performed. Rothwell Road..' Unfortunately. ~ . 2 Maximilian Buja L. Histopathology 1979. The high precision of the readings obtained with this instrument compared with those obtained with a non-reflecting scale was due to (1) the elimination of the parallax error and (2) the mechanical adjustment of capillaries to the instrument scale. A 10 x eye piece of a microscope was used for all the readings because this is available in most haematological laboratories. an accuracy and reliability study..B . MacSween RNM. eds. 1987:185202. Pressure fixation would be required to circumvent this problem. In: Antony PP. Morphometric analysis of coronary artery stenosis.. however.Published by group. O'Connell DL. Popple A.bmj. In experiments where manipulation was reduced to the necessary minimum. Dobson AJ. This was due to the fact that manipulation between readings led to some crowding of the uppermost erythrocyte layer after four to six readings (table). Davies MJ. McKimmie A. Figure Reflexion haematocritometer with haematocrit capillary and eye piece in position and screw (a) for driving the capillary holder (b) and light source (c). . Histopathology 1985. 5 Manwarring L. the coefficients of variation averaged 2 5%. The 10 capillaries were centrifuged together for five minutes (12500 x g at the bottom of the tubes). Sudden unexpected death. The . At a higher concentration oferythrocytes in buffer. Edinburgh: Churchill Livingstone. this chart can only be used as a rough guide in these cases. the coefficient of variation was zero for whole blood and erythrocytes suspended in buffer at a low haematocrit (experimennts 14. Northamptonshire NN16 8UZ Northampton General Hospital. Between each filling procedure the blood tube was closed and mixed by hand.Downloaded from jcp. *Kettering and District General Hospital. Willerson JT. 3 Davies MJ. In experiments 1-16 haematocrit measurements were performed with the instrument placed horizontally. J Pathol 1988. CS CHAMP. indicating the reading position of the eye and the lens. the readings of the erythrocytes. 1979. experiment 17 was done with the instrument in vertical position. Houston I. 2011 . The table Departments ofPathology.. the precision resulting from magnification may be undermined by the parallax error. Nicoll SM. 7 Arnett EN.36:1406-9. buffy layer and plasma concentration will be completely changed. The pathology of ischaemic heart disease. thus avoiding the parallax error. Elimination of parallax error in haematocrit readings using reflexion baematocritometry The precision of haematocrit readings can be improved by using a magnifying glass. The role of coronary artery lesions in ischaemic heart disease. Post-mortem investigation and quantification of coronary artery disease.3:255-77. 6 Thomas AC.com on June 23.* SB COGHILL Letters to the Editor respective error of the haematocrit increases with decreasing haematocrit and cytocrit. At high concentrations of haematocrit all the coefficients of variation were around or below 0-5%. Hum Pathol 1987. and the degree of collapse will vary according to the proportion of the wall which is free of disease. Ten microhaematocrit capillaries of 75 mm in length were filled to a 60 mm mark and sealed. Northampton NNI 5BD References I Davies MJ. a reflexion haematocritometer was developed according to the following principle. 15). The consequence of the parallax error is easily recognised if the eye or the lens is moved along the axis of the microhematocrit tube.
8.bmj. 2011 .bmj.com/content/42/8/887.bmj.com/subscribe/ .Published by group.com/cgi/reprintform To subscribe to BMJ go to: http://group.com Visual aid for quick assessment of coronary artery stenosis at necropsy.citation These include: Email alerting service Receive free email alerts when new articles cite this article.com/group/rights-licensing/permissions To order reprints go to: http://journals.com on June 23.887 Updated information and services can be found at: http://jcp.bmj.1136/jcp.bmj. Notes To request permissions go to: http://group. C S Champ and S B Coghill J Clin Pathol 1989 42: 887-888 doi: 10.bmj.Downloaded from jcp.42. Sign up in the box at the top right corner of the online article.
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