Notes: Three hundred women attending colposcopy for the first time, following an abnormal cervical smear, were invited to fill in a questionnaire. This covered aspects of their understanding of the cervical smear test and the NHS Cervical Screening Programme (NHSCSP). In addition, it covered aspects of consent to the test. The response rate was 83%. Seventy percent thought that the NHSCSP is working well and 72% were aware that probably over 3000 cases of cervical cancer per year are being saved by the NHSCSP. However, 55% did not know that the death rate from cervical cancer is decreasing. 96% were aware that the main reason for a cervical smear is to prevent the development of cervical cancer, by finding early treatable abnormalities. Similarly, 94% were aware that the presence of abnormal cells on a cervical smear indicated a possible but not definitive indication of cervical precancer or cancer. Disappointingly, only 5% had seen the new NHSCSP information poster on the cervical smear test and only 44% had been given written information about the test. Consent for the test in 59% of women had been implied rather than expressed and 30% of women providing expressed consent had signed to that effect. In 42% of women, the smear taker or a doctor had failed to discuss the reason for having a cervical smear and had not explained about its advantages and limitations. In 72%, the smear taker or doctor had not explained that the cervical smear test can never be 100% accurate and that some laboratory errors are unavoidable. It is likely that women attending for colposcopy are a highly motivated cohort in relation to their understanding of the cervical smear test and the NHSCSP. Accordingly, understanding in the more general female population is likely to be considerably less. It would appear that women are often suboptimally informed to provide valid consent for the cervical smear test.

Notes: This is a statistical analysis of individual NHS Cervical Screening Programme laboratories screening smear ‘pick-up’ rates (defined here as percentage low grade and percentage high grade of total adequate smears for ages 20–64 years derived from general practitioners and community clinics) in relation to their nonscreening smear workload proportion (here defined as percentage nonscreening smears of total laboratory workload from all sources for all ages). This was achieved by the use of three one way anova models in order to receive a complete overview of the results. The models were applied to the following: (1) Laboratories with a total workload of less than 15 000 general practitioner (GP) and community clinic smears; (2) laboratories with a total workload of greater than 15000 GP and community smears and; (3) all laboratories (i.e. a combination of 1 and 2). The ‘test’ groups within each of these models comprised three subgroups based on the percentage of laboratory workload that consisted of smears from a nonscreening source. This figure ranged from 2.8% to 82.6%. The subgroups were divided so as to contain approximately the same number of laboratories in each one (172 laboratories in total, 42 with workload 〈 15000 and 130 with 〉 15000). The results show that laboratories high and low grade pick-up rates have a positively correlated but variable relationship with the proportion of their workload that consists of nonscreening smears. The results show significance overall at the 5% level for high grade and the 10% level for low grade (high grade at P= 0.045 and low grade at P= 0.071). Significance for laboratories viewing less than 15000 screening smears at the 1% level (high grade P= 0.006 and low grade P= 0.005). They show no significance, however, for laboratories viewing more than 15000 screening smears (high grade P= 0.457 and low grade P= 0.622). There is an intriguing possibility that a greater exposure to abnormal smears results in a greater tendency to detect them. The current data provides no evidence to support the NHS Executive's use of 15000 as a designated figure when quality monitoring and service provision becomes a specific issue. The closure or amalgamation of laboratories with workloads less than this would appear to have no scientific evidence base.

Notes: Accepted for publication 19 February 1999THE PASTThe value of EQA in pathology, including proficiency testing in gynaecological cytology, has been the subject of much recent lively debate1–6. In summary, the proven role of EQA in the monitoring of personal performance and ability is still uncertain. Furthermore, its potential to prevent critical incidents remains purely speculative. Also, whether EQA would be better replaced, for some or all professional groups, by other methods of quality assurance is unknown. Similarly, whether EQA can justify the considerable professional time, effort and expense involved has not been resolved.〈section xml:id="abs1-1"〉〈title type="main"〉THE PRESENTNot surprisingly, events at Kent & Canterbury Hospitals abruptly halted much of the debate about the foregoing issues7. Indeed, as a direct consequence of this and other incidents, the NHS Executive stipulated unilaterally that EQA is now mandatory within the NHS Cervical Screening Programme (CSP)8 and reinforced the necessity for all qualified laboratory staff to participate8–10. A surprise, however, was the Executive's enlightened comments on EQA. First, and of greatest significance, that the principal function of EQA in pathology is to improve standards and advance quality through personal education. Second, that EQA should be seen to complement other QA systems for the early identification of potential problems which might affect patient care. Third, that the identification of individual poor performance through EQA will be exceptional and in essence is a by-product of the basic educational exercise. The latter conclusion was drawn, as far as one can judge, from previous experience with the NHS Breast Screening Programme (NHSBSP) EQA.〈section xml:id="abs1-2"〉〈title type="main"〉THE FUTURE—PERSONAL SUGGESTIONS FOR OPEN DEBATE

Notes: This paper describes the light and electron microscopy and monoclonal antibody findings in the lymph nodes of nine patients with mycosis fungoides. Four cases showed dermatopathic change characterized by close association between small convoluted T4 lymphocytes and T6 antigen-presenting cells (Langerhans' and indeterminate dendritic cells) in the sinuses and paracortical zones. The T4:T8 ratio was between 3 and 5:1. One case showed dermatopathic change but included large convoluted T4 lymphocytes and occasional T10 lymphocytes. The T4:T8 ratio was 4:1. The antigen-presenting cells were mostly T6 negative (interdigitating reticulum cells). One case showed extensive paracortical expansion by small and large convoluted T4 lymphocytes. The T4:T8 ratio was 20:1. Few B lymphocytes and antigen-presenting cells were present. Two cases showed partial and one case total effacement by atypical lymphoid tissue. This included small and large convoluted T4 lymphocytes and T4 immunoblasts. The T4:T8 ratios were between 30 and 40:1. The changes in their antigen-presenting cell population were complex. Langerhans' cells in one case generally failed to express T6 antigen and in two displayed histiocyte features. In one case, both immature and budding type C retrovirus-like particles were identified in Langerhans cells. One extracellular mature type C virus-like particle was identified in another case. No ultrastructural distinction could be made between similarly sized primary lysosomes and possible intracytoplasmic mature type C retrovirus particles. These findings support the hypothesis that mycosis fungoides may represent an altered dermatonodal cycle resulting from an interaction between retrovirus, Langerhans' cells and lymphocytes.

Notes: Renal morphological changes are described in four cases of idiopathic acute fatty liver of pregnancy. Light microscopy showed mild glomerular hypercellularity together with thickening and narrowing of capillary loops. In two cases the tubules showed lipid accumulation which included free fatty acids. Electron microscopy showed mesangial cell interposition between the basal lamina and endothelial cells. Glomeruli contained electron dense material in a subendothelial location. Immunoperoxidase stains showed diffuse segmental deposits of fibrin/fibrinogen and IgM in relation to glomerular capillary loops. IgG and C3 were found in three and two cases respectively. Pathogenetic mechanisms including disseminated intravascular coagulation, immune complex deposition and alterations in lipid metabolism are discussed. Coexistent preeclampsia is considered to be an unlikely explanation for the changes. There is a possibility that these renal changes comprise an early feature of idiopathic acute fatty liver of pregnancy.