Breastfeeding by Women Living With Human Immunodeficiency Virus in a Resource-Rich Setting: A Case Series of Maternal and Infant Management and Outcomes.

The reduction in human immunodeficiency virus (HIV) transmission through breastmilk with maternal combination antiretroviral therapy (cART) has led many pregnant women living with HIV and healthcare providers to question exclusive formula feeding in resource-rich settings. Here, we describe cART prophylaxis in 3 breastfed infants whose mothers had sustained virologic suppression; all 3 of these infants remained uninfected.

Treatment of isolated articular cartilage lesions of the medial femoral condyle. A clinical nad MR comparison of autologous chondrocyte implantation vs. microfracture.

Microfracture (MFX) and Autologous Chondrocyte Implantation (ACI) have been utilized in an effort to promote the regeneration of articular cartilage in the knee. The purpose of this study is first, to determine which of these two treatments yields the best clinical results and, second, to determine whether the MR appearance of treated cartilage lesions correlates with clinical outcome. Thirty-five patients with isolated articular cartilage lesions of the medial femoral condyle (MFC) were treated either with ACI (17 patients) or with MFX (18 patients, 19 knees). Patients were evaluated clinically using the modified Cincinnati Knee Questionnaire and with a physical exam. MRs were graded using eight different criteria: an MR score of 100% represents normal cartilage. The average follow-up was 2,6 years for the ACI group and 2,8 years for the MFX group. The average size of the lesion was 472 mm2 for the ACI group and 326mm2 for the MFX group. The Cincinnati scores improves an average of 22% for the ACI patients and 42% for the MFX patients from preoperatively to postoperatively. The average MR score was 66% for the ACI group and 44% for the MFX group. Fifty-nine percent of the ACI patients required at least one additional procedure. This is the first clinical and MR comparison of ACI and MFX to treat full thickness cartilage lesions of the MFC. Clinical improvement was 2 times greater for the MFX patients compared to the ACI patients. The MR scores did not correlate with clinical outcome using our grading system.

Multiplanar analysis of acromion morphology.

To more completely describe acromion morphology and its relationship to impingement syndrome, we performed three-dimensional magnetic resonance imaging (N = 111) or computed tomography (N = 27) on 132 symptomatic shoulders. The mean patient age was 46.2 years (range, 14 to 86). Four parameters were evaluated: the angle of anterior slope of the acromion in the midsagittal and lateral-sagittal planes, lateral acromial angulation in the coronal plane, and the presence or absence of medial encroachment in the acromioclavicular joint. Twenty-five asymptomatic age-matched shoulders were used as controls. All imaging data were combined because no significant differences existed between the two imaging techniques. The mean acromion angle was 19.4 degrees in the midsagittal plane and 20 degrees in the lateral-sagittal plane. In the coronal plane, 97 (73%) acromions were neutral and 35 (27%) were downward sloping. Medial encroachment was present in 31 (24%) shoulders. Age distribution from the 2nd to 8th decade demonstrated a consistent and gradual transition from a flat acromion in the younger decades to a more hooked acromion in the older decades that was significant in both the midsagittal and lateral-sagittal planes. Furthermore, a greater percentage of patients were found to have downward angulating acromions with increasing age. Ninety-eight patients (74%) had stage II or III impingement. Of these shoulders, 39 (40%) had type I acromions, 51 (52%) type II, and 8 (8%) type III. Twenty-eight of 33 acromions with coronal lateral downward sloping had impingement, and all 31 shoulders with medial encroachment had impingement.

Functional transplantation of the rat pituitary gland.

OBJECTIVE: These studies evaluated the ability of transplanted pituitary cells to restore pituitary function in hypophysectomized rats. METHODS: The pituitary glands of neonatal Lewis rats were rapidly removed, enzymatically dispersed, and stereotactically introduced into the third ventricle of hypophysectomized adult male Lewis rats. Four weeks after implantation, plasma levels of anterior pituitary hormones in implanted animals were compared with those of sham-transplanted control animals. RESULTS: Plasma levels of prolactin, growth hormone, thyroid-stimulating hormone, and beta-endorphin were below the range of detection in 14 sham-operated animals. In implanted animals, restitution of serum prolactin occurred in 100% of the animals tested, with levels of 2.6 +/- 1.0 ng/ml (mean +/- standard error of the mean; normal, 2-4 ng/ml). Growth hormone was assayable in 71% of the animals, with a mean value of 29 +/- 13 ng/ml over all animals (normal, 1-100 ng/ml); thyroid-stimulating hormone was restored in 68%, with mean resting levels of 79 +/- 13 ng/ml (normal, 100-400 ng/ml); luteinizing hormone levels were found in 53%, with mean levels over all animals of 0.2 +/- 0.1 ng/ml (normal, 0.5-1.0 ng/ml); and beta-endorphin was restored in 45% to high resting levels of 163 +/- 31 pg/ml (normal, 20-30 pg/ml). A challenge with hypothalamic releasing factor and a cold stress test were performed on the animals that had received transplants. Positive hormone responses to both of these tests suggested sensitivity of the pituitary grafts to both endogenous and exogenous sources of stimulation. Histological sections of paraformaldehyde-fixed brains from implanted animals clearly demonstrated survival of clusters of grafted pituitary cells. Positive immunohistochemical staining for adrenocorticotropic hormone and thyroid-stimulating hormone was demonstrated in sections of the grafted tissue. CONCLUSION: These data suggest survival of neonatal pituitary transplants in the third ventricle of adult hypophysectomized rats with concomitant restoration of anterior pituitary hormone function.

CHOP-based chemotherapy is as effective as alternating PEEC/CHOP chemotherapy in a randomised trial in high-grade non-Hodgkin's lymphoma. Scotland and Newcastle Lymphoma Group.

The aim of this study was to test whether survival for patients with high-grade non-Hodgkin's lymphoma (NHL) can be improved with a non-cross-resistant regimen as compared to a CHOP-based regimen. This is a multicentre study comprising 325 adult patients, median age 58 years, with high-grade non-Hodgkin's lymphoma: patients of any age and performance status were eligible provided they were able to receive the drugs in the regimens. Patients were randomised to either B-CHOP-M (bleomycin, cyclophosphamide, doxorubicin, vincristine, prednisolone and methotrexate) or PEEC-M (methylprednisolone, vindesine, etoposide, chlorambucil and methotrexate) alternating with B-CHOP-M. At a median follow-up of 9 years, there was no significant difference in overall survival or disease-free survival between the two arms. Toxicities for the two regimens were equivalent. This study confirms that for relatively unselected patients with high-grade non-Hodgkin's lymphoma, an alternating multidrug regimen does not improve upon the results obtained with B-CHOP-M.

A retrospective analysis of the cost effectiveness of treatment with Metastron (89Sr-chloride) in patients with prostate cancer metastatic to bone.

The objectives of the study were to estimate the cost of medical care for patients recruited into the Trans Canada trial of Metastron (89Sr-chloride) as adjunct therapy in patients with prostate cancer metastatic to bone and to compare the costs of those receiving Metastron with those receiving placebo. Data from case report forms, hospital records and, where necessary, telephone follow-up were used. Twenty-nine patients, recruited into the trial at the Cross Cancer Institute, were followed from time of entry into the trial over the balance of their lifetime. Data were costed by reference to fee schedule, pharmacy and government and hospital defined costs as indirect (investigations, outpatient visits and total and tertiary hospital inpatient days) and direct (analgesics, hormones, radiotherapy and transfusions). Meaningful differences in analgesic, hormone and radiotherapy costs were seen between the two groups, with the group receiving Metastron showing a lifetime reduction of Can $1720 per person when compared with placebo. A reduction of Can $5696 per patient in the Metastron group was shown based upon requirements for admission for tertiary care; however, if total hospital stay costs are calculated there is no difference between the two groups. This retrospective study suggests that treatment with Metastron can bring about meaningful reductions in lifetime management costs in patients with advanced prostate cancer. These findings should be correlated with the significant improvement in quality of life reported in the Trans Canada study and appear to offer financial support to the clinical rationale for the use of Metastron in the palliative treatment of these patients.

A retrospective analysis of the cost effectiveness of treatment with Metastron in patients with prostate cancer metastatic to bone.

A retrospective study was performed on the cost-effectiveness of treatment for advanced prostate cancer metastatic to bone. Patients (n = 29) recruited into the trans Canada trial at the Cross Cancer Institute, Edmonton and randomized to treatment with Metastron (strontium-89 chloride) (n = 14) or placebo (n = 15) after local field irradiation therapy for pain palliation were studied over their entire survival time. Estimates were made of the direct costs of treatment, i.e. drugs (analgesics and hormonal agents) and external radiotherapy, and the indirect costs (investigations, outpatient visits and inpatient days, either total or for tertiary care) based on records from the referring hospital, the cancer clinic and any hospitals to which the patients may subsequently have been referred. Meaningful differences were apparent between the two groups in direct costs with the group receiving Metastron showing a reduction over the entire survival time of Can$ 1,720/person compared with placebo; it should be noted that in this analysis neither the costs of the Metastron, nor of the initial radiotherapy, have been included. The Metastron group also showed a reduction in costs of hospitalization for tertiary care of Can$ 5,696/person, though the total cost of hospitalization was similar in the two groups. These results suggest that treatment with Metastron can bring about reductions in management costs for patients with advanced prostate cancer and, coupled with the findings of the Trans Canada trial on the improvement in quality of life for patients given Metastron, they add financial support to the clinical rationale for the use of Metastron for the palliative treatment of patients with bone metastases resulting from prostate cancer.

Continuous passive motion after arthroscopically assisted anterior cruciate ligament reconstruction: comparison of short- versus long-term use.

The use of continuous passive motion (CPM) following anterior cruciate ligament (ACL) reconstruction has become common. The duration of use of CPM for maximal therapeutic benefit is not known. This study compared 4-day CPM use with 14-day CPM use following arthroscopic ACL reconstruction using a bone-patellar tendon-bone autograft prospectively in 20 patients. The patients were randomly allocated to the CPM 4-day group [6 h daily CPM for 4 days in hospital followed by intermittent passive motion (IPM) at home] or to the CPM 14-day group (6 h daily CPM for 14 days). The objective parameters measured were girth measurements at four lower limb locations for joint swelling and muscle atrophy; range of motion of the knee, measured goniometrically; and KT-1000 arthrometry measurements for joint laxity. The measurements were made prior to surgery, and on days 2, 7, 14, and 42, postoperatively. There were no statistically significant differences (p greater than 0.05) at 42 days postoperatively between groups in all parameters measured with the exception of KT-1000 laxity at 42 days.

Malignant melanoma in Scotland 1979-1983.

1318 cases of primary malignant melanoma of the skin first presenting in Scotland in the years 1979-83 and registered with the Scottish Melanoma Group are described. The annual age-adjusted incidence rate is 4.75 per 100 000 for females and 2.77 per 100 000 for males. Incidence rose by an annual average of 2.5% over the five-year period. The female: male ratio was 2:1, and 48.5% of all cases were of the superficial spreading histogenetic variety. Five-year survival rates for the patients registered in 1979 confirm the prognostic value of the tumour-thickness (Breslow) measurement. They were 93% for patients with tumours less than 1.5 mm thick (39% of patients), 67% for those with tumours 1.5-3.49 mm thick (30%), and 37% for those with tumours thicker than 3.5 mm (31%). This study shows that methods for early recognition of thin tumours should be encouraged.

Incidence of familial Hodgkin's disease.

The family histories of 131 patients with histologically defined Hodgkin's disease (HD) were studied and 2,517 first and second degree relatives and spouses were identified and followed-up. The causes of death in deceased relatives were ascertained from death certificates. The numbers of deaths from selected causes were compared with the numbers that would be expected if the relatives had suffered the same mortality rates as the Scottish national population. A 4-fold increase in deaths due to HD was found among first and second degree relatives of patients with the disease (6 cases observed compared with 1.4 expected). Five of the 6 familial cases were related to index patients with the mixed cellularity form of the disease, the remaining case was the brother of a patient with the lymphocyte-depleted form of the disease. The increased risk was seen among relatives of both young and older patients and there was no consistent intrafamilial similarity in age of onset or time of onset of disease.

Prognostic value of measurement of elastosis in breast carcinoma.

The extent of elastosis in the stroma within the anatomical "tumour" in 80 patients with breast carcinoma was assessed by observational microscopy using a 4-point grading system, and measured by semiautomated histometry as an area percentage with a Quantimet 720 image-analysing computer. In this retrospective study, measurement of elastosis in tissue removed at time of initial diagnosis was shown to have little value for prediction of duration of survival.

Jejunal morphology in multiple sclerosis.

In a prospective survey jejunal biopsy samples from 11 patients with multiple sclerosis on normal diets were compared with those from controls matched for age and sex. Quantitative histology, morphometry, and electron microscopy showed no difference between the two groups. Since there was no evidence that gluten sensitivity plays a role in the aetiology of multiple sclerosis, the wide adoption of gluten exclusion by patients seems unjustified.

Differential cell counts in the histiocytic variant of lymphocytic predominance subtype of Hodgkin's disease.

Differential cell counts were made on a lymph node, the structure of which was replaced by the histiocytic variant of the lymphocytic predominance subtype of diffuse Hodgkin's disease. In terms of numbers of cells in various categories, this lymph node bears a closer relationship to the mixed cellularity subtype than to the classical lymphocytic predominance subtype. In this node, unlike the mixed cellularity subtype, the histiocytes are largely differentiated into epithelioid cells; the significance of this cellular adaptation for defence against neoplastic cells is not known.

Cytological basis of histological typing of diffuse Hodgkin's disease. Demonstration of an implied misnomer in the terminology of the Rye classification.

Differential cell counts were made on nine lymph nodes whose structure was replaced by diffuse Hodgkin's disease; two of these nodes had the classical histological appearance of the lymphocytic predominance subtype, four of the mixed cellularity subtype, and three of the lymphocytic depletion subtype. Our attempts to achieve valid sampling methods are recorded. The counts, in general, confirm the postulated histological basis of the Rye classification of the subtypes of the diffuse disease. The major discrepancy is that, contrary to the histological descriptions, our direct counts have shown that lymphocytes, are, in general, more numerous in the lymphocytic depletion than in the mixed cellularity subtypes. The cell counts also show that normal mononuclear cells (mainly fibroblasts and macrophage-type cells) are much more numerous in the mixed cellularity subtype than in the other forms of diffuse Hodgkin's disease; this feature has not been emphasised in the Rye classification. On the basis of our differential counts, a hypothesis is proposed that could explain the natural history of the different subtypes of diffuse Hodgkin's disease as the resultant of three processes: (a) tumour aggressiveness, (b) specific cell-mediated immunological reactions, and (c) non-immunological stromal responses.

A case of Lennert's lymphoma.

A 73-year-old man who presented with a tonsillar mass and generalised lymphadenopathy died two months after admission to hospital. The appearances in the surgical biopsy material resembled those of Lennert's lymphoma, while the necropsy findings were those of a diffuse lymphocytic lymphoma composed mainly of cells with small nuclei showing only slight irregularity. The implication of these findings in relation to the nature of Lennert's lymphoma are briefly discussed.

Malignant histiocytosis (histiocytic medullary reticulosis) with spindle cell differentiation and tumour formation.

Malignant histiocytosis (histiocytic medullary reticulosis) in a 45-year-old white man is described. Unusual features were presentation as a surgical emergency with signs of obstruction and peritonitis due to an ileal tumour and extensive spindle cell differentiation. Problems in the differential diagnosis of malignant histiocytosis are briefly discussed.

Problem solving cases in teaching of applied pathology.

A "problem solving case" method of teaching practical pathology is described, illustrated and compared with more traditional teaching methods. This method offers many advantages-the most important being that it shows the effect of pathological lesions in an actual patient, thus emphasizing the relevance of pathology to clinical medicine. Other advantages are that self-assessmetn is encouraged; guidance is given on the depth of knowledge expected from a student; student response is favourable; no elaborate or expensive equipment is required; the method is economic in the use of staff time, and it is very flexible in use in terms both of time and place.

Mucosal metaplasia in the appendix.

Metaplastic foci do not appear to have been previously described in the mucosa of the appendix. Eight examples are reported, two of which were found in a series of 100 consecutive appendicectomies.