Withholding breast milk for HIV exposed infants in sub-Saharan Africa: benefit or harm?

Feeding options for HIV exposed infants has remained topical and controversial in most settings of sub-Saharan Africa. This commentary, expresses the author's opinions on this topical issue for and against breastfeeding or infant formula, with supporting evidence drawn from relevant literature on researches conducted in settings of sub-Saharan Africa. At the moment, it seems sensible to recommend that health care workers and policy makers should explore the options of making breastfeeding safer rather than withholding it for sub-Saharan African HIV exposed infants. It is hoped that when Highly Active Antiretroviral Therapy (HAART) becomes universally accessible and available to HIV infected women in sub-Saharan Africa, breast milk HIV transmission will be a rare event and the health benefits of breastfeeding for the infant and mother will be maximized.     

Cut-resistant protective gloves in pathology—effective and cost-effective

Cutting injuries and needle-stitch injuries constitute a potentially fatal danger to both pathologists and autopsy personnel. We evaluated such injuries in a large German institute of pathology from 2002 to 2007 and analysed the effect of the introduction of cut-resistant gloves on the incidence of these injuries. In the observation period, 64 injuries (48 cutting injuries and 16 needle-stitch injuries) were noted in the injury report books. Most injuries were located at the non-dominant hand, preferentially at the index finger and the thumb. Around one fifths of the injuries were at the side of handedness. The average number of injuries per month was 1.22 for the 50 months prior to the introduction of cut-resistant gloves, more than seven times higher than after their introduction (0.158; 19 months; p < 0.001). Considering the medical and administrational costs of such injuries, cut-resistant protective gloves are an effective and cost-effective completion of personal occupational safety measures in surgical pathology and autopsy. We strongly recommend the use of such gloves, especially for autopsy personnel.     

Filariasis in Africa—treatment challenges and prospects

Lymphatic filariasis (LF) and onchocerciasis are parasitic nematode infections that are responsible for a major disease burden in the African continent. Disease symptoms are induced by the immune reactions of the host, with lymphoedema and hydrocoele in LF, and dermatitis and ocular inflammation in onchocerciasis. Wuchereria bancrofti and Onchocerca volvulus, the species causing LF and onchocerciasis in Africa, live in mutual symbiosis with Wolbachia endobacteria, which cause a major part of the inflammation leading to symptoms and are antibiotic targets for treatment. The standard microfilaricidal drugs ivermectin and albendazole are used in mass drug administration programmes, with the aim of interrupting transmission, with a consequent reduction in the burden of infection and, in some situations, leading to regional elimination of LF and onchocerciasis. Co-endemicity of Loa loa with W. bancrofti or O. volvulus is an impediment to mass drug administration with ivermectin and albendazole, owing to the risk of encephalopathy being encountered upon administration of ivermectin. Research into new treatment options is exploring several improved delivery strategies for the classic drugs or new antibiotic treatment regimens for anti-wolbachial chemotherapy.     

Surgical pathology of native valve endocarditis in 310 specimens from 287 patients (1985–2004)

BackgroundFew large studies have documented the clinical and pathologic features of native valve endocarditis (NVE) independently from prosthetic valve endocarditis (PVE).MethodsA retrospective study of medical records of all patients undergoing operation for NVE at Mayo Clinic in Rochester, MN (1985–2004), was performed. Medical records were reviewed from 287 patients for demographics, infecting organism, and comorbidities. Microscopic slides from 310 valves were reviewed for features of infection.ResultsThe study cohort included 287 patients, with age ranging from 9 to 87 years (mean, 54), yielding 310 valves. Most (73%) were from men, and 84% were regurgitant. Risk factors included bicuspid aortic valve (23%), dental manipulation (20%), mitral valve prolapse (18%), diabetes mellitus (16%), and others (< 5% each); in 15%, no risk factor was identified. The four most commonly identified organisms were viridans group streptococci (28%), Staphylococcus aureus (18%), enterococci (9%), and coagulase-negative staphylococci (8%). NVE was histologically active in 58% and healed in 42%, and affected left-sided valves in 94%. It was associated with embolization in 29%, acute heart failure in 29%, and annular abscess in 18%. Men accounted for a higher percentage of aortic NVE than mitral NVE (82% versus 63%, respectively; P=.001). Among 126 valves with active endocarditis, 25% had no microorganisms identified histologically.ConclusionNVE affected men nearly three times as frequently as women. Diabetes mellitus emerged as a prevalent (and previously underrecognized) risk factor for NVE. The most common infecting organisms were streptococci and staphylococci. Microorganisms were identified histologically in the majority of active endocarditis cases.     

Quality assurance in pathology in colorectal cancer screening and diagnosis—European recommendations

In Europe, colorectal cancer is the most common newly diagnosed cancer and the second most common cause of cancer deaths, accounting for approximately 436,000 incident cases and 212,000 deaths in 2008. The potential of high-quality screening to improve control of the disease has been recognized by the Council of the European Union who issued a recommendation on cancer screening in 2003. Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document consists of ten chapters and an extensive evidence base. The content of the chapter dealing with pathology in colorectal cancer screening and diagnosis is presented here in order to promote international discussion and collaboration leading to improvements in colorectal cancer screening and diagnosis by making the principles and standards recommended in the new EU Guidelines known to a wider scientific community.     

Systems pathology—or how to solve the complex problem of predictive pathology

To understand the extreme complexity of biological events requires a systemic approach. This holds particularly for the disordered biological interactions that are characteristic of disease, the subject of pathology. Which options are available to untie the Gordian knot? In this contribution, the potential role of systems biology and, as a further development, systems pathology will be discussed.     

Dysplasia classification: pathology in disgrace?

Grading of dysplasia is demanded almost daily from most diagnostically active pathologists. It is also notoriously subjective and lacks intra- and inter-observer reproducibility. This is partly due to the lack of validated morphological criteria, upon which pathologists have reached consensus. It is largely due to the biological nature of the evolution of dysplasia, not in discrete steps but as a continuum. Better morphological definition, but also fundamental research into the nature of the process, is necessary to resolve this issue.     

What is quality in surgical pathology?

Quality in surgical pathology may be defined as accurate, timely, and complete reports. Achieving quality requires substantial investment in the basic structure and in the people who undertake surgical pathology. Quality assurance and improvement works best when it is woven into the systems of surgical pathology with well informed, well trained, and knowledgeable staff.     

Surgical pathology of cystic renal cell carcinomas: is there an overestimation of malignancy?

Most cystic renal epithelial tumors have excellent prognosis after resection despite the high proportion of renal cell “carcinoma” diagnosis. The 2019 Bosniak classification revision and recent downgrading of multilocular cystic renal cell carcinoma (RCC) to multilocular cystic renal neoplasm of low malignant potential (MCNLMP) may help reduce the discrepancy. Cystic clear cell (CC) RCC has been shown to behave favorably compared to non-cystic CC RCC and suggests a continuum with MCNLMP which would represent the most indolent of this spectrum. Further, the current pathological criteria distinguishing MCNLMP and extensively (>75%) cystic CC RCC should be revisited as both tumors show similar excellent prognosis. Clear cell papillary (CCP) RCC, which often has cystic change, should be renamed as “clear cell papillary neoplasm of low malignant potential”. However, cystic (and pseudocystic) features may also occur in other non-CC RCC types, including uncommon aggressive tumors with metastatic potential. This review highlights the need for reappraisal of the pathological categorization of cystic RCCs including the cystic CC RCC and CCP RCC.     

The hematoxylin and eosin stain in anatomic pathology—An often-neglected focus of quality assurance in the laboratory

Accuracy in morphological diagnosis is the cornerstone of anatomic pathology. Proficiency with the microscope offers values to the health care system that cannot be overestimated. However, that skill is only possible if high-quality histological substrates are available for assessment, particularly focusing on hematoxylin and eosin (H&E)-stained slides. This brief review considers the several steps that are necessary to control in the preparation of high-quality H&E sections, including those dealing with fixation, embedding, microtomy, histochemical staining, and coverslipping. A table for the troubleshooting of problem slides is also included.     

Impact of antibiotic intake on the incidence of extended-spectrum β-lactamase–producing Enterobacterales in sub-Saharan Africa: results from a community-based longitudinal study

ObjectivesThe global prevalence of intestinal extended-spectrum β-lactamase–producing Enterobacterales (ESBL-PE) is approximately 17% in communities, with significant variations among regions. This longitudinal study aimed to assess the impact of antibiotic intake on the incidence of intestinal ESBL-PE in Ghanaian pharmacy customers outside of hospitals.MethodsScreening for ESBL-PE was performed in four independent pharmacies in Kumasi, Ghana, using rectal swabs and an ESBL-PE–selective medium. Pharmacy customers purchasing antibiotics were recruited, and those buying non-antibiotic drugs served as controls. Participants who were negative for ESBL-PE provided follow-up swabs for up to 28 days.ResultsAt baseline, 302 (75%) of 404 participants were colonized with ESBL-PE. Sixty-three participants who were negative for ESBL-PE at baseline received per-protocol follow-up, including 28 individuals who took antibiotics and 35 controls. The cumulative proportions of ESBL-PE in the antibiotics and control groups were 71% (20/28) and 54% (19/35) at the first follow-up (p 0.258), 86% (24/28) and 80% (28/35) at the second follow-up (p 0.741) and 86% (24/28) and 94% (33/35) at the third follow-up (p 0.393), respectively.DiscussionThe rate of intestinal ESBL-PE carriage among pharmacy customers outside of hospitals was higher than expected at baseline and further increased during the 28 days of follow-up, irrespective of antibiotic intake. This alarming finding needs to be considered in the antibiotic treatment of outpatients and emphasizes the urgent need for improved prevention strategies, development of new antibiotic drugs and potential future elimination strategies. Further longitudinal studies on ESBL-PE in African communities, also outside of pharmacy settings, are required.