Hepatitis B outbreak at Glenochil prison during January to June 1993.

This data linkage study examined the extent of hepatitis B transmission and co-infection with HIV among 636 former inmates of Glenochil prison, Scotland, during an outbreak of bloodborne diseases in 1993 which was related to needle sharing. Eleven inmates imprisoned during the first half of 1993 presented with hepatitis B infection, of whom co-infection with HIV was detected in six. Based on dates of test results in relation to time of imprisonment, seven definitely acquired their hepatitis B infection within the prison. Only two infections were reported to Scotland''s hepatitis B register and neither could be prison-linked. This outbreak of hepatitis B is the first of its kind to be reported but not the first to have occurred. It not only highlights the urgency for measures to prevent further spread of infection among prisoners but also illustrates the need for comprehensive surveillance of hepatitis B infection, and the need for a protocol on how to manage such outbreaks and on how to establish the extent of transmissions when acute hepatitis B occurs in prison.     

Crystal deposition in a case of cutaneous Rosai-Dorfman disease

Rosai-Dorfman Disease (RDD) is an idiopathic reactive proliferation of distinctive histiocytes that have abundant cytoplasm and commonly exhibit intracytoplasmic ingestion of inflammatory cells (emperipolesis). The histiocytes are immunopositive for S100 protein and are typically associated with an infiltrate of lymphocytes, plasma cells, and neutrophils. The classic clinical presentation is massive enlargement of (usually) cervical lymph nodes with a histologic appearance that mimics exaggerated sinus histiocytosis. RDD can also involve extra-nodal sites and skin involvement is common either as part of disseminated disease or as a result of primary disease. We report an exceptional case of cutaneous RDD with crystal deposition in a young male presenting with skin nodules. Skin biopsy showed classic features of cutaneous RDD with the additional feature of conspicuous rhomboidal and needle-shaped crystals within the cytoplasm of many lesional plasma cells, histiocytes, and also in an extra-cellular location. The plasma cells were polyclonal by light chain immunostaining. Crystal deposition has not been reported to date in RDD and is likely a result of the reactive plasma cell proliferation.     

Incidence of hepatitis C virus infection and associated risk factors among Scottish prison inmates: a cohort study

To gauge the incidence of hepatitis C virus (HCV) infection and associated risk factors among inmates during their imprisonment, the authors recruited adult males in a long-stay Scottish prison into a cohort study between April 1999 and October 2000. On two occasions (at 0 and 6 months), saliva was collected for anonymous HCV antibody testing and risk behavior data were obtained through a self-administered questionnaire. The participation rate was 85% at both initial recruitment (612/719) and follow-up (375/441; 171 men were ineligible for follow-up). For inmates who reported never having injected drugs, ever having injected drugs, having injected drugs during follow-up, and having shared needles/syringes during follow-up, HCV incidences per 100 person-years of incarceration risk were 1, 12, 19, and 27, respectively. Ever having injected drugs (relative risk = 13.0, 95% confidence interval: 1.5, 114.3) and having shared needles/syringes during follow-up (relative risk = 9.0, 95% confidence interval: 1.1, 71.7) were significantly associated with HCV seroconversion. The effectiveness of existing interventions, including the provision of bleach tablets for sterilizing injection equipment, was suboptimal. The development of methadone maintenance programs in prisons and the creation of drug courts to keep offending drug injectors out of prison might help to reduce transmission in this setting.     

Synovial sarcoma in older patients: clinicopathological analysis of 32 cases with emphasis on unusual histological features

AIMS: To analyse the clinicopathological features of synovial sarcoma presenting in patients over 60 years of age, an uncommon subset which have not been specifically studied. METHODS AND RESULTS: Thirty-two cases of primary synovial sarcoma in patients aged > or =60 years were retrieved from the authors' consultation files. These were analysed histologically and immunohistochemically and clinical follow-up was obtained in 26 cases (median duration 41 months). Mean age at diagnosis was 71.6 years (range 60-84) with 19 females and 13 males. Anatomical sites were lower limb (n = 13), upper limb (n = 5), lung/pleura (n = 5), trunk (n = 4), head/neck (n = 3), mediastinum (n = 1) and scrotum (n = 1). Histologically, 23 were monophasic and nine were biphasic; 14 were poorly differentiated, of which five showed focally marked pleomorphism. Unusual features in two cases each included organoid nodules, granular cell change, squamous metaplasia and papillary architecture. Ten patients developed local recurrence and 11 developed metastases, of whom seven died. Large tumour size, poorly differentiated morphology and high mitotic rate correlated with poor outcome. CONCLUSIONS: Less than 10% of synovial sarcomas occur in patients over 60, in which age group this diagnosis is often not considered. Despite inevitable bias in consultation material, it seems that these cases, when compared with younger age groups, more often show poorly differentiated histology and more often develop at unusual locations.     

Anatomy of Complications workshop: an educational strategy to improve performance in obstetricians and gynaecologists

Many specialist obstetricians and gynaecologists feel inadequately trained to deal with certain situations such as injury to bowel, bladder, ureter and major vessels, and value further training to prevent and manage these problems. We present the structure, objectives and rationale for a surgical skills workshop, which is an intensive practical learning experience aimed to improve the performance of obstetricians and gynaecologists. The overall objective of the workshop is improvement in the prevention and management of complications in obstetric and gynaecological surgery. Over 100 participants have completed the workshop so far. Pre-workshop preparation includes anatomical illustrations to guide reading and a training video describing surgical skills, ewe anatomy and hysterectomy in the ewe. There are four modules: anatomy includes an interactive lecture, cadaveric dissection and examination of prosections with specific learning tasks. Surgical skills involves the demonstration, practice and learning of techniques needed to deal with unexpected operative injury to bowel, bladder, ureter and major blood vessels. Live animal surgery on a ewe allows further supervised practice of the previously learned skills plus the repair of serious vascular injury. Case presentations allow each participant to present a complicated case in a facilitated group session with discussion and feedback from their peers. This session is controlled, non-threatening and a valuable interactive learning experience. Participant feedback suggests that this workshop format is useful and appears to improve the confidence, competence and performance of the participants. This workshop is presented as a template on which other educational activities can be developed.     

Cellular myxoma of soft tissue: a clinicopathological study of 38 cases confirming indolent clinical behaviour

AIMS: To characterize the clinicopathological features and biological potential of a group of soft tissue lesions with morphology intermediate between intramuscular myxoma and low-grade myxofibrosarcoma. METHODS AND RESULTS: Thirty-eight lesions in 37 patients were retrieved from the authors' consultation files. Clinical and follow-up data were obtained and the lesions were also studied immunohistochemically. Tumours occurred in adults aged 25-83 years (mean 51.9 years) with a slight predominance in females. All cases, except two, were solitary. The extremities were preferentially involved (18 lower limb; nine upper limb), with seven lesions arising around the upper (2/7) and lower limb (5/7) girdles and four lesions occurring at other locations. Twenty-nine of 31 of the tumours, for which the depth was known, were situated deep to the superficial fascia, although only 19 were strictly intramuscular. Histologically these lesions were both more cellular and more vascular than intramuscular myxoma, while lacking the cytological pleomorphism, nuclear atypia and curvilinear vascular pattern characteristic of low-grade myxofibrosarcoma. CD34 positivity in lesional cells was identified in 17/30 (57%) cases, probably reflecting their fibroblastic nature. Staining for alpha-smooth muscle actin was focally positive in 3/30 (10%) cases, while desmin and S100 protein staining were consistently negative. Clinical follow-up data (available in 22 cases; median duration 30 months) demonstrate that these lesions behave in a benign fashion with only a small risk of local recurrence if not excised completely; in this study only two tumours recurred, both of which originally had been incompletely excised. None metastasized. CONCLUSIONS: The risk of recurrence in this group of lesions which we have designated 'cellular myxoma' appears to be low. Consequently simple complete local excision is most often adequate treatment. Longer follow-up (5-10 years or more) in a larger number of cases will be important in more definitively confirming the natural history of these lesions.     

Effect of combination therapy on immunologic progression of human immunodeficiency virus at a population level

There is accumulating evidence from clinical trials and cohort studies that highly active antiretroviral combination therapy is effective at halting immunologic and clinical progression of human immunodeficiency virus (HIV). Its impact at a population level is less well known because the regimes may be difficult to tolerate and compliance poorer. The authors make use of population data for almost all of the HIV-infected people in Scotland in 1997 who were under clinical care and monitor their response to therapy during the first year when these effective treatments became widely available. More than two thirds of the HIV-positive patients were on some form of antiretroviral therapy during the year. The authors show that all treated groups, even those who were on changing regimes, showed net improvement in immunologic status during the year. For the group of patients on triple or quadruple therapy, there was an average increase of more than 100 CD4 cells/mm(3) over the year, with other treatment groups showing more modest, but significant, increases.     

Reticular perineurioma: a distinctive variant of soft tissue perineurioma

Soft tissue perineurioma is a relatively recently characterized, uncommon tumor composed of perineurial cells exhibiting immunoreactivity for epithelial membrane antigen (EMA). These lesions occur preferentially in adults and may arise in a wide variety of anatomic sites. We report the clinicopathologic, immunohistochemical, and ultrastructural features of six cases of a poorly recognized morphologic variant of soft tissue perineurioma, characterized by a highly distinctive reticular growth pattern. Four of the patients were women, two were men (age range, 34-61 yrs; median, 43 yrs). Four of the cases arose in the subcutis of the upper extremity; three were located distally (thumb, finger, palm), whereas one was situated more proximally near the elbow region. One case each was located in the gingiva and subcutaneous tissue of the inguinal region, respectively. In those cases in which clinical information was available (n = 5), the lesions were asymptomatic and had been present from 4 months to 10 years before resection. Tumor size ranged from 1.5 cm to 10 cm (median size, 4.25 cm). Microscopically the lesions demonstrated a predominantly lace-like or reticular growth pattern composed of anastomosing cords of fusiform cells with bipolar cytoplasmic processes and palely eosinophilic cytoplasm. Nuclei were centrally placed, ovoid to fusiform in shape, and no mitoses were seen. Transition to more cellular areas was focally present in all cases. The stroma was variably collagenous to myxoid. Immunohistochemically all six cases stained positively for EMA but not for S-100 protein. Two cases demonstrated focal positive cytoplasmic staining for cytokeratin, whereas one case was focally desmin positive. Ultrastructural examination of two tumors showed typical features of perineurial cells. Follow up (available in only two cases) showed no evidence of recurrence. Reticular perineurioma of soft tissue represents an unusual morphologic variant within the perineurioma group, which should be distinguished from myoepithelial tumors, extraskeletal myxoid chondrosarcoma, and myxoid synovial sarcoma.