Rao et al. describe a wide range of testing in pathology where
targeted effort could improve appropriateness.[1]
One of the blocks to improving use of pathology testing is the
limited evidence base. This should not stop us however trying to improve
practice.[2] The medical literature contains a large resource of reviews
and consensus guidance, some of which has an evidence base, and the...
Rao et al. describe a wide range of testing in pathology where
targeted effort could improve appropriateness.[1]
One of the blocks to improving use of pathology testing is the
limited evidence base. This should not stop us however trying to improve
practice.[2] The medical literature contains a large resource of reviews
and consensus guidance, some of which has an evidence base, and there are
many interventions, both published and unpublished, which have been
introduced to attempt to improve use of tests.
Some 95% of primary care tests are contained within a limited
repertoire of under 30 investigations across laboratory medicine. These
make up half or more of the laboratory activity in many district general
hospitals.[3]
Standardised general practice activity data also show very large
differences in testing activity between practices, and although it is
difficult to define optimal testing activity, it is apparent that there is
both over-use and under-use of tests and it is important that the pursuit
of good practice includes both stimulating the increased use of under-used
tests alongside demand control aspects of over-use.
To this end, a cross-laboratory medicine group has recently been
established[4] with representation from the Royal College of Pathologists,
Royal College of General Practitioners, Association of Clinical
Pathologists, PRODIGY, Association of Clinical Biochemists, Association of
Medical Microbiologists and British Society for Haematology. The purpose
of this group initially is to construct an information resource, bringing
together available guidance and evidence to answer a series of everyday
questions affecting primary care users, and subsequently to examine ways
in which this information can be disseminated and used in interventions.
In order to do this it would be valuable to hear from colleagues
initially in the disciplines of clinical biochemistry, haematology,
microbiology and immunology, who have set up specific initiatives to
improve practice and/or would like to participate in this exercise. Many
good ideas are slow to seed across the NHS and it is only by gathering
these together and making them widely available, that the profession will
be able to help to orchestrate a concerted approach to good practice.
References
(1) RAO GG, Crook M, Tillyer ML. Pathology tests: is the time for demand management ripe at last? J Clin Pathol 2003;56:243-248
(2) Barth JH, Jones RG. Indiscriminate investigations have adverse
effects (letter) BMJ 2003;326:393.
(3) Smellie WSA, Galloway MJ, Chinn D. Benchmarking general practice
use of pathology services: a model for monitoring change. J Clin Pathol
2000;53:476–80.
(4) Smellie WSA. Demand Management in primary care pathology. Bull R
Coll Path 2003;122:16-19.
The article by Williams et al. [1] published in April issue highlights
the analytical issues related to LH measurement, as reported.[2] The article
fails to mention problems with measurement of steroid hormones due to the
presence of closely related cross-reacting substances.[3] Traditionally,
most steroid hormones were determined after removing those cross reactants
by various methods, most co...
The article by Williams et al. [1] published in April issue highlights
the analytical issues related to LH measurement, as reported.[2] The article
fails to mention problems with measurement of steroid hormones due to the
presence of closely related cross-reacting substances.[3] Traditionally,
most steroid hormones were determined after removing those cross reactants
by various methods, most commonly by solvent extraction. Currently, direct
assays without extraction have replaced them due to increased pressure on
laboratories to improve the turnaround time. Although these newer methods
are rapid and have good precision (reproducibility), accuracy (wide
variation between methods) is still a problem. [4,5] In addition, there is
batch to batch variation for the same method.[6] Such problems have been
reported for serum female (range) testosterone, oestradiol and
progesterone.[4-6] The accuracy of measurement of serum progesterone is
affected by varying degrees of cross-reaction with other progesterone –
like steroid molecules in the serum (mostly with 17-hydroxyprogesterone).
This bias increases linearly with the increased concentration of cross-
reacting species in the patient sample. Clinically results from these
methods can lead to spuriously elevated progesterone concentration causing
confusion in interpretation and may place patients at risk.[7] The United
Kingdom National External Quality Assurance Scheme (NEQAS) is making
vigorous efforts to reduce this variation and harmonise these
measurements. *[4-6] Therefore, the readers should be aware of cross-
reaction in steroid measurements and always interpret these hormone
results in the context of relevant clinical details so as to avoid
clinical error.
* UKNEQAS has created a “Steroid Accuracy forum” to act on the
problems and invites contributions from interested readers.
References
(1) Williams C, Giannopoulos T, Sherriff EA. Investigation of infertility with the emphasis on laboratory testing and with reference to radiological imaging. J Clin Pathol 2003;56:261-267
(2) Vivekanandan S, Andrew CE. Cross reaction of human
chorionic gonadotrophin in immulite 2000 luteinizing hormone assay. Ann Clin Biochem 2002; 39:318-319.
(3) Middle J. Standardization of steroid assays. Ann Clin Biochem 1998;35:354-363.
(4) Middle JG, French J. UK NEQAS for steroid hormones: has
performance improved with automation and have standardization initiatives had any effect. Proceedings of Pathology 2000:153.
(5) Middle JG, French J. UK NEQAS Steroid Hormones: highlights from the 2001 Annual Review. Proceedings of
the Association of Clinical Biochemists national Meeting 2002:85.
(6) Middle JG, French J. UK NEQAS Steroid Accuracy Forum: aims and objectives. Proceedings of the Association of Clinical Biochemists National - Meeting 2002:89.
(7) Vivekanandan S, Tariq TA. A patient with primary amenorrhoea. CPD Bull Clin Biochem 2000;2:69
I read with interest the case report by GL Stark and PJ Hamilton [1].
In 1970 we drew attention to the occurrence of megaloblastic anaemia in
asian migrants coming to the UK [2]. Further investigation [3,4] revealed
many of these to be nutritional vitamin B12 deficiency.
The features in the case reported certainly do not rule out this
possibility in their patient. They administered three injec...
I read with interest the case report by GL Stark and PJ Hamilton [1].
In 1970 we drew attention to the occurrence of megaloblastic anaemia in
asian migrants coming to the UK [2]. Further investigation [3,4] revealed
many of these to be nutritional vitamin B12 deficiency.
The features in the case reported certainly do not rule out this
possibility in their patient. They administered three injections of
vitamin B12 which would presumably provide adequate amounts of the vitamin
for months or longer.
While carrying out a survey in Punjab N. India in recent years, we
have found many young vegetarian women with macrocytosis and sub-normal
B12 levels which we will be reporting.
References
[1] Stark G.L, Hamilton P.J. Dietary folate deficiency with normal red
cell folate and circulating blasts. J Clinical Pathology 2003; 56; 313-315
[2]Britt R.P. and Harper C. 1970 Nutritional megaloblastic anaemia in
migrants. Brit med Journal 3, 348
[3]Stewart J.S, Roberts P.D, and Hoffbrand A.v. 1970 Lancet;2;542.
We are grateful to Dr Campodonico’s for the interest shown in our
recent report of a case of chronic osteomyelitis mimicking a sarcoma.[1,2] The
main point made in the letter is the need for a high level of suspicion of
malignancy in unusual cases of chronic osteomyelitis (COM).
We entirely agree with this point of view. In fact, the reason for
reporting the present case was that to highlight the...
We are grateful to Dr Campodonico’s for the interest shown in our
recent report of a case of chronic osteomyelitis mimicking a sarcoma.[1,2] The
main point made in the letter is the need for a high level of suspicion of
malignancy in unusual cases of chronic osteomyelitis (COM).
We entirely agree with this point of view. In fact, the reason for
reporting the present case was that to highlight the reverse situation
which is extremely unusual: COM interpreted as malignancy on clinical
grounds with a large resection. The lesion described by us was completely
resected and no tumour was present despite extensive sampling of the
specimen (29 blocks).
Dr Campodonico also mentions in his letter that we suggested that a
definitive diagnosis of COM is possible via immunohistochemical stains.
This, however, was not our point. Immunohistochemistry is not diagnostic
of COM but in this case served to rule out (unlikely) malignancies such as
spindle cell carcinoma and spindle cell melanoma.
In conclusion, we agree with Dr Campodonico that a high index of
suspicion for malignancy should be maintained in unusual cases of presumed
COM. The present case, on the other hand, illustrates the reverse point,
namely that a degree of suspicion should be maintained for COM in unusual
cases of presumed malignancies adjacent to or involving bone.
References
(1) Campodonico F. Chronic osteomyelitis mimicking sarcoma [electronic response to C Gulmann C et al. Chronic osteomyelitis mimicking sarcoma] jclinpath.com 2003 http://jcp.bmjjournals.com/cgi/eletters/56/3/237#19
(2) C Gulmann, O Young, M Tolan, D O’Riordan, and M Leader. Chronic osteomyelitis mimicking sarcoma. J Clin Pathol 2003;56:237-239.
In
reply to the points raised by Cunningham et al.[1] to the British Andrology
Society post vasectomy guidelines, we feel that the authors answer their own criticism - especially the need to assess fresh samples if sperm are found in the initial sample. Our guidelines are to allow the identification of men with few motile cells following heavy c...
In
reply to the points raised by Cunningham et al.[1] to the British Andrology
Society post vasectomy guidelines, we feel that the authors answer their own criticism - especially the need to assess fresh samples if sperm are found in the initial sample. Our guidelines are to allow the identification of men with few motile cells following heavy criticism from our own referees.
24 hour old azoospermic samples, whilst unpleasant give you the same answer
and we clearly say that patient compliance is more important than time
to examination - i.e. an aged sample is better than no sample.
We recommend positive displacement pipettes & phase contrast
microscopy as these are normally found in laboratories that provide high
quality andrological services. The highly viscous nature of semen can mean
that a positive displacement pipetteis the only way to actually remove a
complete pellet. Phase contrast also offers benefits over standard bright-
field illumination as a more rapid medium for screening semen samples.
The other point raised concerned unexpected pregnancies. In our guidelines
we did state this was a difficult area to quantify, as if pregnancies did
occur we do not know how many women would seek termination rather than the
potential trauma associated with pregnancy following a supposedly
sucessful vasectomy.
Our guidelines are best practice, and we feel that in this increasingly
litigatious society this is what is required. If workers want to take the
risk of missing someone with a failed vasectomy by not following them then
that is a choice they make, but it may have to be justified in court. We
can only give best practice and leave it to their judgement.
References
(1) Richard Cunningham, David Dance, Jim Greig, and Adam Brown. Assessment of post vasectomy semen samples [electronic response to P Hancock and E McLaughlin. British Andrology Society guidelines for the assessment of post vasectomy semen samples (2002)] jclinpath.com 2003 http://jcp.bmjjournals.com/cgi/eletters/55/11/812#14
I think the time has come for the medical profession to admit a major mistake in
its history and for a moment leave pride and arrogance on one side. I have a
university degree, am father of two and have spent several days reading books
about childhood vaccination and information downloaded from the Internet. As
vaccination was a “joke” of industrial development, owing to the coincidence of
improving general...
I think the time has come for the medical profession to admit a major mistake in
its history and for a moment leave pride and arrogance on one side. I have a
university degree, am father of two and have spent several days reading books
about childhood vaccination and information downloaded from the Internet. As
vaccination was a “joke” of industrial development, owing to the coincidence of
improving general hygiene, nutrition and standard of living, and the development
and diffusion of vaccination programmes, its death will result from
post-industrial technological development and diffusion of information via the
Internet, which allows non-partial (i.e. not sponsored by pharmaceutical
corporations) information to circulate. For anyone confronted with the issue, it
seems clear that:
Vaccination is a multibillion-dollar business for the pharmaceutical
corporations, which do not sell a few well-tested medicines but huge stocks of
not so well tested vaccines to numerous governments with relatively low and
simple "Promotion costs". The doctors are unfortunately both consciously and
unconsciously part of this process.
Part of the joke of history is because oblivious children contribute to the
problem. The parents usually arrive at a decision to vaccinate their children
under the stress of the first months of parenthood and usually without any
objective information. The will to have your children vaccinated is owing to the
protective instinct that is in every parent. The paediatricians on their side get
only sponsored information!
All the statistical analysis I have read suggests that vaccination makes no
difference and the one study that suggested that it did, was sponsored by
pharmaceutical corporations.
The problem lies also in the fact that the majority of doctors are unwilling
to tell to a parent not to vaccinate because in the very rare case that the child
does actually die as a result of not being vaccinated, the parent would have
every right to sue. Nobody considers that that child would probably die as a
consequence of vaccination and that anyhow deaths related to vaccinations are
higher than the ones related to not being vaccinated (It would be enough to
consider SIDS, Sudden Infant Death Syndrome, between 5000 and 10,000 yearly only
in the USA). However, in these cases the responsible agent is practically
impossible to find!
The least anyone who read this letter could do (especially if they are going to
have children!) is to search on the Internet for the word “vaccination” and check
what he or she finds, especially on independent websites. There are also many
interesting books on this subject. A big surprise awaits them!
Gulmann et al. reported on a case of chronic osteomyelitis presenting
as a mass of the chest mimicking a soft tissue sarcoma.[1] The authors
suggested that, although chronic osteomyelitis is a known cause of
confusion with bone tumors, a definitive diagnosis is feasible by specific
immunohistochemical staining. However, the potential risk of
transformation of a chronic osteomyelitis in a malignant l...
Gulmann et al. reported on a case of chronic osteomyelitis presenting
as a mass of the chest mimicking a soft tissue sarcoma.[1] The authors
suggested that, although chronic osteomyelitis is a known cause of
confusion with bone tumors, a definitive diagnosis is feasible by specific
immunohistochemical staining. However, the potential risk of
transformation of a chronic osteomyelitis in a malignant lesion is an
unforgettable point either for the clinician or the pathologist.[2] Two
years ago, I encountered a patient developing a rapidly aggressive sarcoma
with an uncommon onset. He was a 23-year-old man, with a sixteen-month
history of chronic osteomyelitis of the left hip bone, referred to
urologic department. Three years before, he had been involved in a road
accident with a bilateral fracture of the thigh bone and left acetabulum.
On admission to the ward the patient reported fever, dysuria and
suprapubic pain. Physical examination demonstrated an osteocutaneous
fistula with smelling drainage on the lateral aspect of the left hip bone.
On standard computed tomography an haemorragic mass causing bladder
impression and connected with the fistula was observed. A surgical
exploration was performed with drainage of septic tissue and a 5 cm pelvic
lymph node was excised from the left iliac chain for histological
examination. Light microscopy showed a solid proliferation of spindle-
shaped cells, with a high mitotic index, associated with lymphatic
aggregates and foci of necrotic tissue. Staining for S-100 protein,
desmine, vimentine and focal smooth actine were positive. The histological
and immunohistochemical features of the pelvic node confirmed an
undifferentiated sarcoma. The patient died three months postoperatively.
Malignant lesions are rare complications of chronic osteomyelitis. As
reported in a large serie by McGrory et al,[3] squamous cell carcinoma
is by far the most common type of associated malignant disease, while
sarcoma has been exceptionally reported.[4] The latency period between
onset of osteomyelitis and development of neoplasia may be as short as 1
year ot it may be decades. Generally the neoplasia occurs in the
osteomyelitic sinus or in a chronic draining fistula. The most frequent
clinical findings of malignancy in chronic fistulating osteomyelitis are
persistent foul discharge, pain and bleeding.[3] In this case, the
osteocutaneous fistula was connected to the left iliac area where the
sarcoma arised and spread to pelvic lymph nodes. In conclusion, even
though chronic osteomyelitis may be a cause of difficult diagnosis with
bone tumors, I would emphasize the need to mantain an high index of
suspicious in case of chronic osteomyelitis with an unusual presentation.
(2) Slominski A, Wortsman J, Carlson A, Mihm M, Nickoloff B, McClatchey KD. Molecular pathology of soft tissue and bone tumors. A review. Arch Pathol Lab Med 1999;123:1246-59
(3) McGrory JE,Pritchard DJ,Unni KK et al. Malignant lesions arising in chronic osteomyelitis. Clin Orthop 1999;362:181-9.
(4) Akbarnia BA,Wirth CR,Colman N. Fibrosarcoma arising from chronic osteomyelitis. Case report and review of the literature. J Bone Joint Surg Am 1976;58:123-5.
I read with interest the case report by Stenhouse et al. [1] since I
recently discussed the terminology of these lesions in a report of a
similar case.[2]
The parallels between mucinous neoplasms of the urachus and of the
appendix are striking. They have similar morphology and both can produce
the clinical picture of pseudomyxoma peritonei, in which low-grade
mucinous adenocarcinoma caus...
I read with interest the case report by Stenhouse et al. [1] since I
recently discussed the terminology of these lesions in a report of a
similar case.[2]
The parallels between mucinous neoplasms of the urachus and of the
appendix are striking. They have similar morphology and both can produce
the clinical picture of pseudomyxoma peritonei, in which low-grade
mucinous adenocarcinoma causes mucinous ascites. Furthermore, it can be
difficult to distinguish benign adenomas from lesions that may produce
pseudomyxoma peritonei; the World Health Organization classification of
tumours states that it is appropriate to use the term 'mucinous tumour of
uncertain malignant potential' for neoplasms in which the histological
features do not allow distinction between a lesion that is benign and one
that has the potential to metastasis.[3] Other terms, such as 'low grade
mucinous cystic tumour' have also been proposed.
Therefore, I was gratified to see that Stenhouse et al. reported their
case as 'a mucinous neoplasm of uncertain malignant potential', since this
is the terminology that we used for our case.[2] It reflects the
difficulty in predicting behaviour from morphological appearances in these
unusual lesions.
References
(1) Stenhouse G, McRae D, Pollock AM. Urachal adenocarcinoma in situ
with pseudomyxoma peritonei: a case report. J Clin Pathol 2003; 56:152-153
(2) Carr NJ, McLean AD. A mucinous tumour of the urachus: adenoma or
low grade mucinous cystic tumour of uncertain malignant potential? Adv
Clin Pathol 2001; 5:93-97.
(3) Carr NJ, Arends MJ, Dean GT, et al. Adenocarcinoma of the
appendix. In: Hamilton SR, Aaltonen LA, (Eds) World Health Organization
International Classification of Tumours. Pathology and Genetics of Tumours
of the Digestive System. Lyon: IARC Press, 2000. Pp.95-98.
We read with interest the British Andrology Society (BAS) guidelines
for the assessment of post vasectomy semen samples (2002).[1] The authors
have carried out a thorough and comprehensive review of the topic, and we
are convinced by their recommendation that assessment should be undertaken
16 weeks and at least 24 ejaculates after vasectomy. We are unconvinced
however, by the specific recommendations ab...
We read with interest the British Andrology Society (BAS) guidelines
for the assessment of post vasectomy semen samples (2002).[1] The authors
have carried out a thorough and comprehensive review of the topic, and we
are convinced by their recommendation that assessment should be undertaken
16 weeks and at least 24 ejaculates after vasectomy. We are unconvinced
however, by the specific recommendations about sample collection,
transport and examination.
First, no evidence is provided to support the need for samples to be
maintained at body temperature, delivered to the laboratory within one
hour, and examined within four hours. Since the presence of any
spermatozoa in the sample indicates a need for further samples, assessment
of motility and morphology is not essential. Secondly, the
recommendations for the use of a direct displacement pipette,
centrifugation of samples negative on direct microscopy and quantitation
of spermatozoa are excessive and potentially costly, and appear to have
been taken directly from methods used appropriately in assessment of
infertility. We would question the need for such sensitive methods in
determining whether or not a vasectomy has been successful. The majority
of patients undergoing vasectomy will have been previously fully fertile,
with sperm counts ³106/ml. The success of the operation can be judged on
the basis of the disappearance of sperms based on a simpler assessment of
sperm count.
For many years our method for assessment of post-vasectomy semen samples
has involved requesting samples at 10 and 12 weeks after 5 days of
abstinence. Samples are delivered on the day of collection via the
routine GP transport services and examined at the end of each working day.
We examine each specimen by direct light microscopy using an x40
objective. One drop of uncentrifuged sample is transferred to a slide
using a disposable Pasteur pipette for each sample. The presence of
motile and non-motile spermatozoa in one scan across the slide is reported
semi-quantitatively (+, ++, or +++. Samples are repeated until 2
consecutive negative samples have been reported. 4542 patients have been
assessed by this method between 1997 and 2002. We are not aware of any
unexpected pregnancies after reporting patients negative by our method,
excluding a small number clearly due to late recanalisation. The surgeons
or GPs who carried out vasectomies on 1781 of these patients were
contacted, again they were unaware of any unexpected pregnancies. We
estimate that with a median frequency of sexual intercourse of 4 in 4
weeks in males aged between 25 and 44 years,2 that there are likely to
have been over 3.5 million episodes of sexual intercourse in our cohort
over the last 5 years. These results support our contention that more
elaborate methods of semen analysis are not necessary. Our results are
consistent with those of Haldar et al who reviewed over 30,000 vasectomies
assessed without centrifugation and did not report any pregnancies which
were not attributable to late recanalisation.3
Guidelines from learned societies are always welcome, but must take into
account the opportunity costs of unnecessarily rigorous laboratory
methods. It is easy to suggest a more complex way of processing any
pathology specimen, but far more difficult to define the most cost-
effective method, while still maintaining high levels of sensitivity and
specificity.
References
(1) British Andrology Society. British Andrology Society guidelines
for the assessment of post vasectomy semen samples (2002). J Clin Pathol
2002;55:812-816.
(2) Johnson AM et al. Sexual behaviour in Britain:partnerships, practices,
and HIV risk behaviours. Lancet 2001;358:1835-42.
(3) Haldar N, Cranston D, Turner E, MacKenzie I, Guillebaud J. How reliable
is a vasectomy? Longterm follow-up of vasectomised men. Lancet 2000;356:43-44.
I read the contribution in Historical Perspectives, 'Molten gold was
poured down his throat until his bowels burst,'[1] with mounting horror
and incredulity. Though the subject atter was unusual and the animal model
dubious, I was most puzzled by the nature of the references. The second
and fourth references are to web pages. Investigation of these pages shows
that both are postings taken from books at lea...
I read the contribution in Historical Perspectives, 'Molten gold was
poured down his throat until his bowels burst,'[1] with mounting horror
and incredulity. Though the subject atter was unusual and the animal model
dubious, I was most puzzled by the nature of the references. The second
and fourth references are to web pages. Investigation of these pages shows
that both are postings taken from books at least one of which is in print
in English translation in several editions.[2,3] The third reference
appears to be a duplicate of the fourth and mistakenly attributes an
anthology of literature to the individual that put together the web page
rather than the compiler of the anthology. While it may be convenient for
readers to be able to find references on the Internet, web addresses can
be very ephemeral and a true historical perspective should require
quotation of the title and author of the original published work.
References
(1) Van de Goot FRE, ten Berge RL, Vos R. Historical Perspectives. J Clin Pathol 2003;56:157.
(2) Wylie JA. History or Protestantism. London: Cassell and Company, 1878.
Dear Editor
Rao et al. describe a wide range of testing in pathology where targeted effort could improve appropriateness.[1]
One of the blocks to improving use of pathology testing is the limited evidence base. This should not stop us however trying to improve practice.[2] The medical literature contains a large resource of reviews and consensus guidance, some of which has an evidence base, and the...
Dear Editor
The article by Williams et al. [1] published in April issue highlights the analytical issues related to LH measurement, as reported.[2] The article fails to mention problems with measurement of steroid hormones due to the presence of closely related cross-reacting substances.[3] Traditionally, most steroid hormones were determined after removing those cross reactants by various methods, most co...
Dear Editor
I read with interest the case report by GL Stark and PJ Hamilton [1]. In 1970 we drew attention to the occurrence of megaloblastic anaemia in asian migrants coming to the UK [2]. Further investigation [3,4] revealed many of these to be nutritional vitamin B12 deficiency.
The features in the case reported certainly do not rule out this possibility in their patient. They administered three injec...
Dear Editor
We are grateful to Dr Campodonico’s for the interest shown in our recent report of a case of chronic osteomyelitis mimicking a sarcoma.[1,2] The main point made in the letter is the need for a high level of suspicion of malignancy in unusual cases of chronic osteomyelitis (COM).
We entirely agree with this point of view. In fact, the reason for reporting the present case was that to highlight the...
Dear Editor
In reply to the points raised by Cunningham et al.[1] to the British Andrology Society post vasectomy guidelines, we feel that the authors answer their own criticism - especially the need to assess fresh samples if sperm are found in the initial sample. Our guidelines are to allow the identification of men with few motile cells following heavy c...
Dear Editor
I think the time has come for the medical profession to admit a major mistake in its history and for a moment leave pride and arrogance on one side. I have a university degree, am father of two and have spent several days reading books about childhood vaccination and information downloaded from the Internet. As vaccination was a “joke” of industrial development, owing to the coincidence of improving general...
Dear Editor
Gulmann et al. reported on a case of chronic osteomyelitis presenting as a mass of the chest mimicking a soft tissue sarcoma.[1] The authors suggested that, although chronic osteomyelitis is a known cause of confusion with bone tumors, a definitive diagnosis is feasible by specific immunohistochemical staining. However, the potential risk of transformation of a chronic osteomyelitis in a malignant l...
Dear Editor
I read with interest the case report by Stenhouse et al. [1] since I recently discussed the terminology of these lesions in a report of a similar case.[2]
The parallels between mucinous neoplasms of the urachus and of the appendix are striking. They have similar morphology and both can produce the clinical picture of pseudomyxoma peritonei, in which low-grade mucinous adenocarcinoma caus...
Dear Editor
We read with interest the British Andrology Society (BAS) guidelines for the assessment of post vasectomy semen samples (2002).[1] The authors have carried out a thorough and comprehensive review of the topic, and we are convinced by their recommendation that assessment should be undertaken 16 weeks and at least 24 ejaculates after vasectomy. We are unconvinced however, by the specific recommendations ab...
Dear Editor
I read the contribution in Historical Perspectives, 'Molten gold was poured down his throat until his bowels burst,'[1] with mounting horror and incredulity. Though the subject atter was unusual and the animal model dubious, I was most puzzled by the nature of the references. The second and fourth references are to web pages. Investigation of these pages shows that both are postings taken from books at lea...
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