Technical Aspects and Clinical Limitations of Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

PURPOSE

Sperm DNA fragmentation (SDF) is a functional sperm abnormality that can impact reproductive potential, for which four assays have been described in the recently published sixth edition of the WHO laboratory manual for the examination and processing of human semen. The purpose of this study was to examine the global practices related to the use of SDF assays and investigate the barriers and limitations that clinicians face in incorporating these tests into their practice.

MATERIALS AND METHODS

Clinicians managing male infertility were invited to complete an online survey on practices related to SDF diagnostic and treatment approaches. Their responses related to the technical aspects of SDF testing, current professional society guidelines, and the literature were used to generate expert recommendations via the Delphi method. Finally, challenges related to SDF that the clinicians encounter in their daily practice were captured.

RESULTS

The survey was completed by 436 reproductive clinicians. Overall, terminal deoxynucleotidyl transferase deoxyuridine triphosphate Nick-End Labeling (TUNEL) is the most commonly used assay chosen by 28.6%, followed by the sperm chromatin structure assay (24.1%), and the sperm chromatin dispersion (19.1%). The choice of the assay was largely influenced by availability (70% of respondents). A threshold of 30% was the most selected cut-off value for elevated SDF by 33.7% of clinicians. Of respondents, 53.6% recommend SDF testing after 3 to 5 days of abstinence. Although 75.3% believe SDF testing can provide an explanation for many unknown causes of infertility, the main limiting factors selected by respondents are a lack of professional society guideline recommendations (62.7%) and an absence of globally accepted references for SDF interpretation (50.3%).

CONCLUSIONS

This study represents the largest global survey on the technical aspects of SDF testing as well as the barriers encountered by clinicians. Unified global recommendations regarding clinician implementation and standard laboratory interpretation of SDF testing are crucial.

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

PURPOSE

Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition.

MATERIALS AND METHODS

An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method.

RESULTS

A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated.

CONCLUSIONS

This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

PURPOSE

Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations.

MATERIALS AND METHODS

Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus.

RESULTS

The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing.

CONCLUSIONS

This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians.

Salvage resection of a large chemorefractory mediastinal germ cell tumor

Immature mediastinal teratomas refractory to chemotherapy are very rare and require management by an aggressive surgical approach. We describe resection of a large mediastinal teratoma in a 23-year-old man, with a satisfactory early result.

Telomerase activity in Kaposi's sarcoma, squamous cell carcinoma, and basal cell carcinoma

Patients with acquired immune deficiency syndrome (AIDS) often develop Kaposi's sarcoma (KS), an unusual skin tumor. The malignant nature of KS has long been disputed. Telomerase activity that maintains telomere length and ensures chromosomal stability, a frequently appearing marker in human malignancies, has been proposed to play a critical role in supporting continued cell growth, hence formation of tumors. We examined telomerase activity in tissue extracts from 22 KS, 10 squamous cell carcinoma (SCC), and 22 basal cell carcinoma (BCC) using the telomeric repeat amplification protocol (TRAP). All of the tumor tissues were previously cryopreserved at -80 degrees C. In this study, all tumor samples tested were positive for telomerase activity. Consistent with the presence of the enzyme activity, the skin tumors had relatively long telomeres. Inhibitors in the tissue extracts of some samples needed to be diluted or extracted by phenol before the enzyme activity was detected in the TRAP assay. All KS as well as two other skin carcinoma samples revealed positive telomerase activity. Our finding supports telomerase's role in tumor cell immortality and suggests the true neoplastic nature of KS.

Nasal tip ulceration from infection and extrusion of a nasal alloplastic implant

Nasal augmentation rhinoplasty is a common cosmetic procedure. Alloplastic or synthetic materials are frequently used with Silastic, the most commonly used type worldwide. In the Orient, this common procedure has a low complication rate. However, infection and extrusion of the implant through the skin may occur and patients may be reluctant to report the augmentation procedure to the dermatologist. Therefore, the dermatologist needs to be highly suspicious and include this complication in the differential of ulcerated nasal tip nodules.

Palisaded angioleiomyoma

BACKGROUND

We report a case of a palisaded angioleiomyoma, a histopathologic variant of angioleiomyoma with prominent Verocay body formation.

RESULTS

A healthy 31-year-old male requested removal of a subcutaneous nodule on the back of his head. The striking Verocay-like body formation of this tumor led to an initial frozen section diagnosis of neurilemoma. On hematoxylin and eosin staining, areas consistent with an angioleiomyoma were found as well. Immunohistochemistry gave positive reactions for actin and desmin, but was negative for S-100.

CONCLUSIONS

To our knowledge this morphologic pattern in an angioleiomyoma has not been previously described. Palisaded angioleiomyoma should be added to the ever-expanding list of tumors that demonstrate nuclear palisades.

Current concepts: the use of immunoperoxidase techniques in mohs micrographic surgery

Mohs micrographic surgery is used for the removal of certain malignant tumors, both ensuring complete excision by histologic examination of margins as well as minimizing normal tissue loss. Recently, several investigators have incorporated the use of immunoperoxidase techniques to aid in the removal of selected high-risk carcinomas, sarcomas, and melanomas. We describe the basic principles of immunoperoxidase and review recent articles in which immunoperoxidase was used as an adjunct to routine hematoxylin-eosin staining in Mohs micrographic surgery. Additionally, we show examples of selected tumors comparing routine hematoxylin-eosin stains and immunoperoxidase. We believe the use of immunoperoxidase can be of significant value in the removal of certain high-risk tumors. In particular, this technique is useful in "unmasking" malignant cells in areas of dense inflammation, identification of some cases of perineural invasion, identification of pagetoid spread in carcinomas and melanomas, and finally in helping to identify subtle margins in dermatofibrosarcoma protuberans.

Immunohistochemical staining for Ber-EP4, p53, proliferating cell nuclear antigen, Ki-67, bcl-2, CD34, and factor XIIIa in nevus sebaceus

Increased expression of p53 has been found in the majority of basal cell carcinomas (BCCs). The pattern and intensity of this staining, as well as staining for proliferation antigens, seems to correlate with behavior of histologic subtypes of BCC. Nevus sebaceus (NS) is considered a hamartoma. Multiple epithelial neoplasms do arise in NS, and, rarely, they show an aggressive biologic behavior. Significant numbers of these neoplasms, however, have areas of basaloid hyperplasia that are often reported as BCC. Although morphologically similar to BCC, the mechanism underlying the development of these areas has not been investigated, so we sought to evaluate the expression of Ber-EP4, p53, proliferating cell nuclear antigen, Ki-67, bcl-2, Factor XIIIa, and CD34 in areas showing basaloid hyperplasia, arising in NS. We performed immunohistochemical stains for Ber-EP4, p53, proliferating cell nuclear antigen, Ki-67, bcl-2, Factor XIIIa, and CD34 on seven cases of NS with areas of basaloid hyperplasia. All of the eight cases of NS showed diffuse positive membrane staining for Ber-EP4 and negative nuclear staining for p53. Proliferating cell nuclear antigen and Ki-67 staining was only slightly increased in the areas of basaloid hyperplasia, compared with the surrounding epidermis and with areas of the epidermis peripheral to the hamartomatous proliferation, and bcl-2 was only focally positive. Factor XIIIa-positive cells and CD34-positive vascular endothelial cells were increased within the subjacent dermis, a pattern suggestive of follicular differentiation. Our findings suggest that even though areas of basaloid hyperplasia in NS are morphologically similar to BCC, they are induced by different stimulatory and molecular mechanisms. These different mechanisms result in expression of immunohistochemical markers more characteristic of benign follicular tumors than of BCC.

Intravascular angioleiomyoma

A 59-year-old man presented with a 6-year history of a 2-cm tender nodule on his left lateral elbow. Excisional biopsy led to the diagnosis of angioleiomyoma. However, unlike typical angioleiomyoma which demonstrate extravascular extension, this lesion demonstrated purely intravascular growth.

Nodular fasciitis: response to intralesional corticosteroids

Nodular fasciitis is one of the more common soft-tissue lesions, frequently presenting as a rapidly enlarging subcutaneous mass on the arm. Management is usually surgical excision; however, large infiltrative lesions may be difficult to manage. We describe a patient in whom intralesional corticosteroid injections provided rapid resolution.

Recognition and management of high-risk cutaneous tumors

The majority of cutaneous malignancies can be treated by the military dermatologist in a clinical setting. Recognition of tumors at high risk for recurrence or metastasis is important for any dermatologist but especially list care. Providing optimal care includes knowledge about which patients should be medavacced to larger medical centers for advanced surgical and medical treatments.

Blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome is a rare autosomal dominant disorder of multiple venous malformations of the skin and gastrointestinal tract. The fragility of the gastrointestinal lesions may lead to significant occult blood loss and subsequent anemia.

Umbilical pilonidal sinus

Although most cases of pilonidal sinus occur in the sacrococcygeal region, umbilical presentations can occur. Due to risk of peritoneal extension of inflammation from this lesion, the umbilical pilonidal sinus should be treated more aggressively than its sacrococcygeal counterpart. Pilonidal sinus should therefore be included in the differential diagnosis of umbilical nodules.

Vesiculobullous reaction to diethyltoluamide revisited

Diethyltoluamide is an effective insect repellent known to cause irritant dermatitis. We describe an interesting case resulting from a unique occupational exposure.

A review of tumor suppressor genes in cutaneous neoplasms with emphasis on cell cycle regulators

Cells normally have five options. These include renewal or proliferation, terminal differentiation, quiescence, senescence, and apoptosis. Many factors interact with cell cycle regulators to direct the cells toward these different options. Tumor suppressor genes play a pivotal role in this process. Alterations in these genes may limit the options that cells have and thus play a significant role in the multistep process of carcinogenesis. We will focus on tumor suppressor genes and especially tumor suppressor genes that interact directly with the cell cycle proteins.

Is CD30 (Ki-1) immunostaining in cutaneous eruptions useful as a marker of Th1 to Th2 cytokine switching and/or as a marker of advanced HIV-1 disease?

CD30 is a member of the tumour necrosis factor/nerve growth factor receptor superfamily, which is expressed on CD4+ and CD8+ T-cell clones which produce T helper (Th) 2-type cytokines. It has been proposed that disease progression in HIV-1 is associated with Th1 to Th2 cytokine switching. In 70 cutaneous biopsies from HIV-1 positive patients in different stages of disease, we performed a battery of immunohistochemical stains. These included antibodies to CD3, UCHL-1, OPD-4, L-26, KP-1 and CD30 (Ki-1). In addition, we used a similar battery of stains on cutaneous biopsies of HIV-1 negative patients with inflammatory dermatoses which are established as Th1 or Th2 dominant, e.g. polar leprosy. CD30+ cells were rarely present in early stages of HIV-1 disease, but commonly present in later stages of disease. However, there were cases of late HIV-1 disease which did not contain CD30+ cells. Increased numbers of CD30+ cells were more commonly seen in later stages of HIV-1 disease. However, the expression of CD30 appeared to be better in predicting other established Th2 cutaneous infiltrates in HIV-1 negative patients than in predicting a Th2 cutaneous cytokine pattern in advanced HIV-1 disease.

Immunohistochemical nuclear staining for p53, PCNA, and Ki-67 in different histologic variants of basal cell carcinoma

BACKGROUND

Increased expression of p53 has been found in the majority of basal cell carcinomas (BCCs); however, UV-light-induced signature mutations are present in only about 50% of cases. Increased nuclear staining with an immunohistochemical marker of proliferation, proliferating cell nuclear antigen (PCNA), has been correlated with aggressive behavior in BCC.

OBJECTIVE

Our purpose was to determine whether there is any relationship between different histologic variants of BCC and their expression of p53, PCNA, and Ki-67.

METHODS

We used immunohistochemical stains for p53, PCNA, and Ki-67, in superficial-multicentric, nodular-noduloulcerative, sclerosing, infiltrative, and metatypical BCC, to determine whether the staining patterns differ in these different histologic variants of BCC.

RESULTS

Superficial-multicentric BCCs were negative for p53 in four of eight tumors. Nodular BCC showed moderately intense p53 nuclear staining with some peripheral accentuation. PCNA nuclear staining was greater than Ki-67, and PCNA-positive cells were fewer than 10% in nodular BCC. Sclerosing and infiltrative BCC showed intense p53 nuclear staining with peripheral accentuation. PCNA nuclear staining was greater than Ki-67, and PCNA-positive cells were greater than 30% in the majority of these tumors. Metatypical BCCs showed diffuse intense p53 staining. PCNA nuclear staining was greater than Ki-67, and PCNA-positive cells were greater than 30% in all tumors studied. When overlying actinic keratoses showed p53 staining, the staining did not necessarily correlate with the intensity or even the presence of positive staining in the subjacent BCC.

CONCLUSION

There are at least four distinctive patterns for staining of p53, PCNA, and Ki-67 that correlate with different histologic variants of BCC.

Ossifying fibromyxoid tumor of soft parts: a case report and review

Ossifying fibromyxoid tumor of soft parts is a recently described, rare but morphologically distinctive tumor of soft tissue, including subcutaneous soft tissue. We report a case of ossifying fibromyxoid tumor of soft parts which occurred in the subcutaneous tissue of a 68-year-old male, and review the clinical, histologic, and immunohistologic features of this tumor. Ossifying fibromyxoid tumor of soft parts tends to occur in the subcutaneous tissue and have been reported from the head and neck, upper and lower extremities, and trunk. Immunohistologic studies have supported a neural origin. While considered benign, local recurrence after excision is common and these tumors should be excised with clear margins to prevent recurrence.

Cutaneous pseudosarcomatous polyp: a histological and immunohistochemical study

Two unusual acquired polypoid skin lesions exhibited prominent histological atypia, but were biologically benign. Both patients were elderly females. The lesions clinically mimicked fibroepithelial polyp or nevus lipomatosus. Both had been present for about 20 years. One lesion was located on the back, the other on the posterior thigh. Each lesion exhibited dilated, hyalinized vessels in the dermis with focal fibrin deposits, myxoid stroma, and a population of bizarre, pleomorphic spindle to stellate cells, some of which were multinucleated. Occasional atypical mitoses were present. One lesion had abundant admixed fat. Immunohistochemical staining was strongly positive only for vimentin. The lesions share features with degenerating angiofibroma and vaginal pseudosarcomatous polyp. As in these lesions, the atypia is most probably reactive and degenerative.

Histologic and immunohistochemical features in biopsy sites in which bovine collagen matrix was used for hemostasis

BACKGROUND

Bovine collagen matrix (Helistat and Helatene), which is used primarily for hemostasis, decreases wound contracture in skin biopsy sites and promotes wound granulation.

OBJECTIVE

Our purpose was to evaluate excision specimens of previous biopsy sites to determine whether there are histologic differences between cases in which bovine collagen matrix was used for hemostasis and those in which it was not used.

METHODS

Thirty-two diagnostic punch biopsies were done with hemostasis obtained with bovine collagen matrix in 24 biopsies and by pressure alone in eight. The biopsy sites were reexcised at various time intervals, and the histologic and immunohistochemical features were evaluated and compared.

RESULTS

In specimens in which collagen matrix was used, migration of stromal and epithelial cells along the bovine collagen matrix was evident by 2 days and had progressed rapidly by 4 days. Around and within the matrix hyaluronic acid increased during the first 8 to 10 days. Initially stromal cells stained with CD34 and reticulum fibers were present at 8 to 10 days. AT 12 to 15 days, factor XIIIa+ stromal cells were present within the matrix, and host collagen fibers were present and well-oriented within the degenerating matrix. Biopsy specimens allowed to heal without the matrix showed a delayed and an uneven increase in hyaluronic acid. Furthermore, the granulation tissue within the dermis showed no organization with a persistent acute inflammatory infiltrate and increased muscle actin-positive stromal cells as scar formation proceeded.

CONCLUSION

Bovine collagen products appear to provide a matrix that promotes thrombosis. The collagen matrix also promotes migration and attachment of stomal and epithelial cells, thereby organizing and accelerating wound healing.

Quality standard for assurance of measles immunity among health care workers. Infectious Diseases Society of America

OBJECTIVE

The objective of this quality standard is to prevent nosocomial transmission of measles by assuring universal measles-mumps-rubella (MMR) vaccination of all health care workers who lack immunity to measles. Although the primary emphasis is on health care workers in hospitals, those at other sites, such as clinics, nursing homes, and schools, are also included. It will be the responsibility of designated individuals at these institutions to implement the standard.

OPTIONS

We considered advocating the use of measles vaccine rather than MMR vaccine but chose the latter because it also protects against mumps and rubella and because it is more readily available.

OUTCOMES

The desired outcome is a reduction in the nosocomial transmission of measles.

EVIDENCE

Although direct comparative studies are lacking, nosocomial outbreaks of measles have been reported (as recently as 1992) in institutions where measles immunization of nonimmune health care workers is not universal, whereas such outbreaks have not been reported in institutions with universal immunization. VALUES AND VALIDATION: We consulted more than 50 infectious-disease experts from the fields of epidemiology, government, medicine, nursing, obstetrics and gynecology, pediatrics, and surgery. In light of disagreement regarding the implementation of the standard, we used group discussions to reach a consensus.

BENEFITS, HARMS, AND COSTS

The consequences of the transmission of measles (and of mumps and rubella) in a health care institution include not only the morbidity and mortality attributable to the disease but also the significant cost of evaluating and containing an outbreak and the serious disruption of regular hospital routines when control measures are instituted. The potential harm to health care workers after the implementation of the standard consists of untoward effects of MMR vaccine, although the reactions of vaccinees should be minimal with adherence to recommended vaccination procedures. Implementation of the standard should entail no expense to health care workers; the precise cost to institutions is unknown, but the expense would be mitigated by the prevention of measles outbreaks.

RECOMMENDATIONS

We recommend MMR vaccination of all health care workers who lack immunity to measles.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.L.B.). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.

Quality standard for the treatment of bacteremia. The Infectious Diseases Society of America

OBJECTIVE

The objective of this quality standard is to optimize the treatment of bacteremia in hospitalized patients by ensuring that the antibiotic given is appropriate in terms of the blood culture susceptibility of the pathogen. Although this standard may appear to be minimal in scope, it is needed because appropriate antimicrobial treatment is not given in 5% to 17% of cases. To implement the standard, physicians, pharmacists, and microbiologists will need to devise a coordinated strategy.

OPTIONS

We considered criteria for appropriate dosing, most cost-effective selection, proper antibiotic levels in serum, least toxicity, narrowest spectrum, specific clinical indications, and optimal duration of treatment. All these criteria were rejected as the basis for the standard because they were too controversial and too difficult to be applied by a nonphysician chart reviewer. In contrast, the selection of an antibiotic to which the pathogen is sensitive is a noncontroversial criterion and easy for a chart reviewer to apply.

OUTCOMES

The standard is designed to reduce the incidence of adverse outcomes of septicemia such as renal failure, prolonged hospitalization, and death.

EVIDENCE

Several well-designed clinical trials without randomization as well as case-controlled studies have confirmed the benefit of using an antibiotic that is appropriate in light of the susceptibility of the isolate in blood culture. Prospective, randomized, placebo-controlled trials are not available.

VALUES

Our premise is that the presence of bacteremia is a risk factor for serious adverse outcomes. We also believe that the administration of antibiotics must always be guided by the susceptibility report for the pathogen(s) obtained from blood cultures. This concern is more critical for pathogens from the blood than for those from most other body sites. We had evidence that susceptibility reports for pathogens from positive blood cultures were not always used properly. We used group discussion to reach a consensus among the members of the Quality Standards Subcommittee.

BENEFITS, HARMS, AND COSTS

Through the implementation of this standard, at least 5% of bacteremias could be treated more appropriately. An unknown number of deaths would likely be prevented, and mortality from bacteremia treated inappropriately would probably be reduced. The primary undesirable feature of the standard is an increased workload of pharmacists and microbiologists.

RECOMMENDATIONS

Treatment of bacteremia with an antibiotic that is appropriate in terms of the pathogen's blood-culture susceptibility is a minimal standard of care for all patients.

VALIDATION

We consulted more than 50 experts in infectious diseases from the fields of medicine, surgery, pediatrics, obstetrics and gynecology, nursing, epidemiology, pharmacology, and government. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists and were tested by one of the members of the Quality Standards Subcommittee.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Diseases Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. This standard is endorsed by the IDSA.

Quality standard for assurance of measles immunity among health care workers. The Infectious Diseases Society of America

OBJECTIVE

The objective of this quality standard is to prevent nosocomial transmission of measles by assuring universal measles-mumps-rubella (MMR) vaccination of all health care workers who lack immunity to measles. Although the primary emphasis is on health care workers in hospitals, those at other sites, such as clinics, nursing homes, and schools, are also included. It will be the responsibility of designated individuals at these institutions to implement the standard.

OPTIONS

We considered advocating the use of measles vaccine rather than MMR but chose the latter because it also protects against mumps and rubella and because it is more readily available.

OUTCOMES

The desired outcome is a reduction in the nosocomial transmission of measles.

EVIDENCE

Although direct comparative studies are lacking, nosocomial outbreaks of measles have been reported (as recently as 1992) in institutions where measles immunization of nonimmune health care workers is not universal, whereas such outbreaks have not been reported in institutions with universal immunization. VALUES AND VALIDATION: We consulted more than 50 infectious-disease experts in epidemiology, government, medicine, nursing, obstetrics and gynecology, pediatrics, and surgery. In light of disagreement regarding the implementation of the standard, we used group discussions to reach a consensus.

BENEFITS, HARMS, AND COSTS

The consequences of the transmission of measles (and of mumps and rubella) in a health care institution include not only the morbidity and mortality attributable to the disease, but also the significant cost of evaluating and containing an outbreak and the serious disruption of regular hospital routines when control measures are instituted. The potential harm to health care workers after the implementation of the standard consists of untoward effects of MMR vaccine, although the reactions of vaccines should be minimal with adherence to recommended vaccination procedures. Implementation of the standard should entail no expense to health care workers; the precise cost to institutions is unknown, but the expense would be mitigated by prevention of measles outbreaks.

RECOMMENDATIONS

We recommend MMR vaccination of all health care workers who lack immunity to measles.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Diseases Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.

Quality standard for the treatment of bacteremia. Infectious Diseases Society of America

OBJECTIVE

The objective of this quality standard is to optimize the treatment of bacteremia in hospitalized patients by ensuring that the antibiotic given is appropriate in terms of the blood culture susceptibility of the pathogen. Although this standard may appear to be minimal in scope, it is needed because appropriate antimicrobial treatment is not given in 5%-17% of cases. To implement the standard, physicians, pharmacists, and microbiologists will need to devise a coordinated strategy.

OPTIONS

We considered criteria for appropriate dosing, most cost-effective selection, proper antibiotic levels in serum, least toxicity, narrowest spectrum, specific clinical indications, and optimal duration of treatment. All these criteria were rejected as the basis for the standard because they were too controversial and too difficult to be applied by a nonphysician chart reviewer. In contrast, the selection of an antibiotic to which the pathogen is sensitive is a noncontroversial criterion that is easy for a chart reviewer to apply.

OUTCOMES

The standard is designed to reduce the incidence of adverse outcomes of septicemia, such as renal failure, prolonged hospitalization, and death.

EVIDENCE

Several well-designed clinical trials without randomization as well as case-controlled studies have confirmed the benefit of using an antibiotic that is appropriate in light of the susceptibility of the isolate in blood culture. Prospective, randomized, placebo-controlled trials are not available.

VALUES

Our premise is that the presence of bacteremia is a risk factor for serious adverse outcomes. We also believe that the administration of antibiotics must always be guided by the susceptibility report for the pathogen(s) obtained from blood cultures. This concern is more critical for pathogens from the blood than for those from most other body sites. We had evidence that susceptibility reports for pathogens from positive blood cultures were not always used properly. We used group discussion to reach a consensus among the members of the Quality Standards Subcommittee.

BENEFITS, HARMS, AND COSTS

Through the implementation of this standard, at least 5% of cases of bacteremia could be treated more appropriately. An unknown number of deaths would likely be prevented, and mortality from bacteremia treated inappropriately would probably be reduced. The primary undesirable feature of the standard is an increased workload for pharmacists and microbiologists.

RECOMMENDATIONS

Treatment of bacteremia with an antibiotic that is appropriate in terms of the pathogen's blood-culture susceptibility is a minimal standard of care for all patients.

VALIDATION

We consulted more than 50 experts in infectious diseases from the fields of medicine, surgery, pediatrics, obstetrics and gynecology, nursing, epidemiology, pharmacology, and government. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists and were tested by one of the members of the Quality Standards Subcommittee.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.L.B.). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.

Quality standard for antimicrobial prophylaxis in surgical procedures. The Infectious Diseases Society of America

OBJECTIVE

The objectives of this quality standard are 1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and 2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice.

OPTIONS

We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis.

OUTCOMES

The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help.

EVIDENCE

Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these--rather than an exhaustive list of original references--are cited.

VALUES

We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighed against the cost and potential morbidity associated with excessive use of antimicrobial agents.

BENEFITS, HARMS, AND COSTS

More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics.

RECOMMENDATIONS

All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended.

VALIDATION

More than 50 experts in infectious disease and 10 experts in surgical infectious disease and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Disease Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Disease Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Contr

Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America

OBJECTIVE

The objectives of this quality standard are (1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and (2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice.

OPTIONS

We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis.

OUTCOMES

The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection in conjunction with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help.

EVIDENCE

Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these--rather than an exhaustive list of original references--are cited.

VALUES

We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighted against the cost and potential morbidity associated with excessive use of antimicrobial agents.

BENEFITS, HARMS, AND COSTS

More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics.

RECOMMENDATIONS

All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended.

VALIDATION

More than 50 experts in infectious diseases and 10 experts in surgical infectious diseases and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.

Spindle cell neoplasms coexpressing cytokeratin and vimentin (metaplastic squamous cell carcinoma)

Spindle cell squamous carcinoma (SCSC) and atypical fibroxanthoma (AFX) are both spindle cell neoplasms (SCN) that usually arise in areas of solar or ionizing radiation of elderly patients. Both lesions have a similar biologic behavior. In addition, the morphologic and ultrastructural similarities found in AFX and the spindle cell component of SCSC, have led some investigators to conclude that these tumors have a similar cell of origin. We studied 15 SCNs with no evidence of epithelial origin and no morphologic epithelial component, that showed immunohistochemical and ultrastructural evidence that would support metaplastic changes of a squamous cell carcinoma to a neoplasm with mesenchymal characteristics.

HMB-45 staining in benign and malignant melanocytic lesions. A reflection of cellular activation

The antibody HMB-45 used as an immunohistochemical reagent has often been labeled as a marker for melanoma, even though some benign lesions have been noted to show positive staining reactions with this reagent. Biopsy specimens from 225 benign and malignant melanocytic lesions were examined after immunoperoxidase staining for S-100 protein and HMB-45. The lesions studied included common acquired nevi, spindle cell and epithelioid cell nevi (Spitz nevi), cellular blue nevi, deep penetrating nevi, congenital nevi, nevi from hormonally reactive areas (genital), malignant melanoma, and desmoplastic malignant melanoma. A positive reaction for HMB-45 was seen in the dermal component in a high percentage of each of these types of lesions except for the common acquired nevi and the desmoplastic malignant melanomas that were uniformly negative for HMB-45 in the dermal component. HMB-45 correlates with melanosome production and thus a melanocytic origin of HMB-45-positive cells. HMB-45 may correlate best with factors that stimulate melanocytic proliferation and production of melanosomes.

Papular eruption of human immunodeficiency virus disease. A review of the clinical, histologic, and immunohistochemical findings in 48 cases. The Military Medical Consortium for Applied Retroviral Research

The papular eruption (PE) associated with human immunodeficiency virus infection, although described as a distinctive clinicopathologic entity, has shown a wide range of histologic findings ranging from eosinophilic folliculitis to granuloma annulare. We examined 48 cases of the PE in order to define the histologic spectrum of these lesions, and to correlate these findings with clinical presentations. The most distinctive clinical features are the frequency of these lesions in this population, the large number of lesions, pruritus, and the chronic nature of the lesions. Histologically, the distinctive features are the prominent perivascular factor XIIIa-positive dermal dendritic cells, atypical vascular proliferation, and dermal fibrosis sometimes associated with diffuse necrobiotic changes.

Majocchi's granuloma

Majocchi's granuloma (nodular granulomatous perifolliculitis) is a well recognized but uncommon infection of dermal and subcutaneous tissue by fungal organisms (dermatophytes) usually limited to the superficial epidermis. The organism usually associated with Majocchi's granuloma is Trichophyton rubrum; however, other dermatophytes including T. mentagrophytes (variety granulosum), T. epilans, T. violaceum, M. audouinii, M. gypseum, M. ferrugineum, and M. canis may be the causative agent. A review of 17 cases revealed not only the variety of possible organisms but also a marked variation from the usual hyphal forms. The morphologic variations including yeast forms, bizarre hyphae, mucinous coatings, and the Splendore-Hoeppeli phenomenon may be factors which allow the dermatophytes to persist and grow in an abnormal location. Also, there is evidence that Majocchi's granuloma may occur in two distinct groups of patients.

Spindle cell and epithelioid cell nevi with atypia and metastasis (malignant Spitz nevus)

We report on the clinical and pathologic features of 32 lesions diagnosed as malignant spindle cell and epithelioid cell nevus (S&E nevus). Because of the clinical or initial histopathologic diagnosis of malignant melanoma, six patients had lymph node dissection. Three of these patients also had an enlarged lymph node. In all six cases, metastatic spindle or epithelioid cells were found in at least one of the resected lymph nodes. Of the 30 patients with follow-up information, including all six patients with lymph node metastases, all are alive and well. No recurrences or further metastases have been found. On histopathologic reevaluation, all the lesions had features of S&E nevi. Study of these cases suggests that although some lesions with features of S&E nevi may involve local lymph nodes, widespread metastases do not result.

Cutaneous myofibroma

The clinical and pathologic features of an acquired skin tumor, which histologically is identical to infantile myofibromatosis, are presented. Thirty-four cases were studied, 26 of which were in patients over 14 yr of age. The median age was 36. None of the lesions was associated with recurrence after surgery, and metastases were not observed. Microscopically, the lesions were relatively well circumscribed and had a characteristic biphasic pattern which centrally showed features of vascular tumors, including hemangiopericytoma or glomus tumor. Ultrastructural examination identified cells with features of myofibroblasts, glomus cells, and pericytes. Immunoreactivity for muscle actin was strongly and diffusely positive in all tumors. The clinical significance of this entity lies primarily in its recognition as a distinctive benign neoplasm, most probably of vascular origin. The occurrence of this lesion is not limited to children; it may be an acquired lesion, and it may be found in the skin as well as soft tissue.