Nonsecretory multiple myeloma in a 26-year-old man with acquired immunodeficiency syndrome, presenting with multiple extramedullary plasmacytomas and osteolytic bone disease.

High grade B-cell lymphoma and leukemia have been well described in patients with the acquired immunodeficiency syndrome (AIDS). Malignant transformation of more differentiated lymphoid cells has not been well described in these patients. We report a 26-year-old man with AIDS-associated multiple myeloma, who had a highly unusual presentation and clinical course. A review of the literature indicates that monoclonal gammopathy in patients seropositive for the human immunodeficiency virus (HIV) is common. Multiple myeloma and extramedullary plasmacytomas, diseases that are extraordinarily rare in young persons, are now being reported in patients with AIDS and should be added to the list of neoplastic diseases now associated with HIV infection.

Smoldering HTLV-associated T-cell leukemia.

Human T-cell lymphotropic virus type I-associated adult T-cell leukemia/lymphoma is a newly described clinical entity characterized by the abrupt onset of cutaneous manifestations, hypercalcemia, lymphadenopathy, and pleomorphic lobulated T cells found in the peripheral blood. The vast majority of cases reported in the United States have emphasized the rapid onset and fulminant course of the disease, which is unresponsive to conventional chemotherapeutic regimens. A smoldering form of this disease characterized by long duration of skin involvement has recently been described primarily in Japan. We describe a case of "smoldering" human T-cell lymphotropic virus type I disease in a patient from the United States.

The laboratory test justified. An effective means to reduce routine laboratory testing.

In an attempt to reduce clinical laboratory testing, a strategy was designed for a clinician-oriented restriction policy imposed on the laboratory test-ordering mechanism. The program examined the requirement of a written justification to accompany test requests. Directed justification, where specified conditions were required for test performance, was applied to the prothrombin and partial thromboplastin times and resulted in a mean reduction of 44% (P less than 0.001) in these tests; a nonspecific justification directive for leukocyte differentials, where any clinical condition listed generated the test, reduced differentials 35% (P less than 0.001). The justification policy then was extended more broadly and applied on a trial basis to general medical wards. Although no review was made on validity of listed test rationalizations, the justification process alone significantly reduced four common laboratory tests from 28% (BUN/creatinine) to 45% (electrolytes); significant reductions were not seen in less frequently ordered tests. The authors concluded that the most common clinical laboratory tests may be reduced by demanding that the clinician perform a clerical justification when requesting these tests. This mild restrictive policy in the ordering process allows the clinician to maintain responsibility over laboratory testing, while effectively reducing laboratory volume.

The athlete's mouthpiece.

This article points out several needs. The first is the need to have research on the design of the athlete's mouthpiece. This study demonstrates that the most frequently used athlete's mouthpieces alter the relationship of the lower jaw to the upper jaw. Second, this article expresses the need for design change in the present mouthpiece. It shows statistics that indicate a design change could be very advantageous to the athlete's performance. A strong case is made for viewing the mouthpiece as an aid as well as a protector.