Evaluating the cost and efficacy of leg ulcer care provided in two large UK health authorities.

OBJECTIVE: This prospective study investigated the cost and efficacy of leg ulcer care over a three-month period during 1993, 1994 and 1999. It compared two health authorities (Stockport and Trafford) whose populations totalled 540,000. METHOD: All patients with active leg ulcers were invited to community leg ulcer clinics offering research-based innovations in care. Patients without significant arterial disease (ankle brachial pressure index less than 0.8) were treated with multilayer compression bandaging. RESULTS: The 42% healing rate reported in the original Stockport study was maintained at 40% in 1999, although the 65% healing rate achieved by the leg ulcer clinics in 1993 was not replicated, with rates falling to 46%. Following the opening of community leg ulcer clinics in Trafford, healing rates rose from 20% to 42%. The annual expenditure on leg ulcer care in Stockport increased from 65,545.56 Pounds to 83,344.30 Pounds, while in Trafford the cost of care dropped from 151,375.35 Pounds to 53,176.76 Pounds between 1994 and 1999. CONCLUSION: This study suggests that reductions in costs and improvements in healing rates can be sustained in a mature community leg ulcer clinic programme staffed by specialist leg ulcer nurses.

Tumors of the autonomic nervous system.

Tumors of the adrenal medulla, extra-adrenal paraganglia of the sympathetic neuroendocrine system, and paraganglia of the head and neck are derivedfrom neural crest cells. These tumors manifest as growing masses and can cause endocrine dysfunction due to unregulated secretion of hormones. Tumors arising in the adrenal medulla (pheochromocytomas) and extraadrenal paraganglia (paragangliomas) usually present in adulthood. Their diagnosis is based on histologic features, immunohistochemical stains, and electron microscopy. These features are reviewed, as are familial syndromes and their associated gene mutations.

Clonal telomeric fusions and chromosome instability in a subcutaneous sacrococcygeal myxopapillary ependymoma.

Subcutaneous sacrococcygeal myxopapillary ependymoma (SSME) is a very rare neurologic tumor with no demonstrable connection to the spinal column. Little is known of its etiology, clinical characteristics, or cytogenetics. Giemsa-band analysis revealed a stemline karyotype showing 62 chromosomes. Sidelines within the tumor showed clonal telomeric fusions resulting in dicentric chromosomes involving the fusion of numerous chromosomes. Recurrent telomeric fusions resulted in the progressive deletion of chromosome bands 11q25 and 11q23 and subsequently the entire long arm. This is the first case of a SSME to show clonal cytogenetic aberrations. However, of greater interest is the demonstration of the clonal progression of telomeric fusions resulting in dicentric chromosomes and the subsequent loss of chromosome arms. The observation of clonal telomeric breakage/fusion cycles as progenitor lesions to subsequent deletions provides evidence for telomeric association as an intermediate step in the progression of chromosomal instability.

Management practice at leg ulcer clinics.

These three papers, presented at a Journal of Wound Care master class, describe procedures used at specialist clinics for the care of patients with leg ulcers.

Monitoring wound healing by odour.

A pilot study using electronic aroma detection was performed over a six-month period to assess the aroma of chronic non-healing venous leg ulcers and the effect of appropriate antibiotic therapy on modification of the aroma. Deep infection with pathogenic organisms was found on biopsy culture in 13 out of 15 patients. Odour analysis was performed at weekly intervals on the ulcer dressings using an AromaScan instrument. Data points on the aroma maps moved from their pre-treatment presentation. Alterations in aroma data correlated well with the progress of the ulcers. Aroma analysis is shown to be a potential tool in monitoring the progress towards healing of chronic venous ulcers.

Single-layer and multilayer bandaging in the treatment of venous leg ulcers.

This study compares levels of compression achieved in the application of both multilayer compression bandage systems and single-layer bandages by practitioners who are experienced with levels achieved by those who are inexperienced. Nineteen practitioners experienced in compression bandaging (13 nurses, six doctors) and 18 inexperienced (12 nurses, six doctors) participated in the study. Both experienced and inexperienced practitioners achieved a pressure of 40 mmHg more consistently when applying multilayer compression bandage systems than in the application of single-layer bandages. Compression bandaging experience does not result in significantly better sub-bandage pressure when using a multilayer system. Inexperienced practitioners are more likely to apply dangerously high levels of pressure with single-layer bandages than with a multilayer system. Single-layer compression bandages should be applied only by those health-care professionals with extensive experience of applying compression bandages.

Role of immunocytochemistry, electron microscopy, and DNA analysis in fine-needle aspiration biopsy diagnosis of Wilms' tumor.

We reviewed the cytologic features and results of ancillary studies in eight fine-needle aspiration biopsies (FNAB) performed by posterior approach in 8 patients with unresectable Wilms' tumor (WT). Chemotherapy was given following the FNAB diagnosis of WT, which was confirmed subsequently by histologic examination of surgically resected specimens. Indications for FNAB included: unresectable tumor, bilateral disease, initial presentation with metastatic disease, uncertainty regarding tumor site, and documentation of recurrence. Cytologic examination revealed blastemal cells (8/8 aspirates), spindle cells (3/8 aspirates), and epithelial differentiation or tubules (3/8 aspirates). There was no cytologic evidence of anaplasia in any of the cases. Immunocytochemical studies on cell blocks and/or smears showed cytokeratin positivity in 5/8 and vimentin positivity in 5/5 of the aspirates in which these studies were performed. Focal positivity for neuron-specific enolase (NSE) was seen in 3/3 aspirates. Stains for actin and leukocyte-common antigen were negative (0/3 and 0/2 aspirates, respectively). DNA ploidy analysis of the aspiration material by flow cytometry revealed near-diploid populations in three aspirates. Electron microscopic findings helpful for diagnosis included: cell junctions, microvilli, flocculent basement membrane-like material, cilia, autophagolysosomes, and lack of neuroectodermal differentiation. Diagnostic morphologic pitfalls for an incorrect diagnosis of neuroblastoma included nuclear molding (all aspirates), pseudorosette formation (one aspirate), and focal NSE positivity (3/3 aspirates). None of the tumors showed anaplasia on histologic examination. Cytologic recognition of the triphasic cellular components of WT (blastemal cells, spindle cells, and epithelial cells) can be helpful for a correct diagnosis; however, in 5/8 aspirates in this study, only the blastemal component was present. In these cases, immunocytochemical stains and electron microscopy proved useful in arriving at a correct FNAB diagnosis of WT. However, NSE positivity can be a pitfall for a diagnosis of neuroblastoma if the radiologic, clinical, and other cytologic features are not clearly delineated. Presence of cytokeratin and vimentin positivity would be helpful in the diagnosis of WT in such instances.

Fine-needle aspiration of chondroblastic osteosarcoma of the skull: report of a case in an 11-year-old girl.

We describe an unusual case of chondroblastic osteosarcoma of the skull in an 11-yr-old girl in whom a preoperative diagnosis was made by fine-needle aspiration (FNA) biopsy, followed by histologic confirmation of tissue biopsy and the surgically resected specimen. FNA cytology revealed pleomorphic oval cells with prominent nucleoli along with spindle cells, tumor giant cells, and a chondromyxoid background. The cell block of the aspirated material showed osteoid associated with the malignant cells. Immunocytochemical stains revealed S-100 and vimentin positivity; actin, myoglobin, and cytokeratin stains were negative. Electron microscopy revealed neoplastic cells with chondrocytic differentiation. This case demonstrates the value of FNA biopsy combined with immunocytochemical and ultrastructural studies performed on the aspirated material in diagnosing osteosarcoma from an unusual location such as the base of the skull.

Quantitative DNA analysis of fresh solid tumors by flow and image cytometric methods: a comparison using the Roche Pathology Workstation Image Analyzer.

The clinical utility of DNA ploidy and cell cycle parameters as prognostic indicators has been demonstrated for selected malignant tumors. Previous quantitative DNA analysis studies have used various tumor sample preparation methods and analyzers. We undertook a pilot study to compare the results of DNA analysis of fresh solid tumors by flow cytometry with the new Roche Pathology Workstation Image Analyzer. Flow cytometric DNA analysis was done on cell suspensions of fine needle aspirates from fresh tumor specimens and analyzed for ploidy and cell cycle statistics with a Becton-Dickinson FACScan Analyzer, using a rectangular model. Small aliquots from these same aspirates were prepared as direct cytologic smears and Feulgen stained for DNA analysis with the Roche Image Analyzer. Additional smears were stained with Diff-Quik for morphologic correlation with DNA histograms. The study group consisted of 40 malignant neoplasms. There was a high correlation between the flow and image DNA indices (R = 0.93, slope = 1.0036, P < 0.001) but a weaker relationship between the flow and image estimated S-phase fractions (R = 0.57, slope = 0.5401, P < 0.01). DNA ploidy categorization for the two methods was concordant in 30 (75%) cases, discordant in seven (17.5%) cases, and equivocal in three (7.5%) cases. In our experience, quantitative DNA analysis of fresh tumor aspirates by flow and image cytometric methods yielded comparable and/or complementary results, with each method having certain advantages and disadvantages. Proposed reasons for false and true discordances and an approach for evaluation are discussed.

Transient hyperglycemia during abdominal aortic surgery.

A 64-year-old man undergoing abdominal aortic aneurysm repair with no history of diabetes mellitus had an episode of marked hyperglycemia during surgery. The peak concentration of glucose in plasma was 43.2 mmol/L. This hyperglycemia responded immediately to administration of 30 units of regular insulin. Factors involved in the hyperglycemia included surgical stress, multiple medications, and the anesthetic used (isoflurane), but do not fully account for the magnitude of the increase in glucose. The data suggest that the patient may have had an underlying insulin deficiency, which was unmasked by the stress of surgery.