Management of metastatic disease of other bones.

Metastases to the scapula and distal sites on the upper and lower extremities are infrequent. Although these metastases tend to occur in patients with advanced disease, a distal metastasis is occasionally the sole metastatic location. Distal metastases do not pose an immediate threat to a patient's life; however, they may cause significant pain and disability. Appropriate management can considerably enhance function, quality of life, and, occasionally, survival. Seven cases of distal metastasis are presented in this article with discussion of operative and nonoperative approaches to management.

Marjolin ulcers: secondary carcinomas in chronic wounds.

Marjolin ulcers are malignant tumors arising in chronic wounds. Strictly defined, they include carcinomas that transform from the chronic open wounds of pressure sores or burn scars. They behave aggressively and have a propensity for local recurrence and lymph node metastases. A retrospective study was done at a single institution identifying six individuals who had chronic wound ulcers that underwent malignant transformation into a carcinoma. Sinus tract degeneration in osteomyelitis was not included. The average latency time between ulcer formation and documentation of a malignancy was 30 years. All wounds were about the pelvis or flank. Major oncologic surgical procedures were done in an attempt to eradicate the cancer. High-grade tumors had positive lymph node metastases, portending a grave prognosis. All four individuals with nodal metastases eventually died of systemic disease. Early recognition and proper staging offers the best chance for cure.

Use of physical restraints in a nineteenth-century state hospital.

Archival records of physical restraint usage at the St. Louis Insane Asylum (now the St. Louis State Hospital) were examined from January through June 1885. The demographics of restrained patients were determined from archival admission records. In the 6-month (181-day) sample period, 53 patients accounted for the total of 2,537 incidents of night restraint. Sixty percent of the restrained patients were women and 53% were immigrants. By far most (98.5%) of the incidents of restraint were brought on by violent behaviour (fighting, destroying property, injury to self) while most incidents in modern hospitals result from verbal threats or shouting. When these records were combined with day restraint records from the same 6-month period in 1889, an overall incidence rate of 9.7% per month was estimated. This is similar to rates reported from modern psychiatric hospitals. Possible reasons for the discrepancies and similarities in the types of patients restrained and the activities which brought on restraint in the nineteenth and twentieth centuries are discussed.

Differential antigen preservation during tissue autolysis.

Immediate fixation or snap freezing of tissue is ordinarily done to maximize antigen preservation for immunocytochemistry; however, delay in tissue allocation or spontaneous lymph node infarction can render tissue suboptimal for immunostaining. To test the effects of tissue autolysis/necrosis on the preservation of various lymphoid, epithelial, and mesenchymal markers, two lymph nodes (one with reactive lymphoid hyperplasia and one with metastatic ductal breast carcinoma) were evaluated for immunocytochemically demonstrated antigen preservation at 0-, 4-, 8-, 12-, 24-, 48-, and 72-hour intervals of autolysis at 37 degrees C. All specimens were stained by frozen section and formalin-fixed paraffin section immunocytochemical reactions with antibodies against CLA (CD45), UCHL-1 (CD45RO), L-26, kappa, lambda, anti-epithelial keratins (AE-1 and AE-3), epithelial membrane antigen, and vimentin. Frozen sections were additionally stained for Leu-1 (CD5), Leu-2a (CD8), Leu-3a+b (CD4), Leu-4 (CD3), and Leu-14 (CD22). The most resilient lymphoid antigen preservation was observed with CLA and UCHL-1, both exhibiting immunoreactivity at 72 hours in both frozen and fixed preparations. L-26 showed similar reactivity in frozen sections, but detectable antigen was observed only up to 24 hours in formalin-fixed tissue. Leu-2a proved to be the most labile antigen, persisting for only 12 hours in frozen sections. The epithelial markers epithelial membrane antigen and AE-1 exhibited excellent antigenic preservation in both frozen and fixed preparations; AE-3 persisted well in frozen section but was not demonstrated in fixed tissue. Vimentin immunoreactivity was vastly superior in frozen, as compared with fixed, tissue sections. Most antigens showed remarkable preservation despite morphologic degradation; however, differential antigenic resilience was demonstrated. Knowledge of this variation in antigen decay is critical for evaluation of immunoperoxidase phenotypic studies of autolyzed or necrotic tissue.