Clinical outcomes and cost-effectiveness of an externally applied electroceutical device in managing venous leg ulcers in clinical practice in the UK.

OBJECTIVE: To estimate the cost-effectiveness of treating patients with a venous leg ulcer (VLU) with an externally applied electroceutical (EAE) device, plus dressings and compression bandaging or continuing with their previous care plan, from the perspective of the National Health Service (NHS) in the UK. METHOD: This was a prospective, single-arm, non-blinded, clinical and economic evaluation of EAE therapy performed in 2013/14. Patients' VLUs were treated with six active units of EAE therapy (each unit for two days) plus dressings and compression bandaging over a period of 12 days. Afterwards, patients were managed with a combination of dressings and bandages. Each patient acted as their own control so that clinical outcomes, resource use and costs associated with the wound over 12 months before the start of EAE therapy were retrospectively compared with the first 12 months after the start of treatment. The relative cost-effectiveness of EAE therapy was estimated at 2013/14 prices. RESULTS: Within 12 months of starting EAE therapy 77% of all wounds healed and the other 23% improved. This difference in effectiveness between the 12-months period before and after EAE therapy was estimated to yield a 12% improvement in health gain of 0.09 QALYs (p<0.01), a 34% reduction in the requirement for nurse visits (from a mean 50.7 to 33.3 visits per patient) and a 26% reduction in the number of dressings. This resulted in an 11% reduction in the NHS cost of VLU management over 12 months after the start of treatment when compared with the previous 12 months (from £1,981 to £1,754 per patient). Hence, use of EAE therapy was found to be a dominant treatment (i.e. improved outcome for less cost). CONCLUSION: Within the study's limitations, use of the EAE device potentially affords the NHS a cost-effective treatment for managing VLUs when compared with patients remaining on their previous care plan.

Subcapsular liver hematoma causing cardiac tamponade in HELLP syndrome.

HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome is an obstetric complication with heterogeneous presentation, multisystem involvement and variable prognosis, but which usually resolves after delivery. We report a case of HELLP syndrome with subcapsular hematoma of the liver causing extrapericardial cardiac tamponade. The subcapsular hematoma and cardiac tamponade were managed conservatively.

Telecytology of fine-needle aspiration biopsies of the pancreas: a study of well-differentiated adenocarcinoma and chronic pancreatitis with atypical epithelial repair changes.

Four experienced cytopathologists provided consultations using telecytology and routine microscopy. Twenty-seven fine-needle aspiration biopsies (FNABs) from patients with chronic pancreatitis with atypical epithelial repair changes (n = 9) and pancreatic low-grade adenocarcinomas (LG-AC) (n = 18) were studied. False-positive and false-negative diagnostic rates were 19.4% and 12.5% by microscopy and 11.1% and 2.8% by telecytology. Comparisons of agreements between the correct diagnoses and consultations rendered by the two methods and among the diagnoses rendered on the same cases by the two modalities yielded kappa coefficients ranging from 0.444-1.000. Telecytology yielded slightly better kappa coefficients than microscopy. This method, which to our knowledge has not been previously applied to pancreatic FNAB, provides a potentially useful consultative tool for the interpretation of these difficult specimens. The diagnosis of FNAB from patients with chronic pancreatitis and LG-AC is difficult even for experienced consultants, as underscored by the considerable intraobserver and interobserver variability encountered in this study.

Follicular lesions of thyroid: a 5-year fine-needle aspiration experience.

BACKGROUND: Fine-needle aspiration (FNA) of the thyroid is of limited value in discriminating between nonneoplastic and neoplastic lesions in approximately 5-29% of patients. Indeterminate lesions are due primarily to the overlapping cytologic features found in follicular lesions. In this report, the authors describe their experience with FNA biopsy of the thyroid, concentrating on the analysis of those aspirates placed in the follicular lesion category. METHODS: A blinded, retrospective analysis of 92 patients who underwent FNA and were diagnosed with follicular lesions was performed by three of the authors (T.S.G., B.D.F., and M.O.) at a multihead microscope. A worksheet assessing a variety of cytologic and architectural features was filled out for each FNA patient. The reviewers then reached a consensus diagnosis. RESULTS: The reviewers agreed with the reported FNA diagnosis of follicular lesion in 63 of the 92 patients studied. No distinguishing cytologic features predictive of the histologic outcome were found in any of these 63 patients. Seven patients were judged by the reviewers to have insufficient cells for evaluation. In the remaining 22 patients, the reviewers' diagnoses were in agreement with the histologic diagnoses in 17 patients. CONCLUSIONS. The authors found that there is a gray area in the cytologic diagnosis of patients with thyroid lesions by FNA due to inherent similarities at the light microscopic level. However, increased specificity may be achieved by careful attention to cytologic features and morphologic detail. Skillful application of FNA techniques, with the recovery of an adequate sample, will further decrease both interpretive errors and the number of patients diagnosed with "follicular lesions."

Cardiac arrest as a possible sequela of critical airway management and intubation.

Immediate cardiac arrest may occur as a result of the physiological consequences of critical airway management, which may include one or all of the following: (1) sedation and/or paralysis, (2) tracheal intubation, and (3) positive pressure ventilation. Two patients are reported, both with myocarditis, who developed cardiac arrest within minutes of simple intubations. Their arrests were not related to technical difficulties of critical airway management. Any disease process that creates a preload-dependent cardiovascular system also creates a situation wherein critical airway management may cause cardiac decompensation. All medications administered to sedate patients and facilitate intubation, as well as mechanical ventilation itself, can cause a decrease in preload. This may be a significant mechanism through which immediate decompensation occurs. Potential conditions that cause preload-dependent cardiovascular systems, as well as alternate therapeutic considerations, are outlined. In these patients intubations should not be delayed, but should be done with extreme caution in anticipation of possible cardiac arrest.

Core needle biopsy. A useful adjunct to fine-needle aspiration in select patients with palpable breast lesions.

BACKGROUND: Fine-needle aspiration (FNA) biopsy is an established, highly accurate method for diagnosing palpable breast lesions. However, in some cases a definitive diagnosis cannot be made by FNA alone, either due to the inherent limitations of cytology itself or the ability to obtain adequate material for diagnosis. This study evaluated the usefulness of a supplemental core needle biopsy performed by a cytopathologist in conjunction with an FNA biopsy in select patients. METHODS: Twelve patients with palpable breast lesions underwent the combined FNA/core needle biopsy procedure during the study period from March 1995 through March 1996. All 12 patients first had an FNA aspiration that was preliminarily evaluated by the FNA cytopathologist while the patient was at the clinic. If the cytopathologist was unable to render a definitive diagnosis of the lesion type or if a repeat FNA was requested by the clinician because of a previous non-definitive FNA result, a core needle biopsy was then performed. RESULTS: When the FNA and the core needle biopsies were reviewed together, a correct definitive diagnosis was made in 10 of the 12 cases. In contrast, review of the FNA material alone yielded a correct definitive diagnosis in only five cases. CONCLUSIONS: The supplemental core needle biopsy was found to be especially useful in: 1) providing a definitive diagnosis of infiltrating carcinoma in those cases in which the FNA diagnosis was reported as "suspicious;" 2) providing ample tissue for ancillary studies; and 3) differentiating a phyllodes tumor from a fibroadenoma. It is the authors' opinion that the FNA cytopathologist is the physician best qualified to perform the combined FNA/core needle biopsy procedure should he/she deem it necessary.

Local anesthesia for fine-needle aspiration biopsy of palpable breast masses: the effectiveness of a jet injection system.

To determine the effectiveness of the Biojector 2000 needle-free lidocaine injection system in achieving satisfactory local anesthesia for fine-needle aspiration (FNA) of palpable breast lesions, we studied 29 female patients. Each patient served as her own control and had two FNA biopsies performed on the lesion. The first FNA biopsy was preceded by either no anesthesia, ethyl chloride cold spray, or traditional needle lidocaine injection. The second FNA was preceded by the Biojector 2000. Twenty-four patients (83%) reported that they preferred the Biojector 2000 over either no anesthesia, ethyl chloride spray, or needle and syringe lidocaine injection. The Biojector 2000 needle-free injection system is an effective and useful method of local anesthesia for FNA of palpable breast masses.

Fine needle aspiration cytology of malacoplakia of the thyroid. A case report.

BACKGROUND: Malacoplakia was first described by Michaelis and Gutmann in 1902 and further characterized by Von Hansemann, who coined the term malacoplakia to describe the soft, yellow-tan, raised plaques he encountered in a case involving the urinary bladder.11 CASE: Fine needle aspiration cytology of a case of malacoplakia of the thyroid gland was performed on a 60-year-old woman. Fine needle aspiration demonstrated histiocytes with abundant granular cytoplasm that were eosinophilic with hematoxylin-eosin stain. Many of the cells contained numerous round, regular-appearing inclusions, which ranged in size from 4 to 10 microns in diameter. Many of these inclusions demonstrated the characteristic concentric appearance of Michaelis-Gutmann bodies. The inclusions were strongly positive for periodic acid-Schiff stain and stained weakly with Von Kossa stain. Clinically and radiologically the lesion mimicked a malignant neoplasm by virtue of its large size and destruction of adjacent cervical vertebrae. The diagnosis was ascertained only after surgical excision. CONCLUSION: This is the first report of fine needle aspiration cytology of malacoplakia of the thyroid. The case demonstrates how difficult it may be to diagnose this rare entity, regardless of its characteristic features. It also underscores the point that malacoplakia may occur anywhere in the body and should always be considered when round, concentric intracytoplasmic inclusions are seen within histiocytes.

Helminths of the black bear, Ursus americanus, in New Brunswick.

Between May 1989 and October 1991, 544 black bears Ursus americanus were collected in New Brunswick and examined for Trichinella spiralis larvae. In addition, 110 of these bears were examined for filarial nematodes, and the entire intestinal tracts of 12 bears were examined for intestinal helminths. Four species of helminths were identified from these bears, including Trichinella spiralis, Dirofilaria ursi, Baylisascaris transfuga, and Taenia krabbei. This represents the first documentation of T. spiralis in Maritime Canada and extends eastward the range of T. krabbei.

Pneumocystis carinii thyroiditis. Report of three cases and review of the literature.

Pneumocystis carinii infection of the thyroid gland has previously been described in only four living patients with acquired immunodeficiency syndrome, three of whom had been receiving inhaled pentamidine prophylaxis against P carinii pneumonia. We treated three additional patients with P carinii thyroid involvement, all of whom were receiving aerosolized pentamidine. Two of our patients presented with clinical features suggestive of subacute granulomatous thyroiditis. The diagnosis of P carinii in our patients, as well as in the previously described patients, was established by thyroid fine-needle aspiration and Gomori's silver methenamine stains. The recent emergence of P carinii infection of the thyroid gland is likely related to the use of inhaled pentamidine prophylaxis, which appears to predispose to the development of extrapulmonary pneumocystosis. Clinicians need to be aware of the possibility of P carinii thyroiditis and should use aspiration and Gomori's methenamine silver staining in studying patients with the acquired immunodeficiency syndrome who have a painful (or other unexplained) thyroid mass so as to be able to initiate prompt and appropriate therapy.