CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia.

BACKGROUND: Dementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated. METHODS: A randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer. Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted. DISCUSSION: CELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention. TRIAL REGISTRATION: ACTRN12622000611729 registered 22/04/2022.

Rare oesophageal tumours: experience of one centre.

AIM OF STUDY: The aim of this study is to compare demographic and clinical data as well as applied treatment methods in patients with rare benign and malignant tumours of the oesophagus. METHODS: Eight hundred and thirty patients with oesophageal cancer were treated in the Department of Surgical Oncology in 1960-2005. In 15 cases (1.8 %), rare benign (n = 11) or malignant (n = 4) types of tumours were diagnosed. Patients with rare oesophageal tumours were included in the study, excluding those with squamous cell carcinoma or adenocarcinoma of the oesophagus. Demographic and clinical data were analysed from each patient qualified for the study. Oesophageal X-rays with contrast medium, gastroscopies and, as of 1991, computed tomographies (CTs) were performed as preoperative diagnostic procedures. RESULTS: In the postoperative histopathological examinations, all benign tumours proved to be oesophageal leiomyomas. Four different malignant tumours-a sarcoma, a neuroendocrine carcinoma, a lymphoma, and a squamous cell carcinoma in a patient with Crohn's disease, were diagnosed in the other four patients. In a group of 15 patients with rare oesophageal tumours there were ten (66.7 %) males and five (33.3 %) females. In patients with benign and malignant tumours, the mean age for the benign group reached 44 years (range: 26-75 years old) and 54.7 years (range: 47-59 years old) for the malignant group. In the preoperative period, symptoms such as swallowing disturbances, retrosternal pains, and epigastric pains were observed. Dysphagia was the leading symptom in patients with benign and malignant oesophageal tumours. Out of 15 patients, surgical procedure was carried out in 13 cases with rare oesophageal tumours. In the group of 11 patients, with benign tumours, ten (90.2 %) warranted surgical treatment. Three patients (75 %) with malignant oesophageal tumours underwent an extensive Akiyama procedure of oesophageal resection. Chemo- and radiotherapy alone were performed on one (25 %) patient with oesophageal lymphoma. Postoperative complications were observed in only four (26.6 %) patients; pneumonia in the postoperative period was diagnosed in two patients who underwent surgery; infections of the postoperative wounds were diagnosed in the other two patients. CONCLUSIONS: Benign oesophageal tumours are characterised by similar clinical symptoms to malignant tumours of this organ. It is more complicated to obtain biopsy specimens for a histopathological examination in cases of benign tumours in comparison to malignant tumours. Treatment methods should be adjusted individually for each patient with a rare oesophageal tumour. For rare benign oesophageal tumours, the results of treatment are very good; however, for malignant tumours the prognosis depends on their histopathological type.

Peritoneal "melanosis" associated with a ruptured ovarian dermoid cyst: report of a case with electron-probe energy dispersive X-ray analysis.

A case of peritoneal "melanosis" due to a ruptured left ovarian dermoid cyst is described. Histology showed that the dermoid contained gastric mucosa associated with ulceration, necrosis, and hemorrhage. The areas of pigmentation within the dermoid, omentum, and peritoneal cavity were due to collections of heavily pigment-laden macrophages. The pigment lacked the histochemical features of either melanin or hemosiderin, but electron-probe energy dispersive x-ray analysis showed that the pigment contained a high concentration of iron. It is postulated that peptic ulceration with hemorrhage is the most likely source of the pigment and that the peritoneal pigmentation is secondary to spillage of the contents of the dermoid cyst.

Squamous cell carcinoma in situ arising in inflammatory cloacogenic polyps: report of two cases with PCR analysis for HPV DNA.

Inflammatory cloacogenic polyp (ICP) is regarded as part of the spectrum of pathological changes encountered in mucosal prolapse syndrome (MPS)/solitary rectal ulcer. We present the clinicopathological features of two females with squamous cell carcinoma in situ arising in their ICPs. Human papillomavirus (HPV) type 16 was demonstrated in the areas of squamous carcinoma in situ in both polyps by polymerase chain reaction. These cases highlight the need for close scrutiny of the squamous components of these lesions.

Relative expression of progesterone receptors A and B in endometrioid cancers of the endometrium.

The nuclear receptor for the female hormone progesterone (PR) is widely expressed in uterine cancer. PR is expressed as two proteins (PRA and PRB) with different functions, and in vitro evidence reveals PRA to inhibit PRB function, so the cellular ratio of PRA:PRB is likely to be an important determinant of progesterone action. The relative expression of PRA and B and their involvement in the pathogenesis of endometrial cancer is not known. The aims of this study were to determine PRA and B expression by dual immunofluorescent histochemistry in endometrial adenocarcinomas compared with expression in normal and hyperplastic glands, and to correlate expression in tumors with clinical features including grade. Significantly lower PR levels were found in tumors compared with normal glands and areas of complex atypical hyperplasia within the same specimen. The normal glands expressed both of the isoforms at similar levels, whereas there was increased predominance of one isoform in hyperplastic areas and in tumors, which suggested that the loss of coordinated expression of PR isoforms was an early event in tumor progression. The majority of tumors [27 (58%) of 46] expressed only one PR isoform, and the proportion expressing either PRA or B was the same [14 (30%) of 46, and 13 (28%) of 46, respectively]. One-half of all tumors ([23 (50%) of 46] expressed either PRA only or a predominance of PRA, and a few tumors [10 (22%) of 46] expressed comparable levels of PRA and B. Similar levels of PRA and B were noted only in FIGO grade 1 tumors, whereas higher grades (2 and 3) were associated with a predominance of one isoform. In summary, expression of only one PR isoform was common in endometrial cancers, which indicates that the decreased PR levels observed in these cancers arise from the loss of one PR isoform. Expression of a single PR isoform was associated with higher clinical grade, which suggests a relationship between the loss of PR isoform expression and features of poorer prognosis. Disruption of relative PR isoform expression was observed in complex atypical hyperplasia, which suggests that early alterations in the ratio of PRA:PRB may precede and/or be implicated in the development of endometrial adenocarcinoma. Alterations in the ratio of PR isoform expression are likely to cause disordered regulation of target genes, resulting in altered progestin action in the uterus, and this may be involved in the pathogenesis of endometrial cancer.

Primary peritoneal mesodermal adenosarcoma: report of a case and review of the literature.

BACKGROUND: Mesodermal (müllerian) adenosarcoma arising from the peritoneum is rare and is thought to arise from pluripotent mesothelial and mesenchymal cells of the pelvic cavity or from endometriotic deposits. CASE: A case of primary peritoneal mesodermal adenosarcoma arising from the omentum is described. A 50-year-old woman presented with sudden abdominal distension. Initial laparotomy revealed a 13-kg mass arising from the omentum, which was determined from frozen and paraffin sections to be serous cystadenofibroma. The tumor recurred within 10 months and weighed 18 kg at a second laparotomy. Histopathology and review of the original tumor established the correct diagnosis of mesodermal adenosarcoma. The patient died from disseminated disease 6 months later. CONCLUSION: Adenosarcomas are difficult to differentiate from adenofibromas or endometriosis histologically because of the presence of large areas of low cellularity and infrequent mitotic figures. In such cases, stromal nuclear atypia and periglandular stromal cuffing are features that are diagnostic of adenosarcoma.

Parabrachial nucleus modulates cardiovascular responses to blood loss.

The goal of this study was to determine the role of the pontine lateral parabrachial nucleus (LPBN) in the compensatory responses to blood loss. Conscious unrestrained rats with complete, partial, or sham bilateral ibotenic acid lesions of the LPBN were subjected to a hypotensive 16-ml/kg blood withdrawal via arterial catheter. Complete lesions (LPBNx) encompassed the entire LPBN and extended into the ventrolateral parabrachial region to encroach on the Kolliker-Fuse nucleus. Partial lesions were restricted to the body of the LPBN and spared the outer rim of the external lateral subnucleus of the LPBN. In all three groups, serum corticosterone concentration and plasma renin activity increased four- to fivefold after hemorrhage (P < 0.01), and immunocytochemistry demonstrated numerous Fos-positive neurons in the hypothalamic supraoptic nucleus. However, the cardiovascular responses to hypotensive blood loss differed for complete and partial lesions. Blood pressure failed to recover in LPBNx rats and was significantly lower in LPBNx (66 +/- 4 mmHg) than in rats with partial or sham lesions (98 +/- 4 and 85 +/- 5 mmHg, respectively) at 40 min posthemorrhage. In contrast, rats with partial lesions had a significant attenuation of the posthemorrhage bradycardia. This implies that a population of neurons within the body of the LPBN is essential for full expression of the bradycardia that accompanies hemorrhagic hypotension, whereas the ventrolateral parabrachial region is essential for normal restoration of arterial pressure after hypotensive hemorrhage.

Vulval squamous cell carcinoma arising in chronic hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic inflammatory disease of the sweat glands and hair follicles which is rarely associated with squamous cell carcinoma (SCC). A case of vulval SCC complicating hidradenitis suppurativa is presented. In addition to being the first case to report the association of vulval SCC and hidradenitis suppurativa in the English language literature, it also illustrates the difficulty inherent in distinguishing between invasive SCC and pseudoepitheliomatous hyperplasia on histological examination. The success of wide local excision of the vulval lesion and primary closure without recourse to skin grafts, rotational flaps, or healing by secondary intention is demonstrated.

Integrated multimodality therapy for embryonal rhabdomyosarcoma of the lower genital tract in postpubertal females.

Embryonal rhabdomyosarcoma of the female lower genital tract is generally regarded as a neoplasm occurring in childhood, but has also been reported in adults. The philosophy of therapy, largely based on data obtained from pediatric patients, has evolved slowly from ultraradical surgery, without adjuvant therapy, to neoadjuvant chemotherapy followed by less radical surgery and postoperative radiation. We report here three cases of lower genital tract rhabdomyosarcoma in postpubertal females. A failure to observe complete responses from any single treatment modality suggests that for embryonal rhabdomyosarcoma in adult and adolescent women a multimodality approach to therapy is essential.

[The applicability of phleboscintigraphy in diagnosis and treatment result evaluation of patients with disorders of leg venous circulation]. / Przydatnosc fleboscyntygrafii w diagnostyce i ocenie wyników leczenia chorób ukladu zylnego konczyn dolnych.

The aim of the paper was the applicability of phleboscintigraphy in the diagnosis and monitoring of the treatment in patients with various disorders of venous circulation in lower extremities. The study comprised eighty-eight patients with the suspicion of deep veins impatience. The examination was performed using DTPA 99mTc by means of a gamma camera connected with a computer. The radioisotope was injected into the foot dorsal veins. The dose was 185 MBq. Its activity was monitoring continuously for 1 min. The estimation of the results was performed by scintigraphy imaging and curves of activity changes of chosen regions over deep veins. Phleboscintigraphy was found out to be of a great value in the diagnostics and assessment of treatment results in thrombotic-embolic disease, extra-thrombotic syndromes and in qualification of patients with lower legs varices for surgical procedures. Because of easy performance, possibility of repeating, small invasiveness and rather low cost, the method can be recommended as an introductory examination in patients with above mentioned diseases.

[Analysis of iatrogenic injuries in 1988-1996]. / Analiza uszkodzen jatrogennych w latach 1988-1996.

The analysis of 77 iatrogenic injuries observed in the authors department in the group of 75 patients was conducted. Immediate repair was performed in 71 cases. Serious complications were noticed in 11 cases. 7 patients died in the consequence of the injury.

Immunoneutralization of beta-endorphin blocks prolactin release during suckling without affecting tuberoinfundibular dopaminergic neural activity.

The effect of immunoneutralization of beta-endorphin on the suckling-induced prolactin increase and on the activity of the tuberoinfundibular dopaminergic (TIDA) neurons was determined in lactating female rats between days 8 - 12 post-partum. Two antisera were used in the immunoneutralization studies. Both were specific for beta-endorphin, exhibiting little cross reactivity with met- or leu-enkephalin or dynorphin. Antisera to beta-endorphin completely abolished the suckling-induced prolactin increase indicating that this endogenous opioid peptide is involved in this response. Suckling significantly inhibited DOPA accumulation in the median eminence and antiserum to beta-endorphin did not prevent this inhibition. Additionally, 5-endorphin antiserum significantly reduced TIDA neural activity even in pup-deprived dams. These results indicate that beta-endorphin is involved in the prolactin secretory response to suckling but that inhibition of TIDA neuronal activity is not its mechanism of action. Other possible mechanisms are discussed.

Primary peritoneal carcinoma: a treatable subset of patients with adenocarcinoma of unknown primary.

The syndrome of adenocarcinoma of unknown primary (ACUP) is a frequent problem in both medical and surgical practice. The prognosis is poor, the median lifespan being 4 months. In general, multiple invasive procedures aimed at determining the primary tumour are not warranted due to the low frequency of detecting a tumour for which adequate treatment exists. In this paper we wish to highlight a subset of female patients presenting with malignant ascites and no evidence of a pelvic mass, who on laparotomy were found to have primary peritoneal papillary serous adenocarcinoma. These tumours must be regarded as a potentially treatable subset of patients with ACUP in view of their frequent response to chemotherapy and relatively good prognosis.

Bringing nursing informatics into the undergraduate classroom.

Nursing informatics is not formally addressed in most undergraduate nursing education programs. Nurses usually rely on their employer and/or device vendors to provide this education. Few nurses are able to capitalize on the potential of computer technology because they have not been sufficiently exposed to nursing informatics during their nursing education. Biomedical computer technology/informatics needs to be brought into the classroom, away from the pressures of the work environment. Informatics training needs to be incorporated into undergraduate nursing education through an integrated systems approach, combining elements of nursing, systems analysis, and engineering. In this article, a university-based state-of-the-art classroom and education plan using an integrated approach to educate nurses in nursing informatics is described.

Re-evaluating the need for hospitalization following synovectomy using Yttrium-90 silicate.

In 51 patients treated with Yttrium-90 (Y-90) synovectomy for rheumatoid (inflammatory) arthritis (IA) and OA of the knee we found that decreased retained knee activity (RKA) and increased extra-articular activity in lymph nodes and liver are more likely to be found in IA than OA and following bilateral knee injections. Joint inflammation, as assessed by radionuclide blood pool scan but not by SF white cell count, correlates with decreased RKA and increased activity in lymph nodes. Intra-articular steroid had no significant effect on retention or extra-articular uptake. Strict hospital immobilization improves RKA of Y-90 in IA but not in OA. Y-90 synovectomy in OA shows good RKA and low extra-articular uptake. We recommend strict immobilization following Y-90 synovectomy, particularly in IA patients and/or those with high joint blood flow.

Squamous cell carcinoma arising in an eccrine hidrocystoma.

This report describes the case of a 63 yr old male with an enlarging lesion on the left cheek. Excision biopsy showed a squamous cell carcinoma arising from an eccrine hidrocystoma. The eccrine hidrocystoma showed foci of squamous metaplasia and the sequence of squamous metaplasia complicated by squamous carcinoma is postulated. Squamous differentiation in eccrine neoplasia is discussed.

In-situ hybridization using biotinylated DNA probes to human papillomavirus in adenocarcinoma-in-situ and endocervical glandular dysplasia of the uterine cervix.

In-situ hybridization using biotinylated probes to human papillomavirus (HPV) DNA was performed on formalin fixed paraffin embedded tissue in 30 patients with histologically confirmed adenocarcinoma-in-situ (AIS). Thirteen of the 30 cases contained areas of endocervical glandular dysplasia (EGD) admixed with AIS. Twenty one patients showed positive staining of the AIS nuclei for HPV DNA. Ten cases (33%) were positive for HPV 16 DNA and 11 cases (37%) were positive for HPV 18 DNA. No case showed synchronous expression of HPV 16 and 18 DNA. All cases of AIS were negative for HPV 6b and 11 DNA. Four cases of EGD were positive for HPV 18 DNA and 2 cases were positive for HPV 16 DNA. Four of 6 cases of intestinal dysplasia/AIS were positive for HPV 18 DNA. Associated squamous abnormalities (HPV +/- CIN +/- SCC) were noted in 15 cases. Of these, 7 showed positive staining for HPV DNA in the squamous lesion. Moreover, 5 of these were positive in both the AIS and squamous lesion. In-situ hybridization using biotinylated DNA probes is a sensitive and safe technique readily adaptable to routine histopathology.

Hookworm folliculitis.

A case of persistent folliculitis in a 21-year-old man was demonstrated to be due to Ancylostoma caninum larvae. Treatment with oral thiabendazole was curative. Cutaneous larva migrans may be due to A caninum, but this presentation appears to be unique. The literature concerning etiology and pathogenesis of larva migrans is discussed with reference to this case.

The turtle's revenge: a case of soft tissue Mycobacterium chelonae infection.

A case of cutaneous Mycobacterium chelonae infection with sporotrichoid spread and extensive antibiotic resistance is presented. Control of this problem was only achieved after extensive debridement and grafting of the involved limb. The importance of surgery in management is discussed and the literature is reviewed.