Severity assessment tools in ICU patients with 2009 influenza A (H1N1) pneumonia.

The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1) years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2 ± 43.2 points, the CURB-65 score was 1.7 ± 1.1 points and the PIRO-CAP score was 3.2 ± 1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I-III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU.

Public education and cancer of the skin. What do people need to know about melanoma and nonmelanoma skin cancer?

Cutaneous melanoma (CM) and nonmelanoma skin cancer (NMSC) have a high chance for cure if detected in an early phase of development. Patients who have these tumors may now be treated in the outpatient setting with a minimum of discomfort, inconvenience, and cost. Most skin cancer deaths are caused by CM. Until recently, CM incidence in the United States has been increasing faster than any other potentially lethal cancer, attributable at least in part to aggressive case detection and greater public awareness about the significance of risk factors and early warning signs of evolving tumors, resulting in increased numbers of curable tumors. Most CMs are discovered by patients or close acquaintances. Most CM deaths are related to patient delay in seeking medical care. Patient delay is attributed mostly to lack of knowledge rather than to fear and denial. In the United States, primary prevention of CM and NMSC has focused on encouraging sensible sun-exposure behaviors, while secondary prevention consists of a yearly national campaign that promotes skin awareness and self-examination and free examinations to detect evolving tumors, sponsored by the American Academy of Dermatology and the American Cancer Society. More attention is needed to encourage timely consultation for evolving tumors and predisposing risk factors and to focus screening and surveillance efforts of those people at greatest risk. Public education must continue to promote personal responsibility in the intervention process to reduce the morbidity and mortality associated with CM and NMSC.

Mid-dermal elastolysis with inflammation.

A 71-year-old white woman had finely wrinkled, erythematous patches of skin that met the clinical and histologic criteria for mid-dermal elastolysis. In addition to the loss of mid-dermal elastin described in previous cases, histopathologic examination revealed a superficial and deep perivascular inflammatory infiltrate of lymphocytes and plasma cells and interstitial collections of multinucleated giant cells containing phagocytized elastin. These results support a previously postulated inflammatory pathogenesis for mid-dermal elastolysis.

Small congenital nevocellular nevi and the risk of cutaneous melanoma.

The relative risk of melanoma associated with small congenital nevi was estimated by comparing the published frequency of histologically documented nevocellular nevi in newborn infants with the frequency of: (1) congenital nevi at the tumor site, ascertained by history in 134 patients with melanoma; and (2) tumor-associated nevi with congenital features in 234 melanoma specimens. A 21-fold increase in melanoma risk was estimated for persons with small congenital nevi when nevi were ascertained by history, and a three- to tenfold increase in risk when nevi were ascertained by histology. Based on these approximations of relative risk from historic and histologic methods of detection, persons with small congenital nevi who live to age 60 are estimated to have cumulative risks for melanoma of 4.9/100 and 0.8 to 2.6/100, respectively. The increased risk is related presumably to the markedly increased probability of melanoma arising in association with small congenital nevi. In other words, small congenital nevi may represent precursors for at least some cases of cutaneous melanoma. The estimated risk are highly dependent on the specificity of methods used for ascertainment of congenital nevi.