Non-return valves do not prevent backflow and bacterial contamination of intravenous infusions.

Non-return valves (NRVs) are designed to avoid backflow of infusion fluid against the designated direction of flow (DDF) when more than one infusion is delivered via one venous access. We tested in vitro whether NRVs reliably prevent flow against the DDF at clinically relevant low flow rates. Since catheter-related infections caused by the infusion of contaminated fluids represent a relevant problem in patient care, we tested whether NRVs preclude bacterial contamination of infusions proximal to the NRVs and thus might play a role in preventing healthcare-associated infections. Additionally, the incidence of bacterial contamination of drips and infusion fluids in our intensive care unit (ICU) was quantified. In vitro, a low flow against the DDF of ten examples each of five different NRV models was applied and the integrity for fluid and transmigration of three different indicator micro-organisms was tested. Second, we investigated whether contamination of intravenous infusion tubing collected from patients treated on our ICU occurred. Largely independent from the model, 40% of the tested NRVs were not leak-tight for fluids when a pressure against the DDF was built up slowly. In 30%, bacteria migrated against the DDF and were detected proximal to the valve. In 6.7% of the tubing samples collected from ICU patients we detected bacterial contamination. In conclusion, contamination of drips is a relevant problem on ICU. NRVs neither reliably prevent backflow of fluids nor serve as micro-organism filters. Therefore they cannot be recommended as a way of reducing healthcare-associated infections.

Prediction of non-sentinel node status and outcome in sentinel node-positive melanoma patients.

AIMS: Sentinel lymph node (SLN) -positive melanoma patients are usually recommended completion lymph node dissection (CLND) with the aim to provide regional disease control and improve survival. Nevertheless, only 20% these patients have additional metastases in non-sentinel lymph nodes (NSLN), indicating that CLND may be unnecessary in the majority of patients. In this retrospective study, we (i) sought to identify clinico-pathological features predicting NSLN status, as well as disease-free (DFS) and -specific (DSS) survival and (ii) evaluated the applicability of previously published algorithms, which were able to define a group of patients at zero-risk for NSLN-metastasis. METHODS: This analysis included 504 consecutive melanoma patients stage I and II who underwent successful SLN-biopsy (SLNB) at our institute between 1998 and 2005. Metastatic SLN were re-evaluated for tumor burden and categorized according to two different micro-anatomic classifications and the S/U-score (Size of the sentinel node metastasis > 2 mm/Ulceration of the primary melanoma) was assessed. DFS and DSS were calculated for all analyses. RESULTS: Out of 504 melanoma patients stage I or II, 85 (17%) were SLN-positive and 18 of 85 (21%) were found with positive NSLN in the CLND specimen. Median follow-up was 31 months. Neither primary tumor characteristics (age, gender, Clark level, Breslow thickness, ulceration of the primary melanoma, site and histological subtype of the primary melanoma), nor features of the sentinel node tumor (number and site of draining lymph node basins, number of positive sentinel nodes and size of sentinel node tumor (< 2 mm vs. > or = 2 mm) were able to predict additional positive lymph nodes in the CLND specimen. Likewise the implementation of published algorithms was not able to identify patients at negligible risk for harboring NSLN metastases. Upon univariate analysis, disease-free survival in SLN-positive patients was correlated with Breslow thickness, sentinel node tumor size > 2 mm and S/U score. In respect to disease-specific survival the significant prognostic parameters were Breslow thickness, ulceration, sentinel node tumor size > 2 mm and the S/U score. After a median follow-up of 31 months recurrence rates (37% vs. 78%, p=0.02) and death from disease (24% vs. 50%, p<0.01) were significantly different in patients with SLN-metastasis only as compared to patients with NSLN-metastasis. CONCLUSION: NSLN status cannot be predicted in this data analysis by using clinico-pathological characteristics. Therefore, CLND is recommended for all patients after positive SLNB pending the results of the second Multicenter Selective Lymphadenectomy Trial.

Expression of RPE65, a putative receptor for plasma retinol-binding protein, in nonmelanocytic skin tumours.

BACKGROUND: In a recent report we described RPE65, a protein originally characterized in retinal pigment epithelium, to be expressed in normal human epidermis. RPE65 is suspected to be involved in cellular uptake of retinol which is transported in the bloodstream complexed with plasma retinol-binding protein. OBJECTIVES: To evaluate protein and mRNA expression of RPE65 in actinic keratosis (AK), squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) compared with normal skin. METHODS: RPE65 mRNA expression in skin tumours relative to normal skin of the respective donor was studied by real-time polymerase chain reaction in AK (n = 15), invasive SCC (n = 30) and BCC (n = 18). A peptide-specific anti-RPE65 antibody was used for immunohistochemical staining of formalin-fixed and paraffin-embedded tissue sections of the respective tumours. RESULTS: RPE65 mRNA expression was reduced in AK. A highly significant reduction of RPE65 mRNA was observed in invasive SCC relative to normal skin of the respective donors. Immunohistochemistry revealed a continuous staining of basal and suprabasal keratinocytes in normal human epidermis. RPE65 in AK shown by immunohistochemical staining was reduced and quite irregular, whereas invasive SCC revealed no staining of tumour cells with the anti-RPE65 antibody. RPE65 mRNA values were elevated, whereas immunohistochemical staining for RPE65 protein was heterogeneous in BCC. CONCLUSIONS: These results suggest progressive downregulation of RPE65 from AK to invasive SCC.

Sentinel node status in melanoma patients is not predictive for overall survival upon multivariate analysis.

Sentinel lymph node biopsy (SLNB) has become a widely accepted standard procedure in the staging of patients with cutaneous melanoma and absence of clinical lymph node metastases, although there is no final proof that SLNB influences overall survival in these patients. This study investigated the accuracy of SLNB and the clinical outcome of patients after a mean follow-up of 22 months. Between 1998 and 2003, SLNB was performed in 309 consecutive patients. Patients with one or more positive sentinel lymph nodes (SLNs) were subjected to selective lymphadenectomy (SL). Survival analyses were performed using the Kaplan-Meier approach. A Cox proportional-hazard analysis was used for univariate and multivariate analysis to explore the effect of variables on survival. Sentinel lymph nodes were identified in 299 of 309 patients (success rate: 96.8%). Of these, 69 (23%) had a positive SLN. The false-negative rate was 9.2%. Recurrence of disease to the regional lymph node basin (3.0%) and to the locoregional skin (2.6%) was rare in SLN-negative patients in contrast to SLN-positive patients (7.2 and 17.4%, respectively). The 3-year overall survival was 93 and 83% for SLN-negative and SLN-positive patients, respectively. Upon multivariate analysis, SLN status (P<0.001), Breslow thickness (P<0.02) and ulceration (P<0.026) were all found to be independent prognostic factors with respect to disease-free survival, whereas Breslow thickness proved to be the only significant factor with respect to overall survival.

Looking beyond caseload numbers for long-term home-care case managers.

Determining the best use of case managers' time is difficult both because of the great variability in the factors and the lack of outcome studies. In place of the outcome studies, the responses to focus group questions of 89 experienced case managers from across Canada were used to indicate a value for case management functions in the areas of direct care, indirect care management, and program management. The case managers identified greater value for direct care with clients and families who are new to home care or who have complex problems in comparison to clients in more stable or manageable situations. Case managers were frustrated by the lack of agency and community policies and resources to allow case managers to properly support people in their homes. The case managers valued addressing problems on a program or community basis rather than the usual case-by-case. Although preliminary, the approach could be useful in assessing the efficient and effective use of a scarce resource, case managers' time.

Long-term monitoring of sister chromatid exchanges and micronucleus frequencies in pharmacy personnel occupationally exposed to cytostatic drugs.

OBJECTIVES: Many antineoplastic drugs were found to have carcinogenic, mutagenic and teratogenic potential. The aim of this study was to carry out cytogenetic and internal dose monitoring of hospital pharmacy personnel regularly involved in the preparation of cytostatic agents, in order to test possible cytostatics-induced genotoxic effects due to occupational exposure under routine working conditions, and in cases of accidental contamination. METHODS: Platinum in whole blood and anthracyclines in plasma were measured to assess internal exposure to cytostatics. The level of cytogenetic damage was determined in peripheral blood lymphocytes with the micronucleus test and the sister chromatid exchange assay. Five series of monitoring were performed over a period of 2 years. RESULTS: No significant differences in the mean frequencies of sister chromatid exchanges (SCE) and micronuclei (MN) were found between occupationally exposed probands and controls (9.9 +/- 1.4 vs 10.1 +/- 1.2 SCEs/cell and 21.2 +/- 7.2 vs 23.3 +/- 7.5 MN/2000 binucleated (BN) cells, n = 16). Significant elevations of SCE or MN were detected in seven out of 12 cases of accidental contamination at the workplace, whereas no increase in platinum in blood and anthracyclines in plasma was observed in these probands. Two cases of non-reported contamination were identified by measurement of epirubicin in plasma. Smoking was found to increase the SCE significantly. No correlation between individual SCE scores and MN scores was observed. CONCLUSIONS: Our findings support a transient increase in SCE or MN after relevant exposure to cytostatic drugs in cases of accidental contamination. The lack of significant differences in SCE and MN between hospital pharmacy personnel and unexposed controls, points to high standards of safety at the corresponding workplaces.

Balancing relationship and discipline: the pressing concern of mothers of early-adolescent girls.

Mothers of early-adolescent girls (10-14 years) often experience difficulties in dealing with their daughters. This study explored the mother-daughter relationship from the perspective of the mothers, to identify their most pressing concern and the strategies that might help them address this concern. A qualitative design employing a feminist participatory approach was used with 2 groups of mothers living in low socioeconomic status (SES) areas of a small city in Ontario, Canada, over a 10-week period. The most pressing concern of both groups was balancing relationship and discipline. Through the use of questioning to explore their issues, the mothers gained the reassurance, knowledge, skill, and confidence to deal with their daughters. This introductory study should contribute to nurses' understanding of the mother-daughter relationship during adolescence, and it offers a small-group strategy that shows promise in assisting mothers to address their concerns.

Role identity and job satisfaction of community health nurses.

Although many efforts have been made to articulate the nature of community health nursing practice, there continues to be a great deal of confusion about the roles and functions of community health nurses. This article reports a descriptive research study of the role identity and job satisfaction of 43 staff community health nurses practicing in home health care, generalized public health nursing, combined public health/home health care (PH/HHC), and specialized programmes. Although differences were found, the home health, generalized public health, and PH/HHC nurses shared a similar core identity. The major differences were seen for the nurses working in specialized programmes. No significant differences were found in job satisfaction among the four groups.

Functional reconstruction of the upper eyelid after excision of squamous cell carcinoma in xeroderma pigmentosum.

This paper describes a technique for excision of a squamous cell carcinoma of the upper eyelid and subsequent functional reconstruction of the lid in a patient with xeroderma pigmentosum. By applying the modified technique of temporalis muscle flap, the upper eyelid was reconstructed by a skin graft from non-sun-exposed skin and a muscle pocket of the temporalis muscle. For the mucosal layer of the upper eyelid, a transplant of oral mucosa was used. An effective functional and aesthetic outcome has been achieved by this technique.

[Pyoderma gangrenosum as a precursor of myeloid leukemia]. / Pyoderma gangraenosum als Vorläufer einer myeloischen Leukämie.

A 34-year-old woman who was 20 weeks pregnant developed pyoderma gangrenosum while receiving treatment for infarct pneumonia. Because of her septic condition an abortion was performed. The patient received intravenous prednisolone as a pulse treatment for her pyoderma gangrenosum, which was followed by oral methylprednisolone and oral dapsone for 6 weeks. After dose reduction the patient had a severe relapse. The steroid dose was increased and dapsone was replaced by cyclosporin A. The smaller ulcers healed spontaneously, but skin grafting had to be performed for the large ulcer. The steroid therapy was tapered and discontinued. Cyclosporin A was continued for 10 weeks as monotherapy. Subsequently, the patient was free of symptoms for 7 months. Twelve months after the diagnosis of pyoderma gangrenosum the patient developed acute myeloid leukaemia accompanied by a recurrence of the skin disease.

Health concerns of adolescent girls.

An anonymous self-report questionnaire designed to assess adolescent girls' health concerns was administered to 1,416 female students in grades 7-10 from 38 schools in northwestern Ontario. Results indicated that the future and items of appearance were of the highest level of concern in the sample. Factor analysis of the 27 concern items produced grouping of concerns into four factors: risk-taking behavior, appearance, health promotion/future orientation, and psychological functioning. Comparison of the four factors across grades revealed that concern about risk-taking behavior and psychological functioning did not change; concern about health promotion/future orientation issues decreased as the grade increased; and concern about appearance increased as the grade increased. It is anticipated that the grouping of concerns and differences by grade revealed in this study will assist in designing pertinent health programs to interest and motivate the teenage female population.

Female adolescent alcohol, cigarette, and marijuana use: similarities and differences in patterns of use.

Five categories of variables were examined as predictors of alcohol, cigarette, and marijuana use in a sample of 1,416 girls aged 13 to 17 years in Northwestern Ontario. A similar pattern of unique predictors emerged for the three drugs for three of the categories: the concurrent use of another drug, conventional educational attitudes and behaviors, and rebellious behaviors. A different pattern was found for the social and demographic categories between the inhaled drugs and alcohol. These differences emphasize the need to determine the specific predictors of drug use for each substance before planning regionally based drug prevention programs.

[Schoenlein-Henoch purpura associated with chronic post-traumatic osteomyelitis]. / Purpura Schönlein Henoch assoziiert mit chronischer posttraumatischer Osteomyelitis.

In Schönlein-Henoch purpura, a distinctive form of leucocytoclastic vasculitis, immune complex deposits in vessel walls characteristically contain IgA. Complement activation, neutrophil chemotaxis and the subsequent destruction of vessel walls make up the pathologic substrate behind the clinical symptoms, which are characterized by palpable purpura lesions, renal and gastrointestinal symptoms and arthralgias. Viral infections, malignant neoplasms and drugs, but especially streptococcal infections, are incriminated as possible causes of the disease. A case of Schönlein-Henoch purpura associated with chronic osteomyelitis is described. It is note-worthy insofar as there is only one similar case reported in the literature.

[Basalioma]. / Das Basaliom.

The basal cell carcinoma (BCC) is one of the most frequent tumours. The entire destruction of the BCC is the aim of the therapy. The different methods of treatment have to respect the biological type, the histologic form of the BCC. Tumours at critical localizations (face, hands and feet) should be controlled microscopically, if the tumour has been excised totally. By the microscopic control fatal destructive recurrence can be avoided. The dermatologic treatment of BCC offers different methods in respect to the biological type and localization of BCC and also in respect to the age of the patient.

[Wound myiasis. Facultative myiasis]. / Wundmyiasis. Fakultative Myiasis.

Two cases of traumatic myiasis, one in Bowen carcinoma and one in chronic leg ulcer, are described. The maggots isolated were reared to the adult stage; they proved to be Calliphoridae of the genus Lucilia (presumably L. sericata). The various forms of myiasis and the species involved in such parasitism are described, and the therapeutic efficiency of proteolytic enzymes and the necrolytic potency of maggots are briefly discussed.

[Standardized therapy concepts in circumscribed burns. Wishes and reality!]. / Einheitliches Therapiekonzept umschriebener Verbrennungen. Wunsch und Wirklichkeit!

The vast majority of minor burns requiring treatment are best managed by clear rational concepts of therapy. If these burns are either treated less than optimal or overtreated, complications like infections or delayed wound healing may ensue. In order to draw conclusions from data obtained in studies on patients with minor burns, we need cohort studies making use of clearly defined therapeutic concepts.

[Embolization therapy of cavernous hemangiomas]. / Die Embolisations-Therapie kavernöser Hämangiome.

Hemangiomas are the most frequent tumors found in newborns, but mostly regress by the age of 7. Spontaneous progression and such complications as hemorrhage, disseminated intravascular coagulation (Kasabach-Merritt syndrome), threatened cardiovascular decompensation, and threatened interference with vital functions are rare and must be treated. Embolization therapy is a new therapeutic approach: vascular malformations and hemangiomas with pronounced arteriovenous shunts are treated by selective arterial embolization of the most peripheral branches of the supplying blood vessels. In contrast, lesions with a steady, slow blood perfusion can be treated by direct embolization of the cavernous system; further thrombosis and organization of the thrombus may lead to a permanent and complete occlusion of the hemangioma. If permanent occlusion cannot be achieved, temporary or partial thrombosis may allow curative plastic or reconstructive surgery, which would otherwise be impossible.