[Pylephlebitis with air in the portal vein system. An unusual focus in a patient with sepsis]. / Pylephlebitis mit Luft im Pfortadersystem. Ungewöhnlicher Fokus bei einem Patienten mit Sepsis.

HISTORY AND CLINICAL FINDINGS: A 30-year-old male was transferred to the intensive care unit with worsening sepsis of unknown origin and a known history of Crohn's disease. The patient presented with a five-day history of nausea, fever, and serous diarrhea. Clinical examination of the abdomen was unremarkable except for mild epigastric pain on palpation. INVESTIGATIONS: Computed tomography (CT) of the abdomen revealed gas within the intrahepatic branches of the portal venous system, thickening of the wall of the neoterminal ileum, and mild ascites. In addition, ultrasonography showed acute thrombosis of the portal vein and the superior mesenteric vein. No wall perfusion was seen in either the neoterminal ileum or the ascending colon on color Doppler sonography. DIAGNOSIS, TREATMENT AND COURSE: Based on the combination of portal vein thrombosis along with venous gas in the portal venous system and absence of intestinal perfusion, the diagnosis of pylephlebitis with septic shock was suspected and a laparotomy was performed. Intraoperative exploration revealed phlegmonous terminal ileitis, a significant amount of cloudy fluid, and thrombosis of the mesenteric vein. A right-sided hemicolectomy with ileotransversostomy was performed. Histologic examination confirmed Crohn's disease that was associated with vasculitis and, in particular, with thrombophlebitis and subsequent transmural bowel necrosis. Antibiotic and anticoagulation therapy was resumed without further complications. CONCLUSION: In the differential diagnosis of sepsis, especially in combination with abdominal pain or gas in the portal venous system, pylephlebitis should be taken into account. Because of the high mortality, immediate further diagnostic testing and appropriate therapy of this rare diagnosis are necessary.

Prediction of left ventricular functional recovery by dobutamine echocardiography, F-18 deoxyglucose or 99mTc sestamibi nuclear imaging in patients with chronic myocardial infarction.

BACKGROUND: Currently, several modalities are available to predict viability, however, studies comparing various modalities validated by functional recovery after revascularization are scarce. This study analyzed the relative merits of low-dose dobutamine echocardiography, F-18 deoxyglucose (FDG) positron emission tomography (PET) and (99m)Tc sestamibi single-photon emission computed tomography to predict functional recovery after revascularization in patients with chronic myocardial infarction. METHODS: Patients with chronic coronary occlusion (duration: 3.1 +/- 4.8 years) and impaired left ventricular function (ejection fraction: 42 +/- 13%) underwent low-dose dobutamine echocardiography (20 microg/kg/min), FDG-PET and (99m)Tc sestamibi imaging before revascularization. Revascularization was performed irrespective of any viability data. Follow-up angiography was obtained 4.8 +/- 2.5 months after revascularization. RESULTS: Viability analysis was performed in 34 patients with patent target vessel at follow-up, of whom 9 (27%) exhibited functional recovery on left ventricular angiography. For dobutamine echocardiography, improvement of >/=2 adjacent akinetic segments resulted in improved sensitivity of 89% and specificity of 80% to predict functional recovery. For glucose metabolism, FDG uptake >55% was an optimal threshold yielding a sensitivity of 89% and a specificity of 68%. With respect to perfusion, (99m)Tc sestamibi uptake >60% was the best cutoff resulting in a sensitivity and a specificity of 56 and 88%, respectively. A concordant match of FDG >55% and of (99m)Tc sestamibi >50% resulted in optimized sensitivity (78%) and specificity (80%) with dual imaging. CONCLUSIONS: Recovery of chronically dysfunctional myocardium can be predicted with high accuracy by stimulation of contractile reserve or by concordant match of preserved glucose metabolism and residual perfusion.

Thrombolytic therapy for adhesion of percutaneous central venous catheters to vein intima associated with Malassezia furfur Infection.

OBJECTIVE: To report our experience with thrombolytic agents in the management of two infants with silicone central venous catheters that had adhered to the vein wall as a result of infection with Malassezia furfur. STUDY DESIGN: Case review of two very low birth weight infants with adherent central venous catheters. RESULTS: Treatment with urokinase and tissue plasminogen activator facilitated the removal of these catheters without breakage or surgical intervention. CONCLUSIONS: Thrombolytic agents should be considered as a treatment of adhered catheters, as well as of occluded catheters.

Neonatal skin care: evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. Association of Women's Health, Obstetric and Neonatal Nurses/National Association of Neonatal Nurses.

OBJECTIVE: To develop and evaluate an evidence-based clinical practice guideline for assessment and routine care of neonatal skin, educate nurses about the scientific basis for practices recommended in the guideline, and design procedures that facilitate implementation of the project guideline into clinical practice. DESIGN: Descriptive report of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. SETTING: Neonatal intensive-care unit (NICU) and special-care nurseries and well-baby nurseries in 51 hospitals located throughout the United States. PARTICIPANTS: Member site coordinators (N = 51), nurses who work at the selected sites, and the neonates observed during both the pre- and postimplementation phases of the project (N = 2,820). METHOD: An evidence-based clinical practice guideline was developed, sites were selected from all respondents of the call for sites, site coordinator training was provided, data collection was facilitated by project-specific data collection tools, and the project was evaluated by the science team. MAIN OUTCOME MEASURES: Diversity and numbers of sites represented, patient representation, site coordinator knowledge of neonatal skin care pre- and postimplementation, use of project-designed implementation tools, satisfaction with project guideline and the data collection process, changes in practices and product use, and site coordinators' experiences during guideline implementation. RESULTS: Fifty-one sites completed the project, representing NICU, special-care, and well-baby nurseries in both academic and community hospital settings in 27 states. Registered nurses working in these sites totaled 4,754 full-time equivalent positions (FTEs) (in NICU/special-care and well-baby nurseries). Site coordinators demonstrated increased knowledge of research-based neonatal skin care and satisfaction with the implementation tools and data collection process. Product use changed, reflecting acquisition of new knowledge. Barriers to implementation of the guideline were identified. CONCLUSIONS: The AWHONN/NANN Neonatal Skin Care Research-Based Practice Project demonstrated increased knowledge among site coordinators who received training, facilitated changes in neonatal skin care as defined by the practice guideline, and thus advanced evidence-based clinical practice.

Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses.

OBJECTIVE: To test the effectiveness of an evidence-based clinical practice guideline for neonatal skin care on selected clinical outcomes for newborns in neonatal intensive-care units (NICU), special-care units (SCU), and well-baby nurseries. DESIGN: Prospective evaluation of the collaborative neonatal skin care research-based practice project of the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. SETTING: NICU and well-baby units in 51 hospitals located throughout the United States. PARTICIPANTS: Member site coordinators (N = 51) and the neonates (N= 2,820) observed during both the pre- and postimplementation phases of the project. METHOD: Site coordinators received specialized education in neonatal skin care and implemented an evidence-based clinical practice guideline addressing 10 aspects of neonatal skin care. Baseline observations of skin condition, care practices, and environment of newly admitted neonates were collected by site coordinators. Postimplementation observations were then completed. MAIN OUTCOME MEASURES: Skin condition was assessed with the Neonatal Skin Condition Score (NSCS), which ranges from a score of three (best condition) to a score of nine (worst condition), based on dryness, erythema, and skin breakdown. Changes in frequency of selected skin care practices were used to assess the effectiveness and feasibility of using the practice guideline in everyday clinical practice. Aspects of the care environment with potential effect on skin integrity were monitored to determine risk factors. RESULTS: Fifty-one site coordinators made 11,468 systematic assessments of 2,464 NICU and SCU newborns and 356 well newborns. Baseline skin scores were better in well newborns compared with premature newborns. After implementation of the guideline, skin condition was improved, as reflected by less visible dryness, redness, and skin breakdown in both the NICU/SCU and well newborns. The guideline was integrated into care, as evidenced by increased use of emollients, particularly with premature infants, and decreased frequency of bathing. A relationship was shown between selected aspects of the environment and alterations in skin integrity. CONCLUSIONS: Use of the AWHONN/NANN Neonatal Skin Care Research-Based Clinical Practice Guideline was successfully implemented at 51 sites, and effectiveness was demonstrated by changed care practices and improved skin condition in premature and full-term newborns. The results of this project support a wider dissemination of the project's practice guideline for neonatal skin care.

Positron emission tomography in the staging of small-cell lung cancer : a preliminary study.

STUDY OBJECTIVES: Small-cell lung cancer (SCLC) has an unfavorable prognosis, especially when the disease is extensive at presentation. Accurate staging procedures are therefore needed for treatment planning. Positron emission tomography (PET) is a modern noninvasive imaging technique, the value of which for the staging of SCLC was investigated in the present study. SETTING: University hospital. PATIENTS: Thirty-one patients with suspected lung cancer were investigated for staging purposes using chest radiography, CT of the thorax and abdomen, abdominal ultrasound, and bone scanning. Twenty-five patients also received PET examinations during the staging procedures. Five of these patients were found to have SCLC, while two patients had mixed lesion types. Further analysis of the latter group was carried out. RESULTS: PET detected the primary tumor in all patients, and lymph nodes in five patients. All lymph nodes were proved to be malignant by endoscopic ultrasonography-guided fine-needle aspiration. Only one patient had distant metastases, which were detected by both CT and PET. CONCLUSIONS: PET appears be a suitable imaging method in SCLC. A potential role for the technique as a standard staging procedure will need to be tested by investigating a larger number of patients in a prospective study.

Male caregivers of mentally ill relatives.

TOPIC: To describe the lived experiences of male caregivers of severely mentally ill relatives and their perceptions of this nontraditional role. METHODS: A qualitative study of informal interviews with purposively selected male caregivers (N = 10), using an informal interview guide that addressed psychosocial, physical, financial, and crisis-management categories. FINDINGS: The data yielded three themes of caregiving: expressions of burden, duration and depth of commitment, and role affirmation. CONCLUSIONS: The results can help health professionals develop needed education and support services for men in this emerging role and contribute to family health in the community.

Development of skin barrier function in premature infants.

Histologic analysis suggests that epidermal development is complete in utero at approximately 34 wk gestational age. Infants born more prematurely have elevated rates of both transepidermal water loss and transcutaneous heat loss, and have difficulty maintaining homeostasis. The underdeveloped integument is also a portal of entry for infection and the percutaneous uptake of toxins. Previous measurements of transepidermal water loss have suggested that, regardless of gestational age, competent barrier function is attained within 2-4 wk postnatal age. In this study we have utilized another noninvasive biophysical technique, low frequency impedance spectroscopy, to complement transepidermal water loss measurements. We present longitudinal data from infants ranging from 23 to 32 wk gestational age. The results suggest that, for ultra-low birth weight infants (23-25 wk gestational age), the complete development of a fully functional stratum corneum can require significantly longer than 4 wk. In contrast, the data from the older infants suggest that a postnatal existence period of 2-4 wk may not be necessary to attain functional maturity, because infants born at 30 and 32 wk gestational age were found to have barrier function comparable with that of adults.

Benefits and challenges of a graduate nursing consortium.

The Intercollegiate Consortium for a Master of Science in Nursing (ICMSN), a partnership among four universities in Louisiana, is a proven articulation model for delivering graduate education in nursing. The authors describe the benefits and challenges of an academic consortium. Recommendations are offered for establishing similar models of multi-institutional collaboration in higher education.

Disruption of barrier function in neonatal skin associated with adhesive removal.

OBJECTIVE: Patients in the neonatal intensive care unit require life support and monitoring equipment that must be securely attached to the skin; removal or replacement often causes skin trauma. In this study, we compared the effects of application and removal of three different adhesives on the skin barrier function of premature neonates. The effects were measured by transepidermal water loss (TEWL), colorimetric measurements, and visual inspection. DESIGN: Thirty neonates, between 26 and 40 weeks of gestational age and with birth weights ranging from 690 to 3000 gm, were enrolled in the study during the first week of life. Pieces of plastic tape (1 cm2), pectin barrier, and hydrophilic gel were applied to previously undisturbed sites on the back. A fourth site was used as a control. We measured TEWL, colorimetric readings, and visual inspection scores of skin irritation and stripping at each of the four sites serially: before adhesive application, 30 minutes after adhesive removal, and 24 hours later. RESULTS: Thirty minutes after adhesive removal, TEWL, colorimetric measurements, and visual inspection scores were all significantly higher at the sites of plastic tape and pectin barrier removal than at the control and gel adhesive sites (p < 0.01), demonstrating greater disruption of skin barrier function with removal of the plastic tape and pectin barrier. When the neonates were divided into three groups on the basis of birth weight (< 1000 gm [n = 10], 1000 to 1500 gm [n = 11], and > 1500 gm [n = 9], the same pattern of greater disruption in skin barrier function, as measured by TEWL, was observed in each birth weight group. Twenty-four hours after adhesive removal, TEWL of the plastic tape and pectin barrier sites were not significantly different from the control site, indicating recovery of skin barrier function. CONCLUSIONS: This study demonstrates that a single application and removal of two commonly used adhesives, plastic tape and pectin barrier, disrupts skin barrier function in neonates of varying gestational ages.

[CT and supplementary HR-CT of Kaposi's sarcoma of the pulmonary parenchyma--the morphology of the findings and the diagnostic value]. / CT und ergänzende HR-CT des Kaposi-Sarkoms des Lungenparenchyms--Befundmorphologie und diagnostischer Stellenwert.

AIM OF THE STUDY: was an analysis of the CT appearances of Kaposi's sarcoma (KS) in the lung and to determine the diagnostic value of CT and supplementary high resolution CT. MATERIALS AND METHOD: 38 AIDS patients with cutaneous and/or mucocutaneous KS were examined by conventional radiography and CT of the chest during a prospective study. RESULTS: Evaluation of the CT appearances in 16 patients with proven pulmonary KS showed a typical pattern consisting of patchy and flame-shaped infiltrates in relation to the bronchovascular bundle these may be combined with non-necrotic confluent shadows surrounded by areas of ground glass opacity, thickened interlobular septa and round foci. In 12 patients the CT appearances were regarded as characteristic and in four as suggestive but not diagnostic. CONCLUSION: Combination of these features in patients with cutaneous or mucocutaneous manifestations but otherwise negative findings of pulmonary infection allows one to make a diagnosis of pulmonary KS with a high degree of certainty and helps to avoid invasive diagnostic procedures.