Predictors of bloodstream infection associated with permanently implantable venous port in solid cancer patients.

BACKGROUND: The purpose of this study is to characterize the risk factors of bloodstream infection (BSI) associated with the use of permanent implantable venous ports (Port-A) in solid cancer patients. METHODS: Solid cancer patients implanted with a Port-A were prospectively observed for the occurrence of Port-A-associated BSI (PABSI), defined as BSI without other identifiable infection foci. A PABSI risk score was developed using the Cox proportional hazards model. RESULTS: A total of 415 patients were registered; 88 PABSI episodes occurred in 58 patients (incidence1.05 per 1000 catheter-days). All but one patient had stage IV cancer. Independent predictors of PABSI occurrence included neutropenia, total parenteral nutrition (TPN), chronic steroid use, invasive procedures, postoperative antibiotics, and preoperative antibiotics. A PABSI risk score with a cut-off value of 0 (sensitivity 88.5%, specificity 64.3%) was defined for stage IV cancer patients as follows: neutropenia, +1.350; TPN, +1.256; chronic steroid use, +1.947; preoperative antibiotics, -0.970; postoperative antibiotics, +0.959; and invasive procedures, +1.098. The median PABSI-free survival was 4.47 months for patients with scores ≥ 0 but not reached for patients with scores <0 (P < 0.0001). CONCLUSION: The PABSI risk score can assist in identifying high-risk solid cancer patients and may assist in designing future preventive strategies.

Family experiences related to the decision to institutionalize an elderly member in Taiwan: an exploratory study.

Industrialization and urbanization have changed the structure of Taiwanese families. Placing elder family members with impairments in nursing homes has become a new caregiving alternative. However, Taiwanese commonly consider this placement to be a violation of traditional filial obligation. Therefore, institutionalization is a highly sensitive cultural issue. Data were gathered through semi-structured interviews with nine family members, revealing three major processes in the decision of institutionalization -- breaking harmony, rebuilding harmony and evolution, as well as four important factors that influence the decision -- the quality of the relationship between the elder and his/her family, characteristics of the elder, financial condition of the family and perceived public opinion toward institutionalization. The findings suggest that the decision process in institutionalization is a gradual, fluid, cyclical movement without definite steps.

Persistent light reaction with erythroderma caused by musk ambrette: a case report.

Persistent light reaction is an uncommon type of photodermatitis caused mainly by musk ambrette, a synthetic fragrance material commonly used in foods and cosmetics. Erythrodermic persistent light reaction is rare. We report a case of erythroderma with underlying persistent light reaction due to musk ambrette. A 71-year-old man showed a photodermatitis that waxed and waned for five years before it became more persistent and finally evolved into erythroderma. Positive results of a photopatch test to musk ambrette and a low minimal erythema dose to ultraviolet B were noted. A biopsy specimen of the erythrodermic lesion revealed spongiotic dermatitis. The erythroderma and photodermatitis responded to systemic steroids and psoralen/ultraviolet A therapy (total dose: 90 J/cm2). We suggest that persistent light reaction be included in the differential diagnosis of erythroderma.

Quantitation of calcium levels in the nails of psoriasis patients by energy dispersive X-ray microanalysis.

Energy dispersive X-ray microanalysis was used to study the calcium levels in the involved and uninvolved nails of patients with psoriasis, and in the nails of healthy controls. A significant difference was found between the involved and uninvolved psoriatic nails. Calcium levels were higher in the dystrophic nails than in the normal nails of the same patients, patients without nail lesions, and healthy controls. No difference was noted in the calcium levels of normal nails between psoriasis patients and healthy controls. Calcium depletion from the horny layer may play a role in the formation of psoriatic skin lesions.

Extrathoracic sarcoidosis in a Chinese man presenting with multiple, large plaques and tumors.

We report an unusual case of tumorous sarcoidosis in a 42-year-old Chinese man with extrathoracic sarcoidosis. He presented with multiple large plaques and tumors on the neck and extremities of a nine-year duration. Because of the atypicality of the cutaneous manifestation, the lack of intrathoracic lesions and the rarity of sarcoidosis in Taiwan, the case remained undiagnosed for nine years despite numerous examinations and tests. A subsequent skin biopsy revealed sarcoidal granulomas. The detection of cytoplasmic birefringent inclusions in the granulomas led to the final diagnosis. Originally thought to be foreign bodies, the inclusions were proven to be calcium oxalate by x-ray microanalysis and calcium oxalate stain. Lymph node and liver biopsies confirmed the diagnosis. The skin lesions in this case may have been precipitated by frequent harsh scrubbing to clean the skin. Sarcoidosis should be considered in the differential diagnosis in patients presenting with multiple cutaneous tumors. This case also illustrates that detection of calcium oxalate inclusions in granulomas, while not specific, can serve as a valuable clue in the diagnosis of cutaneous sarcoidosis.

Cutaneous alternariosis in association with scabies or iatrogenic Cushing's syndrome.

Cutaneous alternariosis is rare. Most infections occur in immunocompromised hosts. We report the first three cases in Taiwan. The patients were elderly farmers residing in Tainan. They developed indolent, erythematous, ulcerated or crusted papules, plaques or pustules over the extensor aspect of the forearms or hands. Pure colonies of Alternaria sp were isolated from biopsy specimens in each case. The diagnosis was confirmed by detecting pleomorphic fungal elements in the dermis within suppurative, granulomatous infiltrates. All three patients were immunocompromised. They showed a negative reaction to an intradermal test of seven common antigens. Cases 2 and 3 had iatrogenic Cushing's syndrome. Cases 1 and 3 had extensive scabies, which in Case 1 was of the Norwegian type. To the best of our knowledge, scabies associated with alternariosis has not been reported previously. The infection showed spontaneous regression in Case 1; in Case 2, it resolved after seven weeks of intralesional amphotericin B at a dose of 1 mg/mL twice a week.

Quantitative and morphological changes of Langerhans cells in Bowen's disease from patients with chronic arsenicism.

Langerhans cells (LCs) are considered to be responsible for the immunologic presentation of tumor-associated antigens and play a role in the elimination of neoplastic clones. Ultraviolet light B can cause dysfunction and loss of LCs. Both the number and dendritic morphology of LCs are known to be diminished in squamous cell carcinomas from sun-exposed skin. The effects of arsenics on LCs are unknown. Using an OKT-6 monoclonal antibody to stain intraepithelial LCs, we compared their number and morphology in Bowen's lesions and in the perilesional skin from sun-protected sites in ten patients with chronic arsenicism. There was a significant reduction in the numbers of LCs in the Bowen's lesions as compared to the perilesional skin specimens. Loss of dendrites was observed in all Bowen's lesions and in seven of the perilesional skin specimens. Ultrastructurally, the LCs showed an absence of dendrites, but the Birbeck granules were preserved. Since the specimens were not from sun-exposed skin in our study, the findings may be related to chronic arsenic intoxication. The morphologic alteration of LCs observed in the perilesional skin further suggests an arsenic-related systemic dysfunction of the LCs, which in turn may contribute to the development of skin cancers in these patients.

Mite allergen decreases DC-SIGN expression and modulates human dendritic cell differentiation and function in allergic asthma.

House dust mites (HDMs) induce allergic asthma in sensitized individuals, although how HDMs activate immature mucosal dendritic cells (DCs) to render the T helper cell type 2 (Th2)-mediated immune response is unclear. In this study, our results showed a significant calcium-dependent lectin binding of Dermatophagoides pteronyssinus (Der p) extracts to DC-specific intercellular adhesion molecule-3-grabbing nonintegrin (DC-SIGN), the C-type lectin receptors (CLRs) of DCs. Moreover, monocyte-derived DCs (MDDCs) of Der p-sensitized asthmatics (AS) exhibited decreased expression of DC-SIGN, increased endocytosis, and impaired differentiation of DC precursors. The Der p-induced downregulation of DC-SIGN expression in the differentiation of immature MDDCs may be because of the internalization of Der p-DC-SIGN complex. MDDCs of AS produced more interleukin (IL)-6 and less IL-12p70 cytokines when stimulated with lipopolysaccharide (LPS) or Der p than those of nonallergic controls (NC). In the co-culture experiments, MDDCs pretreated with Der p induced GATA-3 expression and IL-4 cytokine productions in naive CD4(+) T cells. These effects of Der p on the differentiation and function of MDDCs could be partially blocked by anti-DC-SIGN antibodies. In conclusion, our results suggest a critical step of allergen sensitization that involves CLRs in the innate immune response of DCs, which may provide a therapeutic or preventive potential for allergic asthma.