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Background: Traditional medical education strategies teach learners how to correctly perform procedures while neglecting to provide formal training on iatrogenic error management. Error management training (EMT) requires active exploration as well as explicit encouragement for learners to make and learn from errors during training. Simulation provides an excellent methodology to execute a curriculum on iatrogenic procedural complication management. We hypothesize that a standardized simulation-based EMT curriculum will improve learner's confidence, cognitive knowledge, and performance in iatrogenic injury management., Methods: This was a pilot, prospective, observational study performed in a simulation center using a curriculum developed to educate resident physicians on iatrogenic procedural complication management. Pre- and postintervention assessments included confidence surveys, cognitive questionnaires, and critical action checklists for six simulated procedure complications. Assessment data were analyzed using medians and interquartile ranges (IQRs), and the paired change scores were tested for median equality to zero via Wilcoxon signed rank tests with p < 0.05 considered statistically significant., Results: Eighteen residents participated in the study curriculum. The median (IQR) confidence increased significantly by a summed score of 12.5 (8.75-17.25; p < 0.001). Similarly, the median (IQR) knowledge significantly increased by 6 (3-8) points from the pre- to postintervention assessment (p < 0.001). For each of the simulation cases, the number of critical actions performed increased significantly (p < 0.001 to p = 0.002)., Conclusion: We demonstrated significant improvement in the confidence, clinical knowledge, and performance of critical actions after the completion of this curriculum. This pilot study provides evidence that a structured EMT curriculum is an effective method to teach management of iatrogenic injuries.

Background: Squamous cell carcinoma (SCC) may present with or without the feature of acantholysis., Methods: Investigate invasive acantholytic SCC by microscopic maximum tumor surface diameter, depth of invasion, grade of differentiation, perineural invasion (PNI) and percentage of acantholysis. Assess recurrence following excision., Results: A total of 1658 consecutive invasive SCC cases were examined, comprising 4.9% acantholytic SCC. Median tumor microscopic maximum diameter was 8 mm for acantholytic SCC and 7.3 mm for non-acantholytic SCC. Median tumor invasion depth was 1.0 mm for acantholytic SCC and 1.5 mm for non-acantholytic SCC. Well, moderate and poor differentiation were not significantly different between acantholytic SCC and non-acantholytic SCC. One PNI case was found in 82 acantholytic SCC cases. A total of 77 acantholytic SCC cases were followed up over a median 25 months finding histologic proven recurrence at three acantholytic SCC excision sites., Conclusions: Acantholytic SCC were more likely to be located on head sites with less median depth than non-acantholytic SCC. Increasing percentage of acantholysis within acantholytic SCC was not associated with a shift towards poor differentiation. Histologic margins of 1.2 mm may adequately excise small acantholytic SCC. No recorded deaths, low PNI and low recurrence rates suggests acantholytic SCC is low-risk., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Past conceptual and empirical works have identified unique differences between multiple suicide attempters, single attempters, and zero attempters, but have overlooked two distinct subgroups of single attempters: true single attempters who will not attempt suicide again, and future multiple attempters who will. Consistent with fluid vulnerability theory, the authors hypothesized that subgroups should have differences in personality traits that can predict if a first-time attempter is likely to attempt suicide again. In a sample of 127 military members (81% male, 19% female) participating in a clinical intervention study for suicidal behaviors, hypomanic symptoms -- not personality traits -- predicted future multiple attempters, and future multiple attempters more frequently met criteria for a bipolar-spectrum disorder. Clinical implications and convergence of findings with fluid vulnerability theory and existing research are discussed.

Background: Investigation of the reasons for the transfer of women from a birth centre to a hospital in the course of childbirth as well as modalities and effects., Patients and Method: In the prospective investigation from September 1, 1999 to August 31, 2001, information was collected for all women in Berlin and Bavaria transferred intrapartum from a birth centre to a hospital concerning the reason for the transfer, stage of delivery at the start of transfer, details of the transport, accompaniment, state of mother and medical diagnosis on arrival at the hospital, further progress of delivery, and the condition of the baby postnatum. Comparison groups were formed by all birth centre deliveries in Berlin and Bavaria 1999/2000 (n = 3060) and hospital deliveries in Berlin and Bavaria 1998/1999 (selected data, n = 89 696 births)., Results: Three hundred and sixty transfer cases could be evaluated, and a majority of these were nulliparous. The most frequent reasons for transfer were prior premature rupture of membranes and failure to progress in labor. Fifty-seven percentages of the women who were transferred subsequently delivered spontaneously, with an episiotomy rate of approximately 30%. 1-min Apgar value < or = 7 were frequently in nulliparous and multiparous patients in the transfer group than in the comparison groups, as were 5-min Apgar values < or = 7 and pH < 7.10 in arterial cord blood in particular for nulliparous in the transfer group. Hospitalisation of neonates born to the transfer group and in particular the nulliparous was significantly more common., Conclusions: Women delivering in a birth centre represent in general a low-risk group as a result of careful preselection by the centres. However, some neonatal data and the high rate of operative deliveries (cesarean section, forceps, and vaginal extraction) indicate that the intrapartum-transferred women, in particular when nulliparous, represent than a special high-risk group.

High frequencies of contact allergy to fragrance ingredients have been reported in recent years. Only approximately 70-80% are detected by fragrance allergens in the standard patch test series. This investigation compares the patch test reactions to fine fragrances with reactions to fragrance mix (FM), balsam of Peru (BP) (Myroxylon pereirae resin) and a fragrance series. 641 consecutive patients with eczema were patch tested with the European standard series and with selected fine fragrances. Those who were positive to 1 of the fine fragrances or the FM or BP were also tested with the fragrance series. 95 (14.8%) patients were found to have a positive patch test reaction to FM or BP; 41 (6.4%) had positive results to fragrance no. 1 and 29 (4.5%) to no. 2. 9 (9.5% of the 95 positive patients) had a positive reaction to fine fragrances and a negative reaction to all other fragrance allergens in the standard series. These findings indicate that testing with fine fragrances can add to our evaluation of fragrance-sensitive patients.

The use of in vitro release of interferon-gamma (IFN-gamma) in the diagnosis of contact allergy to potassium dichromate was studied in 20 patients who had positive patch tests to chromate and in 30 control subjects (10 patients with contact dermatitis, allergic to other allergens, 10 patients with other dermatologic diseases and 10 healthy subjects). The release of IFN-gamma in the supernatants of the peripheral blood lymphocytes was significantly higher in the patients with proven allergy to chromate (P = 0.001). Further studies are needed to determine if IFN-gamma release may serve as an additional diagnostic tool in contact dermatitis.

Objective: Our purpose was to compare birth complications and fetal outcome in hospitals and birth centers., Method: We retrospectively compared all 801 deliveries between 1992 and 1994 from two free-standing birth centers against 3271 hospital deliveries in Berlin. The hospital collective was selected according to the same risk criteria of the birth centers., Results: The birth center group had significantly fewer medical interventions, with a similar cesarean section rate (3.0% vs. 4.6%, P = 0.057) and occurrence of severe perineal lesions. The episiotomy rate was significantly higher (P < 0.001) in the clinics for first-time and multiple births. The perinatal mortality was not significantly different ( < 0.1 per 1000). One-minute Apgar scores less than 7 were found significantly more often in the birth center group., Conclusion: When birth centers employ thorough risk selection and significant early referral rates to nearby hospitals, there is no evidence of increased maternal or perinatal risk compared to hospital deliveries.

Pigmented contact dermatitis has been found to be caused by fragrances, cosmetics, washing powders, azo dyes in textiles, and rubber products in selected groups of patients. The aim of this study was to run screening patch tests in an unselected group of patients with pigmented contact dermatitis (n=29) encountered in our center over a 2-year period. The test series included the European standard, cosmetics, fragrance, Scandinavian photo, and personal products. 21 patients had a positive reaction in at least 1 of the series (total, 29 reactions): 16 - standard, 3 - cosmetics, 1 fragrance, 9 photo, and 1 - personal products; 16 (55%) had relevant results. We conclude that the highest yield for screening for pigmented contact dermatitis is achieved with the standard and photo series.

Total chromium levels were determined in 38 detergents and 12 bleaches on the market in Israel (45 locally produced, 5 imported). The samples were analyzed by Zeeman-corrected graphite furnace atomic absorption spectrophotometry. Chromium levels were higher than 5 ppm in 28 (56%) of the 50 products, from 1 to 5 ppm in 16 (32%), and lower than 1 ppm in only 6 (12%). Among the 5 imported products, only 1 had a chromium level below 1 ppm and the other 4 (1 from Germany, 3 from the USA) had high levels. Since a most 90% of the detergents and bleaches examined contained chromium levels higher than 1 ppm, it is concluded that these consumer products may be the cause of the high incidence of chromium sensitivity in Israel.

We describe a girl with eosinophilic cellulitis (Wells syndrome) in whom the disease appeared immediately after birth with subcutaneous nodules on the scalp and trunk, followed by the characteristic skin swelling and erythema at the age of 6 months. The lesions disappeared after a few weeks, but recurred several times. The mother had consumed large quantities of medications during the pregnancy, including iron, vitamins, and "natural remedies." Based on time of onset, this may be regarded as a unique case of congenital Wells syndrome. Its relation to the medications taken by the mother remains speculative. Subcutaneous nodules may be the presenting sign of Wells syndrome in children.

We investigated the contribution of different screening criteria to the prenatal detection of Down syndrome (DS) as well as other chromosomal anomalies in the Jewish population in Israel during 1990 and 1992. There was a significant decrease (P < 0.03) in the incidence of DS live-births during 1992 (40:78 442) compared with 1990 (69:73 751) which paralleled a marked increase in total prenatal testing and in DS cases detected prenatally. Private laboratories, which perform amniocenteses mostly for women with a low risk of DS and without genetic counselling, had a significantly lower detection rate (1:917) compared with that of the genetic institutes, which following genetic counselling test both women > or = 37 years of age (1:91) and women younger than 37 years (1:113). The detection of chromosomal anomalies other than DS was less affected by the reason for amniocentesis. Amniocentesis indicated by maternal serum marker screening of women younger than 37 years identified a greater number of chromosomal anomalies other than DS than amniocentesis based on age (> or = 37 years) alone (111:9604 versus 94:9810; P < 0.06). Prenatal detection of DS is most effective when the indication for amniocentesis follows genetic counselling. The increasing use of maternal serum marker screening leads to a significant improvement in the positive detection rate of chromosomal anomalies other than DS in young women.

Background: Four epidemiologic types of Kaposi sarcoma (KS) are known: classic KS, endemic African KS, epidemic or acquired immunodeficiency syndrome-related KS, and KS associated with immunosuppressive therapy. In most of the latter patients, KS was reported to have developed after organ transplantation, particularly renal transplantation. Thirty-nine patients who have not had a transplant have been reported to have KS associated with corticosteroid therapy., Methods: The authors studied 10 patients with the appearance of KS during corticosteroid therapy (6 men, 4 women; age range, 42-79 years) who were treated with corticosteroids for autoimmune disorders (5 patients), lymphoproliferative disorders (2 patients), and diseases unrelated to the immune system (3 patients)., Results: Genetically programmed susceptibility to corticosteroid-related KS was suggested by the descent of the study patients as well as most of those reported previously. The prognosis was guarded in all the study patients., Conclusions: Corticosteroids should be withdrawn to achieve clinical remission.

1. The in vitro effects of endothelins (ET-1 and ET-3) on human platelets were investigated by measurement of the aggregatory responses of washed platelets to thrombin and by the determination of cytosolic pH (pHi) and free Ca2+ concentration ([Ca2+]i) determined with the fluorescent indicators, BCECF and Fura-2. 2. ET-1 and ET-3 at concentrations ranging from 10(-10) to 5 x 10(-7) M, did not promote platelet aggregation but inhibited in a dose-dependent manner the aggregation induced by 0.05 u ml-1 thrombin (P less than 0.002 and less than 0.001, respectively) with maximal effects reached at 10(-8) M (17 +/- 3 and 15 +/- 2%, n = 11, P = 0.002 for each). 3. Even at 5 x 10(-7) M, ET-1 and ET-3 did not cause a measurable change in basal [Ca2+]i and pHi. When tested in combination with thrombin, 5 x 10(-7) M ET-1 and ET-3 decreased the transient peak of [Ca2+]i by 17 +/- 7 and 28 +/- 7% (n = 7 and 11, P = 0.03 and P = 0.002). No effect on pHi variations was detected. In the virtual absence of external Ca2+, 5 x 10(-7) M ET-3 inhibited the peak of [Ca2+]i by 18 +/- 6% (n = 6, P = 0.02). 4. The anti-aggregating agents, prostacyclin (PGI2, 10(-8)-10(-7) M) and nitroprusside (NP, 10 ng-50 micrograms l-1) also induced a dose-dependent inhibition of the thrombin-induced [Ca2+]i peak (P = 0.001 for each).A combination of 10-9M PGI2 and 1O ng P' NP augmented the inhibitory effect of each drug(PGI2 alone 52 +/-11, plus NP 90 +/- 2; NP alone 26 +/- 4, plus PGI2 69 +/- 5% inhibition of [Ca2 ], peak, n = 6 for each, P <0.01 and P <0.001, respectively). Platelet preincubation with 5 x 10-7M ET-3 increased by 34+/-11% (n = 6, P = 0.0 14) the inhibitory effect of NP 1O ng without a significant influence on the PGI2 effect.5. In conclusion, endothelins ET-1 and ET-3 can reduce in vitro the aggregating response of human platelets to thrombin by a mechanism that is probably due to decrease Ca2+ mobilization.

A 57-year-old woman who had undergone a lumpectomy for infiltrating duct cell carcinoma of the right breast was found to have morphea after receiving radiation therapy. The morphea occurred at the site of the irradiated field. It is suggested that the irradiation served as a provoking factor and that the morphea might be an isomorphic response to the trauma of the irradiation.

Among 212 vascular prostheses collected in a vascular explant retrieval program, 50 exhibited one or more criteria of graft infection i.e., (a) clinical evidence of graft infection, (b) positive bacteriological analyses of the graft, and (c) presence at the blood-prosthetic interface of characterized microorganisms. Whereas each of these criteria was noted respectively in 25, 26, and 20 cases, there was no complete overlapping among the three criteria, but their combination led us to consider 50 cases of infected vascular grafts among the 212 collected. These results, and the occurrence in two cases among six investigations for viral infection, suggest that extensive bacteriological investigations of vascular explants should be included in an implant retrieval program, and that infection may represent a high risk in graft failure.

In 10 patients with mycosis fungoides (MF) who were in clinical remission following local treatment with nitrogen mustard, cell-mediated immunity was investigated by means of tests for lymphocytes, forming rosettes in the peripheral blood, and the graft-vs-host reaction as well as intradermal skin tests. The effect of thymic humoral factor (THF) on T lymphocytes with impaired immunecompetence was also investigated. The results provided evidence of various kinds of damage to the immunologic system in most of the patients. Of the 10 patients, 4 had low percentages of T cells. Eight of the 10 had a graft-vs.-host reaction which was weak or negative, and in 4 of these, the administration of THF to the lymphocytes induced an improvement in immunoreactivity. These results together with other recently reported data indicate that the determination of cell-mediated immunity in patients with MF may be of prognostic importance. Those patients whose T lymphocytes respond to treatment with THF are probably the best candidates for immunotherapy.

The skin biopsy specimens from six patients with primary mixed IgM-IgG cryoglobulinemia were examined by immunofluorescence, light and electron microscopy. The biopsy taken from the involved skin of one patient with leg ulcers revealed small blood vessel occlusions by cryoglobulin aggregates. Since a similar finding was not observed in the biopsy material taken from the other five patients who had no ulcerative skin lesions, it seems that the cryoglobulin aggregates play a role in the development of the skin ulcerations in primary mixed IgM-IgG cryoglobulinemia.

Tumor grade has been proposed as an essential factor in the staging of patients with soft tissue sarcomas. In a previous study, a histopathologic grading system using the evaluation of tumor differentiation, mitosis count, and tumor necrosis was described. The current study was conducted to test its reproducibility. The pathologic sections of 25 soft tissue sarcomas were submitted to a study group composed of 15 pathologists who had not been involved in the development of the grading system. The results were compared with those of a panel group. The crude proportion in agreement observed between the study group and the panel group was 81% for the evaluation of tumor necrosis, 74% for tumor differentiation, and 73% for the mitosis count. The crude proportion in agreement for the tumor grade was 75%, which was significantly better than the crude agreement rate of 61% for the diagnosis of histologic type (P = 0.001). A kappa statistical analysis, to check the possibility of chance-related concordance, showed a proportion in agreement of 68%. A two-way variance analysis showed that the homogeneity of the evaluation of tumor grade is impaired by tumor-related and observer-related factors. However, an improvement may be obtained by better training of pathologists. We conclude that the tumor grading system developed inside the French Federation of Cancer Centers, although perfectible, already provides reliable prognostic information and its use in prospective clinical studies may provide more information about its clinical usefulness.

We examined a 6-year-old boy with seborrheic dermatitis like redness of the face, scaling of the scalp, and palmoplantar keratoderma. Skin biopsy showed hyperkeratosis, parakeratosis, follicular plugging, and mild upper dermal perifollicular mononuclear inflammatory infiltrate, which are compatible with the diagnosis of pityriasis rubra pilaris. Immunologic studies revealed normal values of peripheral B and T lymphocytes. The spontaneous activity of T suppressor cells was activated and the function of T helper cells was impaired, however.