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Abstract: In a prospective study, a large number of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) underwent surgery using three dimensional (3D) histology and were evaluated with respect to local recurrence. The excised tumours were treated using 3D-histology with a routine paraffin procedure until the surgical margins were clear of tumour. Prospective evaluation of recurrence-free survival and overall survival of 5227 primary BCCs in 3320 patients and 615 invasive primary SCCs in 600 patients was conducted in the form of a letter-based follow-up with feedback from the patients and the referring physicians. The mean follow-up period was 5 years. In the BCC collective, 36 out of 3320 patients developed local recurrence (1%, calculated as a percentage of treated BCCs: 0.7%). In the SCC collective, 20 local recurrences appeared (3%). The recurrence rate for SCCs with desmoplasia was 24%, whilst the recurrence rate for common types of SCC without desmoplasia was 1%. Surgery followed by 3D histology results in very low recurrence rates for BCC and SCC with no additional effort compared with the normal histopathological procedure. [Copyright &y& Elsevier]

Summary Background Large nonhealing ulcers and wounds frequently pose a great therapeutic challenge to clinicians and often require skin grafting. Various skin grafting methods are available to cover large skin defects that fail to epithelize. These methods include the use of small pinch grafts, full-thickness punch grafts, large-sized full-thickness grafts and split-thickness grafts. Large-sized full-thickness and split-thickness skin grafting requires expertise to produce cosmetically acceptable results and prevent cobblestoning, unlike small pinch and full-thickness punch grafts. Objectives To describe a modified technique of split-thickness skin grafting that can be considerably faster than alternative methods. Methods We describe a method for split-thickness skin grafting using tumescent anaesthesia at the donor site and an electrodermatome and a polyurethane membrane without sutures at the site of the skin defect. Results Since 1997, we have practised a modified, improved, quick and easy split-thickness skin grafting method to cover large skin defects at the extremities. Complete healing is usually achieved 4-6 weeks after the split-thickness skin transplantation, and long-term results are aesthetically successful. Conclusions We provide a sophisticated modified split-thickness skin graft procedure that has been practised for many years and provides cosmetically acceptable results while saving time. [ABSTRACT FROM AUTHOR]

Even today the deaths of King Ludwig II of Bavaria and the Munich-based psychiatrist Bernhard von Gudden on 13 June 1886 remain something of a mystery. In his psychiatric expertise von Gudden had rated Ludwig as insane and incapable of governing. Ludwig was placed under tutelage, deposed and interned under the supervision of guards. After the catastrophe witnesses and the press were silenced by strict censorship under threat of heavy penalties. Even today obstacles to free information still exist, aiding and abetting the birth of legends and the preservation of leading traditional views. We report on the results of a 5-year research project conducted at the Heidelberg Academy of Sciences and Humanities and based on information derived from private and public archives in Germany and abroad. Reference is made to comparable analyses. Neither von Gudden's expertise nor Ludwig's behaviour provide reliable cues to his alleged insanity. The reasons and motives behind the king's deposition are discussed. Apart from von Gudden's tragic death, this was not a singular case of a psychiatric expertise commissioned in the monarchist culture of the nineteenth and the early twentieth century. [ABSTRACT FROM AUTHOR]

Objective For reasons of their outdoor work, mountain guides (MG) are heavily exposed to ultraviolet radiation during their work. Methods A standardized interview and examination were performed on 283 male MG (median 41 years) from Germany, Switzerland and Austria and 309 age-matched controls. The median occupation time as MG was 17 years; 39.9% were working full-time. Results The incidence of skin cancer and precancerous lesions was obtained. Precancerous lesions as solar keratosis (SK) were significantly more frequent in MG (25.4% vs. 7.4%). There was no skin cancer [BCC, SSC, melanoma (MEL)] in the control subjects. Basal cell carcinoma (BCC) was diagnosed in 20 MG (7.1%) and SSC in four MG (1.4%). There were 10 highly suspicious melanocytic lesions; one MG had a histologically confirmed malignant MEL. Risk factors for SK in the multivariate analysis included occupation ( P < 0.0001), age ( P < 0.0001) and skin type ( P = 0.0002). Within the MG group, age ( P < 0.0001) and hair colour ( P = 0.0058) were independent risk factors for SK. Severe lifetime sunburns ( P = 0.0007) and skin type ( P = 0.041) were the significant risk factors for BCC, within the MG group in addition to the number of guiding days ( P = 0.010). The risk factor for skin cancer (BCC, SCC and MEL) was the number of heavy sunburns during lifetime ( P = 0.0014). Conclusion The present study demonstrates an association between high occupational ultraviolet-exposure and an increased prevalence of precancerous skin lesions and skin cancer. MG may be considered as an example for other outdoor professionals. Skin cancer of outdoor workers is likely to be an occupational disease. Primary and secondary prevention should be enforced. [ABSTRACT FROM AUTHOR]

Data on time-dependency of external ventricular drainage (EVD)- and lumbar drainage (LD)-associated meningoventriculitis (MV) are scarce and discussions on the subject are controversial; no data exist for infection rates (IR) relative to drainage-days. For this reason, we conducted an observational study to determine time-dependent IRs and to perform a risk factor analysis. All patients ( n = 210) requiring an EVD or LD during an 18-month period in 2007 and 2008 were enrolled and characterized. Data on type and duration of drainage, ICP measurement, number of drainage manipulations, hospital stay and time point of MV were analysed statistically. A total of 34 MV cases were reported with 17 for each kind of drainage accounting for an IR of 7.5 and 24.7 MV/1000 EVD- and LD-days, respectively. Of these, 28/34 MV (82%) occurred within the first 12 days, and IRs were highest between days 4 and 9. Longer drainage duration (>5 and >9 days, respectively) was correlated with a significant lower risk of MV ( p = 0.03; p < 0.001). In this study, significant risk factors for MV were LD [vs. EVD, OR: 2.3 (1.1–4.7); p = 0.01], a previous MV [OR: 7.0 (2.1–23.3); p = 0.002], and neoplasm [OR: 11.6 (3.4–39); p = 0.001]. Simultaneous drainage, ICP and a previous drainage showed no influence on infection. To the best of our knowledge, this study is the first to provide data on time dependency of EVD- and LD-associated MV-IR based on drainage-days. However, because of the limited scale of our study, it would be desirable to confirm these results in a more powerful larger study. In conclusion, we recommend that future efforts should be made to better identify preventable risk factors as well as to define time periods of higher risk for the difficult-to-diagnose MV infection as a first step in profiling high risk patients. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To evaluate the microscopic growth pattern of dermatofibrosarcoma protuberans (DFSP) and malignant fibrous histiocytoma (MFH) and the long-term outcome using 3D-histologic surgery with paraffin sections to cover complete margins and to detect subclinical spreads very sensitively. Methods: One hundred and one patients have been included comprising 70 DFSP, 31 MFH. Data from 87 patients treated since 1992 were collected prospectively. Results: Mean clinical tumor-size was 45mm, mean histological tumor size 65mm. A mean excision margin of 19mm achieved negative margins. The histological infiltration shows an asymmetrical pattern with horizontal or vertical extension either cord-, sector- or multiple-like up to 70mm in length, detectable by 3D-histology. Age and localization differed significantly between DFSP and MFH lesions. MFH tumors had a significantly deeper infiltration than DFSP. The mean follow up was 60months. In 70 patients with DFSP one local recurrence after 62months occurred, but no metastasis. 31 patients with MFH developed 8 local recurrences, and 4 metastases (lymph nodes and/ or lungs); 3 of them died of the disease, all 3 had a postoperative status of R1 (p =0.001). Conclusions: There are significant differences in growth pattern and clinical outcome between DFSP and MFH. DFSP can be cured by surgery following 3D-histology with paraffin sections. MFH is significantly more malignant. After local R0-resection proofed by 3D-histology higher cure rates can be achieved. [Copyright &y& Elsevier]

Background. People in a putatively late prodromal state not only have an enhanced risk for psychosis but already suffer from mental and functional disturbances. Aims To evaluate the acute effects of a combined supportive and antipsychotic treatment on prodromal symptoms. Method Putatively prodromal individuals were randomly assigned to a needs-focused intervention without (n=59) or with amisulpride (n=65). Outcome measures at 12-weeks effects were prodromal symptoms, global functioning and extrapyramidal side effects. Results Amisulpride plus the needs focused intervention produced superior effects on attenuated and full-blown psychotic symptoms, basic, depressive and negative symptoms, and global functioning. Main side-effects were prolactin associated. Conclusions Co-administration of amisulpride yielded a marked symptomatic benefit. Effects require confirmation by a placebo-controlled study. Declaration of interest None. Funding detailed in Acknowledgements. [ABSTRACT FROM AUTHOR]

Local anaesthetics are an integral part of modern surgery since diluted solutions of cocaine were described nearly 150 years before. Tumescent local anaesthesia (TLA) utilizes a mixture of highly diluted local anaesthetics in a carrier solution and is used for skin biopsies, excision of skin tumours and vein surgery.[1] Also, wide excisions for hidradenitis suppurativa, serial excisions of giant congenital nevi (Fig.), Rhinophyma surgery or lymph node dissections are feasible using TLA.[[2]]. [Extracted from the article]

Background: We assessed data on the epidemiology of nosocomial infections (NIs) in a 14-bed neurosurgical intensive care unit (NSICU) and used surveillance data for the promotion of quality improvement activities. Patients and Methods: Prospective periodic surveillance was performed over five 3-month periods between July 1998 and October 2002 on all patients admitted with a length of stay > 24 hours. Results: 763 patients with a total of 4,512 patient days and a mean length of stay of 5.9 days were enrolled within the 15-month study period. A total of 93 NIs were identified in 82 patients. Urinary tract infections (24.7%), pneumonia (23.6%), and bloodstream infections (17.2%) were the most frequent NIs recorded. Device-associated incidence rates were 6.0 (3.8-9.0, CI95%) for urinary tract infection, 4.4 (2.4-7.4, CI95%) for bloodstream infection, and 10.3 (6.3-15.9, CI95%) for pneumonia per 1,000 days at risk. For improvement of infection control-related processes, evidence-based infection control guidelines were established and an NSICU nurse was designated to be responsible for infection control issues on the ward. In addition, several infection control problems arose during the observation periods and were rapidly responded to by introducing specific intervention strategies. Conclusion: Periodic surveillance is a valuable tool for assessing the epidemiology of NIs in the NSICU setting as well as for promoting the initiation of quality improvement activities. [ABSTRACT FROM AUTHOR]

The article offers the author's insights on professor Jules Angst, who is considered the best candidate for the Burghölzli Award, and his psychiatry-related works. He says that Angst showed that suicide risk has an even distribution on the illness course. He mentions that the laudatio was presented in honour of Angst during the Burghölzli Award ceremony.

Eml® cream is frequently used in surgical dermatology and in anesthesiology, for instance, during vascular surgery procedures. Because local anesthetics can have a vasoactive effect in addition to producing analgesia, we decided to document the effect of 5% Eml® cream on cutaneous circulation in a prospective, placebo-controlled study. Skin circulation was monitored continuously under standardized conditions using video capillaroscopy, laser Doppler flowmetry and skin temperature. Recordings were made at the nailfold of the fourth finger (DIV) of the left hand of 12 volunteers with healthy veins over an observation period of 60 minutes under either Eml® occlusive dressing or an occlusive dressing with placebo. Mean capillary red blood cell velocity changed only minimally under the Eml® occlusive dressing, while placebo occlusive dressing led to a reduction of mean capillary red blood cell velocity from 0.21 mm/s to 0.12 mm/s (p < 0.01). There was no statistically significant change of arterial capillary diameter under Eml® or placebo occlusive dressing. Skin temperature dropped after 60 minutes of Eml® cream occlusive dressing from an initial 26.7 to 24.0°C (-10.1%; p < 0.02). The same duration of placebo caused skin temperature to drop from 27.6 to 23.0°C (-16.7%; p < 0.001). Laser Doppler flux (543 nm) rose 13% with Eml® (p = 0.9) and dropped 41.9% under placebo occlusive dressing (p < 0.03). Eml® cream upregulated nutritive perfusion. No clinically relevant vasoconstrictive effects are expected from an application period of 60 minutes. [ABSTRACT FROM AUTHOR]

Sex differences in schizophrenia can be caused by the disease process itself, by genetic and hormonal differences, by differences in the maturation and morphology of the brain and in age- and gender-specific behavioural patterns. These hypotheses will be tested on the major results reported in the literature as well as on different levels (epidemiology, risk factors, animal experiments, a controlled clinical study) on data from the ABC Schizophrenia Study. Symptomatology, lifetime risk and symptom-related course of illness—the latter without consideration of age—show no gender differences. However, until menopause illness onset is delayed and severity of illness is reduced by oestrogen on the level of gene expression and transmitter functioning. Oestrogen has an antagonistic effect on the—familial or exogenous—predisposition to illness. As a result, the age distribution of onset and the severity of first-episode illness in young men and post-menopausal women differ from the normal. First intervention trials with oestrogen substitution of neuroleptic therapy have demonstrated antipsychotic effects.The poorer social course of schizophrenia in men than in premenopausal women is accounted for by men’s lower level of social development at illness onset and the subsequent impediment of their further development. Men’s socially adverse illness behaviour, too, is a contributing factor. Scarcity of the knowledge of differences in the development, morphology and functioning of the male and female brain does not yet allow any definitive conclusions about gender differences in schizophrenia. [Copyright &y& Elsevier]

A new standardised interview for the retrospective assessment of onset and early course of schizophrenia (IRAOS) was used to study the influence of age and sex on time of onset and psychopathology before first admission in 267 schizophrenic patients admitted for the first time. Mean age at onset, according to various operationalised definitions, differed by three to four years between the sexes. The age distribution at the earliest sign of mental disorder showed an early and steep increase until the age of 25 in males, and a delayed and smaller increase in females, with a second peak in women aged 45-79. Schizophrenia began with negative symptoms in 70% of cases, appearing two to six years before admission, and all positive symptoms appearing up to two years before. Both positive and negative symptoms accumulated exponentially. The early course of the disease was similar across age groups, except there was a longer period of negative symptoms before first admission in late-onset schizophrenia in women. The few significant age differences in symptoms were presumably due to general age-dependent reaction patterns like anxiety and depression or the cognitive development of personality, as indicated by an increase in fully elaborated positive symptoms, especially systematised paranoid delusions, with age. [ABSTRACT FROM AUTHOR]

While the demand for deinstitutionalization, strongly supported by the economic aspect of the issue, has resulted in a steep decline in the number of psychiatric beds in many Western countries, the evaluation of extramural psychiatric care has several difficulties, including that of proving effectiveness without experimental control of confounding influences. For a cohort of schizophrenic patients we investigated the impact of out-patient psychiatric treatment on length of stay in hospital and length of stay in the community. Out-patient care had a significant influence on readmission, but no effect on the length of in-patient treatment. While the average cost of community care was less than half that of traditional hospital care, in 6% of the patients this threshold value of continued in-patient care was exceeded. There also seems to be a non-monetary threshold, above which community care is no longer appropriate. [ABSTRACT FROM AUTHOR]