Prevalence of skin tears in the extremities among elderly residents at a nursing home in Denmark.

OBJECTIVE: The aim of the study was to determine the prevalence of skin tears in the extremities and explore factors in relation to skin tears in elderly residents at a Danish nursing home. METHOD: The study was designed as a point prevalence survey and conducted at a nursing home with 140 residents >65 years of age. The residents were assessed for presence, number and location of skin tears. Data were collected using a data collection sheet developed for this study. The survey team consisted of four expert nurses from a university hospital (two dermatology and two wound care nurses). Data were collected over a period of 10 hours spread over two days. RESULTS: Of the 128 participating residents six had skin tears, yielding a prevalence of 4.6 %. In total, 10 skin tears were observed in the 6 residents. The frequency of previous skin tears was 19.5 %. This frequency was significantly higher in residents with skin tears than in those without skin tears (83.3 % versus 16.4 %, p<0.001). Analysis of the relation between skin tears or previous skin tears versus without skin tears or previous skin tears showed significant differences related to the presence of ecchymosis (76.9 %versus 14.7 %, p<0.0001). There were no other significant factors observed. CONCLUSION: The low prevalence found in this study may reflect the focus on prevention of skin tears that the nursing home has maintained over the past year. Nevertheless, the appropriate prevention and management of residents with skin tears is an ongoing challenge for health professionals.

Final results of the randomized phase III CHARTWEL-trial (ARO 97-1) comparing hyperfractionated-accelerated versus conventionally fractionated radiotherapy in non-small cell lung cancer (NSCLC).

BACKGROUND: Continuous hyperfractionated accelerated radiotherapy (CHART) counteracts repopulation and may significantly improve outcome of patients with non-small-cell lung cancer (NSCLC). Nevertheless high local failure rates call for radiation dose escalation. We report here the final results of the multicentric CHARTWEL trial (CHART weekend less, ARO 97-1). PATIENTS AND METHODS: Four hundred and six patients with NSCLC were stratified according to stage, histology, neoadjuvant chemotherapy and centre and were randomized to receive 3D-planned radiotherapy to 60Gy/40 fractions/2.5weeks (CHARTWEL) or 66Gy/33 fractions/6.5weeks (conventional fractionation, CF). RESULTS: Overall survival (OS, primary endpoint) at 2, 3 and 5yr was not significantly different after CHARTWEL (31%, 22% and 11%) versus CF (32%, 18% and 7%; HR 0.92, 95% CI 0.75-1.13, p=0.43). Also local tumour control rates and distant metastases did not significantly differ. Acute dysphagia and radiological pneumonitis were more pronounced after CHARTWEL, without differences in clinical signs of pneumopathy. Exploratory analysis revealed a significant trend for improved LC after CHARTWEL versus CF with increasing UICC, T or N stage (p=0.006-0.025) and after neoadjuvant chemotherapy (HR 0.48, 0.26-0.89, p=0.019). CONCLUSIONS: Overall, outcome after CHARTWEL or CF was not different. The lower total dose in the CHARTWEL arm was compensated by the shorter overall treatment time, confirming a time factor for NSCLC. The higher efficacy of CHARTWEL versus CF in advanced stages and after chemotherapy provides a basis for further trials on treatment intensification for locally advanced NSCLC.

[Survival and pattern of failure in palliative endobronchial HDR -- brachytherapy using iridium 192 in recurring bronchial carcinoma]. / Uberleben und Todesursachen nach palliativer endobronchialer Brachytherapie mit Iridium 192-High dose bei rezidivierendem Bronchialkarzinom -- Eine Matched Pair Studie.

To evaluate the impact of palliative high dose rate brachytherapy on survival and a pattern of failure, we performed a matched pair study. 94 patients with tumor recurrence after external beam radiation received endobronchial brachytherapy. They were followed prospectively and matched retrospectively with 94 comparable patients who had not received brachytherapy. Matched parameters were age, gender, smoking behaviour, histology, tumor stage, EBRT-dose and fractionation. The leading cause of death in both groups was generalized tumor growth. In the combined therapy group, fatal hemorrage was 27.7 %, two and a half times higher than in the EBRT group with 10.6 %, whereas respiratory insufficiency in the brachytherapy group was 6.4 % and 11.7 % in the EBRT group. A complete remission after brachytherapy yielded a 10.5 months longer mean survival. Patients dying from fatal hemorrhage after endobronchial brachytherapy lived on average 10.2 months longer than matched EBRT patients dying from the same cause. Analyzing the time-course of fatal hemorrage in the brachytherapy group we conclude that - because of its early onset in the first 10 months after induction of therapy roughly 20 % of the deaths can be attributed to a radiation damage. In those patients who died after 10 months the major cause of fatal hemorrhage was the natural course of sqamous cell carcinoma with prolonged survival.

Sequential photodynamic therapy (PDT) and high dose brachytherapy for endobronchial tumour control in patients with limited bronchogenic carcinoma.

BACKGROUND: Bulky endobronchial tumours in patients with lung cancer are difficult to treat. Brachytherapy and photodynamic therapy (PDT) are variably effective, and the combination of these treatments is not often recommended. However, cell culture studies and animal studies indicate a possible synergistic effect of combining PDT with ionising radiation. We assessed the safety and effectiveness of combined brachytherapy and PDT in patients with bulky endobronchial lung cancer. METHODS: Patients with histologically proven non-small cell bronchogenic carcinoma and bulky endobronchial tumours were treated using a combination of PDT (Photofrin, 2 mg/kg) and brachytherapy. Six weeks after PDT, brachytherapy was applied with five fractions of 4 Gy at weekly intervals. Follow up was performed with standard and autofluorescence bronchoscopy and tissue biopsies every 3 months. RESULTS: Thirty two patients were treated. Tumours were extensive with lengths ranging from 10 to 60 mm along the bronchus and estimated volumes ranging from 40 to 3500 mm3. At a mean follow up of 24 months, 26 patients were free of residual tumour and local recurrence. The remaining patients received a second treatment with PDT, brachytherapy, Nd:YAG laser coagulation, or external beam radiation. Distant metastases (lung, lymph node) developed in two of the six patients. Currently, all 32 patients are well. There is no evidence of residual or local recurrent endobronchial cancer in 28 patients and none had severe complications. CONCLUSION: The combination of PDT and brachytherapy for treating patients with lung cancer and extensive endobronchial tumour is safe and, in this study, had excellent therapeutic efficacy.

[High-dose, stereotactic, one-time radiotherapy with curative intent for peripheral lung cancer]. / Hochdosierte stereotaktische Einzeitbestrahlung mit kurativer Intention bei peripherem Bronchialkarzinom.

In peripheral non small cell lung cancer without metastasis, surgical resection achieves 5-year survival rates of at least 65%. In functionally inoperable patients radiation therapy offers the second best changes. However, in cases of severe emphysema with severely limited lung function even conventional radiation therapy is prohibited because of possible fibrotic reactions of the lung parenchyma. For such patients high dose rate stereotactic one-time radiation therapy may be an option. According to the study protocol of the DKFZ Heidelberg a dose rate of 24 Gy at the iso-center is applied with the linear accelerator in a single session. The recognisable tumour is irradiated with 22 Gy (90% isodose included). 20 Gy are applied to the tumour plus 6 millimeters safety margin. Prerequisites of such a therapy are a detailed computer-based planning using CT scans and an exact positioning with immobilisation of the patient. The irradiation is ideally performed under general anesthesia with high-frequency jetventilation to avoid movements due to breathing. We report on this new therapeutic modality in a patient with lung emphysema having a T2 tumour.

Endobronchial radiation therapy for obstructing malignancies: ten years' experience with iridium-192 high-dose radiation brachytherapy afterloading technique in 365 patients.

From 1983 to 1993, 365 patients with obstructing endobronchial malignancies were treated by endobronchial high-dose radiation (HDR) iridium-192 afterloading. In 346 patients, the objective was palliation, and in 19, the objective was curative. A dose of 5 Gy at 10 mm from the source axis was administered on three (palliation) and four (cure) occasions, at intervals of 14 days. The majority of patients were treated after exhaustion of external beam radiation therapy (EBRT), often in conjunction with other interventional bronchologic modalities such as endobronchial laser resection. Of the patients, 65% had a squamous cell carcinoma. Endobronchial HDR brachytherapy results in few acute complications and can be performed with no major discomfort on an outpatient basis. In approximately 66% of patients, a palliative effect is achieved, even after the exhaustion of conventional treatment. Life may be prolonged for a few months, but the enhancement of survival is difficult to assess for several reasons. Mean survival is 9 months for limited disease and 5 months for extensive disease. Endobronchial HDR brachytherapy influences the pattern of failure: a 21% rate of fatal hemorrhages is probably the result of the selection of patients for this treatment rather than a treatment-related complication. There is sufficient evidence to suggest the rational use of HDR brachytherapy in combination with EBRT to effect a cure, or even on its own when tumor growth is strictly limited. However, the standardization of radiotherapy and endoscopic indications is an urgent priority. Prospective, controlled, and cooperative studies are mandatory. Endobronchial iridium-192 HDR brachytherapy complements endobronchial laser resection and is currently an established technique in the treatment of advanced malignant airway obstruction.

[Endobronchial brachytherapy: endoluminal small-volume irradiation of bronchial tumors using the high-dose-rate afterloading method]. / Endobronchiale Brachytherapie: Die endoluminale Kleinraumbestrahlung von Bronchialtumoren mit dem Afterloading HDR-Verfahren.

Endobronchial irradiation has been in use for over 70 years. This method of treatment has become much less of a burden to the patient thanks to developments in isotope technology, bronchoscopy and radiation therapy. It is effective in providing good palliation and in central bronchial tumours with involvement of the large airways, endobronchial irradiation has proved to be a valuable addition to our armamentarium. In the context of curative irradiation it may be combined with external beam irradiation. In tumours confined to the bronchial wall, endobronchial irradiation alone has been successfully used to achieve a cure. This method should however only be used in large thoracic centres as there are relatively few indications for its use.

[Thrombosis of the left jugular-subclavian vein junction as a rare late complication of oleothorax]. / Die Thrombose des linken Jugularis-Subclavia-Venenwinkels als seltene Spätkomplikation eines Oleothorax.

Thirty years after bilateral pneumolysis followed by plombage with paraffin for bilateral upper lobe tuberculosis, a 58-year-old female patient suffered a thrombosis of the left jugular- subclavian vein junction. Compression of the vessel by the plombage in addition to chronic fibrous scar tissue reaction must be assumed as the main cause of thrombosis, since infection of the plombage space was excluded.

[Mediastinal staging of non-small cell bronchial carcinoma. The place of computed tomography and mediastinoscopy]. / Mediastinales Staging des nichtkleinzelligen Bronchialkarzinoms. Stellenwert der Computertomographie und Mediastinoskopie.

Sixty patients with a potentially resectable non-oat-cell lung carcinoma were examined by computed tomography and cervical mediastinoscopy. The sensitivity of computed tomography as opposed to mediastinoscopy was 74% versus 58% and the specificity in 85% versus 100%. Considering the limitations of both methods and the varying prevalence of mediastinal lymph-node metastases associated with peripheral and central lesions, three different situations can be distinguished: 1. with peripheral lesions and a normal mediastinal CT, preoperative mediastinoscopy is unnecessary. 2. With an abnormal mediastinal CT, mediastinoscopy is always indicated irrespective of the location of the tumor. 3. With large central lesions, mediastinoscopy is necessary even when the CT is normal. Using these rules, 37 of 60 mediastinoscopies in our patient group could have been avoided without influencing the resection rate (98%).

The diagnosis, therapy and prognosis of diffuse malignant mesothelioma.

Between 1969 and 1985, 245 patients with diffuse malignant mesothelioma were treated (157 male, 88 female). The average age was 55.8 years and the sex ratio was 1.8:1 in favour of males. The right side was more frequently affected than the left (56.7% vs. 43.3%). A pleural effusion and dyspnoea were the presenting signs and symptoms in 83.7% of the patients and unilateral chest pain in 64.2%. Noninvasive diagnostic procedures included a chest X-ray and computed tomography of the thorax. Pleural effusion and pleural thickening were detected most frequently. Malignant cells were identified by pleural fluid cytology in 45.3% and by needle biopsy of the pleura in 42.7% of the patients. Forty-five patients were treated conservatively and 200 patients underwent operation: diagnostic thoracotomy (78); partial pleurectomy (72); total pleurectomy (46); extended pleuropneumonectomy (2); partial removal of the diaphragm (1) and total pleurectomy and upper lobectomy (1). The perioperative mortality was 6%. The conservative and postoperative treatment depended on the patients' symptoms and included radiotherapy and chemotherapy alone or in combination. The mean survival time of the 222 non-survivors was 9.2 months. After 1 year, 36% of the patients were still alive, after 2 years, 10.8% and the 5-year survival was 4.1%. The median survival time in patients treated non-operatively was 6 months--a little over half that of the patients treated surgically (10.1 months).

[Surgery of lung metastases]. / Chirurgie von Lungenmetastasen.

Between 1975 and 1985 76 patients underwent surgery of pulmonary metastases in our hospital. Most often the primary tumor was located in carcinomas of the colon and rectum (19 patients), followed by carcinomas of the kidney (14 patients), the breast (13 patients) and the skin (malignant melanoma: 9 patients). Conditions for pulmonary metastasectomy are radical removal of the primary tumor, metastases located only in the lung, resectability of the metastases and low operative risk. Three years after pulmonary metastasectomy 35% of the patients were still alive, the 5 year survival rate was 18%. The median survival time was 22 months. The prognosis in patients with pulmonary metastases is largely dependant upon tumor type. Pulmonary metastases of breast carcinomas and carcinomas of colon and rectum can be treated best by surgical intervention. (5 year survival rate: 35% and 33%). Hypernephroma and malignant melanoma have a 5 year survival rate of 0% and 23%. Other prognostic factors are the number of pulmonary metastases and the disease-free interval between surgery of the primary tumor and pulmonary metastasectomy. Furthermore resection techniques are of prognostic importance. Lobectomy and segmental resection showed a better 5 year survival rate than pneumonectomy (21%, 24%, 0%). Median sternotomy is recommended as standard access for pulmonary metastasectomy. Surgery of pulmonary metastases is encouraging.

[Clinical staging of malignant lung and bronchial tumors]. / Klinische Stadieneinteilung maligner Lungen- und Bronchialtumoren.

The use of computed tomography for staging lung cancer is still under discussion. With reference to the literature, a comparison is made between the established conventional X-ray examinations, computed tomography and mediastinoscopy. Computed tomography is a useful non-invasive staging method for pretreatment classification of the primary tumour, the regional lymph node, and distant metastasis. The limitations of this method for staging lung cancer are outlined.

[X-ray diagnosis of retropatellar diseases (author's transl)]. / Zur Röntgendiagnostik retropatellarer Erkrankungen.

The article reports on a comprehensive, stepwise diagnosis in diseases of the knee joints. This includes a description of the indication, the technique of taking x-ray films, and x-ray findings, as well as arthrography of the femoropatellar joint in retropatellar diseases such as chondropathia patellae, osteochondrosis dissecans, traumas of the knee joints and arthrosis deformans.

[Percutaneous demonstration of lactiferous ducts in benign breast tumours. The use of contrast in the diagnosis of breast tumours such as fibroadenomas and proliferative mastopathies (author's transl)]. / Die perkutane Darstellung von Milchgängen in gutartigen Mammatumoren. Eine erweiterte Kontrastmittelanwendung in der Mammatumordiagnostik am Beispiel von Fibroadenomen und proliferlerender Mastopathie

A new method is described which makes it possible to demonstrate the duct system in fibroadenomas and mastopathies by percutaneous injection of contrast. In this way, the pre-operative diagnosis of benign breast tumours can be confirmed. The technique is described and the early results are illustrated.

[Radiotherapeutic results in malignant germinal testicular neoplasms]. / Ergebnisse der Strahlentherapie maligner germinaler Hodentumoren

The results of highvoltage therapy in patients with malignant germinal tumors of the testicle are reported. The radiation technique applied is mentioned, and problems concerning the formation of metastases as well as the prognosis for seminomas and teratomas are considered.