Desmoplastic malignant melanoma presenting as an erythematous nodule tumor

Desmoplastic malignant melanoma is an uncommon neoplasm that presents both as a clinical and diagnostic challenge. Prognosis is frequently adversely affected by misdiagnosis and delayed diagnosis of this tumor, which is often amelanotic. We report a case of an amelanotic desmoplastic malignant melanoma that presented as an erythematous nodular tumor.

The effect of changing the total parenteral nutrition order form on resident physician ordering behavior

The quality assurance process at Scott and White Hospital, Temple, Texas, identified a marked variation in total parenteral nutrition (TPN) prescriptions compared with recommendations by the Nutrition Support Service (NSS). A TPN order form with additive guidelines was designed to assist physicians in ordering TPN specific to patient needs. The effect of the change was assessed by comparing 50 TPN patients using the old form (1990) with 50 patients for whom the new form (1992) was used. The groups demonstrated no difference in demographics, mortality, length of stay, or biochemical parameters and were reflective of all TPN patients treated (1990, n = 280; 1992, n = 392). A significant decrease was noted in overfeeding of kilocalories when resident orders were compared with NSS recommendations (125% +/- 24% versus 110% +/- 29%, p = .017; and amino acids (120% +/- 32% versus 105% +/- 29%, p = .071, mean +/- SD). This resulted in a decrease of 8% in the cost of delivering a patient-day of TPN. We conclude that changing the TPN order form to a teaching vehicle results in decreased overfeeding and costs.