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1. Seclusion and restraint must be a last resort, emergency response to a crisis situation that appears to present imminent risk of harm to the patient, staff, or others. 2. JCAHO-accredited hospitals billing for Medicare or Medicaid must meet HCFA requirements to maintain compliance. 3. Policy writers and administrators must carefully scrutinize all applicable regulatory standards to ensure all requirements are met.

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While this article does not propose to provide answers to the many questions prompted by the new Patient's Rights CoP (1999) or the newly revised JCAHO standards on seclusion and restraint (JCAHO, 2000), a prudent plan of action for any organization serving patients with a behavioral component to their treatment would be to adopt a policy of least restrictive intervention prior to consideration of seclusion and restraint in response to emergency patient care needs. It was the authors' intent to present a representative sample of the available literature and from that to develop a continuum of intervention possibilities ranging from least to most restrictive. In addition, suggestions found in the literature for implementation of least to most restrictive programs have been provided.

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A 17-week-old boy with a giant congenital melanocytic nevus (GCMN) of the left lower extremity was noted to have a reduction in circumference of the left lower extremity relative to the contralateral side. The skin overlying the GCMN was persistently warm when compared with the surrounding and contralateral skin. Comparative plain radiography, ultrasonography, and magnetic resonance imaging showed fat hypoplasia of the left lower extremity, with bone and muscle appearing unaffected. The possible role of cytokines produced by the nevus in fat hypoplasia in GCMN is discussed.

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BACKGROUND: Balanitis xerotica obliterans is a subcategory of lichen sclerosus et atrophicus limited to the male genitalia and is associated with destructive inflammation, phimosis, urethral stenosis, and squamous cell carcinoma. METHODS: The medical literature was searched from 1983-1998 using key words balanitis, lichen, and sclerosis using the MEDLINE system. RESULTS AND CONCLUSIONS: Balanitis xerotica obliterans can be distinguished from other genital dermatoses with similar characteristics through patient history, clinical findings, and laboratory evaluation.. Tzanck smear and cutaneous biopsy, along with a rapid protein reagin test, will provide a definitive diagnosis. Treatment with high-dose topical corticosteroids relieves symptoms, and therapy focuses on prevention of disease progression.

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Myofibroblastoma of the breast is a recently described entity. Since its first description in 1987, less than 50 cases have been reported. We present the first (reported) myofibroblastoma to be detected as a non-palpable mass on a routine screening mammogram and emphasize the importance of not mis-diagnosing this rare cellular lesion as malignant on frozen section. Review of the literature demonstrates changes in the clinical presentation of myofibroblastomas. Once considered more common in men than in women, myofibroblastomas are now being reported with increasing frequency in women. The age at presentation is a decade earlier, and not surprizingly, the size of the earlier detected lesion is smaller. Recently four different cytoskeletal phenotypes (V, VA, VAD and VD) of myofibroblastomas have been described, depending upon the vimentin (V), actin (A), and desmin (D) immunoreactivity. Whereas vimentin reactivity is universal, actin and desmin immunoreactivity is variable, desmin being more frequently positive than actin. As more is known about the clinical behavior of myofibroblastomas, their rate of recurrence and malignant potential, if any, the relationship of the cytoskeletal content to prognosis may become clearer. Currently, complete immunohistochemical analysis and electron microscopic examination of this interesting breast lesion is recommended. List of abbreviations-Vimentin (V), actin (A), and desmin (D), vimentin and actin (VA), vimentin and desmin (VD), vimentin, actin and desmin (VAD).

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Nonmelanoma skin cancers encompass a vast array of malignancies: adventitial, vascular, neuroendocrine, hematologic, adnexal, and epithelial. The skin is also a major site for metastasis of internal disease. With an understanding of the frequency of presentation, clinical distribution, and appearance, the clinician is able to provide an accurate diagnosis for most lesions. Because there are so many nonmelanoma skin cancers, the focus here is on those with a high frequency or significant morbidity. The treatment of nonmelanoma skin cancer is constantly evolving; therefore, emphasis is on diagnosis.

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Extensive dystrophic calcinosis cutis of the hips and anterolateral thighs in a woman with insulin-dependent diabetes mellitus is described. Clinical, histologic, and radiographic data are provided to familiarize the reader with this unique and newly described condition. We speculate that repetitive, chronic, needle trauma in susceptible persons can induce massive dystrophic calcinosis cutis.

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BACKGROUND: The association of multisystem pathologic conditions and epidermal nevi, known as the epidermal nevus syndrome, includes disorders of bone, central nervous system, eye, kidney, vasculature, body symmetry, and skin. Rarely, vitamin D-resistant rickets has been observed in association with this syndrome. Precocious puberty is another rare finding associated with epidermal nevus syndrome, having been observed in 3 patients. OBSERVATION: A female infant with an extensive epidermal nevus, hypophosphatemia, and precocious puberty is described. Despite medical therapy, the patient's phosphate levels continued to be very low (0.87-0.97 mmol/L), establishing the diagnosis of hypophosphatemic vitamin D-resistant rickets. At 21 months of age, areas of the nevus were excised. Laboratory values obtained shortly after the operation showed a significant, but transient, improvement in the serum phosphate level. After a second excision, maintenance of her serum phosphate level in the range of 1.29 to 1.61 mmol/L was possible. CONCLUSIONS: There is evidence that epidermal nevi produce a potent phosphaturic factor. We hypothesize that limited excision debulked the nevus sufficiently to allow medical management of the hypophosphatemia. Surgical intervention should be considered for patients affected with vitamin D-resistant rickets with epidermal nevi. The cause of the precocious puberty is unknown. It may be hypothesized that the nevus released a factor that induced puberty.

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BACKGROUND: Mohs micrographic surgery maximizes the potential for complete tumor removal with normal tissue preservation through the histologic examination of all tissue margins. One component of the histologic examination is the evaluation of excised nerves for the presence of tumor infiltration. During such an evaluation, a subperineurial structure was noted. OBSERVATION: Further investigation displayed a discrete, loosely textured, cell-sparse, whorled, subperineurial structure that invaginated into the peripheral nerve. Inflammation was absent and the nuclei were monomorphous. These findings are those seen with Renaut bodies. CONCLUSIONS: Renaut bodies are found at sites of nerve compression. Mechanical factors are thought to play a major role in pathogenesis. Cells comprising the Renaut body are fibroblasts of perineurial origin with the extracellular matrix comprised of collagen fibrils, basal lamina material, and oxytalan filaments. Renaut bodies are important insofar as the surgeon must recognize that they are benign. Histologic characteristics that differentiate Renaut bodies from malignant neurotropic infiltration are: (a) a cell-sparse mass, (b) absence of nuclear atypia, (c) less than expected inflammatory infiltrate, and (d) well-defined borders.

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BACKGROUND: Dermatology is dependent upon the effects of local anesthetics for diagnostic and therapeutic interventions. A working knowledge of the drugs' actions and interactions is necessary for anyone aspiring to optimize the benefits derived from the use of local anesthetic agents. OBJECTIVE: This article reviews nerve physiology, pharmacology, classification of local anesthetics, adverse reactions (toxic, drug, allergic), local anesthetic use in pregnancy, alternatives to the "-caine" anesthetics, methods for reducing the pain of infiltration, and new agents under development. CONCLUSION: Local anesthetics are safe and effective. With the understanding of the actions and interactions of this class of drugs, maximum patient safety and satisfaction can be achieved.

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A case of umbilical endometriosis is presented to highlight the challenges in its diagnosis. The etiology, clinical findings, histologic evaluation, prognosis and treatment options are discussed. While cyclic symptomatology may lend evidence to the diagnosis of umbilical endometriosis, history and clinical findings are often equivocal. Decidualization of umbilical endometriosis can be initially confused with a malignant process on histologic evaluation. The potential for malignant degeneration appears low. Surgical intervention is the treatment of choice.

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