A dermatological questionnaire for general practitioners in England with a focus on melanoma; misdiagnosis in black patients compared to white patients.

BACKGROUND: Malignant melanoma presents a significant health burden in the UK in terms of mortality and financial cost. This aggressive and often fatal disease is under-diagnosed among patients with darker skin tones (type 5 and 6) such as Afro-Caribbean patients. A lack of both patient and practitioner awareness leads to a later diagnosis in patients with black compared to white skin. There is currently a paucity of literature looking at the diagnosis rates of melanoma between patients of different ethnicities in the UK and the reasons behind these differences. OBJECTIVE: The primary aim was to obtain data on the diagnosis rate of melanoma in the primary care setting, with particular attention to white vs. black skin types. METHODS: An online questionnaire was sent to 2975 general practitioner (GP) practices in England and 287 responses were received. The questionnaire contained 20 high-quality picture questions of differing common skin conditions. The participants were asked to choose their diagnosis from 20 potential diagnoses. Only 4/20 questions were melanomas, two on white and two on black skin. No accompanying histories were provided. RESULTS: The mean score for the questionnaire was 11.6/20 (58%) with a range from 5% to 100%. Of the two black skin melanoma pictures, 177/287 (62%) and 90/287 (31%) responses were incorrectly identified, compared to 37/287 (13%) and 19/287 (7%) in the white skin melanoma pictures. CONCLUSION: The questionnaire results show a clear increased misdiagnosis of melanoma in black patients in primary care vs. white. The results suggest that vigilance is needed when diagnosing possible melanoma in black patients and better quality melanoma teaching is required in GP training concentrating on pigmented skin. This pilot study should encourage more research into ethnic skin inequalities in the UK.

Electronic retinal implants and artificial vision: journey and present.

Retinitis pigmentosa and age-related macular degeneration are two significant causes of severe visual dysfunction. In both, the retinal photoreceptors degenerate, preventing successful conversion of light into electrical energy that is interpreted in the visual cortex as visual function. Artificial vision or visual function began over two centuries ago with the idea of creating artificial light pulses, or phosphenes, through cortical stimulation. The pursuit is now on to improve artificial visual function. Two retinal implants appear the most likely to succeed in the future having undergone multicentre human trials: the Argus II electronic epiretinal device (Second Sight Medical Products, CA, USA) and Alpha-IMS electronic subretinal device (Retina Implant AG, Germany). The trial results to date are encouraging with visual improvement and acceptable safety profiles reported for both devices. At present, the visual function generated by either device does not offer high enough resolution or acuity for a patient to regain a fully functional life. Despite this, both devices not only have the potential, but have actually improved the vision-related quality of life in a significant number of patients implanted. With this in mind, the economic argument is clear. Provided device-life is long enough, its cost should be acceptable for the obtained improvement in the quality of life. The aim of this Review Article is to assist those readers that may be considering offering any of these devices as a treatment for blindness in Retinitis Pigmentosa.

Cholecystectomy and the development of colorectal neoplasia: a prospective study.

One hundred asymptomatic patients over 60 years of age who had cholecystectomy carried out at least 10 years earlier underwent double contrast barium enema and sigmoidoscopy. The incidence of colorectal adenomas and carcinomas was compared with age and sex matched controls undergoing routine post mortems. In the post-cholecystectomy group 12% had tumours (8 adenomas greater than 1 cm in diameter, 4 carcinomas). In the control group 3% had tumours (3 adenomas); P = 0.02. This study confirms that patients with a history of cholecystectomy have an increased risk of developing colorectal adenomas and carcinomas.

Should radiologists talk to patients?

KIE: Radiologists often are relectant to discuss their findings with patients, reasoning that the patients are only temporarily under their care, and that the diagnosis is better communicated by the referring physician. In this study, National Health Service patients, radiologists, and clinicians were surveyed to determine their views on what radiologists should discuss with patients after performing barium studies. The patients, many of whom feared cancer, overwhelmingly preferred to be told the findings immediately by the radiologist. The opinions of the radiologists and clinicians on disclosure varied depending on whether a malignancy was discovered. Given patient anxiety when cancer is a possible diagnosis, the authors recommend that radiologists communicate normal or nonmalignant findings immediately. When a malignancy is discovered, radiologists and clinicians should consult as soon as possible so that patients may be told quickly and privately.^ieng

Radiological examination of the small bowel.

A retrospective study was made of 100 consecutive dedicated per-oral small bowel examinations. 33% of the studies were abnormal, of which almost half were due to Crohn's disease. When grouped according to clinical suspicion, 73.5% of those studies with a high index of clinical suspicion were abnormal. In the abnormal group a correct diagnosis was made in 90%, with two false positives. In the normal group a correct diagnosis was made in 91%, with no false negatives. It is suggested that the dedicated small bowel series offers a justifiable and practical alternative to other techniques such as intubation and direct infusion of contrast medium into the small bowel, or enteroclysis.

Immediate radiological management of disasters.

During the past 13 years, 93 civil disasters have been dealt with by the Accident and Emergency (A/E) department of the Royal Victorial Hospital, Belfast. The average number of patients requiring hospital treatment was 30 per incident. Most of these needed some form of radiographic examination. The radiological work-load in one major disaster is described. The need for senior radiological, radiographic and clerical staff at such times is emphasised. The rapid and efficient management of patients is essential to avoid life-threatening delays. Radiological priorities in the immediate phase of trauma are discussed. Chest, spinal and pelvic X-rays usually take precedence. A review of 100 patients with significant intra-abdominal trauma showed a poor correlation with the plain-film appearances. Early resort to more accurate diagnostic methods, such as angiography and computed tomography, is suggested. The need for more active participation by radiologists in the A/E department is stressed.

Caecal volvulus: a frequently missed diagnosis?

Fifty-eight patients with acute caecal volvulus are presented. Fifty-five patients had plain abdominal radiographs taken shortly after admission and the diagnosis was suspected in 29 (53%). Forty-five of these radiographs have been reviewed and, in retrospect, the diagnosis could have been made in 40 (89%). The dilated caecum usually assumes a 'comma-shape', retains its haustral markings and may be located anywhere within the abdomen but is most frequently seen centrally or occupying the left upper quadrant. Diagnostic difficulties were found in patients with peritonitis and when there was gross small bowel dilatation. Accurate diagnosis is vital as delay in the surgical treatment of this condition may lead to an increased incidence of gangrene of the caecum and a higher mortality.

Adult duodenal webs: a rare cause of obstruction.

Two patients are described with congenital duodenal webs. Both presented with increasing heartburn, an unusual symptom for this condition. The radiological appearances at barium meal examination were misinterpreted in both cases. The radiological features of duodenal webs and their differentiation from intraluminal diverticula are discussed.

Acute large-bowel pseudo-obstruction.

The clinical and radiological features of acute large-bowel pseudo-obstruction occurring in 13 patients over a 7-year period are reviewed. Clinical features included atypical signs and symptoms of large-bowel obstruction and serious concomitant illness, including trauma in 10. The predominant radiological features were gross colonic dilatation, scant fluid levels, a gradual transition to collapsed bowel and a normal gas and faecal pattern in the rectum. Correct diagnosis was established by plain film and/or barium enema examination in the majority of cases (nine out of the 13). In the remaining four cases the diagnosis was made at laparotomy, although review of the radiographs suggested that the correct diagnosis could have been made pre-operatively in three. Instant barium enema is recommended in doubtful cases to rule out distal obstruction. Prompt recognition of the condition, with daily monitoring and conservative management, should eliminate unnecessary surgery and minimise the risk of caecal perforation.

Iopamidol in the diagnosis of suspected upper gastro-intestinal perforation.

Forty patients, mainly post-operative, were examined for suspected leakage from the oesophagus and/or stomach using iopamidol. Oesophageal leaks were demonstrated in seven patients, tracheo-oesophageal fistulae in two and an unsuspected gastro-jejunostomy intusussception in one. Only two cases were regarded as technically unsatisfactory due to poor coating. Normal examinations were found in 28 (70%) patients. This was confirmed by the subsequent clinical course. Aspiration into the bronchial tree occurred in five (12.5%) patients without ill-effects. Furthermore no adverse side effects as a result of the administration of iopamidol were recorded. It is concluded that a non-ionic medium such as iopamidol is the agent of choice in the detection of oesophageal and gastric perforation, particularly in post-operative patients where there is an increased risk of aspiration.

Metachronous colonic lymphomas complicating chronic ulcerative colitis.

The gastrointestinal tract is the most common extranodal site of primary non-Hodgkin's lymphoma. Of these, 10-15% occur in the large bowel. Colonic lymphoma is a recognized complication of inflammatory bowel disease, particularly ulcerative colitis and, less commonly, Crohn's disease. We describe a unique case of two metachronous primary lymphomas of the large bowel in a patient with chronic ulcerative colitis.

Gastrointestinal bleeding due to multiple ileal duplications diagnosed by scintigraphy and barium studies.

A case of multiple ileal duplications presenting with gastrointestinal bleeding is described. Technetium-99m Pertechnetate scintigraphy in conjunction with barium studies provided the initial clue and accurately localised the abnormality pre-operatively.

The investigation of anorectal dysfunction in the solitary rectal ulcer syndrome.

To investigate anorectal function in solitary rectal ulcer syndrome 22 patients were studied by means of balloon expulsion, intestinal transit time, barium enema and evacuation proctography. Half of the patients tested had difficulty in expelling a water filled balloon. Delay in intestinal transit was noted in only three patients. Barium enema was of little benefit in diagnosing the condition. Evacuation proctography was the investigation of choice in that it showed at least one abnormality of pelvic floor function in all of the patients and can help select patients for surgery.

Bile acids and the increased risk of colorectal tumours after truncal vagotomy.

An association between colorectal cancer and previous peptic ulcer surgery is reported. In a prospective screening study, 100 asymptomatic patients (80 men and 20 women) who had undergone truncal vagotomy at least 10 years previously were investigated by barium enema, colonoscopy and gallbladder ultrasonography. Control data were obtained from forensic autopsy subjects. The incidence of neoplasms greater than or equal to 1.0 cm in the vagotomized group was 14 per cent (11 adenomas, 3 carcinomas) and 3 per cent in controls (P = 0.01). Duodenal bile obtained at endoscopy from 21 vagotomized patients with normal gallbladders and from 21 control patients undergoing endoscopy was analysed by high performance liquid chromatography. The mean percentage of cholic (CA), chenodeoxycholic (CDCA), deoxycholic (DCA) and lithocholic (LCA) acids in the bile of vagotomized patients was 32.3, 45.6, 20.7 and 1.4 per cent respectively compared with 45.3, 36.2, 17.9 and 0.7 per cent respectively in controls. The increased proportions of CDCA and LCA and decreased proportions of CA in the duodenal bile of vagotomized patients were significant (P less than 0.001; P = 0.02; P = 0.007). Abnormalities in bile acid metabolism may help to explain the increased risk of colorectal neoplasia 10 years after truncal vagotomy.