Delays in the diagnosis and initial treatment of bladder cancer in Western Australia.

OBJECTIVES: To quantify and examine the causes of delays in the diagnosis and initial treatment of patients with bladder cancer in Western Australia. SUBJECTS AND METHODS: All attendances at a one-stop haematuria clinic at a public tertiary-level hospital in Western Australia between May 2008 and April 2014 were reviewed retrospectively. All patients diagnosed with a bladder tumour over this period were identified. These patients and their general practitioners were contacted retrospectively and invited to participate in telephone interviews, with additional data collected from clinical records as required. Waiting times to presentation, referral, assessment, and initial treatment were established for patients who presented with visible haematuria. RESULTS: Of 1 365 attendances, 151 patients were diagnosed with a bladder tumour and 100 of these were both suitable and agreed to participate in the study. For patients with visible haematuria the median (range) waiting time from initial bleeding to surgery was 69.5 (9-1 165) days. This was comprised of a median (range) pre-referral waiting time of 12 (0-1 137) days, assessment waiting time of 23.5 (0-207) days, and treatment waiting time of 20 (1-69) days. Reasons for prolonged waiting times included poor public awareness, patient fear and anxiety, delayed and non-referral from primary care, administrative delays, and resource limitations. CONCLUSION: Many patients experience significant delays in the diagnosis and treatment of their bladder cancer in Western Australia, and this probably reflects national trends. These concerning data warrant consideration of how delays can be reduced to improve outcomes for these patients.

Who are the Pioneers? A Critical Analysis of Innovation and Expertise in Cutaneous Noninvasive and Minimally Invasive Cosmetic and Surgical Procedures.

BACKGROUND: Few studies illustrate the contributions made by various specialties in pioneering commonly performed noninvasive and minimally invasive cosmetic and surgical procedures. OBJECTIVE: To evaluate the contributions made by various specialties in pioneering noninvasive and minimally invasive cosmetic and surgical procedures. MATERIALS AND METHODS: Key words using the Medical Search Headings Database were used to query in the Thomson Reuters Web of Science Database. The 25 most highly cited studies were sorted according to the citation number. The author specialty was identified and assigned scores based on the number of citations. RESULTS: Dermatology was identified as the specialty with the greatest contribution to botulinum toxin treatments for rhytides, injectable fillers, laser treatments, chemical peels, and noninvasive body contouring. Neurology was identified as the leading specialty in botulinum toxin treatments for hyperhidrosis, and vascular surgery was identified as leading specialty in sclerotherapy. Plastic surgery was identified as having made the greatest contribution to hair transplantation, and liposuction. CONCLUSION: Dermatology was identified as the leading specialty for the majority of noninvasive and minimally invasive cosmetic procedures. Other specialties have also contributed important literature to this area.

Who do you prefer? A study of public preferences for health care provider type in performing cutaneous surgery and cosmetic procedures in the United States.

BACKGROUND: The public preference for provider type in performing cutaneous surgery and cosmetic procedures is unknown in the United States. METHODS: An internet-based survey was administered to the lay public. Respondents were asked to select the health care provider (dermatologist, plastic surgeon, primary care physician, general surgeon, and nurse practitioner/physician's assistant) they mostly prefer to perform different cutaneous cosmetic and surgical procedures. RESULTS: Three hundred fifty-four respondents undertook the survey. Dermatologists were identified as the most preferable health care provider to evaluate and biopsy worrisome lesions on the face (69.8%), perform skin cancer surgery on the back (73.4%), perform skin cancer surgery on the face (62.7%), and perform laser procedures (56.3%) by most of the respondents. For filler injections, the responders similarly identified plastic surgeons and dermatologists (47.3% vs 44.6%, respectively) as the most preferred health care provider. For botulinum toxin injections, there was a slight preference for plastic surgeons followed by dermatologists (50.6% vs 38.4%). Plastic surgeons were the preferred health care provider for procedures such as liposuction (74.4%) and face-lift surgery (96.1%) by most of the respondents. CONCLUSION: Dermatologists are recognized as the preferred health care providers over plastic surgeons, primary care physicians, general surgeons, and nurse practitioners/physician's assistants to perform a variety of cutaneous cosmetic and surgical procedures including skin cancer surgery, on the face and body, and laser procedures. The general public expressed similar preferences for dermatologists and plastic surgeons regarding filler injections.

Pityriasis rosea-like drug eruption due to nortriptyline in a patient with vulvodynia.

BACKGROUND: Nortriptyline and other tricyclic antidepressants are widely used in the treatment of depression. They are also used in chronic pain syndromes such as vulvodynia. We report a case of pityriasis rosea (PR)-like eruption in a young woman who was treated with oral nortriptyline for vulvodynia. CASE REPORT: The patient presented with photosensitivity and erythematous, well-defined, oval papules and patches, with fine collarettes of scale on the dorsal hands, upper arms, and trunk. She showed a complete resolution of her rash with discontinuation of nortriptyline, thereby supporting the diagnosis of a drug-induced reaction. COMMENT: Pityriasis rosea-like drug eruptions have been associated with numerous medications, including angiotensin-converting enzyme inhibitors, antirheumatic drugs, lithium, and, more recently, biologics such as imatinib, adalimumab, and etanercept. A literature review did not reveal an association between PR-like drug eruptions and tricyclic antidepressants such as nortriptyline. We report a case of PR-like drug reaction to nortriptyline for clinical interest.

Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients.

The management of non-melanoma skin cancers (NMSCs) in solid organ transplant recipients (OTRs) presents a variety of clinical challenges for physicians. OTRs are at a 65-fold increased risk for developing cutaneous squamous cell carcinomas (SCC), the most common NMSC that develops after transplantation. Risk factors contributing to the development of NMSCs in OTRs include a past medical history of any previous skin cancer, a personal history of significant sun exposure and a fair skin complexion or phototype. Further, greater immunosuppressive medication levels lead to an increased risk of NMSCs. Among immunosuppressants, specific older agents such as azathioprine and cyclosporine may increase the risk of developing NMSCs in contrast to newer agents such as sirolimus. Early skin biopsy and treatment of premalignant and malignant lesions are essential for treating these patients successfully. In this regard, the concept of field cancerization has been instructive in broadening treatments to include entire affected areas rather than individual lesions given that the areas with significant ultraviolet irradiation will continue to develop numerous individual precancerous and cancerous lesions. Field therapy with photodynamic therapy or topical 5-fluorouracil, imiquimod or diclofenac is often used in OTRs according to individual patient tolerability. Prompt excision or Mohs micrographic surgery is the standard of care of primary, uncomplicated squamous cell and basal cell carcinomas. For patients with in-transit or metastatic squamous cell carcinomas, adjuvant radiation, chemotherapy, and staging by sentinel lymph node dissection may be employed. For patients who develop numerous SCC per year, chemoprophylaxis can be effective in limiting the burden of disease. In consultation with the multidisciplinary transplant team, the immunosuppressive regimen can be revised to lower overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential in OTRs. The greatest impact may be made by the prevention of NMSCs through simple, but rigorous, patient education on the benefits of UV protection, periodic self-skin examinations, and regular follow-ups. Accordingly, vitamin D and calcium supplementation should also be incorporated in transplant recipients. Management of OTRs requires patient education, frequent motivation for vigilance, regular follow-up, and interdisciplinary collaboration between transplant surgeons, nephrologists, hepatologists, cardiologists, transplant nurses, dermatologists, oncologists, pharmacists, and other relevant physicians ideally orchestrated by the essential transplant coordinators.

Transrectal prostate biopsy sepsis rate following reduced quinolone antibiotic prophylaxis from six doses to single dose.

BACKGROUND: This study aimed to evaluate the rates of infective complication related to transrectal prostate biopsy (TRPB) as our centre changed its protocol from six doses over 3 days to a single pre-procedure prophylactic dose. METHODS: This prospective cohort study identified infective complication in patients who attended and subsequently underwent TRPB at the time of their one-stop prostate clinic at our public tertiary hospital between August 2011 and April 2017. Patients who underwent TRPB between August 2011 and November 2014 received six doses of 500 mg of ciprofloxacin, taken twice daily over 3 days. This protocol was changed to a single dose of 500 mg of ciprofloxacin prior to biopsy from February 2015 to April 2017. Patients who had travelled to South East Asia in the 6 months prior to TRPB received a single dose of 1 g intravenous ertapenem prior to biopsy, and this remained unchanged throughout the study period. The rates of infective complication were recorded and compared between the groups of patients who had undergone six doses versus a single dose of prophylactic ciprofloxacin. RESULTS: A total of 766 patients underwent TRPB from August 2011 to April 2017. Of these, 357 patients received the 3-day course of prophylaxis (Group 1) and 409 patients received the single dose prophylaxis (Group 2). Fifty-five patients were excluded from analysis. There was no significant difference in infective complications between the two groups (3.4% (11/326) Group 1 versus 4.9% (19/385) Group 2, P = 0.40). CONCLUSION: Our study supports the use of a single dose of ciprofloxacin as sufficient antibiotic prophylaxis prior to TRPB.

Acral manifestations of contact dermatitis.

Contact dermatitis is a broad term that encompasses both nonimmunologic irritant contact dermatitis (ICD) and immunologically mediated allergic contact dermatitis (ACD). Both ICD and ACD can negatively affect a patient's quality of life and are a source of exorbitant medical and societal costs. Avoidance of inciting irritants and/or allergens and liberal use of emollients or humectants are the cornerstone of therapy. When an allergic cause is suspected, patch testing is highly encouraged. In this contribution, we highlight both the commonalities and differences of acral contact dermatitis as it relates to specific regions of the body. In addition, a review of the predisposing conditions, risk factors, and treatment options in the literature is presented to help with the care of these challenging patients.

Neobladder Obstruction: A Non-ischemic Cause for Hepatic Portal Venous Gas: Case Report.

Hepatic portal venous gas (HPVG) is a rare ominous radiological sign usually indicative of mesenteric ischemia. Increased detection of HPVG has been associated with a growing number of non-ischemic causes. A 64-year-old gentleman following radical cystectomy and neobladder formation developed clinical signs suggestive of bowel obstruction. HPVG was demonstrated on abdominal imaging. Urgent laparotomy revealed no evidence of ischemia. We hypothesize an obstructed neobladder permitted gas to enter the mesenteric circulation. The patient made a complete recovery with supportive management.

Delayed iliacus compartment syndrome following femoral artery puncture: case report and literature review.

Iliacus compartment syndrome is a rare retroperitoneal compartment neuropathy caused by bleeding within the iliacus muscle leading to hematoma formation and compression upon the femoral nerve, causing both sensory and motor deficits. A 75-year-old Caucasian man presented with severe right hip pain associated with motor and sensory deficit in the right lower extremity, 2 weeks post elective balloon aortic valvuloplasty for critical aortic stenosis. A non-contrast computed tomography scan revealed low-attenuation areas in keeping with an iliacus hematoma. An iliacus fasciotomy and hematoma evacuation was performed with retroperitoneal approach. The patient reported marked reduction in his groin pain with clinical improvement of the right hip flexion though the sensory deficit was unchanged. On Day 3, postoperatively the patient died from respiratory and multi-organ failure. Iliac hematomas are rare and can be caused by traumatic and non-traumatic injury, and can be exacerbated by complications of anticoagulant therapy. Delaying surgical evacuation of the hematoma can lead to prolonged or permanent disability. However, there are other reports describing good recovery with non-operative management. Non-surgical intervention is recommended if radiological studies do not explicitly confirm the presence of a discreet hematoma compressing the femoral nerve, unless progression of symptoms increases.

What's new in prognostication of melanoma in the dermatopathology laboratory?

With the advent of genetic and epigenetic research, molecular techniques could someday be used to discriminate nevus from melanoma so that ambiguous melanocytic lesions could be more accurately classified or that prognostication could be improved in melanoma patients. That promised day might be closer than realized. The last 20 years of research in cytogenetic and genetic alterations in melanoma have culminated in defined chromosomal lesions discriminating benign from malignant melanocytic tumors. Exploiting these differences, fluorescence in situ hybridization (FISH) can reproducibly discriminate unequivocal melanomas from melanocytic nevi with high sensitivity and specificity. The discriminating power of FISH in melanocytic tumors with ambiguous histopathology is questionable, however, because there is no standard definition of "malignancy." Additional FISH studies on ambiguous cases are needed through international collaborations where large collections of such cases are shared and the "proof of malignancy" is established by adequate clinical follow-up. This contribution reviews the diagnostic utility of DNA-based FISH technology as it compares the diagnostic accuracy in melanocytic tumors with unambiguous vs ambiguous histopathology. The melanoma epigenome is further characterized through research into various activities of small interfering RNAs, such as microRNAs, providing the pathway for the application of microRNA-based strategies that could be the basis for future diagnostic biomarkers and molecular therapies in melanoma.