The role of micrometastasis in high-risk skin cancers.

The propensity to metastasize is the most important prognostic indicator for solid cancers. New insights into the mechanisms of early carcinogenesis have revealed micrometastases are generated far earlier than previously thought. Evidence supports a synergistic relationship between vascular and lymphatic seeding which can occur before there is clinical evidence of a primary tumour. Early vascular seeding prepares distal sites for colonisation while regional lymphatics are co-opted to promote facilitative cancer cell mutations. In response, the host mounts a global inflammatory and immunomodulatory response towards these cells supporting the concept that cancer is a systemic disease. Cancer staging systems should be refined to better reflect cancer cell loads in various tissue compartments while clinical perspectives should be broadened to encompass this view when approaching high-risk cancers. Measured adjunctive therapies implemented earlier for low-volume, in-transit cancer offers the prospect of preventing advanced disease and the need for heroic therapeutic interventions. This review seeks to re-appraise how we view the metastatic process for solid cancers. It will explore in-transit metastasis in the context of high-risk skin cancer and how it dictates disease progression. It will also discuss how these implications will influence our current staging systems and its consequences on management.

Teledermatology in the provision of biologics through COVID-19 in a rural dermatology practice-A retrospective review.

COVID-19 compounded existing barriers to healthcare for rural patients. We completed a retrospective chart review of patients receiving Pharmaceutical Benefits Scheme subsidised biologics at a Modified Monash Model 3 dermatology practice during the pandemic and examined factors contributing to successful continuation of care, particularly teledermatology. Our experience is instructive in the provision of medical dermatology to regional patients.

Sirolimus in blue rubber bleb naevus syndrome: A systematic review.

The aim of this study is to review sirolimus as a treatment for blue rubber bleb naevus syndrome (BRBNS). A literature search of Medline, Embase, CINAHL, SCOPUS and Google Scholar was conducted for publications reporting treatment of patients with BRBNS with sirolimus. Of 46 articles identified, 17 studies reporting 23 patients met inclusion criteria. Sirolimus was well tolerated in all but one patient who required treatment cessation; 17/18 patients noted an improvement in gastrointestinal disease where this was reported; 21/22 patients noted an improvement in cutaneous disease where this was reported. Based on these results, sirolimus may be considered a first-line treatment of BRBNS depending on patient morbidity.

When Faculty Tell Tales: How Faculty Members' Reflective Narratives Impact Residents' Professional Identity Formation.

PROBLEM: Most training programs have focused on the explicit teaching of professionalism, an approach that has seen limited success, to transform trainees into physicians. It is possible that faculty members' reflective narratives, if appropriately shared with trainees, can facilitate the processes of reflection and socialization and help shift the training paradigm toward supporting professional identity formation. APPROACH: In May 2010, an online forum, where faculty could share personal reflective narratives with all residents and faculty via email, was created for the National University Health System's internal medicine residency program. By 2016, 40 letters had been written and nearly 200 residents and 30 faculty members had read these. This repository of faculty members' reflective narratives touches on a broad range of issues related to professionalism, including altruism, humanism, excellence, and accountability. In February 2017, the authors conducted semistructured focus group discussions with 20 residents to explore the impact of faculty members' reflective narratives on their professional identity development. OUTCOMES: Residents reported that narratives, if written by authors who were recognized as role models, triggered the processes of reflection and socialization; were more effective in provoking reflection if they resonated with residents' experiences; inspired them to follow how their role models reflected on and coped with challenges; and influenced the culture of the workplace, impacting the residents' daily experiences and leading to socialization and development of their professional identity. NEXT STEPS: These early observations on the role of faculty members' reflective narratives highlight the importance of credible role models, the daily work experience, and the culture of the workplace and provide information educators could use to more effectively support trainees' professional identity formation as they design curricula. Among other things, future studies should explore the role and effectiveness of faculty members' reflective narratives in different educational contexts.