Enabling genomic island prediction and comparison in multiple genomes to investigate bacterial evolution and outbreaks.

Outbreaks of virulent and/or drug-resistant bacteria have a significant impact on human health and major economic consequences. Genomic islands (GIs; defined as clusters of genes of probable horizontal origin) are of high interest because they disproportionately encode virulence factors, some antimicrobial-resistance (AMR) genes, and other adaptations of medical or environmental interest. While microbial genome sequencing has become rapid and inexpensive, current computational methods for GI analysis are not amenable for rapid, accurate, user-friendly and scalable comparative analysis of sets of related genomes. To help fill this gap, we have developed IslandCompare, an open-source computational pipeline for GI prediction and comparison across several to hundreds of bacterial genomes. A dynamic and interactive visualization strategy displays a bacterial core-genome phylogeny, with bacterial genomes linearly displayed at the phylogenetic tree leaves. Genomes are overlaid with GI predictions and AMR determinants from the Comprehensive Antibiotic Resistance Database (CARD), and regions of similarity between the genomes are also displayed. GI predictions are performed using Sigi-HMM and IslandPath-DIMOB, the two most precise GI prediction tools based on nucleotide composition biases, as well as a novel blast-based consistency step to improve cross-genome prediction consistency. GIs across genomes sharing sequence similarity are grouped into clusters, further aiding comparative analysis and visualization of acquisition and loss of mobile GIs in specific sub-clades. IslandCompare is an open-source software that is containerized for local use, plus available via a user-friendly, web-based interface to allow direct use by bioinformaticians, biologists and clinicians (at https://islandcompare.ca).

Chemical peels: A review of current practice.

Chemical peels belong to a group of cutaneous resurfacing procedures that are used in the treatment of photoageing, inflammatory dermatoses, epidermal proliferations, pigmentary disorders and scarring. This review describes best current practice, highlights recent advances in chemical peel technology and discusses the recommended uses for different peel types. It also presents the results of a survey of the chemical peeling practices of 30 Australian dermatologists.

Lasers and laser-like devices: part two.

Part two of this review series evaluates the use of lasers and laser-like devices in dermatology based on published evidence and the collective experience of the senior authors. Dermatologists can laser-treat a wide range of dermatoses, including vascular, pigmentary, textural, benign proliferative and premalignant conditions. Some of these conditions include vascular malformation, haemangioma, facial telangiectases, café-au-lait macules, naevi of Ota, lentigines, acne scarring, rhytides, rhinophyma and miscellaneous skin lesions. Photodynamic therapy with lasers and intense pulsed light is addressed, with particular reference to actinic keratosis and actinic cheilitis. A treatment algorithm for acne scarring based on scar morphology and severity is comprehensively outlined. Following from part one, the various devices are matched to the corresponding dermatological conditions with representative pictorial case vignettes illustrating likely clinical outcomes as well as limitations and potential complications of the various laser and light therapies.

Lasers and laser-like devices: part one.

Lasers have been used in dermatology for nearly 50 years. Through their selective targeting of skin chromophores they have become the preferred treatment for many skin conditions, including vascular malformations, photorejuvenation and acne scars. The technology and design of lasers continue to evolve, allowing greater control of laser parameters and resulting in increased safety and efficacy for patients. Innovations have allowed the range of conditions and the skin types amenable to treatment, in both general and cosmetic dermatology, to expand over the last decade. Integrated skin cooling and laser beam fractionation, for example, have improved safety, patient tolerance and decreased downtime. Furthermore, the availability and affordability of quality devices continues to increase, allowing clinicians not only to access laser therapies more readily but also to develop their personal experience in this field. As a result, most Australian dermatologists now have access to laser therapies, either in their own practice or within referable proximity, and practical knowledge of these technologies is increasingly required and expected by patients. Non-laser energy devices utilising intense pulsed light, plasma, radiofrequency, ultrasound and cryolipolysis contribute to the modern laser practitioners' armamentarium and will also be discussed.

Visual loss from a pituitary mass: collision tumors of prostatic metastasis and suprasellar meningioma.

Central nervous system spread from prostate cancer is typically associated with raised prostate specific antigen (PSA) levels. The authors describe a unique case of a "collision tumor" of a prostatic metastasis to the pituitary, juxtaposed to a suprasellar meningioma, with normal PSA levels. This case also emphasizes the need to consider prostatic metastasis in the differential diagnosis of a pituitary mass in patients with a known prostatic cancer, despite the normal PSA levels.

Patient's self-evaluation of two education programs for age-related skin changes in the face: a prospective, randomized, controlled study.

BACKGROUND: An interactive software program (HOYS) has been developed utilizing a database of digital images depicting various aspects and degrees of aging of exposed skin across seven geographic regions, representing a total of 35 facial and extrafacial subregions. A five-point photonumeric rating scale, which portrays age-related skin changes across five decades for each of these subregions, underpins this patient-based interactive self-assessment program. Based on the resulting outputs from this program, an individualized treatment prioritization list is generated for each region where significant differences between the patient's chronological and esthetic ages exist. This provides guidance for the patient and the treating physician on treatment options. METHODS: To evaluate the utility of HOYS in the clinic, relative to education programs currently used in Australian private esthetic clinics, a total of 95 esthetically-orientated patients were enrolled in a prospective, randomized, controlled, multicenter study. RESULTS: Compared with a prospective cohort of patients completing a standard education program commonly utilized in Australian esthetic clinics, patients receiving the HOYS education program reported greater empowerment through improved knowledge of specific age-related skin changes. This was associated with a clearer understanding of treatment options available to them, and a perceived ability to participate in the selection of the treatments potentially administered to improve their appearance. These differences between the two education groups were highly significant. CONCLUSION: Patients completing the HOYS patient education program have an improved understanding of age-related changes to exposed skin of their face, neck, décolletage, and hands. Due to the patient-specific nature of the program, these patients perceive a greater role in the deciding which esthetic treatments should be subsequently administered to enhance their appearance, through an improved understanding of the rationale for these treatments and indeed how they should be prioritized to achieve the best outcome for them.

Fractional filling with the microdepot technique as an alternative to bolus hyaluronic acid injections in facial volume restoration.

For volume restoration of the face, hyaluronic acid is conventionally injected through long, large-bore, 18-gauge needles because of the higher viscosity subtypes required. These hyaluronic acids are either more highly cross-linked or larger in particle size than the less-viscous subtypes. The microdepot injection technique involves using the 31-gauge BD insulin syringe (Becton-Dickinson, North Ryde, NSW Australia) to deposit small amounts of filler (0.05-0.1 mL) throughout the area of volume loss. The procedure is extremely well tolerated, requiring only topical and ice anaesthesia. Using this method, volume restoration can be achieved naturally and progressively over a period of time. Fractional filling every 3-4 months is continued until the desired level of volume correction is attained. Patients undergoing fractional filling followed over a 12-month period did not indicate any observable compromise in filler longevity, even when highly viscous hyaluronic acid fillers were injected through small-bore, 31-gauge insulin syringes.

Hyaluronic acid filler injections with a 31-gauge insulin syringe.

Hyaluronic acid gel is a commonly used skin/soft tissue filler in cosmetic dermatology. Hyaluronic acid fillers are packaged in proprietary luer-lock syringes that can be injected via a 30-gauge, 27-gauge or larger diameter needle depending on the consistency of the gel. A method of decanting proprietary hyaluronic acid fillers into multiple 31-gauge insulin syringes for injection is described. The use of a 31-gauge insulin syringe for filler injections can potentially enhance the injection process through more accurate product delivery and placement. This has the potential to produce a more balanced and symmetrical outcome for patients. Additional benefits include less injection pain, less bleeding/bruising and higher levels of patient satisfaction.

The potpourri approach to hyaluronic acid filler injections.

There is an ever-expanding range of hyaluronic acid fillers with varying physical characteristics available to cosmetic dermatologists. These fillers are commercially packaged in syringes of approximately 1 mL (range 0.5-2 mL) volume. Filler injectors are currently qualitatively and quantitatively restricted to fillers packaged in ready-to-go syringes. Patients often present for pan-facial rejuvenation requiring varying amounts of fillers as well as more than one type/subtype of filler for optimum correction. The potpourri approach allows access to a range of prepared hyaluronic acid filler subtypes that can be used on the same patient in the one session. The potpourri method centres on the use of multiple 31-gauge insulin syringes prepared with a range of different hyaluronic acid filler products that are ready for use. This increases flexibility with filler selection and has the potential to provide better filler-to-tissue match for patients.

Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists.

This retrospective study was conducted to assess and compare the diagnostic accuracy between referring general practitioners and dermatologists with regard to skin conditions. Six hundred and fifty-six consecutive general practitioner referrals to a private dermatology practice and a dermatology outpatient department were assessed. The concordance rate in diagnoses from a wide spectrum of dermatological diseases was compared between general practitioners and dermatologists. Referring general practitioners agreed with dermatologists' clinical diagnosis and histology (when available) in 42% of cases. The concordance between general practitioners and dermatologists in the setting of non-biopsied cases is 45%. One hundred and fifty-one of 656 (23%) conditions had histological confirmation. Overall, general practitioners agreed with the histological diagnosis in 24% of cases and dermatologists agreed with the histological diagnosis in 77% of cases.

Operational teledermatology in Broken Hill, rural Australia.

From January 2001 to January 2002, Broken Hill, New South Wales, served as a trial site for teledermatology as one method of access to dermatologists. Fourteen participating general practitioners referred 46 patients making up 48 teledermatology cases. The mean diagnostic agreement between general practitioners and dermatologists was 35% and 50% for primary and differential diagnoses, respectively. Teledermatology patients formed 12% of the collectively referred dermatology patients (outpatients and teledermatology). In this project, high patient and general practitioner acceptability and positive medical outcomes confirm the value of rural teledermatology. However, this project also revealed unexpected barriers and pitfalls in the effective operation of rural teledermatology. Lack of education of participants, inertia among potential users and patient inconvenience are issues that may adversely affect the effective implementation of rural teledermatology.

Allergic contact dermatitis to an expired moisturiser.

A 64-year-old man developed an allergic contact dermatitis while using an expired sorbolene cream. Patch tests to the product ingredients were all negative. Repeated open application test to the expired product produced a strong reaction while an identical-brand non-expired product did not elicit a reaction, suggesting the presence of an unidentified degradation product or compound, acting as an allergen in the expired product. This case is intriguing in that it contrasts the ubiquitous use of over-the-counter topical agents with the exceedingly low incidence of contact dermatitis to expired topical products.

Imaging the skin.

Since the discovery of X-rays, the use of imaging technology has continued to play an important role in medicine. Technological advancements have led to the development of various imaging modalities, most of which have been used to image organs deep within the human body. More recently, attention has focused on the application of imaging technology for evaluation of the skin. A variety of techniques are currently being used to examine the skin and these include specialized photography, surface microscopy, ultrasound, laser Doppler perfusion imaging, confocal microscopy, and magnetic resonance imaging. These modalities can provide information that can assist in the management of skin problems. Although many of these techniques are still undergoing research, they are showing promise as useful clinical tools in dermatology.

A granuloma annulare-like eruption associated with the use of amlodipine.

A granuloma annulare-like drug reaction is a rarely encountered clinical entity. A 64-year-old Caucasian female developed a granuloma annulare-like reaction 13 days after starting amlodipine and cleared within 3 months after drug cessation. The eruption consisted of multiple erythematous pruritic papules, distributed symmetrically over the lateral aspects of the legs and thighs, as well as on both palms. Histology showed focal collagen degeneration and significant interstitial histiocytic dermal infiltrate suggestive of granuloma annulare. We review previously reported cases of granuloma annulare-like drug reactions, in the context of a recently proposed classification for drug-induced interstitial granulomatous reactions.