De novo generalized pustular psoriasis following Oxford-AstraZeneca COVID-19 vaccine.

We present an interesting and novel case of a de novo generalized pustular psoriasis following administration of first dose of Oxford-AstraZeneca COVID-19 vaccine in a patient with no pre-existing psoriasis or any previous dermatological issue.

Is there a role for the development of a supra-regional network for the management of penile cancer in the Republic of Ireland?

INTRODUCTION: There is an average of 25 cases of penile cancer in the Republic of Ireland each year. Due to the low volume of cases, the National Institute for Clinical Excellence recommends that treatment is centralised to allow the best standardised treatment for primary tumours and nodal disease. OBJECTIVES: To determine whether outcomes for patients with penile cancer differed significantly between secondary and tertiary referral centres in the Republic of Ireland. METHODS: Between 2001 and 2014, 36 patients were treated in the Mercy University Hospital (MUH) with penile cancer. Twenty patients were treated primarily in MUH and 16 patients underwent initial management in a secondary referral centre (SRC) with subsequent referral to the MUH. A retrospective matched case-control study was performed on this patient cohort. RESULTS: There were no significant differences in length of follow-up or risk factors for the development of penile cancer between both groups (p = 0.6 and p = 0.5 respectively) Ultimately, the incidence of high risk disease, nodal metasases, high grade disease and pelvic lymph node dissection were significantly greater in patients that were initially managed in a SRC (p = 0.02, p = 0.03, p = 0.004 and p = 0.028 respectively). Patients undergoing initial treatment in a SRC had a non-significantly reduced rate of cancer specific survival (88 Vs 66%, MUH Vs SRCs, p = 0.495) and recurrence free survival (85 Vs 46%, MUH Vs SRCs, p = 0.24). CONCLUSION: Our findings suggest that managing penile cancer in special interest centres may improve oncological outcome.

Six-core versus twelve-core prostate biopsy: a retrospective study comparing accuracy, oncological outcomes and safety.

AIMS: To compare sextant and 12 core transrectal ultrasound-guided (TRUS) prostate biopsies for detecting prostate cancer (PCa) and to determine whether 12-core prostate biopsies are associated with a higher incidence of insignificant prostate cancer and complications. METHODS: A retrospective study was performed on all patients with a positive TRUS biopsy for prostate cancer between January 2011 and December 2013. Group A underwent a sextant core prostate biopsy and group B underwent a 12-core prostate biopsy. Outcome variables were cancer detection rates, oncological outcomes, incidence of clinically insignificant PCa and incidence of biopsy associated complications. Exclusion criteria included a negative TRUS biopsy and metastatic prostate cancer. RESULT: In total 718 prostate biopsies were performed and 286 patients met inclusion criteria (143 patients in each group). The overall cancer detection rate was 43 % in group A compared to 53 % in group B (p = 0.03). In group A, 31 (21.7 %) patients proceeded to open retropubic radical prostatectomy (RRP) compared to 36 (25.2 %) in group B (p = 0.7). Sextant biopsies were associated with a significantly higher rate of upgrading compared to 12-core biopsies in RRP specimens (51.6 versus 25 % respectively, p < 0.01). The incidence of clinically insignificant PCa was 10.5 % in group A versus 14.7 % in group B (p = 0.2). The incidence of urosepsis post biopsy was 0.7 % in both groups (n = 1). CONCLUSION: Twelve-core biopsies were associated with higher PCa cancer detection rates, greater accuracy for Gleason grading and no differences for detecting clinically insignificant PCa or urosepsis compared to sextant biopsies.

A novel rapid access testicular cancer clinic: prospective evaluation after one year.

BACKGROUND: Our institution has recently developed a rapid access outpatient clinic to investigate men with testicular lumps and/or pain suspicious for testicular cancer (TCa). AIMS: To present our experience after 12 months. METHODS: All referrals to the rapid access testicular clinic (RATC) clinic were prospectively analysed from 01/01/2013 to 01/01/2014. The primary outcome variable was incidence of TCa in the referred patient cohort. Secondary outcome variables were waiting times prior to clinical review and waiting times prior to radical orchidectomy in patients diagnosed with TCa. RESULTS: Seventy-four new patients were referred to the RATC during the 1-year period and the mean age was 34 (range 15-81 years). TCa was the most common diagnosis and was found in 18 (25 %) patients. Patients diagnosed with TCa underwent radical orchidectomy, a median of 3 (range 1-5) days after their initial GP referral. Patients requiring surgical intervention for benign scrotal pathology underwent their procedure a median of 32 (range 3-61) days after their initial referral. Of the 18 patients diagnosed with TCa, 9 (50 %) were diagnosed with a seminomatous germ cell tumour on histopathology. CONCLUSION: The RATC is a new initiative in Ireland that provides expedient and definitive treatment of patients with newly diagnosed TCa. Early treatment will ultimately improve long-term prognosis in this patient cohort.

Trigonal versus extratrigonal botulinum toxin-A: a systematic review and meta-analysis of efficacy and adverse events.

INTRODUCTION AND HYPOTHESIS: Botulinum toxin-A (BoNT-A) is a potent neurotoxin that is an effective treatment for patients with pharmacologically refractory detrusor overactivity (DO). Data assessing the effectiveness of trigonal BoNT-A are limited. This study evaluates adverse events (AEs) and short-term efficacy associated with trigonal and extratrigonal BoNT-A. METHODS: Electronic databases (PubMed, EMBASE, and the Cochrane database) were searched for studies comparing trigonal and extratrigonal BoNT-A for DO. Meta-analyses were performed using the random effects model. Outcome measures included incidence of AEs and short-term efficacy. RESULTS: Six studies describing 258 patients met the inclusion criteria. The meta-analysis did not show significant differences between trigonal and extratrigonal BoNT-A for acute urinary retention (AUR; 4.2 vs 3.7 %; odds ratio [OR]: 1.068, 95 % confidence interval [CI]: 0.239-4.773; P = 0.931) or high post-void residual (PVR; 25.8 vs 22.2 %; OR: 0.979; 95 % CI: 0.459-2.088; P = 0.956). The incidence of urinary tract infection (UTI; 7.5 vs 21.0 %; OR: 0.670; 95 % CI: 0.312-1.439; P = 0.305), haematuria (15.8 vs 25.9 %; OR: 0.547; 95 % CI: 0.264-1.134; P = 0.105) and post-operative muscle weakness (9.2 vs 11.3 %; OR: 0.587; 95 % CI: 0.205-1.680, P = 0.320) was similar in both groups. Finally, differences in short-term cure rates between two study arms were not statistically significant (52.9 vs 56.9 %; OR: 1.438; 95 % CI: 0.448-4.610; P = 0.542). CONCLUSIONS: Although data are limited, no significant differences between trigonal and extratrigonal BoNT-A in terms of AEs and short-term efficacy were observed. Additional randomised controlled trials are required to define optimal injection techniques and sites for administering intra-vesical BoNT-A.

Immediate care of open extremity fractures: where can we improve?

Clear guidelines are set by the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) on the preoperative management of open fractures. This as well as the clinical consequences of poor management of open fractures means the patient workup for surgery is important as well as the timing of surgery. Experience suggests few patients are managed 100% as per the guidelines and we look to test this hypothesis. A retrospective analysis was undertaken of all open long bone fractures (total 133), excluding hand injuries, which presented to a district general hospital over a 5-year period. The implementation of 7 defined key tasks for initial management was recorded. 101 cases were eligible, with the majority of cases (71.4%) having initial orthopaedic assessment outside normal working hours. The mean number of tasks completed was 3.23/7. Assessment out of hours was associated with less tasks being implemented but doctor seniority and the presence of polytrauma made no difference to the quality of acute care. Staff involved in the acute care of open fractures require targeted education to improve the delivery of initial preoperative care. We recommend that other centres assess their performance against this data.

Trends and attitudes towards paediatric circumcision in the South of Ireland.

BACKGROUND: Paediatric circumcision is one of the oldest surgical procedures performed worldwide. Traditionally performed by general surgeons, paediatric surgeons and urologists, there is a falling trend in the rate of paediatric circumcision being performed by adult and paediatric general surgeons. There is currently no corresponding contemporary data pertaining to trends and attitudes of general surgeons to paediatric circumcision in Ireland. AIM: The aim of this study was to assess the trends and attitudes of consultant general surgeons, and to assess its potential impact on the specialist delivery of paediatric urological care. METHODS: A questionnaire was mailed to all practicing general surgeons in whom we identified as having a potential role in the management of paediatric circumcision. Data pertaining to population demographics within the south of Ireland were accessed through the Central Statistics Office. RESULTS: There was an 89 % response rate to the questionnaire survey. Seventy-seven percent of those under 50 were trained in adult circumcision compared with 100 % of those respondents over 50 years. There was a significant difference in paediatric circumcision with only 24 % those under 50 performing this procedure compared with 68 % above 50 years. Eighty-six percent respondents under 45 years (35 % over 45 years) felt that this procedure should be carried out by urology. CONCLUSION: In a region with an expanding paediatric population, it is crucial to maintain paediatric urological services. Given present trends and attitudes of newer appointed general surgeons, it is essential that further specialist appointments are made, and funding directed towards demand in order to keep pace.

Characteristics of modern Gleason 9/10 prostate adenocarcinoma: a single tertiary centre experience within the Republic of Ireland.

INTRODUCTION: The 2005 international society of urological pathology consensus statement on Gleason grading in prostate cancer revised Gleason scoring in clinical practice. The potential for grade migration with this refinement poses difficulties in interpreting historical series. We report the characteristics of a recent cohort of consecutive Gleason score 9 or 10 prostate cancers in our institution. The purpose of this study was to define the clinicopathologic variables and staging information for this high-risk population, and to identify whether traditional prostate staging techniques are adequate for this subcohort of men. MATERIALS AND METHODS: A computational review of our pathology database was performed. Between May 2010 and September 2012, 1,295 consecutive biopsies were undertaken, 168 of which were high-grade tumours (12.97 %). This group were divided into two cohorts of which 84 (12.05 %) had a highest reported Gleason score of 9 (N = 79) or 10 (N = 5) and 84 were reported as Gleason 8. All biopsies were double-reported by pathologists with a special interest in uropathology. RESULTS: Men diagnosed with a Gleason pattern 5 tumour were statistically far more likely to have advanced disease on direct rectal examination of the prostate compared with Gleason sum 8 tumours (p < 0.001) and a positive first-degree family history of prostate cancer (p < 0.001). Overall, Gleason sum 9/10 prostate cancers were also found to be statistically more aggressive than Gleason sum 8 tumours on TRUS core biopsy analysis with significantly higher levels of perineural invasion (p < 0.0001) and extracapsular extension (p = 0.001) as well as a higher levels of tumour found within the core biopsy sample. Those men diagnosed with Gleason pattern 5 prostate cancer also had radiological indicators of increased tumour aggressiveness compared with Gleason sum 8 cancer with respect to bone (p = 0.0002) and visceral (p = 0.044) metastases at presentation. CONCLUSIONS: This series of Gleason score 9/10 prostate cancers serves to highlight the large disease burden, adverse pathologic features, and locally advanced nature of this aggressive subtype, which has previously been under-described in the literature, and differs from historical series in having a large high-grade cohort demonstrating high rates of metastatic disease. A history of prostate cancer amongst first-degree relatives was particularly prevalent in this population raising the issue of screening in a high-risk population. The high incidence of visceral metastatic disease at presentation supports upfront staging with CT thorax, abdomen, and pelvis in patients with Gleason 9 or 10 prostate cancers.

Buried or unburied K-wires for lateral condyle elbow fractures.

INTRODUCTION: Lateral humeral condyle fractures typically require a longer period of internal fixation than other distal humeral fractures due to the increased risk of non-union. K-wires can be buried and left in situ until union or they can be left unburied and require removal after four weeks, with plaster immobilisation until union. There is no consensus as to whether wire burial is preferable or not. The aim of this study was to determine whether K-wire burial is associated with more complications than non-buried wires in treating lateral condyle fractures of the elbow. METHODS: All patients with lateral humeral condyle fractures treated with K-wire fixation at our institution from May 2008 to August 2011 were included in the study. Fracture configuration, mode of reduction, wire burial and complications were assessed. RESULTS: Sixty-seven patients (19 girls and 48 boys, mean age: 6.5 years, range: 1-17 years) were included in the study. All had closed injuries and were treated with open reduction and K-wire fixation. K-wires were buried in 55 patients. Thirteen cases of buried wires eroded through skin and were removed on average 45 days (range: 30-58 days) post-operatively. Of the wire erosion cases, three developed microbiologically proven infections, one of which was a deep infection. There were a further three superficial wound infections in the absence of wire erosion through the skin. There were complications in 2 of the 12 cases in the unburied wires group: 1 microbiologically proven superficial wire site infection and 1 wire backed out after 11 days, requiring refixation. CONCLUSIONS: Wire erosion through the skin is the most common complication of K-wire burial. This may be due to the decrease in swelling after fracture fixation, making the wires more prominent under the skin. Skin integrity should be monitored closely if wires are buried.

Efficacy of chloroquine and sulfadoxine/pyrimethamine mono- and combined therapy against falciparum malaria in Sudan.

We assessed the efficacy of chloroquine and sulfadoxine/pyrimethamine monotherapy in several sentinel sites in northern Sudan and the efficacy of combined therapy in 2 sites. Chloroquine efficacy in children under 5 years was also assessed in 2 sites in southern Sudan. Patients with indications of uncomplicated falciparum malaria and sufficient parasite density were enrolled. The chloroquine failure rates in the northern and southern sites were 43.4% and 80.2% respectively. Treatment failure was significantly higher in children than adults, while there was no significant sex difference. Sulfadoxine/pyrimethamine had an overall failure rate of 4.4%. Combination of the 2 drugs had a failure rate of 14.5% and 5.9% in the 2 sites.

From chloroquine to artemisinin-based combination therapy: the Sudanese experience.

BACKGROUND: In Sudan, chloroquine (CQ) remains the most frequently used drug for falciparum malaria for more than 40 years. The change to artemisinin-based combination therapy (ACT) was initiated in 2004 using the co-blister of artesunate + sulfadoxine/pyrimethamine (AS+SP) and artemether + lumefantrine (ART+LUM), as first- and second-line, respectively. This article describes the evidence-base, the process for policy change and it reflects the experience of one year implementation. Relevant published and unpublished documents were reviewed. Data and information obtained were compiled into a structured format. CASE DESCRIPTION: Sudan has used evidence to update its malaria treatment to ACTs. The country moved without interim period and proceeded with country-wide implementation instead of a phased introduction of the new policy. The involvement of care providers and key stakeholders in a form of a technical advisory committee is considered the key issue in the process. Development and distribution of guidelines, training of care providers, communication to the public and provision of drugs were given great consideration. To ensure presence of high quality drugs, a system for post-marketing drugs surveillance was established. Currently, ACTs are chargeable and chiefly available in urban areas. With the input from the Global Fund to fight AIDs, Tuberculosis and Malaria, AS+SP is now available free of charge in 10 states. CONCLUSION: Implementation of the new policy is affected by the limited availability of the drugs, their high cost and limited pre-qualified manufacturers. Substantial funding needs to be mobilized by all partners to increase patients' access for this life-saving intervention.

The efficacies of artesunate-sulfadoxine-pyrimethamine and artemether-lumefantrine in the treatment of uncomplicated, Plasmodium falciparum malaria, in an area of low transmission in central Sudan.

In an efficacy trial of artemisinin-based combination treatments (ACT) in central Sudan, cases of uncomplicated, Plasmodium falciparum malaria were given artesunate-sulfadoxine-pyrimethamine (ASP) or artemether-lumefantrine (AL) as first-line treatment. On enrolment, the 71 patients given ASP were similar to the 72 given AL, apart from having generally lower parasitaemias (geometric mean counts of 4893 nu. 10,215 asexual parasites/microl) and having a lower mean age (15 nu. 23 years). Each patient was treated on days 0, 1 and 2, and all 137 who completed follow-up without further, unscheduled treatment were found aparasitaemic and afebrile from day 2 until the last follow-up, on day 28. No moderate or severe adverse side-effects, clinical failures or parasitological failures were observed among these 137 patients. ACT therefore appear both efficacious and safe for the treatment of uncomplicated malaria in central Sudan.

The Efficacy of Artemether/Lumefantrine for the Treatment of Uncomplicated Falciparum Malaria in Children in an Area of High Transmission in Southern Sudan

"Objectives: Sudanese health authority adopted a new antimalarial drug policy in response to the reported high level of chloroquine resistance. ""Artesunate+ sulfadoxine/pyrimethamine"" (ASP) and ""artemether/lumefantrine"" (A/L) are recommended as first and second lines for the treatment of uncomplicated falciparum malaria respectively. This study aims to evaluate the clinical and parasitological response to A/L and to report any side effects related to the drug in children living in high transmission areas. Methods: This evaluation of the clinical and parasitological response to directly observed treatment with 6 doses A/L following WHO protocol for monitoring antimalarial drugs efficacy. Giemsa-stained thick and thin blood smears were examined microscopically. Results: A total of 75 (40.8) patients met the inclusion criteria; of them 70 (97.2) patients showed adequate clinical and parasitological response (radical cure); 2 (2.8) patients were classified as early treatment failure and 3 (4) patients were lost to be followed-up by day 3. No progression to severe illness or danger signs occurred for any patient during the study. Conclusion: The main outcome of study was that A/L was found to be highly effective against Plasmodium falciparum uncomplicated malaria; well tolerated by children with no reported serious side effects. Dramatic decrease in parasites density and fever were observed in most of the cases by day 3 of treatment."

Classification of perinatal death in a developing country.

OBJECTIVES: To evaluate and compare the three most commonly used perinatal death classification systems: (1) the Nordic-Baltic; (2) the Aberdeen; and (3) the Wigglesworth, and assess their applicability in a developing country (Sudan) with a high perinatal mortality rate, and their justification for practical use in quality assurance and audit activities. METHODS: At Omdurman Maternity Hospital (OMH), Khartoum, Sudan, 166 perinatal deaths were prospectively assessed during a 3-month period (May-August 2000) with a total of 2260 births. Narratives of 166 perinatal deaths were prepared for the purpose of audit. A panel of two Danish and one Sudanese obstetrician categorized the cases according to: (1) the Nordic-Baltic; (2) the Aberdeen; and (3) the Wigglesworth classification. RESULTS: By all three classifications a similar fraction of cases (approx. 85%) were allocated to one category only, and in 15% of cases the assessors were in doubt into which of two categories the cases should be allocated. The necessary information is often not available, giving at least 40% classified as 'unknown' in the Aberdeen classification, whereas the Wigglesworth classification results in an even larger group of unspecified asphyxia. CONCLUSION: Classification of perinatal deaths in developing countries is associated with problems regarding application, validity and usefulness. The Nordic-Baltic classification seems to be most suitable for appropriate stratification using routinely recorded variables and providing categories associated with specific levels of care.