Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma.

After 2 years of holistic self-treatment on his home island, an elderly Samoan man presented with a painful, hyperpigmented mass on his left heel. Physical examination revealed a black, friable tumour with necrotic tissue and superficial ulcerations with no other associated symptoms. Further investigation revealed that the mass was invasive. The tumour was treated with resection and a final diagnosis of acral lentiginous melanoma, stage T4b was made. Poor access to care and screening services are large barriers to care for minorities and patients with low socioeconomic status. Once access is obtained, however, patient compliance is not guaranteed. Healthcare practices often clash with societal beliefs, and so patient education regarding their disease and its possible progression, along with treatment options, is important. Furthermore, a lack of ethnically diverse physicians contributes to low cultural competency during interaction with patients from minorities, resulting in poor communication and low patient satisfaction.

Lupus erythematosus tumidus: a unique disease entity.

Lupus erythematosus tumidus (LET) is a photosensitive skin disease characterized by succulent, edematous, and non-scarring plaques. Histologic features include perivascular and periadnexal lymphocytic infiltration and interstitial mucin deposition. Despite being first described in 1909, there are few case reports in the current literature describing this disease and even fewer that discuss treatment. We describe a case of a 22-year-old woman with systemic lupus erythematosus (SLE) and secondary class V lupus nephritis. She was referred to Dermatology for an intermittent pruritic facial eruption that was clinically and histologically consistent with LET. There is much controversy in literature as to whether or not LET is a unique variant of cutaneous lupus erythematosus. Interestingly, the mainstay of treatment for LET, in the limited case reports and series that exist, is with antimalarial drugs, which our patient had already been taking for SLE. This case exemplifies the need for complete disease characterization, evidence-based treatment, and a multidisciplinary approach.

Application of the AJCC 7th edition carcinoma of the eyelid staging system: a medical center pathology based, 15-year review.

CONTEXT: The purpose of this study was to conduct a quality improvement (QI), applied practical review of the American Joint Committee on Cancer (AJCC) 7th edition, Carcinoma of the Eyelid staging system. AJCC utilizes a primary tumor, lymph node, metastasis (pTNM) cancer staging approach. OBJECTIVE: We wanted to determine if the AJCC pTNM carcinoma staging system identified patients with highly aggressive carcinoma of the eyelid. We also wanted to determine if there were any unexpected issues in its practical application. DESIGN: We conducted a 15-year, consecutive, retrospective review of all cases of excisional biopsy for carcinoma of the eyelid. We reviewed the original histopathology slides and complete pathology records for each case. RESULTS: Over a 15-year review period, 52 cases of excisional biopsy for carcinoma of the eyelid were identified. The average age of the study population was 72 years. Nodular well-differentiated basal cell carcinoma (BCC) was the predominant histology for 85% of cases. Morpheaform/metatypical BCC was the next dominant at 9%. Squamous cell carcinoma and sebaceous carcinoma followed at 4% and 2%, respectively. We were able to assign clear staging to 50 of the 52 cases with the available pathology data. The stage results were as follows: stage 1A 72%, stage 1B 22%, stage II 4%, stage III 2%, with no cases of stage IV metastatic disease. CONCLUSIONS: The 7th edition AJCC Carcinoma of the Eyelid chapter proved to be a practical tool for carcinoma staging of the eyelid. The largest tumor dimension remains an effective predictive factor. High-grade pathologic prognostic factors such as tumor necrosis or perineural spread had a 100% association with a final stage of II or greater. Concordance and compliance was 100% for the recommended site-specific pathologic risk factors. Regarding squamous cell carcinoma of the eyelid, three new required data points had a 0% reporting rate over 15 years. Overall, smaller less invasive tumors were classified as stage 1A and 1B tumors. More invasive and higher risk tumors fell into appropriate higher staging classifications. The newly recommended prognostic site-specific tumor factors appear to work well with a high concordance with staging severity, and strong medical community acceptance.

Blood enzymes and oxidative stress in chronic kidney disease: a cross sectional study.

BACKGROUND: Cardiovascular disease causes morbidity and mortality in chronic kidney disease. Increased formation of oxygen-derived radicals can accelerate the development of atherosclerosis. Several studies have shown an imbalance in antioxidant activity, resulting in high oxidative stress and lipid peroxidation, in subjects undergoing hemodialysis. METHODS: Eighty-nine subjects with chronic kidney disease and varying degrees of renal impairment, some of who were undergoing peritoneal or hemodialysis, were studied and compared with a group of healthy controls. F2-isoprostanes, selenium, and oxidized low density lipoprotein (LDL) concentrations were used as markers for in vivo oxidative stress; paraoxonase and glutathione peroxidase were used as markers of antioxidant activity. RESULTS: We quantified serum F2-isoprostanes, paraoxonase, selenium, oxidized LDL, and RBC glutathione and compared the treatment regimens using post-hoc pair-wise comparisons and Tukey's honest statistical difference. A significant increase in oxidative stress between the hemodialysis and control group was noted. The renal insufficiency and peritoneal dialysis groups showed increased oxidative stress and decreased antioxidant capacity, reaching statistical significance for some serum analytes. Selenium concentrations and oxidized LDL did not vary significantly between the hemodialysis and control groups. CONCLUSION: These data suggest that increased oxidative stress and decreased antioxidant activity are associated with declining renal function.

Gallbladder duplication: evaluation, treatment, and classification.

Duplicate gallbladder is a rare congenital anomaly resulting from abnormalities in embryogenesis during the fifth and sixth weeks of gestation. Approximately 210 cases have been described. Variations include duplicate, triplicate, and septated gallbladder. We encountered a 15-year-old girl with both a duplicated gallbladder and a duplicated cystic duct who underwent successful laparoscopic cholecystectomy. This combination is extremely unusual, and based upon our findings in this case and a review of the literature, we propose the Unified Classification of Multiple Gallbladders.

Using peripheral smear review, age and absolute lymphocyte count as predictors of abnormal peripheral blood lymphocytoses diagnosed by flow cytometry.

Absolute lymphocytosis in the elderly raises the possibility of malignancy and generally warrants further investigation. To better correlate clinical variables with the frequency of neoplastic lymphoid processes in this population, we retrospectively reviewed archived flow cytometric analyses from peripheral blood specimens on patients of 50 years of age and older that had been deemed suspicious for a lymphoproliferative process after peripheral smear review. Age, absolute lymphocyte count (ALC), white blood cell count and relative lymphocyte count were correlated with the results of flow cytometry. Of 71 total cases, 42 (59%) had an abnormal immunophenotype. Independent variables that showed significant differences between normal and abnormal immunophenotype were mean age (p = 0.001) and ALC (p = 0.0032). We combined age and absolute lymphocyte count variables to look for the best possible cutoff values to predict the likelihood of an abnormal immunophenotype. ALC cutoff values of >or=4 x 10(9) cells/L for patients over 67 years of age, and >6.7 x 10(9) cells/L for patients between 50 and 67 years of age, had a high sensitivity for detecting an abnormal immunophenotype.