Bladder malignancy as a cause of spontaneous bladder rupture: A systematic review.

Objectives: To characterise cases of spontaneous rupture of the urinary bladder in the context of bladder cancer. Methods: A systematic review was performed to characterise cases of spontaneous bladder rupture in patients with bladder cancer. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) system was utilised, with databases being searched for relevant cases. Patient characteristics were extracted, including age, sex, presenting signs and symptoms, management modalities, tumour histology and mortality. Results: Thirty cases were included. Seventeen (57%) were male, and the median age of presentation was 59. Abdominal pain and peritonism were the most common presenting symptoms, in 80% and 60% of patients, respectively. Most patients (n = 16, 53%) had urothelial cell carcinoma. Nine patients (30%) died during their initial hospitalisation. Conclusion: Spontaneous bladder perforation in the context of bladder cancer is a rare cause of acute abdomen. The diagnosis is associated with high mortality, highlighting the aggressive nature of the malignancies that cause spontaneous bladder rupture. This raises important questions about the role of emergency cystectomy, the timing of systemic therapy and the appropriate involvement of palliative care.

Hypereosinophilic syndrome with cutaneous manifestations successfully treated with Dupilumab as a sole agent: A case report.

Hypereosinophilic syndrome describes a process in which eosinophils in the peripheral blood are persistently increased, with variable clinical manifestations. Finding efficacious treatments for this disease can be challenging. This case describes a 72-year-old man with idiopathic hypereosinophilic syndrome with cutaneous manifestations who was successfully treated with dupilumab as a single agent therapy. There was complete clinical and biochemical resolution of disease (eosinophils levels decreased from 4.13 to 0.92) without complications.

Management of basal cell carcinoma with pulmonary metastasis.

A man in his 50s presented with an ulcerative lesion within the left axillary fold that had progressively worsened over 18 months. Biopsy revealed an ulcerative basal cell carcinoma (BCC), which was surgically managed. CT chest scans done 7 months later assessed post-treatment of radiotherapy. This revealed pulmonary lesions, which were biopsy-proven metastatic BCC. Sonidegib, a hedgehog signalling inhibitor, was used for first-line treatment. Due to progressive disease, sonidegib was ceased. Cemiplimab, a checkpoint inhibitor, was used as second-line treatment based on a phase II trial demonstrating efficacy in the setting of metastatic BCC. CT reports were initially consistent with response but after 6 months of cemiplimab treatment, repeat CT chest scans revealed a decrease in size of the previously cited pulmonary lesions.This is a rare case of BCC metastases which has limited treatment options. This case provides insight of the patient experience on such treatment.

Pathways from Diagnosis to Death from Keratinocyte Cancer in Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients are at increased risk of developing and dying from keratinocyte cancer. We aimed to describe the clinical course of keratinocyte cancer-related deaths in a cohort of kidney transplant recipients. METHODS: In kidney transplant recipients transplanted between 1995 and 2014 in Queensland, Australia, we ascertained keratinocyte cancer deaths by searching national transplant and state death registries to March 2020. Deceased transplant recipients' medical records were reviewed to assess features of the primary lesion of the fatal keratinocyte cancer, metastases, and clinical information before death. RESULTS: Of 658 kidney transplant recipient deaths, 49 (7%) were due to keratinocyte cancer, and medical records were available for 36 (73%). One death was due to basal cell carcinoma, and 35 were from squamous cell carcinoma (SCC), primarily from the head and neck (24; 69%). The most common site of metastasis was the lungs (21; 58%). Median time (minimum, maximum) from the diagnosis of primary SCC to metastasis was 5 months (0, 29). After this, the median time to death was 9 months (1, 50). CONCLUSION: Fatal keratinocyte cancers overwhelmingly arise on the head and neck, with lungs the most common metastasis site. The short time from diagnosis of primary to death indicates the aggressive nature of these keratinocyte cancers.

Keratinocyte Cancer Mortality in Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients are at increased risk of developing and dying from keratinocyte cancer. Risk factors for keratinocyte cancer death have not been previously described. METHODS: In a cohort of kidney transplant recipients transplanted in Queensland from 1995 to 2014, we identified keratinocyte cancer deaths by searching national transplant and state death registries to March 2020. Standardized keratinocyte cancer mortality rates and mortality ratios were calculated. We used a competing risks model to identify factors associated with keratinocyte cancer death and calculated relative risks (RRs) and 95% confidence intervals (CIs). RESULTS: There were 562 deaths in 1866 kidney transplant recipients (62% male individuals; 86% Caucasian) with 25 934 person-y of follow-up, of which 36 were due to squamous cell carcinoma and 1 to basal cell carcinoma with standardized mortality rates of 78 (95% CI, 53-111) and 2 (95% CI, 0.1-11) per 100 000 person-y, respectively. The standardized mortality ratio for keratinocyte cancer was 23 (95% CI, 23-24). Besides Caucasian ethnicity (associated with 100% of keratinocyte cancer deaths), male sex (RR, 3.24; 95% CI, 1.26-8.33), and older age at transplantation (≥50 versus <50 y; RR, 3.09; 95% CI, 1.38-6.89) were associated with increased risk of keratinocyte cancer death. CONCLUSIONS: Keratinocyte cancer mortality in kidney transplant recipients is over 20 times higher than in the general population. Most keratinocyte cancer deaths are due to cutaneous squamous cell carcinoma, however, basal cell carcinoma can be fatal. Education in skin cancer prevention is essential to avoid unnecessary deaths from keratinocyte cancer among kidney transplant recipients.

Two-step versus 1-step subretinal injection to compare subretinal drug delivery: a randomised study protocol.

INTRODUCTION: There is increasing interest in subretinal injections as a surgical procedure, largely as a result of emerging treatments for ocular diseases which necessitate this manoeuvre. However, surgical variables in the efficacy of such treatments have to date been largely overlooked and the proportion of drug which reaches the intended compartment of the subretinal space remains unknown. Our aims are twofold: first, to determine the proportion of subretinally injected medication retained following surgical delivery and second, to compare two different techniques of injection ('1-step' vs '2-step'). METHODS: We outline a randomised controlled trial of subretinal injection of alteplase following vitrectomy for the management of submacular haemorrhage secondary to age-related macular degeneration. Patients will be randomised to receive either 1-step injection, where the therapeutic solution simultaneously defines the surgical plane or 2-step injection, where the surgical plane is first identified with balanced salt solution prior to injection of subretinal alteplase, as outlined below. Sodium fluorescein will be used as an optical label to track drug reflux into the vitreous cavity using quantitative protocols established in our laboratory. All patients will undergo fluid air exchange at the completion of surgery, with injection of bevacizumab 1.25 mg and 20% sulfahexafluoride gas as the vitreous substitute (both of which may help improve outcomes). Alteplase, sodium fluorescein and bevacizumab will all be used for off-label indications in the trial. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South Eastern Sydney Local Health District's Human Research Ethics Committee (HREC 17/092). The results of this trial will be disseminated in peer-reviewed proceedings (associated with conference presentation) and in scholarly journals. TRIAL REGISTRATION NUMBER: ACTRN12619001121156.

Endophthalmitis: Changes in Presentation, Management and the Role of Early Vitrectomy.

Endophthalmitis is a sight-threatening condition, and its timely and appropriate management is essential in preventing permanent vision loss. Recent changes in clinical practice in endophthalmitis and advances in modern vitreoretinal surgery may limit the applicability of established randomised clinical trial evidence to current management. This review discusses the epidemiology, pathophysiology, changing patient presentation, diagnosis and advances in the management of endophthalmitis, presenting the existing literature on this topic and results from Sydney Eye Hospital.

Cross-sectional study of pigmented lesions of the head and neck in adults aged 40 years and above.

The diagnosis of junctional and lentiginous naevi on sun-damaged skin of the head and neck in adults has been questioned in the literature, with the implication that these lesions should be classified as melanoma in situ. This could result in the overdiagnosis and overtreatment of non-malignant lesions. We conducted a cross-sectional study of the histopathological diagnosis of pigmented lesions biopsied from the head and neck of adults ≥40 years of age that were submitted to a large, Queensland-based pathology centre over seven months. Out of 543 lesions assessed, 293 (54.0%) were flat and 250 (46.0%) were raised. Flat naevi consisted of junctional/lentiginous and compound naevi, either with or without dysplasia. Collectively, flat naevi had a prevalence slightly less than that of melanoma (15.0% versus 19.0% among flat lesions, respectively, and 8.1% versus 11.2% among all lesions, respectively). The mean age of biopsy for all junctional/lentiginous naevi was significantly greater than that of all compound naevi (65.0 years versus 52.2 years; P = 0.001). Junctional/lentiginous naevi were significantly more associated with the neck than intradermal naevi (P < 0.001). In conclusion, benign, flat naevi account for a significant proportion of head and neck lesions in adults ≥40 years of age, and their location alone should not outweigh their histopathology when reaching a diagnosis.

Inflammatory Dietary Patterns and Risk of Keratinocyte Cancers in Kidney Transplant Recipients: Prospective Cohort Study.

BACKGROUND: Kidney transplant recipients (KTRs) are at increased risk of cutaneous squamous (SCC) and basal cell carcinomas (BCC) due to immunosuppression and sun exposure. Skin carcinogenesis involves inflammation, and foods that promote inflammation may promote carcinogenesis. METHODS: We prospectively examined the association between pro-inflammatory diets and SCC and BCC incidence in KTRs in Queensland, Australia. We recruited KTRs at high risk of skin cancer (aged ≥18 years and previously affected; or aged ≥40; or immunosuppressed ≥10 years) between 2012 and 2014 and followed up until June 2016. A baseline dietary questionnaire was used to calculate modified-Empirical Dietary Inflammatory Pattern (EDIP) scores to indicate dietary inflammatory capacity; higher scores indicated pro-inflammatory diets. EDIP scores were ranked into 3 groups. Outcomes were histologically confirmed SCC and BCC. Adjusted relative risks (RRadj) and 95% CIs were estimated using negative binomial regression. RESULTS: Among 260 KTRs, 100 (38%) and 93 (36%) developed at least 1 new SCC and BCC, with 426 SCC and 343 BCC diagnosed in the follow-up period. The highest modified-EDIP score group (vs. lowest) were at increased risk of SCC (RRadj 1.79, 95% CI 1.01-3.16) but not BCC. Pro-inflammatory diets may increase SCC but not BCC risk among KTRs. CONCLUSIONS: Inflammatory diets may increase the risk of SCC in KTRs.

Ab-externo drainage with continuous anterior chamber infusion for non-resolving exudative retinal detachment: a case report.

BACKGROUND: Drainage of exudative retinal detachment may be necessary for either therapeutic or diagnostic purposes (or both). Here, we describe an external drainage technique for non-resolving vision-threatening exudative retinal detachment which combines the advantages of internal drainage (widefield viewing and intraocular pressure control using continuous anterior chamber infusion) with those of external drainage (drainage of sub-retinal fluid without vitrectomy). CASE PRESENTATION: To illustrate this technique, we present a 13-year-old girl with macula-off exudative retinal detachment secondary to Vogt-Koyanagi-Harada syndrome, which was unresponsive to aggressive medical management. External drainage was undertaken using widefield viewing and chandelier illumination. Intraocular pressure was maintained with an anterior chamber infusion. Near-complete drainage of sub-retinal fluid was achieved, and retinal reattachment was maintained at 6 months postoperatively, with a corresponding improvement in visual acuity from 20/63 to 20/40. CONCLUSIONS: External drainage under chandelier-assisted viewing at the surgical microscope with anterior chamber infusion offers the ergonomic and optical advantages of the surgical microscope and widefield visualisation, continuous IOP control and drainage of sub-retinal fluid without the need for pars plana vitrectomy.

Prospective study of pigmented lesions managed by shave excision with no deep margin transection of melanomas.

Shave excision is a simple and cost-effective technique for the removal of suitable skin lesions. We performed a prospective study over six months, collecting data from pigmented lesions that were treated with shave excision by dermatologists. Only shave excisions with the intent to remove the lesion in toto were included. A total of 349 lesions were included in this study, 50 (14%) of these were melanomas and no melanoma diagnosed had deep margin involvement, while 13 (26%) had lateral margin involvement.

Presenting patterns of dermatology conditions to an Australian emergency department.

BACKGROUND: Approximately 5%-8% of emergency department (ED) presentations are due to a dermatological condition. This study aimed to identify and characterise patients with skin conditions presenting to a busy ED. METHODS: A 5-year retrospective study on patients with dermatological conditions presenting to the Princess Alexandra Hospital ED in Brisbane, Australia was performed. Electronic medical records were used to compare demographics and admission status of the dermatology group and the total ED group presentations. A prospective survey was conducted on low priority triage (triage 4 and 5) patients identifying reasons presenting to the ED. RESULTS: Of a total 281,718 ED presentations, 11,748 dermatology presentations were identified between January 2012 to December 2016. Of the dermatology presentations, 41.5% were female and had an average age of 47. The most common dermatology presentations were cellulitis, abscess, rash unspecified, and ulcer. Of those admitted, 36% were female, average age was 53, mean length of stay of 294 minutes and 83.1% had an infectious aetiology. Of triage 4 and 5 presentations, 66% patients we approached had been seen by a health practitioner prior to coming to the ED. CONCLUSION: Within the population presenting with a skin related condition to the Princess Alexandra Hospital ED, characteristics associated with admission include male sex, older age, and an infectious etiology. This data may help ED clinicians decide on the discharge disposition of these patients. There may be a role for streamlined admissions for skin related infections, or improved hospital in the home services to support this group.

Presenting patterns of dermatology conditions to an Australian emergency department / 世界急诊医学杂志（英文）

BACKGROUND: Approximately 5％–8％ of emergency department (ED) presentations are due to a dermatological condition. This study aimed to identify and characterise patients with skin conditions presenting to a busy ED.METHODS: A 5-year retrospective study on patients with dermatological conditions presenting to the Princess Alexandra Hospital ED in Brisbane, Australia was performed. Electronic medical records were used to compare demographics and admission status of the dermatology group and the total ED group presentations. A prospective survey was conducted on low priority triage (triage 4 and 5) patients identifying reasons presenting to the ED. RESULTS: Of a total 281,718 ED presentations, 11,748 dermatology presentations were identified between January 2012 to December 2016. Of the dermatology presentations, 41.5％were female and had an average age of 47. The most common dermatology presentations were cellulitis, abscess, rash unspecified, and ulcer. Of those admitted, 36％ were female, average age was 53, mean length of stay of 294 minutes and 83.1％ had an infectious aetiology. Of triage 4 and 5 presentations, 66％ patients we approached had been seen by a health practitioner prior to coming to the ED. CONCLUSION: Within the population presenting with a skin related condition to the Princess Alexandra Hospital ED, characteristics associated with admission include male sex, older age, and an infectious etiology. This data may help ED clinicians decide on the discharge disposition of these patients. There may be a role for streamlined admissions for skin related infections, or improved hospital in the home services to support this group.