Implications of a new element in the early diagnostic pathway for prostate cancer for rural Australians.

AIMS: To demonstrate the magnitude of the potential problem caused by the trend towards using positron emission tomography prostate-specific membrane antigen scans on men in rural Australia. CONTEXT: Prostate-specific membrane antigen positron emission tomography scans have higher sensitivity to detect metastatic prostate cancer than other imaging modalities, especially at lower prostate specific antigen (PSAs). This has led to proposals that prostate-specific membrane antigen be the gold standard to investigate men with a suspicion of prostate cancer. There is a trial underway in Australia examining the use of positron emission tomography prostate-specific membrane antigen in pre-biopsy men. Disparities in access to care and outcomes for prostate cancer for men in rural Australia are well documented. Incorporating positron emission tomography prostate-specific membrane antigen into the primary diagnostic pathway for prostate cancer creates a risk of further entrenching or worsening this inequity due to the lack of positron emission tomography scanners in rural locations. APPROACH: As a surrogate marker for restricted access, we determined the proportion of men over 50 more than 1.5 hours from a positron emission tomography scanner, with local government areas as the unit of assessment. CONCLUSION: Of the 505 local government areas, 309 were greater than 1.5 hours from the nearest positron emission tomography scanner. Of 3 793 865 men, over 50 585 689 lived in the 309 local government areas with restricted access to a positron emission tomography scanner. Our study highlights the risk of exacerbating inequalities in prostate cancer care experienced by men in rural areas. If positron emission tomography prostate-specific membrane antigen becomes the new gold standard, one in 6 men will face geographic barriers to access the standard of care. Future considerations of positron emission tomography prostate-specific membrane antigen must take this into account.

Editor's choice: Implications of isoniazid resistance in Mycobacterium bovis Bacillus Calmette-Guérin used for immunotherapy in bladder cancer.

We report a case of sepsis from Mycobacterium bovis Bacillus Calmette-Guérin (BCG) with low-level isoniazid resistance following intravesical treatment for bladder cancer. Isoniazid resistance in BCG has therapeutic implications when it causes infections after intravesical instillation. For these circumstances, we propose some modifications to existing treatment guidelines for BCG infection.

Type 2 and clear cell papillary renal cell carcinoma, and tubulocystic carcinoma: a unifying concept.

The clinical and pathological features of multiple different renal neoplasms arising in a setting of end-stage renal disease in a 72-year-old male are described. The kidney showed features of renal oncocytosis with multiple oncocytomas, hybrid tumours and chromophobe renal carcinoma. In addition, the kidney contained a type 2 papillary renal cell carcinoma, clear cell papillary and cystic renal cell carcinoma, and tubulocystic carcinoma. The occurrence of these three tumours in a setting of end-stage kidney disease is unique and suggests a common pathogenesis. Immunostaining of these tumours further suggests they are derived from similar stem cells which show immunophenotypic features of both the proximal and distal nephron.

Screaming, shrieking and muttering: the noise-makers amongst dementia patients.

We have described twelve dementia patients with noise making. We categorized noise making into (i) persistent screaming, (ii) perseverative vocalization, (iii) continuous chattering, muttering, singing or humming, and (iv) swearing, grunting and bizarre noise-making. The patients' ages ranged from 70 to 92 years with a mean of 78. There were four males and eight females. Five had Alzheimer's disease and the remaining seven vascular dementia. Five exhibited mild to moderate aggression while another five displayed severe aggression. All but one had motor restlessness and four had delusions or hallucinations. In ten patients the dementia was moderate to severe with five having total dissolution of speech. All but two were in the third stage of the illness and were totally dependent for basic self care. There was a wide network of anatomical structures involved in the twelve patients. The findings are related to what is known of the neuroanatomic location of the lesions and the role of frontal subcortical circuitry and neurotransmitter systems in relation to behavior. Noise-making could be explained by damage to the frontal lobe or interruption of the complex subcortical circuits and related brain chemistry. Treatment of patients with noise-making remains a challenge.