Leg Lymphoedema After Inguinal and Ilio-Inguinal Lymphadenectomy for Melanoma: Results from a Prospective, Randomised Trial

BACKGROUND

The Evaluation of Groin Lymphadenectomy Extent for Melanoma (EAGLE FM) study sought to address the question of whether to perform inguinal (IL) or ilio-inguinal lymphadenectomy (I-IL) for patients with inguinal nodal metastatic melanoma who have no clinical or imaging evidence of pelvic disease. Primary outcome measure was disease-free survival at 5 years, and secondary endpoints included lymphoedema.

METHODS

EAGLE FM was designed to recruit 634 patients but closed with 88 patients randomised because of slow recruitment and changes in melanoma management. Lymphoedema assessments occurred preoperatively and at 6, 12, 18, and 24 months postoperatively. Lymphoedema was defined as Inter-Limb Volume Difference (ILVD) > 10%, Lymphoedema Index (L-Dex®) > 10 or change of L-Dex® > 10 from baseline.

RESULTS

Prevalence of leg lymphoedema between the two groups was similar but numerically higher for I-IL at all time points in the first 24 months of follow-up; highest at 6 months (45.9% IL [CI 29.9-62.0%], 54.1% I-IL [CI 38.0-70.1%]) and lowest at 18 months (18.8% IL [CI 5.2-32.3%], 41.4% I-IL [CI 23.5-59.3%]). Median ILVD at 24 months for those affected by lymphoedema was 14.5% (IQR 10.6-18.7%) and L-Dex® was 12.6 (IQR 9.0-17.2). There was not enough statistical evidence to support associations between lymphoedema and extent of surgery, radiotherapy, or wound infection.

CONCLUSIONS

Despite a trend for patients who had I-IL to have greater lymphoedema prevalence than IL in the first 24 months after surgery, our study's small sample did not have the statistical evidence to support an overall difference between the surgical groups.

Seasonal variation in high-risk phenotypes of cutaneous malignant melanoma diagnosed in Eastern England: An observational study

BACKGROUND

Despite seasonal variation in malignant melanoma diagnosis being well described, data on the annual variation in high-risk melanomas are scarce.

OBJECTIVES

We set out to investigate the relationship between seasonality, the incidence of melanoma, and the distribution of melanoma characteristics, including Breslow thickness, ulceration, mitotic rate, lymphovascular and perineural invasion, and the presence of microsatellites.

METHODS

Primary cutaneous malignant melanomas diagnosed between 2011 and 2019 in Eastern England were identified from our prospectively maintained melanoma database (n = 2199). These were analysed by year and season of diagnosis, patient demographics, and melanoma characteristics.

RESULTS

There was a variation in rates of melanoma diagnosis across the year, with Summer having the highest incidence (p < 0.0001). There was a significant trend towards more male than female diagnosis in Winter (p = 0.0354). There were no significant seasonal trends in Breslow thickness, ulceration, tumour infiltrating lymphocytes, or mitotic rate. Multivariate analysis showed that microsatellites were more likely to be diagnosed in the Winter (OR=2.00 (1.19-3.43), p = 0.010), lymphovascular invasion significantly more likely to be diagnosed in Autumn (OR=1.78 (1.16-2.76), p = 0.009), and perineural invasion was more likely to be diagnosed in the Summer (OR=0.44 (0.23-0.79), p = 0.007).

CONCLUSIONS

These data confirm that high-risk phenotypes are associated with increasing Breslow thickness and mitotic rate. However, season variability as an independent risk factor for the phenotypes is a novel finding.

Pre-exposure prophylaxis use among men who have sex with men who have experienced problematic chemsex

Men who have sex with men (MSM) who experience problematic chemsex are at high risk of acquiring HIV due to combined drug use and sexual behaviours. Pre-exposure prophylaxis (PrEP) could substantially reduce the risk of HIV transmission in this group of men. The aim of this study was to examine the biopsychosocial characteristics associated with PrEP use among HIV-negative MSM who have experienced problematic chemsex. This was a cross-sectional analysis of secondary data collected during client assessments at a specialist alcohol and drug service based within the United Kingdom. We compared the socio-demographics, substance use, sexual behaviours and mental health of MSM who reported ever using PrEP to those who reported never using PrEP. Statistical analysis was conducted using the Mann–Whitney U-test for continuous variables and Fisher’s exact test for categorical variables. Between August 2016 and July 2018, 165 HIV-negative MSM who engaged in chemsex had an assessment completed. Thirty-four per cent (n = 50/145) had ever used PrEP. The median age was 36 years (IQR: 30–42), 92% identified as gay (n = 152/165) and 79% were of white ethnicity (n = 130/164). The use of crystal methamphetamine was associated with higher levels of men ever using PrEP (40% versus 21%) (p= 0.047). Men who had ever used PrEP had a higher median number of sexual partners in the previous three months (20 versus 10) (p= 0.004) and had lower level of condom use in their sex lives (median reported 5% versus 50%) (p= 0.010) in comparison to men who had never used PrEP. It is encouraging that men having higher-risk sex had been accessing PrEP. However, further research is required to explore PrEP uptake, retention and adherence in this high-risk group.

Towards a supportive policy and commissioning environment for chemsex in England

The use of drugs in sexual settings among gay men (colloquially referred to as 'chemsex') was first observed in services supporting gay men in London in the late 2000s. A decade on and it now features as a policy issue in the UK Government's latest Drug Strategy, with several actions to support a health system response. However, reaching this point has been a slow and challenging process and much remains to be done to facilitate an environment in which evidence-based chemsex interventions can be delivered. With a view to informing the development of policies and services in other contexts, this case report examines the initiatives that have driven a response to chemsex and contributed to policy development in England and highlights remaining challenges to effective service provision.

Chemsex-related drug use and its association with health outcomes in men who have sex with men: a cross-sectional analysis of Antidote clinic service data

PURPOSE

Chemsex-related drug use (CDU) is an escalating public health issue among men who have sex with men (MSM), associated with significant physical, biomedical and psychosocial harm. Few interventions exist to help MSM engaging in chemsex and little data exist on which to build. This cross-sectional analysis, using data from Antidote, the UK's only lesbian, gay, bisexual, and transgender specialist drug service, aims to remedy this paucity of data.

METHODS

Modified Poisson regression was used to assess associations between CDU and a range of health outcomes; CDU+ subanalysis disaggregated MSM by primary chemsex drug of concern; and HIV+ subanalysis investigated whether CDU was associated with self-reported treatment adherence, HIV seroconversion and other HIV-specific issues.

FINDINGS

Compared with CDU- MSM, MSM presenting for CDU were more likely to be HIV+, current or previous injectors, to have used postexposure prophylaxis in the last year, and have had ≥6 sexual partners in the last 90 days, though less likely to be hazardous alcohol consumers or to have experienced previous suicidal ideation (all p<0.0005). CDU+ subanalysis revealed health outcome differences-those selecting mephedrone were less likely to be hepatitis C+, HIV+, current or previous injectors, or to have experienced previous suicidal ideation (all p<0.0005), whereas those selecting methamphetamine were more likely (all p<0.0005, except suicidal ideation p=0.009).

IMPLICATIONS

This analysis shows MSM presenting for CDU are a heterogeneous high-risk population with unmet health needs. There is a need for standardised chemsex surveillance and for improved intersectorial working between sexual health and drug treatment services. Future research should investigate typological differences between MSM presenting for CDU.

ORIGINALITY/VALUE

To date, this is the world's largest analysis of MSM seeking treatment for CDU. Further, the publication of 'real-world' service data is a valuable addition to the literature alongside surveys and recruited studies.

Effective treatment of chondrodermatitis nodularis chronica helicis using a conservative approach

BACKGROUND

Chondrodermatitis nodularis chronica helicis (CNCH) is usually treated by surgical excision, but is prone to recurrence.

OBJECTIVES

To examine whether CNCH could be treated nonsurgically using a home-made, pressure-relieving prosthesis.

METHODS

A retrospective comparison was made of the outcome in 41 subjects treated surgically and 15 treated nonsurgically between 1999 and 2001.

RESULTS

Thirteen of the 15 patients (87%) treated nonsurgically were healed at follow-up after 1 month of conservative treatment and so have avoided surgery to date. In contrast, the recurrence rate of the surgically treated group was 14 of 41 (34%) patients.

CONCLUSIONS

As a result of this study, we recommend that patients presenting with CNCH be managed conservatively in the first instance.

A simple classification of the resolution and depth of imaging systems for pigmented skin lesions

The resolving power of imaging systems used in the diagnosis of cutaneous malignant melanoma is usually presented in the literature in terms of numerical values, yet it is often difficult for the reader to ascertain what tangible information these systems are extracting. This paper presents a classification system of two aspects of imaging systems that allows rapid appraisal of the resolution of the different imaging systems used in the diagnosis of melanoma and the additional clinical information they reveal.

Spectrophotometric intracutaneous analysis: a new technique for imaging pigmented skin lesions

BACKGROUND

Spectrophotometric intracutaneous analysis (SIA) is a new technique for imaging pigmented skin lesions and for diagnosing melanoma. The SIAscope produces eight narrow-band spectrally filtered images of the skin over an area of 24 x 24 mm with radiation ranging from 400 to 1000 nm.

OBJECTIVES

To present the early results of a clinical trial with SIA.

METHODS

Spectrophotometric inputs from the skin were analysed using complex algorithms to return high-resolution information regarding total melanin content of the epidermis and papillary dermis, collagen and haemoglobin content as well as the presence of melanin in the papillary dermis.

RESULTS

Simple, highly reproducible and reliable features were identified, e.g. the presence of dermal melanin, collagen holes and 'erythematous blush' with blood displacement. These simple features were found to be highly specific (80.1%) and sensitive (82.7%) for melanoma in a dataset of 348 pigmented lesions (52 melanomas) and compared very favourably with dermatoscopy when analysed using receiver-operator characteristic curves.

CONCLUSIONS

This first clinical trial with SIAscopy has yielded very promising results and delivers new, useful information to the clinician diagnosing pigmented skin lesions.

Can ultrasound reliably detect renal scarring in children with urinary tract infection?

One hundred children with a proven urinary tract infection were studied prospectively using both ultrasound (US) and 99mTc dimercaptosuccinic acid (DMSA) scintigraphy to assess the efficacy of US in the detection of renal scarring. Sixty-nine girls and 31 boys with an age range of 0.5-11.8 years were studied. DMSA scintigraphy detected 19 scarred kidneys in 17 children. Scarring was classified as mild, moderate or gross. US detected a total of seven of the scarred kidneys (sensitivity 37%). US detected 0/6 kidneys with mild scarring, 1/7 kidneys with moderate scarring and 6/6 kidneys with gross scarring. Four kidneys with scarring on DMSA showed abnormalities other than scarring on US. 8/19 scarred kidneys were thought to be normal on US. It is important to detect renal scarring in young children and US cannot be relied upon for this purpose. It should therefore be supplemented with DMSA scintigraphy.

Fanconi syndrome after ifosfamide

A 2-year-old boy developed the Fanconi syndrome 1 year after being treated successfully for a neuroblastoma. This is probably an unusual complication of ifosfamide.

Comparison of ultrasound examination and intravenous urography after a urinary tract infection

The results of ultrasound examination and intravenous urography after a urinary infection were compared in 100 children. Thirty seven had an abnormality on urography, but in 12 this was not seen on ultrasound. One of these had renal scarring, the remainder only minor abnormalities.

Asymptomatic bacteriuria in healthy preterm babies

Urine was cultured from 51 healthy preterm babies. If the initial bag specimen grew more than 50 000 organisms/ml, a second bag specimen was cultured. After two positive bag specimens a suprapubic urine was cultured. Significant bacteriuria was excluded on the basis of one or two bag specimens in 90% of the babies. Suprapubic urine was sterile in a further 11 babies. Four babies with positive bag specimens were unfortunately not completely investigated: 2 had mixed growths and 2 had pure growths of 100 000 organisms/ml. As we and others consider that bacteriuria can only be diagnosed on a suprapubic sample of urine the incidence of proved infection in our series was zero. If both the babies with a pure growth of 100 000 organisms/ml had true bacteriuria, the incidence would rise to 1.3%. In view of the difficulties in obtaining clean urine samples in preterm babies and as the incidence of bacteriuria is so low, we do not recommend that healthy preterm babies be screened for bacteriuria.

Muscular dystrophy in an X; 1 translocation female suggests that Duchenne locus is on X chromosome short arm

A unique combination of a Duchenne-like muscular dystrophy in a girl with a translocation-inversion rearrangement involving an X chromosome and a no 1 chromosome appeared as a result of both gene mutation and chromosome mutation in the mother. The X-autosome rearrangement would permit full expression of an X-linked recessive gene, such as that for Duchenne muscular dystrophy, in a female, and this would satisfactorily explain the characteristic Duchenne-like course of our patient's illness. The simultaneous de novo appearance of the Duchenne mutation and the X;1 rearrange suggests possible sites for the Duchenne locus on the X chromosome short arm (at Xp1106 or Xp2107).

Congenital rickets due to maternal vitamin D deficiency

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