University of Michigan Health System researchers have published new data to help answer two dreaded questions: "Is it cancer?" and "What type of treatment should I have?"
Cancer is the primary concern when abnormal skin lesions are detected.

Macroscopic and microscopic features of a lesion usually provide clues about whether it is benign or malignant. However, the distinction is not always clear-cut, and doctors are faced with the question of how to best treat such patients.

The quandary is especially pronounced in atypical spitzoid tumors (ASTs), a rare proliferation of pigmented skin cells. ASTs have many features of melanoma, a potentially deadly form of skin cancer. ASTs tend to appear in patients who are much younger than the age when skin cancer traditionally occurs, which makes determining whether the lesion is malignant or benign even more difficult.

The new research, led by the University of Michigan Multidisciplinary Melanoma Program and published in the journal Cancer, suggests that ASTs behave differently from other types of melanoma. This finding could eventually lead to fundamental changes in the way ASTs are treated.

"As patients with AST appear to do better than conventional melanoma after similar treatment, we are now able to provide some reassurance to concerned parents and loved ones about the implications of the diagnosis," says lead study author Mathew Ludgate, MBChB, FRACP, assistant professor in the U-M Multidisciplinary Melanoma Program.

Although ASTs are rare, the U-M Multidisciplinary Melanoma Program has considerable experience as a preeminent national referral center. ASTs are an increasing challenge for physicians, as the number of ASTs diagnosed throughout the country appears to be increasing for unknown reasons. The researchers focused on long-term outcomes of ASTs to formulate improved evidence-based treatment guidelines.

Doctors generally treat patients with AST similar to malignant melanoma by surgically removing the lesion and in many cases also with a sentinel lymph node biopsy. The sentinel lymph node biopsy involves the removal and evaluation of one or a few lymph nodes nearest the skin lesion to determine whether the skin lesion has spread to the lymph nodes.

Ludgate and his team analyzed U-M's unique comprehensive melanoma database that has been collecting data for almost two decades for all cases of ASTs of uncertain biological potential between 1994 and 2007.

Data were examined to learn the clinical features of a patient, whether the patient underwent a lymph node biopsy and the histological features of the tumor.

Of the 67 patients in the study, 57 had undergone wide excision and sentinel lymph node biopsy, and 27 biopsies were positive.

All 27 of AST patients with positive sentinel node biopsy are alive and disease-free at an average of about 44 months follow-up, researchers note.

"If AST were a form of melanoma, we would expect that at least some of the patients would have had the AST recur throughout the body by this time" Ludgate explains. "This study provides evidence that although ASTs have some features of melanoma microscopically, they do not behave as aggressively."

These findings can be interpreted in three ways, Ludgate says. "The first is that AST is not cancer at all, but has some ability to spread.

The second possibility is that because ASTs often occur in younger people with intact immune systems, the body is able to successfully fight off the beginnings of metastatic disease. The third possibility is that AST is potentially deadly but removal of the primary AST lesion and the sentinel lymph node biopsy is curative."

Each of these possibilities is considered in the treatment strategy developed collectively as a result of this study. One result of this new strategy is that not every patient with AST must undergo a complete lymph node dissection or treatment with interferon-alpha after a positive sentinel lymph node biopsy, depending on the degree of lymph node involvement and the age of the patient. This is important as complete lymph node dissection is a more extensive surgery than a sentinel lymph node biopsy alone, and has considerable more risk of long term side effects.

Given the difficulty determining whether AST is benign or malignant, Ludgate notes, the melanoma team plans to "identify the molecular profile of ASTs to further characterize the true behavior of these tumors."

In addition to Ludgate, authors of the study are senior author Timothy M. Johnson, M.D., as well as Douglas R. Fullen, M.D., Julia Lee, M.P.H., M.S., Lori Lowe, M.D., Carol Bradford, M.D., James Geiger, M.D., and Jennifer Schwartz, M.D. The authors are affiliated with the U-M Department of Dermatology, Department of Pathology, Comprehensive Cancer Center, Department of Statistics, Department of Otolaryngology and Department of Surgery.

In what is believed to be a first-ever procedure, surgeons at Johns Hopkins have successfully removed a healthy donor kidney through a small incision in the back of the donor's vagina.
"The kidney was successfully removed and transplanted into the donor's niece, and both patients are doing fine," says Robert Montgomery, M.D., Ph.D., chief of the transplant division at Johns Hopkins University School of Medicine who led the team that performed the historic operation.

The transvaginal donor kidney extraction, performed Jan. 29 on a 48-year-old woman from Lexington Park, Md., eliminated the need for a 5-to-6-inch abdominal incision and left only three pea-size scars on her abdomen, one of which is hidden in her navel.

Transvaginal kidney removals have been done previously to remove cancerous or nonfunctioning kidneys that endanger a patient's health, but not for healthy kidney donation. Because transplant donor nephrectomies are the most common kidney removal surgery - 6,000 a year just in the United States - this approach could have a tremendous impact on people's willingness to donate by offering more surgical options," says Montgomery.

"Since the first laparoscopic donor nephrectomy was performed at Johns Hopkins in 1995, surgeons have been troubled by the need to make a relatively large incision in the patient's abdomen after completing the nephrectomy to extract the donor kidney. "That incision is thought to significantly add to the patient's pain, hospitalization and convalescence," says Montgomery. "Removing the kidney through a natural opening should hasten the patient's recovery and provide a better cosmetic result."

Both laparoscopies and transvaginal operations are enabled by wandlike cameras and tools inserted through small incisions. In the transvaginal nephrectomy, two wandlike tools pass through small incisions in the abdomen and a third flexible tool housing a camera is placed in the navel.

Video images displayed on monitors guide surgeons' movements. Once the kidney is cut from its attachments to the abdominal wall and arteries and veins are stapled shut, surgeons place the kidney in a plastic bag inserted through an incision in the vaginal wall and pull it out through the vaginal opening with a string attached to the bag.

Montgomery says the surgery took about three and a half hours, roughly the same as a traditional laparoscopic procedure.

The Jan. 29 operation is one of a family of new surgical procedures called natural orifice translumenal endoscopic surgeries (NOTES) that use a natural body opening to remove organs and tissue, according to Anthony Kalloo, M.D., the director of the Division of Gastroenterology at Johns Hopkins University School of Medicine and the pioneer of NOTES. The most common openings used are the mouth, anus and vagina.

Since 2004, successful NOTES in humans have removed diseased gallbladders and appendixes through the mouth, and gallbladders, kidneys and appendixes through the vagina.

Recently, Kalloo says, some medical experts have called for more studies to compare the safety and effectiveness of NOTES against traditional laparoscopies, which also leave very small scars, have been in use for many years, and are proven to be safer and less painful for patients than older "open" abdominal procedures. He supports more studies.

But, he adds, "natural orifice translumenal endoscopic surgery is the final frontier to explore in making surgery scarless, less painful and for obese patients, much safer." An organ donor, in particular, is most deserving of a scar-free, minimally invasive and pain-free procedure."

Additional surgeons from Johns Hopkins University School of Medicine who participated in the procedure were Mohamad E. Allaf, M.D., assistant professor in the departments of Urology and Biomedical Engineering and director of minimally invasive and robotic surgery; Andy Singer, M.D., Ph.D., assistant professor in the Division of Transplant Surgery; and Wen Shen, M.D., M.P.H., assistant professor in the Department of Gynecology and Obstetrics.

When does severe childhood obesity become a child protection issue? This is just one of the ethical, medical and legal questions confronting doctors as they deal with increasing rates of childhood obesity, according to a series of articles in the latest Medical Journal of Australia.

Dr Shirley Alexander from Westmead Children's Hospital and her colleagues say severe childhood obesity is a common problem that can result in acute and chronic life-threatening complications. Their article examines the case of a severely obese child whose parents were unwilling or unable to adhere to management programs aimed at helping her lose weight.

"We argue that in a sufficiently extreme case, notification of child protection services may be an appropriate professional response," the report says.

According to the report, parental neglect can be a causative factor in ongoing obesity and related medical problems including sleep apnoea.

The case described in the article, an amalgamation of real issues from a number of actual cases, described a four-year-old girl who was 110cm tall and weighed in at a hefty 40kg. The child watched TV for six hours a day and had temper tantrums when denied food. A family-focused multidisciplinary approach failed to stop or reverse the child's weight gain. Child protection authorities were finally notified when the child's health continued to deteriorate. She was introduced to a program of physical activity and reduced dietary intake that soon had her losing weight.

The report concludes that a doctor is duty bound to report severe cases of inadequately managed paediatric obesity to the authorities.

A related article by Joanne Stubbs and Helen Achat says that collecting accurate data is essential in the fight against obesity. The article says monitoring and reporting on childhood obesity provide information on which to base, and subsequently evaluate, our efforts and are dependent on 'opt out' consent to minimise problems of inadequate participation.

"Ongoing population-based anthropometric measurement is fundamental to such efforts (early intervention in weight problems). We argue this is only possible with 'opt out' consent."

'Opt out' consent facilitates the recruitment of a representative sample of the population for valid and meaningful anthropometric information and, at the same time, leaves the individual with the right to decline participation. The article calls on ethics committees to support endeavours to confront the challenges of childhood obesity by allowing opt-out consent for anthropometric measurement studies.

The final article in the series written by nutritionalist Dr Tim Gill and a diverse group of experts in paediatrics, public health, nutrition and endocrinology from the University of Sydney, refutes recent commentary downplaying the prevalence of childhood obesity saying it remains a widespread health concern that warrants population-wide prevention programs.

The statements or opinions that are expressed in the MJA reflect the views of the authors and do not represent the official policy of the AMA unless that is so stated

UK's secretary of state for health, Alan Johnson, said on BBC One's Andrew Marr show on Sunday that on Tuesday he is going to unveil a new government plan to raise the national profile of dementia to improve early diagnosis and quality of treatment and this would include a raft of new initiatives including the provision of "memory clinics" in every town and more support for carers.

The intention is to end the stigma that surrounds dementia: "it's a bit like cancer was 20 years ago," said Johnson. "It wasn't the subject of polite conversation". But unlike cancer, people still joke about dementia and Alzheimer's.

And it takes on average about three years for someone with the condition to receive a diagnosis. Johnson told Andrew Marr he wants people to seek diagnosis much earlier. There are drugs that can improve memory and other ways like changes to diet and lifestyle that can make a measurable difference if diagnosis is early enough.

There are about 700,000 people living with dementia in the UK, many of them without any support from the NHS or social services. Johnson said he wants the national strategy to transform their treatment and quality of life.

According to a report in the Telegraph, Phil Hope, the care services minister, said in December that over the coming decades, the number of people with dementia "is going to double, even treble".

Although Johnson conceded that the NHS needed "re-balancing" to overcome ageism against patients, he said he hoped the days when doctors and health professionals said a condition wasn't worth treating because the patient was too old are long gone.

Johnson is unveiling his plan for a national dementia strategy in the House of Commons on Tuesday. He told Andrew Marr there is money to see the plan through, and it will include more support for people looking after family members with dementia at home.

Johnson said that often it is the carers, the spouses and family members that experience the trauma of dementia, and they need help and support too, and "they need it very early" he said.

Indian Prime Minister Manmohan Singh will undergo heart bypass surgery over the weekend, officials say, after blockages were found in his arteries.

The 76-year-old leader will enter hospital in Delhi on Friday for the surgery on Saturday, a spokesman said.

Mr Singh previously had bypass surgery in the UK in 1990.

The new surgery will raise questions about Mr Singh's participation in the upcoming general elections, which must be held by May.

Foreign Minister Pranab Mukherjee is likely to take charge of prime ministerial meetings while Mr Singh recovers from the operation, reports say.

Mr Singh underwent tests earlier this week after he complained of chest pains.

He will undergo "coronary artery bypass graft surgery" performed by a team of doctors from the All India Institute of Medical Sciences, India's top state-run hospital, and the Asian Heart Institute in Mumbai, a government official said.

Gandhi dynasty

Doctors say there is "very little risk" associated with Mr Singh's surgery and that the prime minister should be fit to resume normal duties in "three to four weeks".

But his ill health may have an effect on the election campaign.

Though Congress party leaders have been saying that Mr Singh will be heading the party into the next elections, there have been reports that Rahul Gandhi, heir to India's powerful Gandhi family, is emerging as a successor.

It is not clear whether Mr Singh will be able to campaign intensively after his surgery, but the economist-politician has never been used by the party to woo voters in a big way.

"The Gandhi family and regional politicians continue to be more important," analyst Yashwant Deshmukh told Reuters news agency.

Apart from Mr Singh's heart bypass in 1990 he has also undergone wrist surgery, prostate gland surgery and a cataract removal procedure, officials said.

Mr Singh - the first prime minister from the Sikh community - has been heading the government since 2004.

He is widely regarded as the architect of the country's economic reform programme.

An academic-turned-civil servant who studied economics at Cambridge and Oxford, Mr Singh became India's finance minister in 1991 when the country was plunging into bankruptcy.

He is widely regarded as the cleanest politician in India, a subject dear to voters' hearts.