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A strong association between periodontitis and higher susceptibility to pregnancy complications like preeclampsia has been reported although the mechanisms remain elusive. Trophoblast cells modulate the recruitment and functional shaping of maternal leukocytes at early stages to sustain an antiinflammatory microenvironment and fetal growth. Neutrophil activation with reactive oxygen species (ROS) release is associated with preeclampsia. Our aim was to study the effect of the gingival crevicular fluid (GCF) from pregnant women on trophoblast cell function and trophoblast-neutrophil interaction.Pregnant women at 16-20 weeks of gestation (n = 27) and non-pregnant women (n = 8) as the control group were studied for gingivoperiodontal clinical score evaluation and GCF collection. Total bacteria and common periodontal pathogens were analyzed in GCF samples. The effect of each GCF sample was tested on first trimester trophoblast-derived cells to assess cell migration, cytokine expression and glucose uptake. Also, the effect of GCF on human peripheral neutrophil chemoattraction by trophoblast cells and ROS formation was assessed.Gingival crevicular fluid from pregnant women reduced trophoblast cell migration, increased proinflammatory marker expression and glucose uptake. A significant correlation between gingivoperiodontal score and trophoblast dysfunction was observed. Upon conditioning of trophoblast cells with GCF, only the GCF from pregnant women stimulated neutrophil chemoattraction. Similarly, GCF from pregnant but not from non-pregnant controls stimulated ROS formation in neutrophils.Gingival crevicular fluid from pregnant women is deleterious for first trimester trophoblast cell function. These effects could lead to placental homeostasis disruption underlying a pathogenic mechanism of pregnancy complications associated to periodontal disease.

Background Arthroplasties in elderly patients are surgeries performed to ensure their quality of life. Perioperative care with specific nutrients can improve nutrition status and metabolic response to orthopedic surgeries, such as total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods Retrospective study with elderly patients divided into 2 groups: control and immunonutrition. The immunonutrition group was instructed to start oral intake of the nutrition supplement 5 days before and to resume it 5 days after arthroplasty (200 mL, 3 times per day). The following were analyzed as primary and secondary outcomes: length of stay (LOS), infectious and noninfectious complications, need for intensive care unit (ICU), transfusion requirement, and C‐reactive protein. Results A total of 3015 elderly patients met the inclusion criteria: control group (n = 1398) and immunonutrition group (n = 1617). Overall, 81.2% were women and mean age was 72.6 ± 6.9 years. Immunonutrition group had a shorter LOS in hours (32.0 ± 19.4 vs 56.0 ± 26.4; P < .001) and lower rates of infectious complications (2.2% vs 4.6%; P < .001). Noninfectious complications and need for ICU also had lower rates in the immunonutrition group. In the logistic regression analysis, immunonutrition reduced the chance of infectious complications by 55% (odds ratio [OR], 0.45; 95% CI, 0.30–0.68; P < .001) even after adjusting for variables (OR, 0.45; 95% CI, 0.28–0.71; P < .001). Conclusion Perioperative immunonutrition in elderly patients undergoing THA or TKA may shorten postoperative LOS and reduce infectious and noninfectious complications and transfusion requirement.

Diagnosis of early invasive breast cancer relies on radiology and clinical evaluation, supplemented by biopsy confirmation. At least three issues burden this approach: a) suboptimal sensitivity and suboptimal positive predictive power of radiology screening and diagnostic approaches, respectively; b) invasiveness of biopsy with discomfort for women undergoing diagnostic tests; c) long turnaround time for recall tests. In the screening setting, radiology sensitivity is suboptimal, and when a suspicious lesion is detected and a biopsy is recommended, the positive predictive value of radiology is modest. Recent technological advances in medical imaging, especially in the field of artificial intelligence applied to image analysis, hold promise in addressing clinical challenges in cancer detection, assessment of treatment response, and monitoring disease progression. Radiomics include feature extraction from clinical images; these features are related to tumor size, shape, intensity, and texture, collectively providing comprehensive tumor characterization, the so-called radiomics signature of the tumor. Radiomics is based on the hypothesis that extracted quantitative data derives from mechanisms occurring at genetic and molecular levels. In this article we focus on the role and potential of radiomics in breast cancer diagnosis and prognostication., Highlights • In the screening setting, radiology sensitivity is suboptimal. • Artificial intelligence hold promise in cancer diagnosis and prognostication. • Radiomics include feature extraction from clinical images.

After spinal cord injury (SCI), patients face many physical and psychological issues including intestinal dysfunction and comorbidities, strongly affecting quality of life. The gut microbiota has recently been suggested to influence the course of the disease in these patients. However, to date only two studies have profiled the gut microbiota in SCI patients, months after a traumatic injury. Here we characterized the gut microbiota in a large Italian SCI population, within a short time from a not only traumatic injury. Feces were collected within the first week at the rehabilitation center (no later than 60 days after SCI), and profiled by 16S rRNA gene-based next-generation sequencing. Microbial profiles were compared to those publicly available of healthy age- and gender-matched Italians, and correlated to patient metadata, including type of SCI, spinal unit location, nutrition and concomitant antibiotic therapies. The gut microbiota of SCI patients shows distinct dysbiotic signatures, i.e. increase in potentially pathogenic, pro-inflammatory and mucus-degrading bacteria, and depletion of short-chain fatty acid producers. While robust to most host variables, such dysbiosis varies by lesion level and completeness, with the most neurologically impaired patients showing an even more unbalanced microbial profile. The SCI-related gut microbiome dysbiosis is very likely secondary to injury and closely related to the degree of completeness and severity of the lesion, regardless of etiology and time interval. This microbial layout could variously contribute to increased gut permeability and inflammation, potentially predisposing patients to the onset of severe comorbidities.

Papular mycosis fungoides (PMF) is a rare variant of mycosis fungoides (MF). The exact nosology and prognosis of PMF are still unclear. We retrospectively identified cases of PMF from the files of the Department of Dermatology of the Medical University of Graz, Austria, and checked the follow-up data. The patients comprised 13 men and 5 women (median age: 57.5 y; range 13 to 77 y). In 4 patients, an initial clinicopathologic diagnosis of atypical pityriasis lichenoides was made; these cases were subsequently reclassified as PMF due to the onset of conventional patches of MF during follow-up. Follow-up data of our cases showed that 2 patients died of disease progression 50 and 199 months after the first presentation, respectively. Two patients are alive with progressive disease after 215 and 300 months, respectively. Ten patients are alive with stable disease (median: 70 mo). Four patients were in complete remission at last follow-up visit (median: 215 mo; 2 of them died of unrelated causes). Our data confirm that PMF represents a clinicopathologic variant of early MF with prognosis similar to conventional presentations of the disease. Familiarity with PMF and distinction from other cutaneous papular lymphoid proliferations is necessary for a precise diagnosis and management of these patients.

Background: Psoriasis (Ps) is a chronic systemic autoimmune disease associated with pruritus in 64–98% of patients. However, few modestly sized studies assess factors associated with psoriatic pruritus. Objective: To investigate factors associated with Ps pruritus intensity. Methods: Psoriasis patients 18years or older seen in one of 155 centres in Italy between September 2005 and 2009 were identified from the Italian PsoCare registry. Patients without cutaneous psoriasis and those with missed information on pruritus were excluded. Results: We identified 10802 patients, with a mean age 48.8±14.3years. Mild itch was present in 33.2% of patients, moderate in 34.4%, severe in 18.7% and very severe in 13.7%. Higher itch intensity was associated with female gender, lower educational attainment compared to university degree, pustular psoriasis, psoriasis on the head, face, palmoplantar areas, folds and genitalia, more severe disease, disease duration

Multicentre cross-sectional study.The objective of this study is to evaluate prevalence, location and characteristics of pain in hospital inpatients people with spinal cord injury (SCI).Ten Italian rehabilitation centres specialized in spinal injury care, where inpatients are admitted both after the acute lesion and for late complications (time since injury, median [IQR]: 0.8 [0.2-8.2] years).All the persons were submitted to AIS scale assessment [1] and modified Ashworth scale [2]; personal data and anamnesis were recorded; any pain within 1 week was investigated and the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) Italian version [3] was administered by physicians expert in type of pain definition.Of 385 included persons, 275 (72%) suffered pain, with the score value median [IQR]: 6 [4-8]. The worst pain of the person was nociceptive in 52% and neuropathic in 48% of the cases; 46% of nociceptive pain was located in the neck-shoulder region, whereas 67% of neuropathic pain was located in the sublesional part of the body. In 48% of the whole population, spasticity was observed but only 74% of them had pain. Being old and female are associated with high pain development, OR (95% CI): 1.24 (1.01-1.04) and 1.83 (1.05-3.20), respectively.A high prevalence of pain is confirmed in persons with SCI, with both nociceptive and neuropathic pain characteristics. Only old age and female sex resulted as variables highly associated with pain.

Because of the COVID‐19 emergency, on March 9, 2020 Italy went in lock‐down imposing the closure of non‐urgent outpatient clinics devoted to care of chronic, severe, inflammatory skin diseases that require periodic follow‐up. In this emergency situation, due to the lack of a teledermatology platform and in order not to leave our vulnerable high‐need patients without proper follow‐up, we started a teledermatologic service in smartworking using phone calls and emails. The total number of patients scheduled was 195; in 12 cases we were not able to talk to the patients. Remote monitoring was performed in 183 patients (126 moderate to severe psoriasis, 10 severe acne, 11 severe atopic dermatitis, 11 hidradenitis suppurativa, 9 blistering autoimmune diseases, 16 other autoimmune skin diseases). During remote‐visits several interventions were conducted: triage for COVID‐19 suspected symptoms, email check of clinical pictures and of laboratory examinations, advices for topical and systemic therapy continuation or discontinuation/switch and re‐schedule of next appointment. Only 5 patients required personal office visit (2.6%), reducing consistently the number of face‐to face visits. Our real‐life experience shows that remote monitoring was effective in preventing unnecessary worsening of severe chronic skin diseases and poor outcomes due to withdrawal of current therapy. This article is protected by copyright. All rights reserved.

The occurrence of pseudolymphomatous infiltrates in cutaneous lupus erythematosus (cLE) is described mainly in lupus panniculitis and lupus tumidus/lymphocytic infiltration of the skin (Jessner-Kanof). We collected 15 cases of pseudolymphomatous cLE other than lupus panniculitis and lupus tumidus (M:F = 4:11; age range: 23-79 years; mean age: 50.9 years; median age: 57 years). Of the 15 cases, 9 (60%) were characterized by dense nodular infiltrates. Three cases (20%) showed an angiocentric pattern with cytological atypia of lymphoid cells; 2 cases (13.3%) showed a band-like infiltrate mimicking mycosis fungoides, and 1 case had mixed features of the band-like and angiocentric patterns. Clues to the histopathological diagnosis of cLE were presence of interface dermatitis, clusters of plasmacytoid dendritic cells, and dermal mucin deposition. Our study shows that the spectrum of pseudolymphomatous presentations of cLE is broader than previously described, including band-like cases that may be misconstrued as mycosis fungoides, and angiocentric cases that may be misinterpreted as an aggressive lymphoma. Recognition of such cases is possible only on careful clinicopathologic correlation and requires a high level of histopathological suspicion to allow a correct diagnosis and the proper management of the patients.

Non-small cell lung cancer (NSCLC) accounts for most cases of lung cancer. The peel oil of Mandarin Citrus reticulata Blanco cv. Dancy (MPO) is a natural source of essential oils and carotenoids. Volatile and non-volatile lipid compounds were characterized by chromatographic methods. We demonstrate that MPO causes a dose-dependent growth inhibition of NSCLC model cells (A549) in culture and tumour growth in vivo of the same cells implanted in nude mice fed with MPO-supplemented diets. MPO induced cell cycle arrest mainly at the G0/G1 phase and reduced the amount of membrane-bound Ras protein along with apoptosis induction. No toxicological effect was found in liver parameters analysed in treated mice and histopathological analyses of their organs did not show any morphological changes. In conclusion, the data suggest that MPO possesses significant antitumor activity without causing systemic toxicity, proposing it as a dietary supplement that may be helpful in cancer prevention. Fil: Castro, Maria Agustina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner". Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner"; Argentina Fil: Rodenak Kladniew, Boris Emilio. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner". Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner"; Argentina Fil: Massone, Adriana Raquel. Universidad Nacional de la Plata. Facultad de Ciencias Veterinarias. Departamento de Patología. Laboratorio de Patología Especial Veterinaria "Dr. Bernardo Epstein"; Argentina Fil: Polo, Monica Patricia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner". Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner"; Argentina Fil: García de Bravo, Margarita. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner". Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner"; Argentina Fil: Crespo, Rosana. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner". Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Instituto de Investigaciones Bioquímicas de La Plata "Prof. Dr. Rodolfo R. Brenner"; Argentina

Background Primary cutaneous follicle center lymphoma (pcFCL) usually presents with reddish nodules, plaques, and tumors on the head and neck or the back. Objective We sought to describe a peculiar clinical presentation of pcFCL and secondary cutaneous follicle center lymphoma (FCL). Methods We report a series of 13 patients (7 male and 6 female; median age 58 years, mean age 58.2 years, age range 26-83 years) with either pcFCL (11 patients) or secondary cutaneous FCL (2 patients) presenting with lesions on the head deviating from the classic clinical manifestations characterized by plaques and tumors. Results All patients presented clinically with diffuse, ill-defined, partly hypochromic, partly erythematous macules or with inconspicuous lesions located predominantly on the scalp and forehead. Dimension ranged between 4 to 5 cm 2 and greater than 30 cm 2 . The initial diagnosis was never cutaneous lymphoma, and all patients received various diagnoses including rosacea, alopecia, erysipelas, discoid lupus erythematosus, angiosarcoma, Borrelia infection, or sarcoidosis. Histologic examination confirmed the diagnosis of FCL in all patients. Limitations Small number of cases and retrospective study design are limitations. Conclusions This clinical presentation of both pcFCL and secondary cutaneous FCL is unusual and represents a pitfall in the clinical diagnosis. Dermatologists should be aware of this clinical variant of FCL to establish a timely diagnosis and treat patients properly.

Aim of the study was to evaluate the value of automated breast ultrasound (AUS) in women with dense breast, in terms of reading times, diagnostic performance and interobserver agreement. The assessment of coronal images alone versus the complete multiplanar (MPR) views was evaluated. Between August and October 2017, consecutive patients with dense breast that were referred to our Institute, for post-mammography ultrasound assessment, pre-operative assessment or follow-up of known benign lesions, were invited to undergo an additional study with AUS. Three radiologists, (5, 15 and 25 years of experience in breast imaging), reviewed the exams twice: first assessing reconstructed coronal images alone, second the complete MPR views. Reading times, diagnostic performance and interobserver agreement were assessed. One hundred eighty-eight women were included, for a total of 67 breast lesions, 25 (37%) malignant and 42 (63%) benign. Compared to MPR, coronal view was associated with: lower reading times, respectively, for the three readers: 83 ± 37, 84 ± 43 and 76 ± 30 versus 163 ± 109, 131 ± 57, 151 ± 42 s (p

Myoelectric Computer Interfaces (MCIs) are a viable option to promote the recovery of movements following spinal cord injury (SCI), stroke, or other neurological disorders that impair motor functions. We developed and tested a MCI interface with the goal of reducing abnormal muscular activations due to compensatory strategies or undesired co-contraction after SCI. The interface mapped surface electromyographic signals (sEMG) into the movement of a cursor on a computer monitor. First, we aimed to reduce the co-activation of muscles pairs: the activation of two muscles controlled orthogonal directions of the cursor movements. Furthermore, to decrease the undesired concurrent activation of a third muscle, we modulated the visual feedback related to the position of the cursor on the screen based on the activation of this muscle. We tested the interface with six unimpaired and two SCI participants. Participants were able to decrease the activity of the targeted muscle when it was associated with the visual feedback of the cursor, but, interestingly, after training, its activity increased again. As for the SCI participants, one successfully decreased the co-activation of arm muscles, while the other successfully improved the selective activation of leg muscles. This is a first proof of concept that people with SCI can acquire, through the proposed MCI, a greater awareness of their muscular activity, reducing abnormal muscle simultaneous activations.

The pathogenesis of leprosy is still not fully understood. Several studies have been performed on the involvement of T cells in leprosy and more recently have focused on genetic factors and innate immune response. There are still only few reports about the role of B cells in active leprosy lesions in different spectral forms of the disease. The literature on tuberculosis suggests that B cells play an important role in the regulation of the granulomas, in cytokine production, T-cell response, and antigen presentation. Only few studies investigated the role of B cell in leprosy. We investigated the distribution of B cells in 85 leprosy biopsies covering all forms of the disease and compared results with 13 biopsies of tuberculosis and atypical mycobacteriosis, expanding the previous experiences. A statistically significant difference in the number of CD20 (P = 0.014) and CD138+ (P = 0.01) cells between the different forms of leprosy was observed. A remarkable amount of CD138+ cells could also be detected in borderline tuberculoid. The median of the CD20 cells decreased from the bacilloscopy-negative samples to the bacilloscopy-positive samples by 50% (P = 0.004). Contrarily, the median of CD138+ cells showed an increase from bacilloscopy-negative to bacilloscopy-positive samples of 966.67% (P = 0.001). In our experience, tuberculoid leprosy showed more B cells and less plasma cells than lepromatous leprosy. Our results show that B cells might be implicated in leprosy pathogenesis, not only in the lepromatous pole as previously postulated, but also in tuberculoid granuloma formation and type 1 reactions.

Mammary Paget’s disease (MPD) is an uncommon intra-epidermal adenocarcinoma of the nipple-areola complex, occurring in 1–5% of all breast carcinomas (1). MPD is difficult to diagnose clinically as it mimics a variety of both inflammatory and neoplastic skin diseases (2). Pigmented mammary Paget’s disease (PMPD) corresponds to an even less common variant, frequently simulating other pigmented lesions of the nipple, including melanoma (3–5). According to the epidermotropic theory, Paget cells (PCs) originate from cancer cells that migrate via the lactiferous ducts along the basal membrane, to invade the epidermis of the nipple and areola (6, 7). Considering its intra-epidermal spreading, PCs are therefore potentially demonstrable using non-invasive diagnostic techniques with near-cellular resolution, such as reflectance confocal microscopy (RCM) (8). The aim of this study was retrospectively to describe the RCM features of 5 cases of MPD, with dermoscopic and histopathological correlation.

OBJECTIVE: The present study was conducted to identify possible dermoscopic patterns, associated with mitotic rate > 1/mm2, histological ulceration in melanoma and metastatic disease. METHODS: For this retrospective data analysis all clinical and dermoscopic digital images of primary malignant melanomas between 2008 and 2013 documented at the Department of Dermatology Graz were included, using the internal image data-base. 550 patients with 559 melanomas were included. RESULTS: While clinical or dermoscopic analysis considered ulceration to be present in 120 (21.5%) and 117 (20.9%) of all lesions, respectively, histopathology reported ulceration in only 96 cases (17.2%). The presence of milky-red areas, shiny-white streaks, a blue-white veil and blue-grey areas in dermoscopy is highly correlated with histological ulceration and a mitotic rate > 1/mm2. The dermoscopic patterns shiny-white streaks, milky-red areas and blue-white veil were also significantly associated with development of distant metastases. CONCLUSION: Our study proves a significant correlation between the dermoscopic patterns "blue white veil", "milky-red areas"and "shiny-white streaks"and the histological findings "ulceration"and "mitotic rate > 1/mm2". Furthermore these dermoscopic patterns are highly related to distant metastases. Thus, dermoscopy renders earlier prognostic statements possible. info:eu-repo/semantics/publishedVersion

Skeletal erosion has been found to represent an independent prognostic indicator in patients with advanced stages of chronic lymphocytic leukaemia (CLL). Whether this phenomenon also occurs in early CLL phases and its underlying mechanisms have yet to be fully elucidated. In this study, we prospectively enrolled 36 consecutive treatment-naïve patients to analyse skeletal structure and bone marrow distribution using a computational approach to PET/CT images. This evaluation was combined with the analysis of RANK/RANKL loop activation in the leukemic clone, given recent reports on its role in CLL progression. Bone erosion was particularly evident in long bone shafts, progressively increased from Binet stage A to Binet stage C, and was correlated with both local expansion of metabolically active bone marrow documented by FDG uptake and with the number of RANKL + cells present in the circulating blood. In immune-deficient NOD/Shi-scid, γcnull (NSG) mice, administration of CLL cells caused an appreciable compact bone erosion that was prevented by Denosumab. CLL cell proliferation in vitro correlated with RANK expression and was impaired by Denosumab-mediated disruption of the RANK/RANKL loop. This study suggests an interaction between CLL cells and stromal elements able to simultaneously impair bone structure and increase proliferating potential of leukemic clone.

Interstitial mycosis fungoides (IMF) is a rare histopathologic variant of mycosis fungoides (MF) that may mimic other inflammatory dermatoses, mainly interstitial granuloma annulare, inflammatory morphea, and interstitial granulomatous dermatitis. Only small series and sporadic case reports of IMF have been described in the literature. We reviewed 27 specimens from 21 patients with IMF (M:F=11:10, median age 60) to better characterize clinical, histopathologic, and immunohistochemical features of this disease. Most patients presented clinically with patches and/or plaques. Conventional MF was documented before, concomitant with, or after IMF in 12 patients, whereas only in 2 patients different biopsies showed exclusive features of IMF over a period of 4 and 191 months, respectively. Histology revealed in all cases variably long, linear aggregates of dermal lymphocytes splaying the collagen fibers, involving predominantly the superficial and mid-dermis (6 cases) or the entire dermis (21 cases). Immunohistochemical stainings revealed a cytotoxic phenotype in 9/18 tested cases. Variable amounts of histiocytes/macrophages were found interstitially in all tested biopsies but never represented a population larger than that of T lymphocytes. Our study shows that IMF is a peculiar variant of MF with frequent cytotoxic phenotype. This histopathologic variant in most cases represents a transient pattern in otherwise conventional MF. Accurate clinicopathologic correlation and phenotypic studies of atypical dermal interstitial lymphohistiocytic infiltrates allow to make a correct diagnosis.

Hydroa vacciniforme-like lymphoma is a recently recognized cutaneous T-cell lymphoma associated with Epstein-Barr virus. The disease is observed in children of Latin American or Asian ethnicity. The authors report the clinical, histopathological, and immunophenotypical features of 9 new Mexican patients (M:F = 2:1; mean age, 14.5 years; median age, 13.3 years; age range, 4-27 years), expanding on previous observations of this elusive disease. The most common clinical aspects were persistent facial edema with necroses and pitted scars. Histopathological analyses revealed variably dense lymphoid infiltrates with common angiodestructive features. Neoplastic cells expressed CD3 and cytotoxic markers in all cases and were constantly positive for Epstein-Barr virus (EBER-1). Expression of other markers was variable. Follow-up data revealed that all patients died within 6 months or less, thus showing a very aggressive course with poor prognosis.

We investigated the feasibility and diagnostic agreement of a virtual slide system (VSS) in teledermatopathology. Forty-six biopsy specimens from inflammatory skin diseases were selected and scanned with a VSS at the Research Unit of Teledermatology, Medical University of Graz, Graz, Austria. Images were stored oil a virtual slide server on which a specific Web application suited for telepathology (http://telederm.org/research/dermatopath/) runs. Twelve teleconsultants from 6 different Countries reviewed the 46 cases, working directly oil the Web application. Telediagnoses agreed with gold standard and conventional diagnosis with an average of 73% and 74%, respectively. Complete concordance among all teleconsultants with gold standard and conventional diagnosis was found in 20% of the cases. In 10 cases in which complete clinical data were missing, the average agreement of telediagnosis with gold standard diagnosis and conventional diagnosis decreased to 65% and 66%, respectively. Only 3 of 4 cases of inflammatory skin diseases were correctly diagnosed remotely with VSS. The system that we have used, despite its usability, is not completely feasible for teledermatopathology of inflammatory skin disease. Moreover, the performance seems to have been influenced by the availability of complete clinical data and by the intrinsic difficulty of the pathology of inflammatory skin diseases. (c) 2007 Elsevier Inc. All rights reserved. RI Soyer, H. Peter/E-6000-2010

The aim of the current study is to present our experience in lumbar spine interventional procedures performed with a newly developed multimodal echo-navigator (EcoNav) and to evaluate short-term clinical outcomes of a series of patients affected by facet joint disease (FJD) treated with steroid and anaesthetic injection under fusion-imaging guidance, compared to a cohort of patients that received the same treatment under computed tomography (CT) guidance. Sixty-five consecutive patients (34 females; mean age 68.3 ± 12.8 years) with a clinical diagnosis of non-radicular low back pain lasting for more than 6-weeks and magnetic resonance (MR) or CT confirmed FJD were enrolled for image-guided FJI. Twenty-eight patients underwent FJI with fusion-guided technique, while CT-guided procedures were performed in the other cases. Clinical and procedural data were recorded and compared at a mean follow-up of 6.1 ± 2.0 months. A significant improvement in clinical parameters was observed for both fusion-guided and CT-guided group. Comparing both groups, no statistically significant difference could be detected neither at baseline conditions nor during the follow-up period. No significant periprocedural complication occurred in both groups. A satisfaction rate of 92.3 and 81.1% was reported for fusion-guided and CT-guided group, respectively. EcoNav fusion-imaging system represents a safe, feasible, effective and reproducible guidance option in FJD infiltration procedures, also avoiding use of ionising radiations.

Using a computational approach to extract the spinal canal from whole-body PET/CT images, Marini et al. reveal increased glucose consumption in the spinal cord in prospectively recruited patients with amyotrophic lateral sclerosis. Simultaneous measurement of brain 18F-Fluorodeoxyglucose uptake reveals a divergent metabolic response in the two structures., We recently reported the potential of Hough transform in delineating spinal cord metabolism by 18F-fluorodeoxyglucose PET/CT scanning in amyotrophic lateral sclerosis. The present study aimed to verify the relationship between spinal cord and brain metabolism in 44 prospectively recruited patients affected by amyotrophic lateral sclerosis submitted to 18F-fluorodeoxyglucose brain and whole-body PET/CT. Patients were studied to highlight the presence of brain hypo- or hypermetabolism with respect to healthy controls, and multiple regression analysis was performed to evaluate the correlation between spinal cord and brain metabolism. Our results confirmed higher 18F-fluorodeoxyglucose uptake in both cervical and dorsal spinal cord in patients with amyotrophic lateral sclerosis with respect to controls. This finding was paralleled by the opposite pattern in the brain cortex that showed a generalized reduction in tracer uptake. This hypometabolism was particularly evident in wide regions of the frontal-dorsolateral cortex while it did not involve the midbrain. Bulbar and spinal disease onset was associated with similar degree of metabolic activation in the spinal cord. However, among spinal onset patients, upper limb presentation was associated with a more pronounced metabolic activation of cervical segment. Obtained data suggest a differential neuro-pathological state or temporal sequence in disease progression.

OBJECTIVE: Atypical ductal hyperplasia (ADH) is a proliferative lesion associated with a variable increased risk of breast malignancy, but the management of the patients is still not completely defined, with mandatory surgical excision in most cases. To report the results of the conservative management with mammographic checks of patients with ADH diagnosed by vacuum assisted breast biopsy (VAB), without residual calcifications. METHODS: The authors accessed the institutional database of radiological, surgical and pathological anatomy. Inclusion criteria were: ADH diagnosed by VAB on a single group of microcalcifications, without residual post-procedure; follow-up at least of 12 months. Exclusion criteria were the presence of personal history of breast cancer or other high-risk lesions; association with other synchronous lesions, both more and less advanced proliferative lesions. RESULTS: The 65 included patients were all females, with age range of 40–79 years (mean 54 years). The maximum diameter range of the groups of microcalcifications was 4–11 mm (mean 6.2 mm), all classified as BI-RADS 4b (Breast Imaging Reporting and Data System 4b) and defined as fine pleomorphic in 29 cases (45%) or amorphous in 36 cases (55%). The range of follow-up length was 12–156 months (mean 67 months). Only one patients developed new microcalcifications, in the same breast, 48 months after and 15 mm from the first VAB, interpreted as low-grade ductal carcinoma in situ (DCIS) at surgical excision. CONCLUSION: These results could justify the conservative management, in a selected group of patients, being the malignancy rate lower than 2%, considered in the literature as the “probably benign” definition. ADVANCES IN KNOWLEDGE: Increasing the length of follow-up of selected patients conservatively managed can improve the management of ADH cases.

Multicentric prospective psychometric study. To provide a translation of the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) for Italian persons and to evaluate the interrater reliability of the translated version. Ten Italian rehabilitation centres specialized in spinal injury care. The initial translation was performed by two medical doctors who had an in-depth knowledge of spinal cord injury (SCI), and then a back translation (from Italian to English) was given to an accredited agency. Sixty-six participants with SCI (53 men, 13 women; mean ± SD age: 53.4 ± 16.0 years) were evaluated by means of the Italian version of the ISCIPBDS by two different examiners. Intraclass correlation coefficient (ICC) or Cohen’s Kappa (ĸ) was calculated to test the interrater agreement for the test−retest cases. All 66 participants had at least one pain problem and 34% of them had only one type of pain. A good interrater agreement was obtained in terms of number of pain (ICC = 0.781), type of pain (ĸ = 0.683), pain intensity (ICC = 0.798), correspondence of pain localization (ĸ = 0.750), and the value of the pain interference in day-to-day activities, overall mood and night’s sleep (ICC = 0.827, ICC = 0.861 and ICC = 0.724, respectively). Eventually a prominent prevalence of neuropathic pain was recorded (64% from the first examiner and 62% from the second one). The authors propose the Italian version of ISCIPBDS that can be used for research and clinical evaluation of pain in SCI persons; it shows a significant interrater reliability.

Mechanisms of hematopoietic reconstitution after bone marrow (BM) transplantation remain largely unknown. We applied a computational quantification software application to hybrid 18F-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) images to assess activity and distribution of the hematopoietic system throughout the whole skeleton of recently transplanted patients. Thirty-four patients underwent PET/CT 30 days after either adult stem cell transplantation (allogeneic cell transplantation [ACT]; n = 18) or cord blood transplantation (CBT; n = 16). Our software automatically recognized compact bone volume and trabecular bone volume (IBV) in CT slices. Within IBV, coregistered PET data were extracted to identify the active BM (ABM) from the inactive tissue. Patients were compared with 34 matched controls chosen among a published normalcy database. Whole body ABM increased in ACT and CBT when compared with controls (12.4 ± 3 and 12.8 ± 6.8 vs 8.1 ± 2.6 mL/kg of ideal body weight [IBW], P < .001). In long bones, ABM increased three- and sixfold in CBT and ACT, respectively, compared with controls (0.9 ± 0.9 and 1.7 ± 2.5 vs 0.3 ± 0.3 mL/kg IBW, P < .01). These data document an unexpected distribution of transplanted BM into previously abandoned BM sites.

The histopathology of lepromatous skin varies according to the cell-mediated immunity of the host against Mycobacterium leprae. In tuberculoid and borderline tuberculoid leprosy, epithelioid noncaseating granulomas predominate, and acid-fast bacilli (AFB) are absent or only rarely present. In borderline lepromatous and lepromatous leprosy, the infiltrate is composed of macrophages with a vacuolar cytoplasm, lymphocytes, and plasma cells. AFB are numerous. Edema inside and outside the epithelioid granulomas, together with the appearance of large giant cells, are the main features of type 1 reactions. A conspicuous neutrophilic infiltrate in the subcutis with or without vasculitis is found in erythema nodosum leprosum. The main histopathologic features of leprosy and its particular forms are discussed in this review.

Smartphones have overcome the limitations of image quality seen in older devices and opened a new field of telemedicine called "mobile teledermatology". Technological advances and the need to reduce health service costs will strongly promote the development of telemedicine. For this reason, we evaluated the concordance between store-and-forward mobile teledermatology and the classical face-to-face dermatological visit. We also measured the time taken to submit a teleconsultation using a smartphone. Before conventional face-to-face visit, a final-year resident of the three-year course for general practitioners collected medical history, took digital images of skin diseases with a smartphone and, measuring the time required to complete this operation, transmitted them to an expert teledermatologist. In 391 patients we obtained a concordance between face-to-face and store-and-forward diagnosis of 91.05% (Cohen κ coefficient = 0.906). On average only few minutes needs to be added to a normal visit to transmit the cases to an expert teledermatologist.

Body machine interfaces (BMIs) are used by people with severe motor disabilities to control external devices, but they also offer the opportunity to focus on rehabilitative goals. In this study we introduced in a clinical setting a BMI that was integrated by the therapists in the rehabilitative treatments of 2 spinal cord injured (SCI) subjects for 5 weeks. The BMI mapped the user's residual upper body mobility onto the two coordinates of a cursor on a screen. By controlling the cursor, the user engaged in playing computer games. The BMI allowed the mapping between body and cursor spaces to be modified, gradually challenging the user to exercise more impaired movements. With this approach, we were able to change our subjects' behavior, who initially used almost exclusively their proximal upper body-shoulders and arms — for using the BMI. By the end of training, cursor control was shifted toward more distal body regions — forearms instead of upper arms — with an increase of mobility and strength of all the degrees of freedom involved in the control. The clinical tests and the electromyographic signals from the main muscles of the upper body confirmed the positive effect of the training. Encouraging the subjects to explore different and sometimes unusual movement combinations was beneficial for recovering distal arm functions and for increasing their overall mobility.

Observational prospective population-based incidence study. The main objective of this study was to assess the incidence of traumatic spinal cord injuries (TSCIs) and incidence rates, in order to provide estimates by age, gender, characteristics and cause. This study was conducted at acute-care spinal cord injury (SCI) hospitals and SCI centers from 11 Italian regions, between 1 October 2013 and 30 September 2014. Data of all consecutive patients with acute TSCI who met the inclusion criteria were obtained through case reporting by clinicians. The data were collected into a web database. Incidence rates and incidence rate ratios were calculated and stratified by age, gender, cause, level and completeness. From 50% of the entire population of Italy, 445 new cases of TSCI were included. The crude incidence rate of TSCI was 14.7 cases per million per year (95% CI: 13.4–16.4); the overall male to female ratio was 4:1 and the mean age was 54. Complete information was available in 85% of the sample and revealed tetraplegia in 58% and incomplete lesion in 67% of cases. The leading cause of TSCI was falls (40.9%) followed by road traffic accidents (33.5%). The leading cause was falls for patients over 55 and road traffic accidents for patients under 55. The changing trend of TSCI epidemiology concerns the increase in the average age of TSCI people and the increase of both cervical and incomplete lesions. The etiology shows the primacy of falls over road traffic accidents and suggests the need for a change in prevention policies.

The specific dermatoses of pregnancy represent a recently reclassified heterogeneous group of pruritic inflammatory skin diseases unique to pregnancy that include pemphigoid gestationis, polymorphic eruption of pregnancy (PEP), intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy (AEP). Among them, PEP and AEP are the most frequent ones. We performed a histopathological study of a series of PEP and AEP patients (n = 41). Twenty-two patients had PEP that started in the third trimester in 16 (73%) patients and postpartum in 6 (27%) patients. Histopathology revealed a superficial or superficial and deep perivascular dermatitis with eosinophils in all biopsies and signs of a lymphocytic vasculitis in 5 (23%) cases. Epidermal changes, including epidermal hyperplasia, spongiosis, and parakeratosis, occurred in 8 cases, in particular in elder lesions. Nineteen patients had AEP that started earlier [less than third trimester, 14 (74%) patients; third trimester, 5 (26%) patients]. Clinically, 5 (26%) patients showed eczematous lesions, 7 (37%) papular lesions, 3 (16%) presented both eczematous and prurigo lesions, and 4 (21%) experienced exacerbation of preexisting atopic dermatitis. Histopathologically, AEP was characterized by a perivascular lymphohistiocytic infiltrate with frequent eosinophils (74%) and epidermal changes in all but most of P-type biopsies. No definitive differential histopathological criteria between PEP and AEP were found. Only lymphocytic vasculitis with a mixed infiltrate with eosinophils was more frequent in PEP patients. Timing of onset, morphology of skin lesions, and a detailed clinicopathologic correlation are essential for diagnosis.

Objectives Performance improvement programs in emergency medicine (EM) have evolved beyond peer reviews of referred cases and now encompass a large set of quality metrics that are measured proactively. However, peer review of cases continues to be an important element of performance improvement, and selection of cases tends to be driven by an ad hoc referral process based on concerns about problems with care in the emergency department (ED). In the past decade, there has been widespread hospital adoption of rapid response teams (RRTs) that respond to patients who decline clinically to reduce adverse outcomes. In an effort to cast a wider net, to take a more systematic approach, and to avoid “blind spots” from individual variability in criteria for referring cases, the institution instituted a new process for selecting cases for ED peer review based on RRT activations within 24 hours of admission from the ED. The hypothesis was that a formal process for review of these activation cases would increase the number of cases for peer review. Methods This was a prospective, observational study conducted from July 1, 2012, to June 30, 2013, at an urban, academic medical center with an EM residency program. A new automated monthly report was created, capturing all RRT activations within 24 hours of admission from the ED. All events were reviewed by three physicians from the ED performance improvement committee to examine for systems issues, individual provider issues, or both, that might yield opportunities for improvement. Cases with potential opportunities were reviewed by the full ED performance improvement committee. Cases were classified according to the indication for response team activation using the system outlined by the U.S. Agency for Healthcare Research and Quality. Results During the study period 61,814 patients were treated in the ED, and 13,067 were admitted to inpatient status. Thirty-two RRT activations within 24 hours of admission from the ED occurred among these admitted patients, representing 0.24% of admissions (95% confidence interval [CI] = 0.16% to 0.33%). Of the 32 cases, only one was also referred independently for ED performance improvement review via the traditional ad hoc process. During the same period of time, 85 cases were referred to the ED performance improvement committee via the traditional ad hoc referral process. Thus, the RRT cases added an additional 31 cases, or 36.5%, to the 85 cases reviewed in ED performance improvement. Of the 32 cases, two were determined by the performance improvement committee to have individual provider factors in their ED care, which contributed to the clinical decline triggering the response teams; none had system factors. Most of the response team activations were for neurologic changes (n = 13) and respiratory status changes (n = 12). In two cases there was long-term morbidity or mortality related to the team activation event; in neither of these cases were ED system or individual provider factors judged to have contributed. Conclusions The review of RRT activations within 24 hours of admission from the ED significantly supplemented the typical ad hoc referral system for peer review of cases, highlighting cases that likely would not have received attention within the ED. This novel and unique case review process revealed opportunities for education and performance improvement. This and other systematic approaches to case detection may be useful adjuncts to traditional case referrals for review. Resumen Objetivos Los programas de mejora del rendimiento (MR) en Medicina de Urgencias y Emergencias (MUE) han evolucionado mas alla de las revisiones por pares de los casos referidos y actualmente abarcan un amplio conjunto de indicadores de calidad que son medidos de forma proactiva. Sin embargo, la revision por pares de los casos continua siendo un elemento importante de la MR, y la seleccion de los casos tiende a ser llevada a cabo por un proceso de referencia ad hoc basado en las preocupaciones acerca de los problemas de la atencion en el servicio de urgencias (SU). En la ultima decada, ha habido una adopcion generalizada en los hospitales de los equipos de respuesta rapida (ERR), que responden a los pacientes que empeoran clinicamente con el fin de reducir los resultados adversos. En un esfuerzo por lanzar una red mas amplia, para adoptar un enfoque mas sistematico y para evitar los “puntos ciegos” de la variabilidad individual en los criterios de los casos referidos, la institucion inicio un nuevo proceso para seleccionar los casos del SU basado en la revision por pares en las activaciones de los ERR en las primeras 24 horas del ingreso desde el SU (ERR24SU). La hipotesis fue que un proceso formal para la revision de casos de los ERR24SU aumentaria el numero de casos para la revision por pares. Metodos Estudio observacional prospectivo llevado a cabo en un centro medico universitario urbano con un programa de residencia en MUE desde el 1 de julio de 2012 hasta el 30 de junio 2013. Se creo un nuevo informe mensual automatizado, que capturo todos los eventos de los ERR24SU. Todos los eventos se revisaron ​​por tres medicos de la comision de MR del SU para examinar los sistemas y/o problemas del sanitario individual que podrian generar oportunidades para la mejora. Los casos con oportunidades potenciales se revisaron ​​por todo el comite de MR del SU. Los casos se clasificaron segun la indicacion para la activacion de los ERR usando el sistema descrito por la Agency for Healthcare Research and Quality. Resultados Durante el periodo de estudio 61.814 pacientes fueron atendidos en el SU y 13.067 fueron hospitalizados. Treinta y dos eventos de los ERR24SU ocurrieron en estos pacientes ingresados​​, lo que represento un 0,24% de los ingresos (IC 95% = 0,16% al 0,33%). De los 32 casos de los ERR24SU, solo uno se remitio tambien de forma independiente para su revision al comite de MR del SU a traves del proceso tradicional ad hoc. Durante el mismo periodo de tiempo, 85 casos se remitieron a la comision de MR SU a traves del proceso de remision tradicional ad hoc. Por lo tanto, los casos de los ERR24SU anaden 31 casos adicionales, o un 36,5%, a los 85 casos examinados en la MR SU. De los 32 de los casos ERR24SU, en dos el comite de MR determino que habia factores individuales del sanitario en la atencion en el SU que contribuyeron al deterioro clinico y desencadenaron el ERR; mientras que en ninguno hubo factores relacionados con el sistema. La mayoria de activaciones de los ERR fueron por alteraciones neurologicas (n = 13) y cambios del estado respiratorio (n = 12). En dos casos hubo morbilidad o mortalidad a largo plazo relacionada con el evento del ERR, y en ninguno de estos casos se juzgo que los factores del sanitario individual o del sistema hubieran contribuido. Conclusiones El proceso de los ERR24SU suplementa de forma significativa el sistema referido ad hoc tipico para la revision por pares de los casos, y detecta casos que probablemente no habrian sido considerados en el SU. Este proceso de revision de casos novedoso y unico revelo oportunidades para la formacion y la MR. Esta y otras aproximaciones sistematicas de deteccion del caso pueden ser complementos de utilidad a los casos tradicionales referidos para su revision.

Background Incidence rates of malignant melanoma have been increasing worldwide and metastatic melanoma is still a significant problem despite widespread prevention programmes. Objectives We made a systemic review of all metastasized melanoma patients treated at the Department of Dermatology, Medical University of Graz in the years 2000–2010 and looked at the kind of melanoma type, e.g. if it has been slowly growing superficial spreading melanoma (SSM) or fast growing nodular melanoma (NM). Methods Histological slides and clinical images of patients treated at our department between 2000 and 2010, who received chemotherapy because of proven metastatic disease were analysed with regard to growth type of their primary tumours. Results A total of 88 patients met the inclusion criteria. Mean age of all patients was 57 years (median 59 years, SD ± 15 years). Of these 88 patients 51 patients (58%) (28 male patients and 23 female patients) had SSM; mean age 58 years (median 58 years, SD ± 14 years) and 37 patients (42%) (18 male patients and 19 female patients) had NM; mean age 56 years (median 61 years, SD ± 17 years). Mean Breslow thickness in the SSM group was 2.26 mm (median: 1.6 mm, SD ± 2.11 mm). In the NM group, mean Breslow thickness was 4.59 mm (median: 3.50 mm, SD ± 4.07 mm). When separated by gender, 46 melanomas were seen in the male group (28 SSM and 18 NM) and 42 melanomas in the female group (23 SSM and 19 NM). Conclusions Our results showed that more than half of the patients with metastatic disease had SSMs and not, as suspected, NMs. As SSMs are growing over a longer period to become invasive and potentially metastatic, there might be a chance to focus primary and secondary prevention programmes not only on fast growing tumours but also on slowly changes of tumours.

In the WHO classification, subcutaneous panniculitis-like T-cell lymphoma (SPTL) is defined as a distinct type of T-cell lymphoma with an aggressive clinical behavior. Recent studies suggest that distinction should be made between SPTL with an α/β T-cell phenotype (SPTL-AB) and SPTL with a γδ T-cell phenotype (SPTL-GD), but studies are limited. To better define their clinicopathologic features, immunophenotype, treatment, and survival, 63 SPTL-ABs and 20 SPTL-GDs were studied at a workshop of the EORTC Cutaneous Lymphoma Group. SPTL-ABs were generally confined to the subcutis, had a CD4-, CD8+, CD56-, βF1+ phenotype, were uncommonly associated with a hemophagocytic syndrome (HPS; 17%), and had a favorable prognosis (5-year overall survival [OS]: 82%). SPTL-AB patients without HPS had a significantly better survival than patients with HPS (5-year OS: 91% vs 46%; P < .001). SPTLGDs often showed (epi)dermal involvement and/or ulceration, a CD4-, CD8-, CD56 +/-, βF1- T-cell phenotype, and poor prognosis (5-year OS: 11%), irrespective of the presence of HPS or type of treatment. These results indicate that SPTL-AB and SPTL-GD are distinct entities, and justify that the term SPTL should further be used only for SPTL-AB. SPTL-ABs without associated HPS have an excellent prognosis, and multiagent chemotherapy as first choice of treatment should be questioned. © 2008 by The American Society of Hematology.

SummaryBackground The nationwide prevalence of latent tuberculosis infection (LTBI) in Italian patients with psoriasis has never been investigated. Objectives To estimate the nationwide prevalence of LTBI in Italian patients with psoriasis who are candidates for systemic treatment. Methods Data were obtained from the Psocare Registry on those patients (n = 4946) with age > 18 years, systemic treatment at entry specified and tuberculin skin test (TST) performed according to the Mantoux method. LTBI diagnosis was based on a positive TST result in the absence of any clinical, radiological or microbiological evidence of active tuberculosis. Results Latent tuberculosis infection was diagnosed in 8·3% of patients with psoriasis (409 of 4946). The prevalence of LTBI was lower in patients on biologics than in those on conventional systemic treatments, ranging from 4·3% (19 of 444) of patients on adalimumab to 31% (eight of 26) of those on psoralen–ultraviolet A (P

N/A

AIMS: Aggressive epidermotropic cutaneous CD8+ lymphoma is currently afforded provisional status in the WHO classification of lymphomas. An EORTC Workshop was convened to describe in detail the features of this putative neoplasm and evaluate its nosological status with respect to other cutaneous CD8+ lymphomas.METHODS & RESULTS: Sixty-one CD8+ cases were analysed at the workshop; clinical details, often with photographs, histological sections, immunohistochemical results, treatment and patient outcome were discussed & recorded. Eighteen cases had distinct features and conformed to the diagnosis of aggressive epidermotropic cutaneous CD8+ lymphoma. The patients typically present with widespread plaques and tumours, often ulcerated and haemorrhagic, and have striking pagetoid epidermotropism histologically. A CD8+ CD45RA+ CD45RO- CD2- CD5- CD56- phenotype, with 1 or more cytotoxic markers was found in 7/18 with a very similar phenotype in the remainder.. The tumours seldom involve lymph nodes but mucosae and central nervous system involvement are not uncommon. The prognosis is poor, with a median survival of 12 months. Examples of CD8+ mycosis fungoides, lymphomatoid papulosis and Woringer-Kolopp presented the typical features well documented in the CD4+ forms of those diseases.CONCLUSIONS: Aggressive Epidermotropic Cutaneous CD8+ Lymphoma is a distinct lymphoma that warrants inclusion as a distinct entity in future revisions of lymphoma classifications. This article is protected by copyright. All rights reserved.

Stings in the head region are considered to be a risk factor for severe systemic reactions to hymenoptera stings. We supposed that stings in skin areas, which are well supplied with blood, lead to more severe reactions and tested our hypothesis in 847 patients with confirmed hymenoptera venom allergy. However, symptom severity was independent from sting site: only 16.3% of patients with severe reactions were stung on the head (P = 0.017). But we confirmed age > 40 years (P < 0.001) as well as elevated basal tryptase levels (P = 0.001) as risk factors. Taking antihypertensive drugs seemed to have an influence: 41.7% of patients taking antihypertensive drugs experienced a severe reaction compared to 29.5% of patients, not taking such drugs (P = 0.019). However, considering patients' age in regression analysis, taking antihypertensive drugs had no effect on symptom severity (P = 0.342). Importantly, in most patients with severe reactions, cutaneous signs were absent (P < 0.001).

Background: Meyerson's phenomenon is characterized by a symmetrical halo of erythema and scale around central, mostly melanocytic lesions. Objective: Our aim was to describe the dermoscopic and reflectance confocal microscopy (RCM) features of melanocytic tumors less frequently associated with Meyerson's phenomenon, with histopathology and immunohistochemistry correlation. Methods: Clinical, dermoscopic and RCM images of 4 histopathologically confirmed melanocytic tumors associated with Meyerson's phenomenon (3 dysplastic compound nevi and 1 melanoma) were retrospectively collected, with additional immunohistochemical analysis. Results: RCM showed in vivo features of both melanocytic and spongiotic nature of the lesion associated with Meyerson's phenomenon, even in cases with absent halo. Our study also supported the involvement of immune-mediated CD4+ T lymphocyte mechanisms and Langerhans cells. Conclusion: Our case series supports the potential of RCM in the evaluation of tumoral and inflammatory skin diseases. RCM features of rare Meyerson's melanoma were also described for the first time.

It has been suggested that both negative pigment network (NPN) and shiny white streaks (SWS) were related to an increase of dermal collagen. To study precisely the dermoscopic-histopathologic correlation of NPN and SWS, we have performed a dermoscopic-pathological correlation study. A total of 25 skin lesions dermoscopically characterized by the presence of NPN and/or SWS, including histopathologically confirmed dermatofibroma (2), Spitz nevus (3), compound nevus (6), dysplastic nevus (7), and melanoma (7), were evaluated for the presence of NPN, SWS, and blue-white veil. The histopathologic features such as orthokeratosis, orthokeratosis plus nests of pigmented melanocytes at the junction, hypergranulosis, hypergranulosis plus nests of pigmented melanocytes at the junction, epidermal invagination plus orthokeratosis, fibrosis, lamellar fibrosis, and elongation and bridging of rete ridges were evaluated. We found a disagreement in 80% of skin lesions between NPN and fibrosis (P = 0.02). For SWS, a significant agreement emerged with hypergranulosis (76%; P = 0.01), and the same occurred with fibrosis (80%; P = 0.01). Moreover, blue-white veil also displayed a significant agreement with hypergranulosis (68%; P = 0.04). Our findings confirm the correlation of SWS with fibrosis, whereas a clear-cut histopathologic substrate of NPN could not be established.

PURPOSE: In amyotrophic lateral sclerosis, functional alterations within the brain have been intensively assessed, while progression of lower motor neuron damage has scarcely been defined. The aim of the present study was to develop a computational method to systematically evaluate spinal cord metabolism as a tool to monitor disease mechanisms. METHODS: A new computational three-dimensional method to extract the spinal cord from 18F-FDG PET/CT images was evaluated in 30 patients with spinal onset amyotrophic lateral sclerosis and 30 controls. The algorithm identified the skeleton on the CT images by using an extension of the Hough transform and then extracted the spinal canal and the spinal cord. In these regions, 18F-FDG standardized uptake values were measured to estimate the metabolic activity of the spinal canal and cord. Measurements were performed in the cervical and dorsal spine and normalized to the corresponding value in the liver. RESULTS: Uptake of 18F-FDG in the spinal cord was significantly higher in patients than in controls (p < 0.05). By contrast, no significant differences were observed in spinal cord and spinal canal volumes between the two groups. 18F-FDG uptake was completely independent of age, gender, degree of functional impairment, disease duration and riluzole treatment. Kaplan-Meier analysis showed a higher mortality rate in patients with standardized uptake values above the fifth decile at the 3-year follow-up evaluation (log-rank test, p < 0.01). The independence of this value was confirmed by multivariate Cox analysis. CONCLUSION: Our computational three-dimensional method enabled the evaluation of spinal cord metabolism and volume and might represent a potential new window onto the pathophysiology of amyotrophic lateral sclerosis.

Phenotypic variants of mycosis fungoides (MF) include mainly the expression of cytotoxic markers by neoplastic cells (either α/β or γ/δ cytotoxic). To manage the patient properly, distinction from other cutaneous cytotoxic natural killer/T-cell lymphomas is paramount. Particularly for cutaneous γ/δ T-cell lymphoma, distinction is often based on clinicopathologic correlation (presence of tumors at first diagnosis as opposed to patches only in MF). The authors report a case of cytotoxic MF characterized by expression of TCRγ in two of three biopsies performed within a time frame of 1 week. The patient presented with patches, plaques, and 1 tumor at the time of first diagnosis; thus, distinction from cutaneous γ/δ T-cell lymphoma was not possible on clinical grounds alone. The diagnosis of MF was established, thanks to the phenotypic variations revealed by the three biopsies, with 1 lacking expression of cytotoxic proteins (TIA-1 and granzyme B) and of TCRγ. This case shows the importance to perform several biopsies in cases of cutaneous lymphoma, as morphologic and phenotypic features are variable and information gathered from a single biopsy may result in a wrong diagnosis.

Background Primary cutaneous follicle center lymphoma (PCFCL) presents usually with reddish nodules, plaques, and tumors on the head and neck area, particularly the scalp, and on the back. Objective We sought to describe a peculiar clinical variant of PCFCL. Methods We report a series of 18 patients (male:female = 7:11; median age 52 years; mean age 50.8 years; age range 27-75 years) with a clinical variant of PCFCL characterized clinically by multiple, miliary, or agminated papules predominantly on the head and neck. Results All patients presented with multiple erythematous, firm papules arranged in a manner that resembled millet seeds or collected together in small clusters. Lesions were located on the entire face in one patient (5.6%), the forehead in 8 (44.4%), the cheeks in 3 (16.7%), the preauricular region in two (11.1%), and multiple regions on the head and neck area in 3 (16.7%). The last patient had miliary papules on the entire face, back, upper aspect of arms, and scattered on the front of the chest. The initial diagnosis was never cutaneous lymphoma, and all patients had been treated unsuccessfully for different skin conditions including mainly rosacea, lupus miliaris disseminatus faciei, and persistent arthropod bite reaction. Microscopic examination confirmed the diagnosis of PCFCL in all patients. Limitations Small number of cases and retrospective study are limitations. Conclusions This peculiar clinical presentation of PCFCL is unusual and represents a pitfall in the clinical diagnosis. Dermatologists should be aware of this variant of PCFCL so as to treat patients timely and properly.

In the present study, we report the occurrence of Lyme's borreliosis in patients from the Brazilian Amazon Region. Borreliosis was investigated by immunohistochemistry and focus floating microscopy for Borrelia burgdorferi in skin biopsy samples from 22 patients with both clinical and histopathology evidences compatible with Erythema Migrans. Spirochetes were detected by specific immunohistochemistry and focus floating microscopy for B. burgdorferi in samples from five patients. Clinical cure of the cutaneous lesions was observed in all the patients after treatment with doxycycline regimen as proposed by the Center Disease Control guidelines. A limitation of our study was the fact that we were not able to isolate and culture these organisms. These are the first known Brazilian cases of borreliosis to have Focus Floating Microscopy confirmation.

To study the association between time to antibiotic administration and survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department.Single-center cohort study.The emergency department of an academic tertiary care center from 2005 through 2006.Two hundred sixty-one patients undergoing early goal-directed therapy.None.Effects of different time cutoffs from triage to antibiotic administration, qualification for early goal-directed therapy to antibiotic administration, triage to appropriate antibiotic administration, and qualification for early goal-directed therapy to appropriate antibiotic administration on in-hospital mortality were examined. The mean age of the 261 patients was 59 +/- 16 yrs; 41% were female. In-hospital mortality was 31%. Median time from triage to antibiotics was 119 mins (interquartile range, 76-192 mins) and from qualification to antibiotics was 42 mins (interquartile range, 0-93 mins). There was no significant association between time from triage or time from qualification for early goal-directed therapy to antibiotics and mortality when assessed at different hourly cutoffs. When analyzed for time from triage to appropriate antibiotics, there was a significant association at the1 hr (mortality 19.5 vs. 33.2%; odds ratio, 0.30 [95% confidence interval, 0.11-0.83]; p = .02) time cutoff; similarly, for time from qualification for early goal-directed therapy to appropriate antibiotics, a significant association was seen at theor =1 hr (mortality 25.0 vs. 38.5%; odds ratio, 0.50 [95% confidence interval, 0.27-0.92]; p = .03) time cutoff.Elapsed times from triage and qualification for early goal-directed therapy to administration of appropriate antimicrobials are primary determinants of mortality in patients with severe sepsis and septic shock treated with early goal-directed therapy.

Summary Background Facial lentigo maligna (LM) and lentigo maligna melanoma (LMM) may be difficult to diagnose clinically and dermoscopically. Reflectance confocal microscopy (RCM) enables the in vivo assessment of equivocal skin lesions at a cellular level. Objectives To assess cytomorphological and architectural RCM features of facial LM/LMM. Methods Four women and eight men aged 58–88 years presenting with facial skin lesions suspicious of LM/LMM were included. In total, 17 lesion areas were imaged by RCM before biopsy. The histopathological diagnosis of LM was made in 15 areas; the other two were diagnosed as early LMM. Results A focal increase of atypical melanocytes and nests surrounding adnexal openings, sheets of mainly dendritic melanocytes, cord-like rete ridges at the dermoepidermal junction (DEJ) and an infiltration of adnexal structures by atypical melanocytes were found to be characteristic RCM features of facial LM/LMM. Areas with a focal increase of atypical melanocytes and nests surrounding adnexal openings were observed at the basal layer in three cases. The remaining cases displayed these changes at suprabasal layers above sheets of mainly dendritic melanocytes. Cord-like rete ridges at the DEJ and an infiltration of adnexal structures by atypical melanocytes were observed in all cases. Previously described criteria for RCM diagnosis of melanoma, such as epidermal disarray, pleomorphism of melanocytes and pagetoid spreading of atypical melanocytes, were additionally observed. Conclusions We observed a reproducible set of RCM criteria in this case series of facial LM/LMM.

Papular-purpuric gloves and socks syndrome is a self-limited febrile illness of children and young adults. Only 50 well documented cases have been reported, most of which were associated with parvovirus B19 infection. Molecular detection of the virus from lesional skin has been described in only 5 patients. The syndrome is characterized by a papular-purpuric edematous rash in a distinct "gloves and socks" distribution. Extracutaneous manifestations are usually mild and transient. We report a 42-year-old female with a highly unusual expression of the syndrome, including bullous lesions, lingual aphthae, and conjunctivitis, accompanied by arthritis and a high-grade fever. She had immunoglobulin M and immunoglobulin G antibodies to parvovirus B19, which was detected from lesional skin with the use of polymerase chain reaction for the first time in such a clinical constellation. Because parvovirus B19 infections are generally more severe in adults, we suspect that the unusual disease expression in our patient was related to being more than 40 years of age.

Background: Cutaneous infectious and inflammatory diseases may contain a significant number of CD30-positive cells, thus mimicking lymphomatoid papulosis (LyP) or anaplastic large cell lymphoma. Methods: We reviewed our cases of non-neoplastic skin conditions with large, CD30-positive cells and searched the literature for similar cases. Results: A total of 28 cases were included in the study: Milker’s nodule (n = 8), Herpes simplex virus infection (n = 7), lymphomatoid drug reaction (n = 3), molluscum contagiosum (n = 3), nodular scabies (n = 2), leishmaniasis (n = 1), syphilis (n = 1), pernio (n = 1), ruptured infundibular cyst (n = 1) and pseudolymphoma in a scar (n = 1). CD30-positive cells were often arranged in clusters and revealed both Golgi and membrane positivity, similar to what was observed in LyP and CD30+ anaplastic large T-cell lymphoma. Conclusions: Analysis of our data and of those published in the literature shows that viruses and drugs are the most common cause for occurrence of large CD30-positive cells in cutaneous pseudolymphomatous infiltrates. Arrangement of these large, CD30-positive cells in small clusters is not unique to cutaneous CD30-positive lymphomas, and in many cases a precise diagnosis can be made only upon accurate clinicopathological correlation or using ancillary methods such as polymerase chain reaction analysis for viral DNA.

Summary Background The influence of phenotype and detection of clonality on prognosis in early mycosis fungoides has never been addressed in large studies. Objectives To correlate immunophenotype and detection of clonality with clinical outcome. Methods We analysed 73 biopsy specimens from 68 patients with early mycosis fungoides (stage Ia or Ib) and at least 10 years of follow up (or dead of disease). Results Four phenotypic groups could be identified: group A (α/β+ CD4+ CD8− TIA1−), 51 patients; median survival time 160 months; group B (α/β+ CD4− CD8+ TIA1+), 10 patients; median survival time 195 months; group C (α/β− CD4− CD8+/− TIA1+), five patients; median survival time 165 months; and group D (α/β+ CD4− CD8− TIA1−), two patients; median survival time 130 months. Survival curves did not show statistical differences among the groups. Monoclonality was detected in 36 of 67 tested biopsies (54%), and statistical analyses did not show prognostic differences between the clonal and nonclonal cases. Conclusions We conclude that cytotoxic phenotype and detection of monoclonal T-cell receptor-γ gene rearrangement in early lesions of mycosis fungoides do not have any prognostic significance.