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Florida residents have the second highest incidence of skin cancer in the nation. Sunscreen usage was found to be the one of the most effective integrative health approaches for reducing risk of skin cancer. Given the limited information on the likelihood of adopting and continuing sunscreen usage behavior, this cross-sectional study aimed to examine the correlates of initiating and sustaining sunscreen usage behavior among Florida dwellers, using the fourth-generation, multi-theory model (MTM) of behavior change. A web-based survey containing 51 questions was emailed to Florida residents aged 18 years or above, who were randomly selected from the state voter file. Psychometric validity of the survey instrument was established using structural equation modeling, and Cronbach’s alpha values were calculated for assessing the internal consistency. An independent-samples-t-test and hierarchical multiple regression tests were used to analyze the data. The results indicated that participants who engaged in sunscreen usage behavior, participatory dialogue (β = 0.062, p &lt, 0.05), behavioral confidence (β = 0.636, p &lt, 0.001), and changes in the physical environment (β = 0.210, p &lt, 0.001) were statistically significant and accounted for 73.6% of the variance in initiating sunscreen usage behavior. In addition, the constructs of emotional transformation (β = 0.486, p &lt, 0.001) and practice for change (β = 0.211, p &lt, 0.001), as well as changes in the social environment (β = 0.148, p &lt, 0.001) were significant predictors of maintaining sunscreen usage behavior and contributed to 59% of variance in sustenance. These findings offer a valuable insight regarding the applicability of MTM models to guiding public health interventions promoting sunscreen usage and preventing UV radiation risk and related skin cancer.

BackgroundThe majority of clinical studies reporting on COVID-19 symptom frequencies focus on patients already hospitalized. Thus, reported symptom frequencies may not be applicable to the general population. Here we report COVID-19 symptom frequencies for the general population in a major European city. MethodsDuring a scientific collaboration between the Vienna Social Fund (FSW, Vienna, Austria), the Public Health Services of the City of Vienna (MA15) and the AI-biotech company Symptoma we recorded symptom frequencies gathered by the COVID-19 chatbot of the city government of Vienna and corresponding SARS-CoV-2 nucleic acid amplification test (NAAT) results. Chatbot users answered 13 yes/no questions about symptoms and provided information about age and sex. Subsequently a medically trained professional came to their address to take a sample and NAAT results were obtained. FindingsBetween November 2 and January 5, a total of 3011 persons experiencing flu-like symptoms had completed the chatbot-session and were subsequently tested by a NAAT. NAATs were performed by at home visitations of medical professionals. NAAT analysis was positive in 816 persons (27.1%). We compared the symptom frequencies between COVID-19 positive and negative users, and between male and female users. The symptoms (sorted by frequency) of users with positive NAATs were malaise (81.1%), fatigue (72.9%), headache (64.1%), cough (57.7%), fever (50.7%), sore throat (40.7%), rhinorrhea (31.0%), sneezing (28.4%), dysgeusia (27.1%), hyposmia (26.5%), dyspnea (11.4%) and diarrhea (10.9%) while 34.9% reported a close contact with a COVID-19 case. Among these the frequencies of cough, fever, hyposmia, dysgeusia, malaise, headache, close contact with COVID-19 case and fatigue were significantly (P < 0.01) increased in COVID-19 positive persons while the frequencies of dyspnea, diarrhea and sore throat were significantly (P < 0.01) decreased in COVID-19 positive persons. There was no significant difference for rhinorrhea and sneezing. InterpretationThis paper provides reliable COVID-19 symptom frequency statistics based on chat-bot conversations and experimental NAATs.

Introduction: Mitochondrial heart disease due to pathogenic mitochondrial DNA (mtDNA) mutations can present as hypertrophic or dilated cardiomyopathy, ventricular arrhythmias and conduction disease. It is estimated that the mutation rate of mtDNA is 10 to 20-fold higher than that of nuclear DNA genes due to damage from reactive oxygen species released as byproducts during oxidative phosphorylation. When a new mtDNA mutation arises, it creates an intracellular heteroplasmic mixture of mutant and normal mtDNAs, called heteroplasmy. Heteroplasmy levels can vary in various tissues and examining mtDNA variants in blood may not be representative for the heart. The frequency of pathogenic mtDNA variants in myocardial tissues in unknown. Hypothesis: Human ventricular tissue may contain mtDNA mutations which can lead to alterations in mitochondrial function and increase individual risk for heart failure. Methods: Mitochondrial DNA was isolated from 61 left ventricular myocardial samples obtained from failing human hearts at the time of transplantation. mtDNA was sequenced with 23 primer pairs. In silico prediction of non-conservative missense variants was performed via PolyPhen-2. Heteroplasmy levels of variants predicted to be pathogenic were quantified using allele-specific ARMS-PCR. Results: We identified 21 mtDNA non-synonymous variants predicted to be pathogenic in 17 hearts. Notably, one heart contained four pathogenic mtDNA variants (ATP6: p.M104; ND5: p.P265S; ND4: p.N390S and p.L445F). Heteroplasmy levels exceeded 90% for all four variants in myocardial tissue and were significantly lower in blood. No pathogenic mtDNA variants were identified in 44 hearts. Hearts with mtDNA mutations had higher levels of myocardial GDF-15 (growth differentiation factor-15; 6.2±2.3 vs. 1.3±0.18, p=0.045), an established serum biomarker in various mitochondrial diseases. Conclusions: Non-synonymous mtDNA variants predicted to be pathogenic are common in human left ventricular tissue and may be an important modifier of the heart failure phenotype. Future studies are necessary to correlate myocardial mtDNA mutations with cardiovascular outcomes and to assess whether serum GDF-15 allows identifying patients with myocardial mtDNA mutations.

Studies have shown that initiating early palliative care of patients with end-stage cancer can improve their quality of life and decrease symptoms of depression. The challenge is to find an effective way to care for these patients while minimizing the burden on healthcare resources. Telemedicine can play a vital role in solving this problem. A user-friendly telemedical device enabling patients encountering medical problems to send a direct request to a palliative care team was developed. A controlled feasibility study was conducted by assigning 15 patients with advanced cancer and their family caregivers to receive either standard palliative care or telemedically augmented palliative care. Th quality of life (QoL) was assessed using standardized validated questionnaires as well as frequency and duration of hospital admissions and user satisfaction. The primary goal of this study was to increase the QoL of patients and their family caregivers. The secondary goal of this study was to decrease the frequency and duration of hospital admissions. This study showed a good feasibility despite the low overall willingness to participate in a relatively “technical” trial. The hospital anxiety and depression scale (HADS) was significantly lower in the intervention group, suggesting an improved quality of life. Although a decrease in the number of hospital admissions could not be shown, the user satisfaction was very good. Telemedicine could be a useful tool to enhance the general well-being of palliative oncology patients. Now that the feasibility of this approach has been confirmed, larger studies are needed to verify its positive impact on the QoL.

Cardiovascular disease is more common in patients with chronic kidney disease (CKD), and traditional risk factors do not adequately predict those at risk for cardiovascular (CV) events. Recent evidence suggests elevated trimethylamine N-oxide (TMAO), created by gut microflora from dietary L-carnitine and choline, is associated with CV events. We investigated the relationship of TMAO levels in patients with stages 3b and 4 CKD to ischemic CV events using the CanPREDDICT cohort, a Canada-wide observational study with prospective 3-year follow-up of adjudicated CV events. Baseline samples were obtained for 2529 CKD patients. TMAO, choline, and L-carnitine levels were measured using tandem mass spectrometry. Baseline median TMAO level was high for the whole cohort (20.41 μM; interquartile range [IQR]: 12.82–32.70 μM). TMAO was independently associated with CV events (hazard ratio 1.23; 95% confidence interval: 1.06–1.42 / 1 SD lnTMAO) after adjusting for all potential CV risk factors. Those in the highest TMAO quartile had significantly higher risk of CV events (adjusted hazard ratio 1.59; 95% confidence interval: 1.04–2.43; P = 0.0351) in the analysis of recurring ischemic events. Among those with stage 3b CKD (hazard ratio 1.45; 95% confidence interval: 1.12–1.87 / 1 SD lnTMAO), independent of kidney function, TMAO levels identified those at highest risk for events. Our results suggest that TMAO may represent a new potentially modifiable CV risk factor for CKD patients. Further studies are needed to determine sources of variability and if lowering of TMAO reduces CV risk in CKD.

Defect repair of GaN-based light-emitting diodes (LEDs) by ultraviolet laser micromachining is reported. Percussion and helical drilling in GaN by laser ablation were investigated using 248 nm nanosecond and 355 nm picosecond pulses. The influence of laser ablation including different laser parameters on electrical and optical properties of GaN-based LED chips was evaluated. The results for LEDs on sapphire with transparent conductive oxide p-type contact on top as well as for thin-film LEDs are reported. A reduction of leakage current by up to six orders in magnitude and homogeneous luminance distribution after proper laser defect treatment were achieved.

Minimal change disease (MCD) accounts for 10-15% of idiopathic nephrotic syndrome in adults. Patients typically present with nephrotic range proteinuria, hypertension, microscopic hematuria and can even progress to acute renal failure. MCD can be primary (idiopathic) or secondary from etiologies such as cancer, medications, autoimmune conditions and infections. The link between infectious etiologies for MCD is important to recognize, since MCD tends to show a good response to treatment of the underlying cause. Influenza A has been reported as a secondary cause of MCD and rarely, influenza A, not B, can also present with liver failure. We present an atypical case of a 60-year-old female with no past medical history who presented with liver failure along with acute kidney injury and nephrotic range proteinuria. She was diagnosed with liver failure and secondary MCD from influenza B, the first reported case, and made a full recovery with treatment of Influenza B.

Summary Background and objectives The increase in minimum inhibitory concentrations (MICs) of cephalosporins for Neisseria gonorrhoeae has given rise to concerns regarding potentially untreatable gonococcal infections. The goal was to ascertain the prevalence of gonorrhea in a Viennese patient group and determine resistance patterns. Another objective was to evaluate resistance profiles and MIC values of gonococcal isolates in an Austria-wide surveillance project. Patients and methods From 1999 to 2014, 350,000 individuals were tested for gonococci at the Viennese Outpatient Clinic. In addition, from 2010 to 2014, the MICs of recommended antibiotics was determined in 3,584 gonococcal isolates, initially by agar dilution and breakpoint determination, and, from 2012 onwards, by Etest®. Results During the observation period, the prevalence of gonorrhea increased eightfold, with a significantly greater number of quinolone, penicillin, and tetracycline- resistant strains. In gonococcal strains isolated from across Austria, there was an increase in cefixime and ceftriaxone MICs toward breakpoints. Twenty-one isolates showed cefixime resistance, and while there was an increase in azithromycin resistance from 0.9 % (2013) to 3.2 % (2014), no resistance to ceftriaxone was observed. Conclusion Currently, there is no imminent risk of untreatable gonorrhea in Austria. However, continuing the use of gonococcal cultures as a diagnostic tool for establishing resistance profiles is essential in order to monitor trends in the development of Neisseria (N.) gonorrhoeae resistance.

Zusammenfassung Hintergrund und Ziel: Die Zunahme der minimalen Hemmkonzentration (MHK) auf Cephalosporine bei Neisseria gonorrhoeae geben Anlass zur Besorgnis einer unbehandelbaren Gonokokkeninfektion. Ziel war die Erhebung der Pravalenz der Gonorrhoe in einem Wiener Patientenkollektiv und Bestimmung des Resistenzmusters sowie die Evaluierung des Resistenzprofils und der MHK-Werte bei Gonokokkenisolaten im Rahmen eines osterreichweiten Surveillance-Projektes. Patienten und Methodik: Von 1999 bis 2014 wurden 350 000 Patienten im Wiener Ambulatorium auf das Vorliegen einer Gonokokkeninfektion untersucht. Zusatzlich erfolgte von 2010 bis 2014 bei 3 584 Gonokokkenisolaten eine MHK-Bestimmung der empfohlenen Antibiotika zunachst mittels Agardilution und Breakpoint-Bestimmung, ab 2012 mittels E-Test. Ergebnisse: Im Beobachtungszeitraum hat sich die Zahl der Gonokokkeninfektionen im Wiener Patientenkollektiv verachtfacht und die Resistenz auf Chinolone, Penicillin und Tetrazykline dramatisch erhoht. Bei den osterreichweit isolierten Gonokokkenstammen war ein Anstieg der MHK von Cefixim und Ceftriaxon in Richtung Breakpoint feststellbar. Eine Cefixim-Resistenz war bei 21 Isolaten zu beobachten, ebenso eine Zunahme der Azithromycin-Resistenz von 0,9 % (2013) auf 3,2 % (2014), nicht jedoch eine Resistenz auf Ceftriaxon. Schlussfolgerungen: Derzeit besteht in Osterreich noch keine unmittelbare Gefahr einer nicht behandelbaren Gonorrhoe. Das Beibehalten der Gonokokkenkultur fur die Erstellung des Resistenzprofils ist jedoch fur die weitere Beobachtung der Resistenzentwicklung von Neisseria (N.) gonorrhoeae essentiell. Summary Background and objectives: The increase in minimum inhibitory concentrations (MICs) of cephalosporins for Neisseria gonorrhoeae has given rise to concerns regarding potentially untreatable gonococcal infections. The goal was to ascertain the prevalence of gonorrhea in a Viennese patient group and determine resistance patterns. Another objective was to evaluate resistance profiles and MIC values of gonococcal isolates in an Austria-wide surveillance project. Patients and methods: From 1999 to 2014, 350 000 individuals were tested for gonococci at the Viennese Outpatient Clinic. In addition, from 2010 to 2014, the MICs of recommended antibiotics was determined in 3584 gonococcal isolates, initially by agar dilution and breakpoint determination, and, from 2012 onwards, by Etest®. Results: During the observation period, the prevalence of gonorrhea increased eightfold, with a significantly greater number of quinolone, penicillin, and tetracycline-resistant strains. In gonococcal strains isolated from across Austria, there was an increase in cefixime and ceftriaxone MICs toward breakpoints. Twenty-one isolates showed cefixime resistance, and while there was an increase in azithromycin resistance from 0.9 % (2013) to 3.2 % (2014), no resistance to ceftriaxone was observed. Conclusion: Currently, there is no imminent risk of untreatable gonorrhea in Austria. However, continuing the use of gonococcal cultures as a diagnostic tool for establishing resistance profiles is essential in order to monitor trends in the development of Neisseria (N.) gonorrhoeae resistance.

As the subcutaneous course of the hair follicle cannot be extrapolated from the angle of hair emergence, the follicular unit extraction (FUE) method bears the risk of follicle transsection potentially affecting the success of the whole intervention. Histological examination can provide this angle information but are too time consuming and invasive to be integrated in the workflow.In this work, the authors present an effective and noninvasive way to determine these subcutaneous follicle angles.For this purpose, the authors use optical coherence tomography to provide images of the first 2 to 3 mm of the surface of the skin.On 3 probands, they scanned 2 regions. We computed the number of hair follicles in a certain angular region around a mean angle, representing an FUE tool, and found a considerable diversity of the angular deviations.As this angular distribution massively influences the transsection rate, the authors suggest such a method to be considered as a future improvement of preoperative assessment.

Summary Sun exposure is causal for melanoma but is subject to bias of recall so that it is difficult to dissect the role of particular patterns of sun exposure. In this hospital-based case-control study (n = 1991), we aimed to analyze pigmentation traits and signs of actinic damage at different anatomic locations as markers of melanoma risk in central European patients. Although all signs of actinic damage (freckling, wrinkling and solar lentigos) were significantly associated with melanoma risk in multivariate logistic regression models adjusting for age and sex, the strongest associations were observed for the dorsal parts of the body: adjusted odds ratios [OR] were 4.22 for wrinkling on the neck, 3.43 for solar lentigos and 3.37 for freckling on the back (all P

The demosponge Suberites domuncula has been described to contain high levels of a proteinaceous toxin, Suberitine, that displays haemolytic activityIn the present study this 7–8 kDa polypeptide has been isolated and was shown to exhibit also cytotoxic effects on cells of the same species. Addition of retinal, a recently identified metabolite of β-carotene that is abundantly present in S. domuncula was found to reduce both the haemolytic and the cell toxic activity of Suberitine at a molar ratio of 1:1. Spectroscopic analyses revealed that the interaction between β-carotene and Suberitine can be ascribed to a reversible energy transfer reaction. The enzyme that synthesises retinal in the sponge system is the β,β-carotene-15,15′-dioxygenase [carotene dioxygenase]. In order to clarify if this enzyme is the only β-carotene-metabolizing enzyme a further oxygenase had been identified and cloned, the (related) carotenoid oxygenase. In contrast to the dioxygenase, the carotenoid oxygenase could not degrade β-carotene or lycopene in Escherichia coli strains that produced these two carotenoids; therefore it had been termed related-carotenoid oxygenase. Exposure of primmorphs to light of different wavelengths from the visible spectrum resulted after 3 days in a strong upregulation of the dioxygenase in those 3D-cell aggregates that had been incubated with β-carotene. The strongest effect is seen with blue light at a maximum around 490 nm. It is concluded that the toxin Suberitine is non-covalently modified by retinal, the cleavage product from β-carotene via the enzyme carotene dioxygenase, a light inducible oxygenase. Hence, this study highlights that in S. domuncula the bioactive metabolite, retinal, has the property to detoxify its homologous toxin.

High-resolution frequency domain optical coherence tomography (OCT) stands out amongst a range of novel dermatologic imaging technologies, with its good detection sensitivity around -100 dB, high measurement speeds allowing real-time image acquisition and its ability to acquire high definition cross-sectional and 3D tomograms of regions greater than 1 cm2, providing tissue information comparable to conventional histopathology without the need for any contrast agents. Typical axial and transverse resolutions of state-of-the-art OCT systems range between 1–10 µm and approximately 20 µm, respectively, depending on the employed wavelength region. This review investigates the significant progress accomplished in the field of dermatologic OCT with respect to other in vivo diagnostic methods for pre-excisional imaging of nonmelanoma skin cancers and specifically emphasizes state-of-the-art results achieved in different clinical pilot studies. Further technological extensions of OCT, various multimodal imaging ap...

Systemic sclerosis (SSc) is a rare autoimmune disorder that is typically divided into limited cutaneous systemic sclerosis and diffuse cutaneous systemic sclerosis. Scleroderma renal crisis (SRC) is a severe complication of SSc and typically presents with new-onset hypertension and a reduction in renal functioning. In patients presenting with typical features of SRC, treatment with an angiotensin-converting enzyme inhibitor along with dialysis as needed is typically initiated empirically. Renal biopsy is not recommended in patients with SSc presenting with typical features of SRC. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare co-occurrence with SSc, in around 2.5% to 9% of patients. AAV is an inflammatory condition that can result in renal failure due to mononuclear cell infiltration and destruction of blood vessels. Treatment of AAV is drastically different from SRC and typically consists of immunosuppressants and dialysis if needed. SRC and AAV can only reliably be distinguished by renal biopsy. We present a rare case of a 70-year-old female with limited cutaneous systemic sclerosis who presented to the emergency department with new-onset renal failure. Her serology was found to be positive for antinuclear antibodies and myeloperoxidase antibodies, resulting in a renal biopsy, which revealed an acute necrotizing vasculitis consistent with AAV. We suggest consideration of a renal biopsy in patients with SSc who present with new-onset renal failure, especially with nonresponse to SRC treatment or positive serology.

The aim of this study was to evaluate the accuracy of a computer-based system for the automated diagnosis of melanoma in the hands of nonexpert physicians. We performed a prospective comparison between nonexperts using computer assistance and experts without assistance in the setting of a tertiary referral center at a University hospital. Between February and November 2004 we enrolled 511 consecutive patients. Each patient was examined by two nonexpert physicians with low to moderate diagnostic skills who were allowed to use a neural network-based diagnostic system at their own discretion. Every patient was also examined by an expert dermatologist using standard dermatoscopy equipment. The nonexpert physicians used the automatic diagnostic system in 3827 pigmented skin lesions. In their hands, the system achieved a sensitivity of 72% and a specificity of 82%. The sensitivity was significantly lower than that of the expert physician (72 vs. 96%, P = 0.001), whereas the specificity was significantly higher (82 vs. 72%, P0.01). Three melanomas were missed because the physicians who operated the system did not choose them for examination. The system as a stand-alone device had an average discriminatory power of 0.87, as measured by the area under the receiver operating characteristic curve, with optimal sensitivities and specificities of 75 and 84%, respectively. The diagnostic accuracy achieved in this clinical trial was lower than that achieved in a previous experimental trial of the same system. In total, the performance of a decision-support system for melanoma diagnosis under real-life conditions is lower than that expected from experimental data and depends upon the physicians who are using the system.

Sentinel lymph node (SLN) -positive melanoma patients are usually recommended completion lymph node dissection (CLND) with the aim to provide regional disease control and improve survival. Nevertheless, only 20% these patients have additional metastases in non-sentinel lymph nodes (NSLN), indicating that CLND may be unnecessary in the majority of patients. In this retrospective study, we (i) sought to identify clinico-pathological features predicting NSLN status, as well as disease-free (DFS) and -specific (DSS) survival and (ii) evaluated the applicability of previously published algorithms, which were able to define a group of patients at zero-risk for NSLN-metastasis.This analysis included 504 consecutive melanoma patients stage I and II who underwent successful SLN-biopsy (SLNB) at our institute between 1998 and 2005. Metastatic SLN were re-evaluated for tumor burden and categorized according to two different micro-anatomic classifications and the S/U-score (Size of the sentinel node metastasis2 mm/Ulceration of the primary melanoma) was assessed. DFS and DSS were calculated for all analyses.Out of 504 melanoma patients stage I or II, 85 (17%) were SLN-positive and 18 of 85 (21%) were found with positive NSLN in the CLND specimen. Median follow-up was 31 months. Neither primary tumor characteristics (age, gender, Clark level, Breslow thickness, ulceration of the primary melanoma, site and histological subtype of the primary melanoma), nor features of the sentinel node tumor (number and site of draining lymph node basins, number of positive sentinel nodes and size of sentinel node tumor (2 mm vs.or = 2 mm) were able to predict additional positive lymph nodes in the CLND specimen. Likewise the implementation of published algorithms was not able to identify patients at negligible risk for harboring NSLN metastases. Upon univariate analysis, disease-free survival in SLN-positive patients was correlated with Breslow thickness, sentinel node tumor size2 mm and S/U score. In respect to disease-specific survival the significant prognostic parameters were Breslow thickness, ulceration, sentinel node tumor size2 mm and the S/U score. After a median follow-up of 31 months recurrence rates (37% vs. 78%, p=0.02) and death from disease (24% vs. 50%, p0.01) were significantly different in patients with SLN-metastasis only as compared to patients with NSLN-metastasis.NSLN status cannot be predicted in this data analysis by using clinico-pathological characteristics. Therefore, CLND is recommended for all patients after positive SLNB pending the results of the second Multicenter Selective Lymphadenectomy Trial.

Introduction Clinical decision support systems (CDSSs) are being developed to assist physicians in processing extensive data and new knowledge based on recent scientific advances. Structured medical knowledge in the form of clinical alerts or reminder rules, decision trees or tables, clinical protocols or practice guidelines, score algorithms, and others, constitute the core of CDSSs. Several medical knowledge representation and guideline languages have been developed for the formal computerized definition of such knowledge. One of these languages is Arden Syntax for Medical Logic Systems, an International Health Level Seven (HL7) standard whose development started in 1989. Its latest version is 2.10, which was presented in 2014. In the present report we discuss Arden Syntax as a modern medical knowledge representation and processing language, and show that this language is not only well suited to define clinical alerts, reminders, and recommendations, but can also be used to implement and process computerized medical practice guidelines. Methods This section describes how contemporary software such as Java, server software, web-services, XML, is used to implement CDSSs based on Arden Syntax. Special emphasis is given to clinical decision support (CDS) that employs practice guidelines as its clinical knowledge base. Results Two guideline-based applications using Arden Syntax for medical knowledge representation and processing were developed. The first is a software platform for implementing practice guidelines from dermatology. This application employs fuzzy set theory and logic to represent linguistic and propositional uncertainty in medical data, knowledge, and conclusions. The second application implements a reminder system based on clinically published standard operating procedures in obstetrics to prevent deviations from state-of-the-art care. A to-do list with necessary actions specifically tailored to the gestational week/labor/delivery is generated. Discussion Today, with the latest versions of Arden Syntax and the application of contemporary software development methods, Arden Syntax has become a powerful and versatile medical knowledge representation and processing language, well suited to implement a large range of CDSSs, including clinical-practice-guideline-based CDSSs. Moreover, such CDS is provided and can be shared as a service by different medical institutions, redefining the sharing of medical knowledge. Arden Syntax is also highly flexible and provides developers the freedom to use up-to-date software design and programming patterns for external patient data access.

BackgroundThis study investigated the mid-term (mean, 3.7 years) clinical results and the results of duplex Doppler sonographic examinations of subfascial endoscopic perforating vein surgery (SEPS) in patients with mild to severe chronic venous insufficiency (clinical class 2-6) and assessed the factors associated with the recurrence of insufficient perforating veins (IPVs).MethodsEighty patients with mild to severe chronic venous insufficiency undergoing SEPS were evaluated, and duplex findings, as well as clinical severity and disability scores before and after the operation, were compared. Patients with prior deep vein thrombosis (

Mass screening for cutaneous melanoma is impracticable because of its low yield and high costs. The validity of self-selection of high-risk individuals through self-assessment of melanoma risk factors is not known. The aim of this study was to assess the validity of an unsupervised self-administered questionnaire for the self-assessment of melanoma risk. In a case-control study, melanoma cases (n = 202) and controls (n = 202) matched for age and gender filled in a questionnaire about melanoma risk factors. After filling in the questionnaire, all participants were interviewed and examined by a dermatologist in order to compare self-assessment with physician-assessment. The number of naevi, skin phototype and ultraviolet damage to the skin were identified as independent risk factors for melanoma on both self-assessment and physician-assessment. Receiver operating characteristics analysis showed no statistically significant difference between the accuracy of the self-assessment-based model and the model based on physician-assessment. While excluding 90% of the controls, the self-assessment-based high-risk group included 39% (95% confidence interval 31-48%) of the melanoma patients and the physician-assessment-based high-risk group included 42% (95% confidence interval 33-52%) of the melanoma patients. In conclusion, an unsupervised self-administered questionnaire is, to some extent, useful for the identification of individuals at high risk for melanoma. The moderate accuracy of self-assessment and physician-assessment to identify individuals at high risk for melanoma is a limitation for the practicability of targeted melanoma screening in general.

Hintergrund und Fragestellung: Ziel dieser Studie war es, die klinische Wertigkeit einer dermatoskopischen Klassifikation von Clark-Navi zu untersuchen. Patienten/Methodik: Die dermatoskopischen Bilder von 268 konsekutiven Lasionen, die klinisch und dermatoskopisch als Clark-Navi imponierten, wurden von zwei Dermatologen ohne Kenntnis der histologischen Diagnose begutachtet. Die begutachteten Lasionen wurden in Anlehnung an das von Hofmann-Wellenhof vorgeschlagenen Klassifikationsschema fur Clark-Navi in 12 verschiedene Grundtypen unterteilt. Ergebnisse: Insgesamt vorherrschend war der retikular-homogene Typ (n = 64, 23,9 %) gefolgt vom globular-homogenen Typ (n = 32, 12 %) und vom homogenen Typ (n = 30, 11,2 %). In bezug auf die Klassifikation fand sich insgesamt eine moderate bis gute Ubereinstimmung zwischen den Untersuchern (kappa = 0,58). Die hochste Ubereinstimmung fand sich beim peripher hyperpigmentiertenTyp (kappa = 0,83). Histologisch wurden siebzehn (6,3 %) Lasionen als Melanome befundet. Die meisten Melanome fanden sich, je nach Untersucher, beim peripher hyperpigmentierten Typ und beim homogenen Typ. Kein Melanom fand sich beim globularen Typ, retikular-globularen Typ und zentral hyperpigmentierten Typ. Schlusfolgerungen: Eine dermatoskopische Klassifikation von Clark-Navi ist praktisch anwendbar und erlaubt mit Einschrankungen eine gewisse Risikoeinschatzung, die das klinische Management von Clark-Navi erleichtern kann. Summary Background and objectives: The aim of this study was to evaluate the practical value of the dermatoscopic classification of Clark nevi Patients and methods: Dermatoscopic images of 268 lesions clinically and dermatoscopically diagnosed as Clark nevi were presented to 2 dermatologists without knowledge of the histological diagnosis. The dermatologists evaluated the lesions according to a simplified version of the classification scheme for Clark nevi proposed by Hofmann-Wellenhof and differentiated between 12 different types of Clark nevi. Results: The most common type of Clark nevus was the reticular-homogenous type (n = 64, 23,9 %), followed by the globular-homogeneous type (n = 32, 12 %) and by the homogenous type (n = 30, 11,2 %). The overall inter-rater agreement between the examiners was moderate to good (kappa = 0,58). The highest level of agreement was found for the peripheral hyperpigmented type (kappa = 0,83). Histologically, 17 lesions (6,3 %) were diagnosed as melanomas. The frequency of melanoma was highest among the peripheral-hyperpigmented type for one observer and among the homogenous type for the other observer. No melanoma was found among the globular, reticular-globular, and the central-hyperpigmented types. Conclusions: A dermatoscopic classification of Clark nevi is practically feasible and allows – to some extent – a risk stratification of Clark nevi, which could be useful for clinical management.

A system for the computerized analysis of images obtained from epiluminescence microscopy (ELM) has been developed to enhance the early recognition of malignant melanoma. As an initial step, the binary mask of the skin lesion is determined by several basic segmentation algorithms together with a fusion strategy. A set of features containing shape and radiometric features as well as local and global parameters is calculated to describe the malignancy of a lesion. Significant features are then selected from this set by application of statistical feature subset selection methods. The final kNN classification delivers a sensitivity of 87% with a specificity of 92%.

A 49-year-old immunocompetent white man had a painful ulcer (1.5 cm in diameter) on the left ventrolateral surface of a grossly enlarged tongue. The ulcer was present for two months. Impaired swallowing resulted in substantial weight loss and fatigue. Histopathologic analysis of a punch biopsy specimen indicated numerous Leishman Donovan bodies within macrophages. A polymerase chain reaction confirmed the presence of L. donovani. Therapy with two cycles of liposomal amphotericin B over a three-month period was administered. Four months after discharge, the ulcer had healed completely and the tongue returned to its normal size and function.

Early melanoma is often difficult to differentiate from benign pigmented skin lesions (PSLs). Digital epiluminescence microscopy (DELM) and automated image analysis could represent possible aids for inexperienced clinicians. We designed an automated computerized image analysis system that has the potential for use as an additional tool for the differentiation of melanoma from dysplastic naevi and common naevi. The PC-based pilot system was attached to a common DELM system as the image source. Digital images of PSLs were automatically segmented and a panel of 107 morphological parameters were measured. Additionally, seven clinical parameters were evaluated and used as an additional source of information. Neural networks were then trained to distinguish melanoma from benign PSLs. One class of networks was trained solely based on the morphometric features, whereas the second class of networks was trained on the combination of morphometric and clinical features. The automatic segmentation algorithm was correct in 96% of cases. Using three-way receiver operating characteristic (ROC) analysis, for networks trained solely on morphometric features the volume under surface (VUS) was 0.617 (SD 0.036). The performance was significantly better for networks trained on the combination of both morphometric and clinical features (VUS = 0.682, SD 0.035). In a dichotomous model, distinguishing benign lesion (common naevi + dysplastic naevi) from melanoma, the area under the curve (AUC) from two-way ROC analysis was 0.942 (SD 0.018) for networks trained solely on morphometric features and 0.968 (SD 0.012) for those trained on the combination of clinical and morphometric data (P= NS). Automated feature extraction from PSLs and the training of neural networks as classifiers has thus shown satisfactory performance in a large scale experiment. The addition of clinical data significantly increases the diagnostic performance for distinguishing three classes of lesions (i.e. common naevi, dysplastic naevi and melanoma). Such integrated systems hold promise as a decision aid for the diagnosis of PSLs.

Background: Digital epiluminescence microscopy (DELM) has been reported to be a useful technique for the follow-up of melanocytic nevi. One of the promises of this technique is to identify modifications over time that indicate impending or incipient malignancy and to facilitate surveillance of melanocytic skin lesions, particularly in patients with multiple clinically atypical nevi. Objective: Our purpose was to report on patterns of modifications over time observed in benign melanocytic skin lesions and melanoma. Methods: A total of 1862 sequentially recorded DELM images of melanocytic lesions from 202 patients (mean age, 36.1 years; 54.0% female patients) with multiple clinically atypical nevi were included in the analysis. The median follow-up interval was 12.6 months. Melanocytic lesions with substantial modifications over time (enlargement, changes in shape, regression, color changes or appearance of ELM structures known to be associated with melanoma) were excised and referred to histopathologic examination. Results: A total of 75 melanocytic skin lesions (4.0%) from 52 patients (mean age, 33.3 years; 63.5% female patients) showed substantial modifications over time and were excised and referred to histopathologic examination. Eight changing lesions were histologically diagnosed as early melanomas. These lesions frequently showed focal enlargement associated with a change in shape as well as appearance of ELM structures that are known to be associated with melanoma. In contrast, the majority of benign changing lesions (common and atypical nevi) showed symmetric enlargement without substantial structural ELM changes. Six of the 8 patients in whom melanoma developed were unaware of the fact that the lesion had changed over time. Conclusion: We demonstrate that follow-up of melanocytic lesions with DELM helps to identify patterns of morphologic modifications typical for early melanoma. DELM may therefore serve as a useful tool to improve the surveillance of patients with multiple atypical nevi. (J Am Acad Dermatol 2000;43:467–76.).

Objectives Recent data indicate an increased vascular reactivity due to an overactivity of the sympathetic nervous system in women with pre-eclampsia. We therefore evaluated whether this increased vascular reactivity can be detected prior to the clinical manifestation of preeclampsia by the use of a physiological stimulus. Design Prospective data collection. Setting Clinic of Obstetrics and Gynecology in a 2000 bed tertiary care hospital. Participants One hundred and twenty-three pregnant women between the 16th to 20th week of gestation. Interventions A cold pressor test was performed by positioning an ice-bag on the forehead of the woman for 3 min. Blood pressure and heart rate were monitored by a continuous, noninvasive blood pressure measurement device during the stimulus and after removal of the icebag. A clinical follow-up was carried out by review of the charts after delivery to identify those women who have developed pre-eclampsia. Results Ten (8%) out of 123 pregnant women developed pre-eclampsia. During the cold pressor test systolic as well as diastolic blood pressure increased significantly and was more pronounced in women developing pre-eclampsia compared with healthy pregnant women (systolic blood pressure: 14.2 +/- 5.5 versus 8.5 +/- 7.2 mmHg, P= 0.02; diastolic blood pressure: 7.3 +/- 4.9 versus 3.9 +/- 4.7 mmHg, P=0.03). The change in heart rate was similar between both groups (8 +/- 2.6 versus 10.4 +/- 6.4 beats/min, not significant). Conclusions An increased vasoconstrictive response to a physiological stimulus is present in women with pre-eclampsia as a sign of an increased vascular reactivity prior to clinical manifestation of the disease. The cold pressor test may be a suitable diagnostic tool to identify women, who will develop pre-eclampsia. However, future studies in larger cohorts are required to establish the final value of this test.

Background: Dermatologists need to interpret an increasing number of research studies and diagnostic tests. Understanding the techniques for interpreting test results and making decisions based upon those tests represent important tools for decision making for both clinicians and researchers. Objective: This article focuses briefly on the key parameters of diagnostic tests: sensitivity, specificity, prevalence, predictive values, likelihood ratios, and the concept of receiver-operating-characteristic (ROC) curves. A simple example is presented in a step-by-step manner. Conclusion: The principles of interpreting test results are easy to learn and applicable in daily clinical routine. Therefore, dermatologists should be familiar with the concepts outlined in this paper.

Purpose: To establish the prognostic role of serum enzymatic prostatic acid phosphatase (PAP) in patients treated with palladium ( 103 Pd) and supplemental external beam irradiation (EBRT) for clinically localized, high-risk prostate carcinoma. Methods and Materials: One hundred twenty-four consecutive patients with Stage T2a–T3 prostatic carcinoma were treated from 1992 through 1995. Each patient had at least one of the following risk factors for extracapsular disease extension: Stage T2b or greater (100 patients), Gleason score 7–10 (40 patients), pretreatment prostate specific antigen (PSA) > 15 ng/ml (32 patients), or elevated serum PAP (25 patients). Patients received 41 Gy conformal EBRT to a limited pelvic field, followed 4 weeks later by a 103 Pd boost (prescription dose 80 Gy). Biochemical failure was defined as a PSA greater than 1 ng/ml (normal Results: The overall, actuarial freedom from biochemical failure at 4 years after treatment was 79%. In Cox-proportional hazard multivariate analysis, the strongest predictor of failure was elevated pretreatment acid phosphatase ( p = 0.02), followed by Gleason score ( p = 0.1), and PSA ( p = 0.14). Conclusion: PAP was the strongest predictor of long-term biochemical failure. It may be a more accurate indicator of micrometastatic disease than PSA, and as such, we suggest that it be reconsidered for general use in radiation-treated patients.

Cbfa2 (AML1) encodes the DNA-binding subunit of a transcription factor in the small family of core-binding factors (CBFs). Cbfa2 is required for the differentiation of all definitive hematopoietic cells, but not for primitive erythropoiesis. Here we show that Cbfa2 is expressed in definitive hematopoietic progenitor cells, and in endothelial cells in sites from which these hematopoietic cells are thought to emerge. Endothelial cells expressing Cbfa2 are in the yolk sac, the vitelline and umbilical arteries, and in the ventral aspect of the dorsal aorta in the aorta/genital ridge/mesonephros (AGM) region. Endothelial cells lining the dorsal aspect of the aorta, and elsewhere in the embryo, do not express Cbfa2. Cbfa2 appears to be required for maintenance of Cbfa2 expression in the endothelium, and for the formation of intra-aortic hematopoietic clusters from the endothelium.

Epiluminescence microscopy (ELM) significantly increases the early diagnosis of pigmented skin lesions (PSL) using established criteria and pattern analysis. The ABCD rule for dermatoscopy (ie, ELM) provides a simplified approach to the interpretation of ELM images on the basis of asymmetry (A), border (B), color (C), and dermatoscopic structure (D).We set out to determine whether the diagnostic accuracy of the ABCD scoring algorithm can be significantly improved by incorporating information about morphologic changes of the lesion observed and provided by the patient.We prospectively collected 356 small pigmented skin lesions (1 cm) including 73 (20.5%) melanomas. Before excision all patients were asked whether the lesion had changed in size, color, or shape within the last year or whether they experienced any sign of ulceration or spontaneous bleeding. ELM images of the lesions were evaluated according to the ABCD rule for dermatoscopy to yield a semiquantitative score. Accuracy of diagnosis was evaluated in terms of sensitivity, specificity, and area under receiver operating characteristic curves (AUC).The frequency of reported changes was significantly higher for melanomas than benign PSL (65.8% vs 29.7%, P.001). In a multivariate model morphologic change was a significant independent predictor of malignancy (odds ratio = 3.17, 95% confidence interval [CI]: 1.96 to 5.14, P.001). The mean final score achieved when using the enhanced ABCD-E criteria including morphologic change (E) was significantly higher for melanomas (5.7, 95% CI: 5.3 to 6.0) than benign PSL (2.9, 95% CI: 2.8 to 3.1, P.001). Diagnostic accuracy was significantly higher when the lesions were evaluated by the enhanced ABCD-E criteria as compared with the standard ABCD score (AUC(ABCD) = 0.87 vs AUC(ABCD-E) = 0.90; P = .006).Information about morphologic changes of PSL as reported by the patient is a useful extension of the ABCD rule for dermatoscopy.

Mcl-1 is a member of the Bcl-2 family that is expressed in early monocyte differentiation and that can promote viability on transfection into immature myeloid cells. However, the effects of Mcl-1 are generally short lived compared with those of Bcl-2 and are not obvious in some transfectants. To further explore the effects of this gene, mice were produced that expressed Mcl-1 as a transgene in hematolymphoid tissues. The Mcl-1 transgene was found to cause moderate viability enhancement in a wide range of hematopoietic cell types, including lymphoid (B and T) as well as myeloid cells at both immature and mature stages of differentiation. However, enhanced hematopoietic capacity in transgenic bone marrow and spleen was not reflected in any change in pool sizes in the peripheral blood. In addition, among transgenic cells, mature T cells remained long lived compared with B cells and macrophages could live longer than either of these. Interestingly, when hematopoietic cells were maintained in tissue culture in the presence of interleukin-3, Mcl-1 enhanced the probability of outgrowth of continuously proliferating myeloid cell lines. Thus, Mcl-1 transgenic cells remained subject to normal in vivo homeostatic mechanisms controlling viable cell number, but these constraints could be overridden under specific conditions in vitro. Within the organism, Bcl-2 family members may act at “viability gates” along the differentiation continuum, functioning as part of a system for controlled hematopoietic cell amplification. Enforced expression of even a moderate viability-promoting member of this family such as Mcl-1, within a conducive intra- and extracellular environment in isolation from normal homeostatic constraints, can substantially increase the probability of cell immortalization. © 1998 by The American Society of Hematology.

Keratoacanthoma (KA) is a fairly common neoplasm that in the past has been considered by many to be benign. Keratoacanthoma is usually differentiated from squamous cell carcinoma (SCC) by histopathologic criteria. However, the cytologic features of KA and SCC are often similar. Hence, KA may be confused with SCC at the histopathologic level. Volume-weighted mean nuclear volume (V v ) is determined by a technique that permits an unbiased and efficient estimation of nuclear volumes in tissues without any assumptions regarding nuclear shape. In this study, the volume-weighted mean nuclear volume was determined in 18 KAs and 19 SCCs to investigate whether this stereologic approach may be of use in the differentiation of these two tumors. V v was determined by computer-assisted image analysis (IBAS 20, Kontron, Germany) on Feulen-stained sections employing stereologic estimation of the volume-weighted mean nuclear volume. The mean V v of KA was 704.5 μm 3 (SD ± 170.5), whereas SCC exhibited a significantly lower V v of 533.9 μm 3 (SD ± 164.9) (p = 0.006). The sensitivity and specificity of V v for the discrimination between KA and SCC was 0.80 and 0.78, respectively. We found that KAs show a significantly larger V v than SCCs and thus, the estimation of the volume-weighted mean nuclear volume may be regarded as a helpful tool for the differential diagnosis of KA and SCC.

Epiluminescence microscopy (ELM) is a useful method for improved diagnostic accuracy in early cutaneous melanoma. Conventional photographs of ELM images are commonly used for clinical research and documentation. Electronic images have advantages compared with photographs and are essential for medical informatics, computerized learning and telemedicine. Compression of electronic images allows a reduction in volume of data, but significant image deterioration may occur at high compression rates. We sought to study the diagnostic informativeness of compressed digital ELM images compared with conventional photographs. Fifty photographs of pigmented skin lesions, including 23 melanomas, were presented to eight dermatologists as photographic slides and as digital images with 30:1 Joint Photographic Experts Group (JPEG) compression. The diagnostic performance of the media and the readers was described in terms of sensitivity, specificity and areas under receiver operating characteristic curves (AUC). Agreement between the readings of the two types of media regarding the presence or absence of ELM criteria was assessed using kappa (kappa) statistics. The mean AUC was 0.81 (95% confidence interval [CI] = 0.73-0.90) for slides and 0.81 (95% CI = 0.72-0.90; P = 0.89) for digital images. Agreement between the readings of the two types of media regarding the presence or absence of ELM criteria ranged from kappa = 0.55 (95% CI = 0.22-0.88) for grey-blue area to kappa = 0.89 (95% CI = 0.74-1.00) for radial streaming. In conclusion, digital ELM images with 30:1 JPEG compression appear to be as informative as photographic slides when used to differentiate between melanoma and non-melanoma.

To assess the association between arterial lactate concentration on admission and the duration of human ventricular fibrillation cardiac arrest, and to what degree the arterial lactate concentration on admission is an early predictor of functional neurological recovery in human cardiac arrest survivors. Cohort study. Arterial lactate concentrations and out-of-hospital data concerning cardiac arrest and cardiopulmonary resuscitation were collected retrospectively according to a standardized protocol. Functional neurological recovery was assessed prospectively at regular intervals for 6 months. Emergency department of an urban tertiary care hospital. A total of 167 primary survivors of witnessed out-of-hospital ventricular fibrillation cardiac arrest. The association between arterial lactate concentration on admission, the duration of cardiac arrest, and functional neurological recovery was assessed. Further, we assessed whether admission concentrations of arterial lactate and duration of cardiac arrest can predict unfavorable functional neurological recovery. Functional neurological recovery was measured in cerebral performance categories (CPC). No or minimal functional impairment (CPC 1 and 2) was defined as favorable outcome; the remaining categories (CPC 3, 4 and 5) were defined as unfavorable functional neurological recovery. In 167 patients, a weak association between total duration of cardiac arrest and admission levels of lactate (r=0.49, P

Objective To assess whether the measurement of cardiac output by computer-assisted analysis of the finger blood pressure waveform can substitute for the thermodilution method in critically ill patients.Design Prospective data collection.Setting Emergency department In a 2000-bed inner city hospital.

Spitz's nevi are acquired benign melanocytic skin tumors. Usually they are differentiated from nodular melanoma by clinical and histopathological criteria. Since Spitz's nevi are one of the most common simulators of nodular melanomas their bizarre histopathology may cause diagnostic confusion and make it difficult to differentiate these two melanocytic tumors. One of the histologic features shared by Spitz's nevus and nodular melanoma is prominent vascularity. The ability of malignant melanoma to induce angiogenesis is well established whereas benign melanocytic tumors do not have a prominent overall vascularity. The purpose of this study was to find out whether the degree of vascularity of nodular melanomas differs significantly from that of benign Spitz's nevi. In this study the number of microvessels and the vessel area were determined in 23 Spitz's nevi and 16 nodular melanomas. The number of microvessels and the vessel area were determined on Ulex Europacus agglutinin I-stained sections by computer-assisted image analysis. Two methods of measurement were used, namely systematic and selective sampling. Measurement of the whole tumor specimen (systematic sampling) revealed a vessel count of 10.83/field (SD±5.97) for Spitz's nevi whereas nodular melanomas exhibited a significantly lower (p=0.04) vessel count of 6.44/field (SD±3.85). This difference was even more pronounced when the vessel area (Spitz's nevi: 17.85×10–4mm2, SD±10.32; nodular melanomas: 7.88×10-mm2, SD×5.23) was investigated (p < 0.001). The difference in vessel area and vessel count was insignificant for areas exhibiting the greatest vascularity (selective sampling). Measurement of vessel count and vessel area lead us to conclude that Spitz's nevi have a significantly higher vascularity than do nodular melanomas. Our results thus indicate that angiogenesis in these pigmented lesions is not correlated with malignancy.

We performed a randomized double-blind study within-group comparison in 11 patients to study the effect of subcutaneous injections of botulinum A toxin in focal hyperhidrosis of the palms. A total dose of 120 mU (mouse units) of botulinum A toxin (Dysport) was injected into six different sites on one palm, whereas the other was injected with sterile saline. Objective quantification of sweat production was performed using digitized ninhydrin-stained sheets. Three weeks after treatment, the mean reduction of sweat production in the botulinum A toxin-treated palms was 26% (P < 0.001), after 8 weeks 26% (P = 0.002) and after 13 weeks 31% (P < 0.001). Subjective assessment of sweat production by the patients using a visual analogue scale showed a 38% improvement in the botulinum A toxin-treated palms at 3 weeks (P = 0.002), 40% at 8 weeks (P = 0.002) and 38% at 13 weeks (P = 0.002). Neither the objective measurement nor the subjective rating showed a statistically significant reduction of sweating in the placebo-treated palms. Three patients reported reversible minor weakness of powerful handgrip after injection at the toxin-treated site, lasting between 2 and 5 weeks.

Background: Epiluminescence microscopy (ELM) makes subsurface structures of the skin accessible for in vivo examination and provides additional criteria for the clinical diagnosis of pigmented skin lesions (PSLs). We demonstrated that ELM increases diagnostic sensitivity in dermatologists formally trained in the use of this technique but decreases diagnostic ability in dermatologists not formally trained in its application. Objective: Our purpose was to determine the effects of short formal ELM training on the diagnostic performance of 11 previously untrained dermatologists. Methods: One hundred image-pairs of randomly selected histologically proven PSLs, photographed with (ELM) and without oil immersion (surface microscopy), were presented by slide projection to the testees. To evaluate the effects on diagnostic performance before and after short-term training, we used the receiver-operator characteristics technique. Results: Without training the use of ELM did not enhance diagnostic accuracy, but rather decreased it in 8 of 11 testees. In contrast, after 9 hours of formal training in ELM the diagnostic performance of the testees was significantly enhanced with an average gain of 8.4%. Conclusion: Our data confirm that formal training is required for the useful application of the ELM technique. (J Am Acad Dermatol 1997;36:197-202.)

BACKGROUND Elevation of activation markers of blood coagulation (thrombin-antithrombin complex [TAT], prothrombin fragment 1 + 2 [F1 + 2], D-Dimer] has not only been found in clinically avert thrombosis but also reflects a prethrombotic state. OBJECTIVE The purpose of our study was to evaluate whether varicose vein stripping, an operative procedure with an extremely low risk of postoperative thromboembolism, induces a prethrombotic state by activation of the hemostatic system. METHODS In a prospective, observational study we compared the baseline and postoperative values of TAT, Fl + 2, and D-Dimers in 15 patients undergoing varicose vein stripping and in 11 control patients undergoing surgical procedures associated with only minor soft tissue trauma. RESULTS A highly significant postoperative elevation of TAT (P < 0.001), Fl + 2 (P = 0.006), and D-Dimer (P < 0.001) was observed in the varicose vein stripping group. No significant postoperative change of the respective parameters was detected in the control group. CONCLUSION We therefore conclude that varicose vein stripping induces a significant hemostatic system activation although postoperative thrombotic events are rare.

We evaluated the accuracy of diagnoses made from pictures taken with the built-in cameras of mobile phones in a ‘real-life’ clinical setting. A total of 263 patients took part, who photographed their own lesions where possible, and provided clinical information via a questionnaire. After the teledermatology procedure, each patient was examined face-to-face and a gold standard diagnosis was made. The telemedicine data and pictures were diagnosed by 15 dermatologists. The 299 cases contained 1–22 clinical images each (median 3). Nine dermatologists finished all the cases and the remaining six completed some of them, thus providing 2893 decisions. Overall, 61% of all cases were rated as possible to diagnose and of those, 80% were correct in comparison with the face-to-face diagnosis. Image quality was evaluated and the median was 5 on a 10-point scale. There was a significant correlation between the correct diagnosis and the quality of the photographs taken ( P & 0.001). In nearly two-thirds of all cases, a teledermatology diagnosis was possible; however, there was insufficient information to make a telemedicine diagnosis in about one-third of the cases. If applied carefully, mobile phones could be a powerful tool for people to optimize their health care status.

Physicians are regularly faced with severely ill patients at risk of developing infections. In literature, standard care wards are often neglected, although their patients frequently suffer from a systemic inflammatory response syndrome (SIRS) of unknown origin. Fast identification of patients with infections is vital, as they immediately require appropriate therapy. Further, tools with a high negative predictive value (NPV) to exclude infection or bacteremia are important to increase the cost effectiveness of microbiological examinations and to avoid inappropriate antibiotic treatment. In this prospective cohort study, 2,384 patients with suspected infections were screened for suffering from two or more SIRS criteria on standard care wards. The infection probability score (IPS) and sepsis biomarkers with discriminatory power were assessed regarding their capacity to identify infection or bacteremia. In this cohort finally consisting of 298 SIRS-patients, the infection prevalence was 72%. Bacteremia was found in 25% of cases. For the prediction of infection, the IPS yielded 0.51 ROC-AUC (30.1% sensitivity, 64.6% specificity). Among sepsis biomarkers, lipopolysaccharide binding protein (LBP) was the best parameter with 0.63 ROC-AUC (57.5% sensitivity, 67.1% specificity). For the prediction of bacteremia, the IPS performed slightly better with a ROC-AUC of 0.58 (21.3% sensitivity, 65% specificity). Procalcitonin was the best discriminator with 0.78 ROC-AUC, 86.3% sensitivity, 59.6% specificity and 92.9% NPV. Furthermore, bilirubin and LBP (ROC-AUC: 0.65, 0.62) might also be considered as useful parameters. In summary, the IPS and widely used infection parameters, including CRP or WBC, yielded a poor diagnostic performance for the detection of infection or bacteremia. Additional sepsis biomarkers do not aid in discriminating inflammation from infection. For the prediction of bacteremia procalcitonin, and bilirubin were the most promising parameters, which might be used as a rule for when to take blood cultures or using nucleic acid amplification tests for microbiological diagnostics.

Clinical and experimental data have shown that after acute myocardial infarction there is a significant release of tumour necrosis factor alpha. Therefore, an attempt was made to correlate changes in serum tumour necrosis factor alpha concentrations with indices of infarct extent in patients with acute myocardial infarction. In 50 patients with acute myocardial infarction, blood samples for evaluation of tumour necrosis factor alpha and alpha-hydroxybutyrate-dehydrogenase were collected every 6 h until 120 h after admission. Infarct extent was estimated by clinical parameters such as the occurrence of heart failure and rhythm disturbances, by enzymatic methods such as cumulative release of alpha-hydroxybutyrate-dehydrogenase and imaging techniques, by late resting single photon emission tomography--201 thallium scintigraphy--using an extent score and by echocardiography using a wall motion index. The maximum change in serum tumour necrosis factor alpha after infarction (delta TNF) was calculated by subtracting tumour necrosis factor alpha concentration on admission from peak tumour necrosis factor alpha concentration. The average peak tumour necrosis factor alpha level was observed 84 h after admission (median: 12 pg.ml-1). Between the 72nd and the 96th h no significant changes in tumour necrosis factor alpha values were observed. Analysis of the data showed that larger delta (TNF) values were found to be associated significantly with signs of heart failure (P = 0.003), the presence of rhythm disturbances (P = 0.001), increased enzymatic infarct extent indicated by cumulative release of alpha-hydroxybutyrate-dehydrogenase (r = 0.74; P0.001), large myocardial perfusion defects measured with 201 thallium scintigraphy (r = 0.80; P0.001), and a considerable number of left ventricular wall motion abnormalities (r = 0.57; P0.001). In conclusion, delta (TNF) is a reliable method of assessing damage severity in the myocardium after acute myocardial infarction. As only two blood samples are necessary within 84 h, the method may be one of the more convenient for the assessment of infarct size in clinical practice.

Lymphedema of the arm is one of the most disabling and serious complications of breast cancer. Apart from tumor infiltration or fibrosis of lymphatic pathways, little is known about factors favoring the development of lymphedema. In the present study, we investigated the impact of rheologic parameters, e.g. red cell aggregation (EA) and plasma viscosity (PV), and of capillary morphology and capillary flow in patients with breast cancer with (n = 18) and without (n = 18) lymphedema. Patients with lymphedema showed a significant increase of red cell aggregation (p < 0.001) that indicates a systemic component of lymphedema and might offer a possibility of prevention and therapy of this condition. A hitherto unclassified protein factor favoring red cell aggregation and lymphedema might be postulated.

Background and Design: Epiluminescence microscopy (ELM) is a noninvasive technique that, by employing the optical phenomenon of oil immersion, makes subsurface structures of the skin accessible for in vivo examination and thus provides additional criteria for the clinical diagnosis of pigmented skin lesions. At present, almost all studies about the value and clinical importance of ELM are based on data derived from ELM experts (ie, dermatologists specifically trained in this technique). In the present study, we attempt to determine whether the clinical diagnosis of pigmented skin lesions is significantly improved using ELM and whether ELM-trained individuals and dermatologists not trained in this technique profit equally from this technique. Randomly selected histologically proven pigmented skin lesion specimens, photographed with (ELM) and without oil immersion (surface microscopy) were presented by slide projection to six ELM experts and 13 ELM nonexperts (ie, dermatologists not formally trained in ELM) for diagnosis. To evaluate the diagnostic performance of ELM experts and nonexperts with and without the oil immersion technique (ie, ELM vs surface microscopy), the following parameters were obtained: intraobserver and interobserver agreement by κ statistics and sensitivity and specificity of diagnostic performance. Results: Our results show that by usinbetter-ELM technique the ELM experts reach a substantially hetter intraobserver agreement than nonexperts (median κ, 0.56 vs 0.36). The interobserver agreement was markedly increased in the ELM experts group (average gain, 7%) but decreased in the ELM nonexperts group (average loss, 6%). The sensitivity of diagnosis was significantly increased in the ELM experts group (average gain, 10%), but decreased in the nonexperts group (average loss, 10%). Finally, the specificity of diagnosis was excellent in the ELM experts group, both with and without oil immersion (0.91) and was somewhat improved by ELM in the nonexperts group (0.77 vs 0.85). Conclusions: We conclude that the ELM technique increases sensitivity in formally trained dermatologists, but may decrease the diagnostic ability in dermatologists not formally trained in the ELM technique. Consequently, formal broad-based training in ELM should be offered to the dermatologic community. (Arch Dermatol. 1995;131:286-291)

Background Common treatment of atrophic acne scars consists of invasive methods such as dermabrasion, chemopeeling, or implantation of bovine collagen. In our study a new noninvasive treatment method consisting of local iontophoresis is demonstrated. Local iontophoresis was performed with either estriol--a mainly topically active estrogen--or with tretinoin. Patients and methods Eighteen women were treated with estriol iontophoresis twice weekly for a period of 3 months. In addition to photographic and clinical documentation of the skin, venous blood for determination of serum levels of prolactin and estradiol according to standard radioimmunoassay methods was obtained monthly. Tretinoin iontophoresis was performed according to the same time schedule in 28 patients (19 women and 9 men) with atrophic acne scars. Results Improvement of acne scars was observed in 93% of patients treated with tretinoin iontophoresis and in 100% of the group treated with estriol iontophoresis. No hormonal changes were noted in the estrogen group. Side effects involving the skin appeared in the tretinoin group in 4 cases and consisted of increased dryness and of retinoid dermatitis. Conclusion Both treatments were shown to be clinically effective in decreasing acne scars and persistence of effects. This promising new therapeutic approach may thus replace invasive treatment methods in many patients.

A preliminary clinical trial using state-of-the-art multiphoton tomography (MPT) and optical coherence tomography (OCT) for three-dimensional (3D) multimodal in vivo imaging of normal skin, nevi, scars and pathologic skin lesions has been conducted. MPT enabled visualization of sub-cellular details with axial and transverse resolutions of

Written by leading teledermatologists and telemedicine experts, here is a hands-on guide on the practical aspects of the everyday management of teledermatology services, especially useful for the treatment of inflammatory and neoplastic skin diseases.

Melanoma arising in a nevus spilus is rare. There are two distinct types of nevus spilus characterized by macular or papular speckles, respectively. We report the case of a melanoma that arose in association with a giant nevus spilus maculosus.