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In recent years, deep learning (DL) has been used extensively and successfully to diagnose different cancers in dermoscopic images. However, most approaches lack clinical inputs supported by dermatologists that could aid in higher accuracy and explainability. To dermatologists, the presence of telangiectasia, or narrow blood vessels that typically appear serpiginous or arborizing, is a critical indicator of basal cell carcinoma (BCC). Exploiting the feature information present in telangiectasia through a combination of DL-based techniques could create a pathway for both, improving DL results as well as aiding dermatologists in BCC diagnosis. This study demonstrates a novel "fusion" technique for BCC vs non-BCC classification using ensemble learning on a combination of (a) handcrafted features from semantically segmented telangiectasia (U-Net-based) and (b) deep learning features generated from whole lesion images (EfficientNet-B5-based). This fusion method achieves a binary classification accuracy of 97.2%, with a 1.3% improvement over the corresponding DL-only model, on a holdout test set of 395 images. An increase of 3.7% in sensitivity, 1.5% in specificity, and 1.5% in precision along with an AUC of 0.99 was also achieved. Metric improvements were demonstrated in three stages: (1) the addition of handcrafted telangiectasia features to deep learning features, (2) including areas near telangiectasia (surround areas), (3) discarding the noisy lower-importance features through feature importance. Another novel approach to feature finding with weak annotations through the examination of the surrounding areas of telangiectasia is offered in this study. The experimental results show state-of-the-art accuracy and precision in the diagnosis of BCC, compared to three benchmark techniques. Further exploration of deep learning techniques for individual dermoscopy feature detection is warranted., (© 2024. The Author(s) under exclusive licence to Society for Imaging Informatics in Medicine.)

A critical clinical indicator for basal cell carcinoma (BCC) is the presence of telangiectasia (narrow, arborizing blood vessels) within the skin lesions. Many skin cancer imaging processes today exploit deep learning (DL) models for diagnosis, segmentation of features, and feature analysis. To extend automated diagnosis, recent computational intelligence research has also explored the field of Topological Data Analysis (TDA), a branch of mathematics that uses topology to extract meaningful information from highly complex data. This study combines TDA and DL with ensemble learning to create a hybrid TDA-DL BCC diagnostic model. Persistence homology (a TDA technique) is implemented to extract topological features from automatically segmented telangiectasia as well as skin lesions, and DL features are generated by fine-tuning a pre-trained EfficientNet-B5 model. The final hybrid TDA-DL model achieves state-of-the-art accuracy of 97.4% and an AUC of 0.995 on a holdout test of 395 skin lesions for BCC diagnosis. This study demonstrates that telangiectasia features improve BCC diagnosis, and TDA techniques hold the potential to improve DL performance., (© 2024. The Author(s).)

Hair and ruler mark structures in dermoscopic images are an obstacle preventing accurate image segmentation and detection of critical network features. Recognition and removal of hairs from images can be challenging, especially for hairs that are thin, overlapping, faded, or of similar color as skin or overlaid on a textured lesion. This paper proposes a novel deep learning (DL) technique to detect hair and ruler marks in skin lesion images. Our proposed ChimeraNet is an encoder-decoder architecture that employs pretrained EfficientNet in the encoder and squeeze-and-excitation residual (SERes) structures in the decoder. We applied this approach at multiple image sizes and evaluated it using the publicly available HAM10000 (ISIC2018 Task 3) skin lesion dataset. Our test results show that the largest image size (448 × 448) gave the highest accuracy of 98.23 and Jaccard index of 0.65 on the HAM10000 (ISIC 2018 Task 3) skin lesion dataset, exhibiting better performance than for two well-known deep learning approaches, U-Net and ResUNet-a. We found the Dice loss function to give the best results for all measures. Further evaluated on 25 additional test images, the technique yields state-of-the-art accuracy compared to 8 previously reported classical techniques. We conclude that the proposed ChimeraNet architecture may enable improved detection of fine image structures. Further application of DL techniques to detect dermoscopy structures is warranted., (© 2022. The Author(s) under exclusive licence to Society for Imaging Informatics in Medicine.)

Missouri's dramatic rise in fentanyl-related overdoses was reported in Part I of this two-part series. In Part II, we report that previous efforts to combat the surge in illicit fentanyl supply from China failed, as Chinese factories shifted production to basic fentanyl precursor chemicals, known as dual-use pre-precursors. Mexican drug cartels now synthesize fentanyl from these basic chemicals and have overpowered the Mexican government. All efforts to reduce the fentanyl supply appear to be failing. Missouri has implemented harm reduction methods: training first responders and educating people who use drugs in safer practices. Harm reduction agencies are distributing naloxone at unprecedented levels. The "One Pill Can Kill" campaign begun by the Drug Enforcement Agency (DEA) in 2021 and foundations created by bereaved parents aim to educate young people on the extraordinary danger of counterfeit pills. In 2022, Missouri is at a crossroads, with record numbers of fatalities from illicit fentanyl and new levels of effort by harm reduction agencies to combat the soaring rate of deaths from this powerful narcotic., (Copyright 2023 by the Missouri State Medical Association.)

Recently, Missouri has followed an overall upward trend in opioid overdose deaths. In 2018, Missouri was the state with the largest absolute and percentage increase in opioid-related overdose fatality rates per capita over the previous year (18.3% and 3.1/100,000). This increase occurred despite an overall decrease in U.S. opioid-related death rates in the same period. This report identifies illicitly manufactured fentanyl (IMF) (and analogues) as the drug most responsible for this rise in opioid deaths in Missouri, with stimulant overdoses (primarily from methamphetamine) in second place. Within Missouri, we find the areas where opioid deaths are highest: St. Louis and the city's fringe areas, following the national trend for high rates in fringe areas. Based on reports from CDC Wonder data, county medical examiners, law enforcement agencies, and drug addiction prevention agencies, we conclude that IMF and related synthetic opioids arriving from China are primarily responsible for fatal narcotic overdoses in Missouri. Despite the COVID-19 disruption of fentanyl manufacturing and distribution centers in and around Wuhan, China early in the pandemic, preliminary 2020 data from medical examiners' offices show an upswing in opioid deaths, an indicator that Chinese fentanyl producers have restored the supply chain., (Copyright 2020 by the Missouri State Medical Association.)

The diagnosis of pyoderma gangrenosum (PG) is often difficult to establish based on a clinical presentation, which can mimic other dermatologic conditions. The formation of a mnemonic that incorporates the most prevalent clinical features of PG could aid in accuracy and speed of diagnosis. The 5 P's of PG: Painful, Progressive, Purple, Pretibial, Pathergy, and systemic associations, incorporate parameters recognizable on the first encounter with a patient with PG without reliance on histopathology and laboratory findings or treatment response. We postulate that this simple mnemonic will have the most utility with non-dermatology clinicians encountering a lesion suspicious for PG. By assisting in differential diagnosis formation, this mnemonic may lead to timelier biopsies and treatment initiation. The limitations of this approach mirror those of other studies and include lower sensitivities in patients with an atypical PG presentation. In conclusion, the 5 P's of PG offer a useful mnemonic for the diagnosis of PG, particularly in the initial clinical diagnosis prior to skin biopsy and treatment. J Drugs Dermatol. 2019;18(12):1282-1283.

Cellulitis, a bacterial infection of the skin and subcutaneous tissue, is often misdiagnosed. Cellulitis accounts for a large number of all infectious disease-related hospitalizations in the U.S. Cellulitis can be challenging to diagnose since it lacks pathognomonic findings. We reviewed all articles on cellulitis within the last 20 years that included a statistical analysis, with odds ratios (OR), of specific clinical features of cellulitis. We then constructed a mnemonic encompassing the features with the highest odds ratios. Our mnemonic is CELLULITIS for cellulitis history, edema, local warmth, lymphangitis, unilateral, leukocytosis, injury, tender, instant onset, and systemic signs. The first characteristic has the highest OR and may be the easiest to recall: past episode(s) of cellulitis.

Background: Venous leg ulcers generally take manyweeks to heal. Novel therapies that shorten healingtime and require less complex care are needed., Purpose: The purpose of this report is to presenta pilot study for a new method that can result ina faster healing time for venous leg ulcers usinginexpensive materials., Methods: A central-gauzeprotocol was developed as described here. A three-ply gauze sponge was placed in the center of theulcer, allowing a peripheral 3-5 mm rim of ulcer toremain exposed. Saline solution was applied to thegauze sponge. A 3-layer Unna boot was applied overthe ulcer with short-stretch compression. This noveltechnique exposed only a peripheral rim of the ulcerto the zinc oxide paste, allowing the central portionof the ulcer to drain through the saline-soaked gauze.The ulcer was photographed at each clinic visit andthe wound area was estimated by finding the bestfitellipse for the ulcer area and computing the areaof the ellipse by a standard formula., Results: Threepatients with small venous leg ulcers treated with thezinc rim technique showed an average healing rate of46.1% per week (range 27.8% - 50.7%). All ulcers werenearly healed by three weeks. After the ulcer size wasreduced sufficiently, patients were discharged withinstructions to apply pieces of Unna dressing to theulcer, under a conventional self-adhesive bandage,maintaining compression, without any saline-gauzein the center., Conclusions: The three patients in thispilot study showed rapid healing for venous leg ulcerswith the central gauze modification of Unna boottherapy.

Background: In previous research, we introduced an automated, localized, fusion-based approach for classifying uterine cervix squamous epithelium into Normal, CIN1, CIN2, and CIN3 grades of cervical intraepithelial neoplasia (CIN) based on digitized histology image analysis. As part of the CIN assessment process, acellular and atypical cell concentration features were computed from vertical segment partitions of the epithelium region to quantize the relative distribution of nuclei., Methods: Feature data was extracted from 610 individual segments from 61 images for epithelium classification into categories of Normal, CIN1, CIN2, and CIN3. The classification results were compared against CIN labels obtained from two pathologists who visually assessed abnormality in the digitized histology images. In this study, individual vertical segment CIN classification accuracy improvement is reported using the logistic regression classifier for an expanded data set of 118 histology images., Results: We analyzed the effects on classification using the same pathologist labels for training and testing versus using one pathologist labels for training and the other for testing. Based on a leave-one-out approach for classifier training and testing, exact grade CIN accuracies of 81.29% and 88.98% were achieved for individual vertical segment and epithelium whole-image classification, respectively., Conclusions: The Logistic and Random Tree classifiers outperformed the benchmark SVM and LDA classifiers from previous research. The Logistic Regression classifier yielded an improvement of 10.17% in CIN Exact grade classification results based on CIN labels for training-testing for the individual vertical segments and the whole image from the same single expert over the baseline approach using the reduced features. Overall, the CIN classification rates tended to be higher using the training-testing labels for the same expert than for training labels from one expert and testing labels from the other expert. The Exact class fusion- based CIN discrimination results obtained in this study are similar to the Exact class expert agreement rate., Competing Interests: There are no conflicts of interest.

Background: Evolving dermoscopic terminology motivated us to initiate a new consensus., Objective: We sought to establish a dictionary of standardized terms., Methods: We reviewed the medical literature, conducted a survey, and convened a discussion among experts., Results: Two competitive terminologies exist, a more metaphoric terminology that includes numerous terms and a descriptive terminology based on 5 basic terms. In a survey among members of the International Society of Dermoscopy (IDS) 23.5% (n = 201) participants preferentially use descriptive terminology, 20.1% (n = 172) use metaphoric terminology, and 484 (56.5%) use both. More participants who had been initially trained by metaphoric terminology prefer using descriptive terminology than vice versa (9.7% vs 2.6%, P < .001). Most new terms that were published since the last consensus conference in 2003 were unknown to the majority of the participants. There was uniform consensus that both terminologies are suitable, that metaphoric terms need definitions, that synonyms should be avoided, and that the creation of new metaphoric terms should be discouraged. The expert panel proposed a dictionary of standardized terms taking account of metaphoric and descriptive terms., Limitations: A consensus seeks a workable compromise but does not guarantee its implementation., Conclusion: The new consensus provides a revised framework of standardized terms to enhance the consistent use of dermoscopic terminology., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

This is the second part of a two-part article on personal details revealed by hand examination. Examining hands to determine daily activities was the focus of Part 1 in the July/August 2014 Missouri Medicine. Personal traits and preferences, including pets, nutrition and psychology are presented here. These articles serve as a guide for visual clues on the hands to discern a patient's daily activities and personal preference, thereby providing social information that may help establish rapport between patient and physician and may have medical significance.

This is the first part of a two-part article on personal details revealed by the hand examination. Daily activities revealed by hand examination are the focus of Part 1, while personal details including nutrition and psychological assessment are presented in Part 2. These clues enable the examiner to discern hobbies, vocation, sporting activities, dietary information, and psychosocial information of the patient. We describe signs that may aid the clinician in determining these activities, enabling us to provide better patient care by establishing good patient rapport. Part 1, presented here, focuses on detection of visible traces on the hands of sporting activities, hobbies, and vocation. The patient through long familiarity may be oblivious to these features or may find them too insignificant to mention, yet they can provide meaningful social details for the

Black-spot poison ivy is an uncommon presentation of poison ivy (Toxicodendron) allergic contact dermatitis. A 78-year-old sought evaluation of a black spot present on her right hand amid pruritic vesicles. The presentation of a black spot on the skin in a clinical context suggesting poison ivy is indicative of black-spot poison ivy. Dermoscopy revealed a jagged, centrally homogeneous, dark brown lesion with a red rim. A skin sample was obtained and compared against a poison ivy standard using ultra-fast liquid chromatography-tandem mass spectrometry (UFLC-MS/MS). This finding confirmed the presence of multiple urushiol congeners in the skin sample. Black-spot poison ivy may be added to the list of diagnoses that show a specific dermoscopic pattern.

Background: Early excision is the only strategy to reduce melanoma mortality, but unnecessary excision of benign lesions increases morbidity and healthcare costs., Objective: To assess accuracy in melanoma detection based on number-needed-to-excise (NNE) values over a 10-year period., Methods: Information was retrieved on all histopathologically confirmed cutaneous melanomas or melanocytic nevi that were excised between 1998 and 2007 at participating clinics. NNE values were calculated by dividing the total number of excised lesions by the number of melanomas. Analyses included changes in NNE over time, differences in NNE between specialized clinical settings (SCS) versus non-specialized clinical settings (NSCS), and patient factors influencing NNE., Results: The participating clinics contributed a total of 300,215 cases, including 17,172 melanomas and 283,043 melanocytic nevi. The overall NNE values achieved in SCS and NSCS in the 10-year period were 8.7 and 29.4, respectively. The NNE improved over time in SCS (from 12.8 to 6.8), but appeared unchanged in NSCS. Most of the effect on NNE in SCS was due to a greater number of excised melanomas. Higher NNE values were observed in patients younger than 40 years and for lesions located on the trunk., Limitations: No data concerning the use of dermatoscopy and digital monitoring procedures were collected from the participating centers., Conclusion: Over the 10-year study period, accuracy in melanoma detection improved only in specialized clinics maybe because of a larger use of new diagnostic techniques such as dermatoscopy., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Photosensitivity to sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, is reported. No previous reports of photosensitivity to any DPP-4 inhibitors are known. Physical examination of the patient revealed edematous plaques confined to sun-exposed areas of the skin. An unusual finding in this case was the spongy sensation upon palpation of the plaques. Histopathology revealed parakeratosis and abundant eosinophils, supporting the clinical impression of cutaneous drug sensitivity. The eruption finally cleared, approximately two years after onset.

We report here a case of systemic loxoscelism, confirmed by bite-site skin surface swab. Features of systemic loxoscelism present in this case included debilitating symptoms, a classic local bite-site reaction, hemolysis causing loss of approximately 15% of the blood volume within 72 hours, and a symptomatic exanthem. A skin surface ELISA test was used to confirm the presence of venom. This test enables confirmation of cases of loxoscelism for which no spider is found.

Background: Diagnosis of Loxosceles reclusa envenomations is currently based upon clinical presentation. An enzyme-linked immunosorbent assay (ELISA) can detect surface Loxosceles venom at the envenomation site, allowing diagnostic confirmation. The length of time that venom on the skin is recoverable non-invasively is unknown., Materials and Methods: To investigate duration of recoverable venom antigen, whole venom and fractionated sphingomyelinase D venom aliquots were injected subcutaneously in New Zealand White rabbits. Cotton and Dacron swabs were compared for venom recovery over a 21-day period using a surface swab technique., Results: Significant amounts of Loxosceles reclusa antigen were found on the surface of rabbit skin after experimental injection of whole venom and sphingomyelinase D. The duration of recoverable antigen using this experimental model appears to be at least two weeks and as long as 21 days in some cases., Conclusions: Because the duration of the recoverable antigen is seen to be at least two weeks, the ELISA venom test appears capable of detecting venom on most patients presenting with Loxosceles envenomations. This detection system will allow the physician more accurate determination of whether the lesion is from a brown recluse spider or some other agent that can cause this type of necrotic ulcer.

We report here one case of tularemia, one case of human monocytic ehrlichiosis, and one case of febrile illness most consistent with tularemia with titers suggestive of Rocky Mountain spotted fever in residents of three south-central Missouri counties. All three cases had with nonspecific symptoms of a febrile illness. All three patients had a history of a tick bite, common in south-central Missouri, but only two patients reported the tick bite when first seen. In these three cases, the severity of the illness provided a clue that led to a diagnosis of tick-borne febrile illnesses by confirmatory serology in two cases. It is very important that physicians be aware of these diseases in the spring and summer months.

Cutaneous vibrators have been introduced to relieve pain associated with a variety of dermatology procedures including injections and laser treatments. The simple tripod massager described in this report is effective and acceptable to patients for cutaneous injection anesthesia.

Confirmed envenomations due to Loxosceles reclusa have not been previously documented in Turkey, to our knowledge. This brief report describes two Turkish patients with suspected envenomation by Loxosceles spider bites on the eyelids. Material obtained by swabbing the lesions with gauze was tested using a venom-specific enzyme-linked immunosorbent assay (ELISA). Both patients tested positive for the presence of Loxosceles venom.