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Background: The assessment of the individual evolution of vitiligo is important for therapeutic decision making in daily practice. A fast, simple and validated physician-reported score to assess clinical changes in depigmentation over time in separate parts (activity and improvement) is currently missing. Objective: The main objective of the study was to develop and validate the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS). Methods: The Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS) were evaluated based on a photo set of 66 patients with two different time points. In the first (short) version, only the number of changing body regions was counted based on 15 predefined areas (VDAS₁₅ and VDIS₁₅), while in the second (extensive) version the degree of worsening or improvement from +4 to −4 for each body area was added for a more detailed assessment (VDAS₆₀ and VDIS₆₀). Content and construct validity were tested. In addition inter-, intrarater reliability and feasibility were evaluated by 7 (test) and 5 (retest) physicians. Results: Evidence for content and construct validity was provided. Overall, VDAS₁₅, VDIS₁₅, VDAS₆₀ and VDIS₆₀ demonstrated good to excellent inter-rater reliability [intraclass correlation (ICC): VDAS: range = 0.797–0.900; VDIS: range = 0.726–0.798]. The intrarater reliability ICCs were 0.865 and 0.781 for the VDAS₁₅ and VDIS₁₅, respectively. Similar results were obtained for the VDAS₆₀ and VDIS₆₀ (ICC = 0.913 and 0.800, respectively). Completion time was short (median: 122 s/patient (first round); 95 s/patient (second round)]. Limitations: Single tertiary centre mainly of skin phototype 2 to 3. Conclusion: The VDAS and VDIS appear to be valid, reliable and feasible instruments to score the evolution of vitiligo lesions. This accommodates the current urgent need for a simple, standardized and practical assessment of vitiligo activity and improvement over time. in press

Background Subungual squamous cell carcinoma (SSCC) and subungual melanoma (SUM) are rare tumors. Several case reports of association of SSCC with SUM (SSCC-SUM) have been published. Objective We sought to document the clinical, dermoscopic, and histologic features in a case series of SSCC-SUMs and describe their relative frequency compared with those of SSCC and SUM. Methods All patients who underwent surgical exploration of the nail apparatus with a dermatopathologic examination from 2012 to 2015 were reviewed retrospectively to identify all cases of SSCC, SUM, and SSCC-SUM. For patients with SSCC-SUM, clinical characteristics were obtained from electronic medical records. All histologic specimens were reviewed by 3 dermatopathologists. Results The medical records of 456 patients were reviewed. SSCC was diagnosed in 78 (17%), SUM was diagnosed in 63 (14%), and SSCC-SUM was diagnosed in 9. Patients with SSCC-SUM accounted for 11% of those with a diagnosis of SSCC (9 of 78) and 14% of those with a diagnosis of SUM (9 of 63). Limitations This was a single-institution retrospective study. Conclusion The association of SSCC and SUM is relatively frequent in patients with SUM and warrants further consideration to understand the underlying mechanisms involved.

Objective Liquid-based (LB)-FNA is widely recognized as a reliable diagnostic method to evaluate thyroid nodules. However, up to 30% of LB-FNA remain indeterminate according to the Bethesda system. Use of molecular biomarkers has been recommended to improve its pathological accuracy but implementation of these tests in clinical practice may be difficult. Here, we evaluated feasibility and performance of molecular profiling in routine practice by testing LB-FNA for BRAF, N/HRAS and TERT mutations. Methods We studied a large prospective cohort of 326 cases, including 61 atypia of undetermined significance, 124 follicular neoplasms, 72 suspicious for malignancy and 69 malignant cases. Diagnosis of malignancy was confirmed by histology on paired surgical specimen. Results Mutated LB-FNAs were significantly associated with malignancy regardless of the cytological classification. Overall sensitivity was 60% and specificity 89%. Importantly, in atypia of undetermined significance and follicular neoplasm patients undergoing surgery according to the Bethesda guidelines, negative predictive values were 85.4% and 90% respectively. TERT promoter mutation was rare but very specific for malignancy (5.5%) suggesting that it could be of interest in patients with indeterminate cytology. Conclusions Mutation profiling can be successfully performed on thyroid LB-FNA without any dedicated sample in a pathology laboratory. It is an easy way to improve diagnostic accuracy of routine LB-FNA and may help to better select patients for surgery and to avoid unnecessary thyroidectomies.

According to the most recent National Health and Nutrition Examination Survey data, 75% of American youth do not participate in moderate to vigorus activity for 60 minutes a day. The 25% that do participate in rigous activity report: basketball, running and football for boys; and running, walking and basketball for girls. In order to increase participation rates different activity choices need to be offered to youth. Therefore, this study examined the energy expenditure and intensity levels of horizontal climbing in prepubescent children. Fifty-one children (males = 23, females = 28) aged 6-10 from a rural elementary school in Washington State participated in this study. Data were collected using an Actigraph GT3X triaxial accelerometer. The overall mean MET value was 10.6 (±1.4) as determined by the sum of all three axes. The collected data revealed that traverse climbing in children aged 6-10 is a vigorous intensive activity. It is recommended that climbing should be included as an effective alternative physical activity to help children meet the daily-recommended minimum of 60 minutes of moderate to vigorous physical activity.

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International audience; Ectodysplasin receptor EDAR is seen as a typical Tumor Necrosis Factor receptor (TNFR) family member known to interact with its ligand Eda-A1, and signaling mainly through the nuclear factor-kappaB (NF-κB) and c-jun N-terminal kinases pathways. Mutations in genes that encode proteins involved in EDAR transduction cascade cause anhidrotic ectodermal dysplasia. Here, we report an unexpected pro-apoptotic activity of EDAR when unbound to its ligand Eda-A1, which is independent of NF-κB pathway. Contrarily to other death receptors, EDAR does recruit caspase-8 to trigger apoptosis but solely upon ligand withdrawal, thereby behaving as the so-called dependence receptors. We propose that pro-apoptotic activity of unbound EDAR confers it a tumor suppressive activity. Along this line, we identified loss-of-pro-apoptotic function mutations in EDAR gene in human melanoma. Moreover, we show that the invalidation of EDAR in mice promotes melanoma progression in a B-Raf mutant background. Together, these data support the view that EDAR constrains melanoma progression by acting as a dependence receptor.

Summary Background Ex vivo fluorescence confocal microscopy (FCM) permits real-time imaging of freshly excised skin tissues. Its usefulness as a time-sparing alternative to frozen sections in Mohs surgery of basal cell carcinoma is well documented. Objectives The purpose of this study was to describe the ex vivo FCM features of a series of benign and malignant nonpigmented tumours of the nail unit, and to correlate them with conventional histopathology. Patients and methods Nail apparatus tumours from 10 patients were imaged during surgical exploration using ex vivo FCM after immersion in acridine orange. Confocal mosaics of the freshly performed biopsies were evaluated in real time and retrospectively compared with haematoxylin and eosin sections. Results Our series included two invasive epithelial tumours (Group 1), four in situ or minimally invasive squamous cell carcinomas (SCC) (Group 2), three benign epithelial tumours (Group 3) and one nodular melanoma (Group 4). The correlation was excellent for malignant epithelial tumours exhibiting marked cytological and architectural atypias (Bowen disease, invasive SCC and onycholemmal carcinoma). Onychomatricomas exhibited a very peculiar aspect with densely cellular papillae. The correlation was less favourable for minimally invasive well-differentiated SCCs with slight cytological atypias. The correlation was poor for our case of amelanotic invasive subungual melanoma. Conclusions Ex vivo FCM could be a useful tool to shorten management of nonpigmented nail tumours: in the case of a malignant tumour, it could indeed lead to performing wide excision during the same surgical procedure and possibly assessing the surgical margins.

Resume Introduction En dehors de la classique necrose sous antivitamines K (AVK) survenant chez les patients deficitaires en proteines C et S, les autres types d’ulcerations induites par les AVK sont peu connus. Nous decrivons ici un cas original d’ulceres recidivants a type de pyoderma gangrenosum (PG) induits par les AVK. Observation Une femme de 70 ans, transplantee cardiaque, presentait, six semaines apres l’instauration d’un traitement AVK par fluindione, une ulceration necrotique de la jambe droite, profonde et hyperalgique, rapidement extensive. L’examen histologique trouvait un infiltrat dermique riche en polynucleaires neutrophiles, faisant discuter une vasculite leucocytoclasique ou un PG. Les explorations eliminaient une cause infectieuse, auto-immune ou un facteur de thrombophilie. La fluindione etait arretee. L’ulceration cicatrisait completement en un mois. Six mois plus tard, l’ulceration de la jambe droite recidivait 15 jours apres la reprise de la fluindione, puis cicatrisait de nouveau un mois apres son arret. Un AVK d’une autre famille (warfarine) etait alors introduit, suivi d’une nouvelle recidive de l’ulceration apres 15 jours de traitement. Discussion La chronologie des evenements et la negativite des explorations etiologiques permettaient de poser le diagnostic d’ulcere induit par les AVK. Les ulcerations cutanees liees aux AVK sont une complication rare dont la physiopathologie est imprecise. A notre connaissance, il s’agit du premier cas publie d’ulceres a type de PG induits par les AVK.

Summary Background New primary melanomas arising in patients with stage IV melanoma and receiving BRAF inhibitors have recently been reported. This raises the question of the nature of the earliest cellular events identifiable within pre-existing moles. Objectives To use reflectance confocal microscopy (RCM) to investigate changing moles in patients using vemurafenib. Methods In the first part of the study 23 lesions were examined by RCM before excision (performed because of digital dermoscopy changes) and histopathological examination. In the second part, 10 randomly chosen lesions in two patients were examined before and after 3 months of vemurafenib treatment. Results The first step permitted the highlighting of an unusual RCM pattern identified in five lesions characterized by areas of marked atypia in otherwise nondysplastic lesions. In the second step, four initially nondysplastic lesions developed focal or multifocal areas of marked atypia under treatment, which were not always correlated with digital dermoscopy changes, but did correlate with histopathology. All four lesions were finally diagnosed as melanomas. Conclusions Although the clinical relevance of such findings remains questionable, RCM allowed us to observe, at the cellular level, the earliest events occurring within vemurafenib-induced changing moles. Moreover, repeated RCM examinations permitted to confirm that microscopic marked atypia that led to the histopathological diagnosis of melanoma appeared under treatment and were not pre-existing.

BackgroundCutaneous adverse drug reactions frequently present as a benign maculopapular exanthema (MPE) with a rapid healing. Sometimes systemic signs are present, which could represent a more severe or systemic MPE (sMPE) or even be the initial phase of a drug reaction with eosinophilia and systemic symptoms (DRESS). Histopathology associated with MPE, sMPE and DRESS has not been well characterized.ObjectivesTo study the cutaneous histopathological changes associated with MPE, sMPE and DRESS.MethodsA retrospective clinicopathological analysis of 13 cases of MPE, 13 of sMPE and 45 of DRESS, collected in one centre from 2005 to 2013.ResultsThe number of histopathological changes per section increased gradually from MPE to sMPE and DRESS. Prevalence of spongiosis, dermal lymphocytes, eosinophils and neutrophils did not differ between MPE, sMPE and DRESS. Keratinocyte damage, rare in MPE, was regularly found in sMPE and frequent in DRESS. The density of the inflammatory infiltrate increased progressively from MPE to sMPE and DRESS. Atypical lymphocytes were absent in MPE, present in sMPE and more frequent in DRESS. Deep dermal involvement and leukocytoclastic vasculitis were only observed in DRESS.LimitationsThis was a retrospective study.ConclusionsNumerous histopathological changes per section in drug-induced exanthema should alert for a more severe form of cutaneous adverse drug reactions, i.e. DRESS.

in situ or minimally invasive melanoma can be treated by nonamputative wide excision of the nail unit followed by a skin graft, performed by a dermatologic surgeon, with an excellent cosmetic and functional result that does not impair the prognosis.1-2 We previously published a preliminary study showing a good correlation between perioperative Reflectance Confocal Microscopy (RCM) and histopathology of the nail matrix in case of subungual melanoma (SUM)3. Since then, we used perioperative in vivo RCM in our centre, after informed consent of patient, during surgical exploration of 30 consecutive cases of suspicious MS between 1/11/2012 and 31/03/2016. This study was approved by the institutional review board of our centre (n°0180) and followed the ethical principles of the Declaration of Helsinki. This article is protected by copyright. All rights reserved.

International audience; Targeted therapies with MAPK inhibitors (MAPKi) are faced with severe problems of resistance in BRAF-mutant melanoma. In parallel to the acquisition of genetic mutations, melanoma cells may also adapt to the drugs through phenotype switching. The ZEB1 transcription factor, a known inducer of EMT and invasiveness, is now considered as a genuine oncogenic factor required for tumor initiation, cancer cell plasticity, and drug resistance in carcinomas. Here, we show that high levels of ZEB1 expression are associated with inherent resistance to MAPKi in BRAFV600-mutated cell lines and tumors. ZEB1 levels are also elevated in melanoma cells with acquired resistance and in biopsies from patients relapsing while under treatment. ZEB1 overexpression is sufficient to drive the emergence of resistance to MAPKi by promoting a reversible transition toward a MITFlow/p75high stem-like and tumorigenic phenotype. ZEB1 inhibition promotes cell differentiation, prevents tumorigenic growth in vivo, sensitizes naive melanoma cells to MAPKi, and induces cell death in resistant cells. Overall, our results demonstrate that ZEB1 is a major driver of melanoma cell plasticity, driving drug adaptation and phenotypic resistance to MAPKi

Background Reflectance confocal microscopy (RCM)'s interest has been well established for the non-invasive diagnosis of skin cancers, especially melanocytic, and in the differential diagnosis between benign and malignant cutaneous lesions. However, its diagnostic interest in inflammatory skin diseases still needs to be demonstrated. Our purpose was to evaluate the correlation between RCM and conventional histopathology in a series of pustular eruptions of different pathogeny. Methods Reflectance confocal microscopy analysis was performed in eight consecutive unselected patients in whom the diagnoses of pustular psoriasis, bacterial sur-infection, herpes-type virus skin sur-infection, Sneddon-Wilkinson subcorneal putulosis and Hailey-Hailey disease have been made and images were compared to conventional histopathology. Results Neutrophils within the epidermis exhibited never reported earlier specific features, with either a shiny granular sludge or polylobated particules with a bright granular content. Moreover, some specific etiologies could be identified, such as acantholysis and herpes-type virus-infected keratinocytes. Conclusion Our studies show a good correlation between RCM and conventional histopathology in pustular eruptions. Reflectance confocal microscopy may play an important role in the differential diagnosis of pustular eruptions; as most of the pathologic clues are epidermal, narrow thickness of the field of imaging, its main technical limitation, is indeed of lesser importance.

Summary Background Although dermoscopy of the nail plate is helpful to discriminate between benign and malignant causes of nail pigmentations, there remain ambiguous cases in which a matricial biopsy is required. When a subungual melanoma is diagnosed histopathologically, a complementary surgical treatment is performed secondarily, the duration of postoperative disability being accordingly prolongated. Objectives The purpose of our study was to evaluate the feasibility of an intraoperative diagnosis by reflectance confocal microscopy (RCM). Patients and methods Our series included nine consecutive patients who underwent a matricial biopsy for an acquired melanonychia (one benign lentigo and eight melanomas). RCM examination was performed in vivo on the nail matrix after reclination of the nail plate, and/or ex vivo on the fresh tissue biopsy. RCM data were compared with histopathology. Results There was a good correlation between confocal and histopathological features. Seven melanoma cases were unequivocally diagnosed intraoperatively according to the confocal features, whereas the lentigo was correctly classified as a benign lesion according to RCM. The remaining lesion could not be unequivocally classified by RCM and corresponded histopathologically to an early melanoma that required immunostaining to be diagnosed. Conclusions Intraoperative RCM examination of the nail matrix is an efficient diagnostic approach of melanonychia striata that permits an extemporaneous diagnosis of malignancy and therefore a one-step surgical treatment of in situ or minimally invasive melanoma, reducing dramatically the duration of postoperative disability.

Background The ‘dermoscopic island’ is a term that was recently proposed to design an area of a pigmented lesion with a uniform dermoscopic pattern different from the remainder of the lesion. The positive predictive value of this sign for the diagnosis of melanoma is about 50%. Objective The purpose of our study was to see if reflectance confocal microscopy (RCM) permitted to accurately distinguish between nevi and melanoma in such lesions. Methods Five lesions of five consecutive unselected patients, with a dermoscopic island but no feasible clear cut diagnosis on the basis of dermoscopy alone were examined by RCM before excision for histopathological evaluation. Results Two lesions corresponded to nevi, and three lesions were early melanomas arising on a benign naevus in one case, and on a dysplastic naevus in two cases. In all five cases, RCM permitted to make the correct diagnosis, with a very good correlation with conventional histopathology. Conclusion Reflectance confocal microscopy appears as a promising tool not only to enhance the early diagnosis of melanoma but also to avoid unnecessary excisions of lesions with a dermoscopic island.

International audience; BACKGROUND: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and severe adverse drug reaction. Large detailed studies of histopathological features of DRESS are sparse and suggest an association between keratinocyte damage and the severity of visceral involvement. OBJECTIVES: To describe the dermatopathological features in a large series of DRESS and their possible association with clinical features and the severity of the disease. METHODS: A retrospective analysis of the clinicobiological and dermatopathological features in a monocentric cohort of patients with DRESS. RESULTS: From January 2005 to January 2013, 45 patients were validated as probable or definite cases of DRESS. The median age was 64~years (range 3-87). The most frequent clinical and biological features included: fever >=38.5°C (95%), facial oedema (72%), enlarged lymph nodes (51%), visceral involvement (75%), blood eosinophilia (97%) and atypical lymphocytes (82%). Severe DRESS occurred in 24% and a fatal outcome in 6% of patients. Histopathological analysis showed that no specific histopathological pattern was characteristic for DRESS. However, several changes in different cutaneous compartments were observed in 2 of 3 of cases. Spongiosis (55%) and keratinocyte damage (53%) were the most common epidermal changes. Spongiosis was associated with non-severe DRESS (P~=~0.041) whereas confluent keratinocyte necrosis correlated with severe DRESS (P~=~0.011). Vascular changes were frequent (88%). A moderate dermal perivascular lymphocytic infiltrate was invariably present, containing eosinophils, neutrophils and/or atypical lymphocytes in 57% of cases. CONCLUSIONS: Epidermal changes are indicative for the severity of DRESS.

ejd.2013.1991 Auteur(s) : Axel Patrice Villani, Daniela Zaharia, Stephane Dalle, Laurianne Depaepe, Brigitte Balme, Luc Thomas luc.thomas@chu-lyon.fr Department of Dermatology, Lyon 1 University, Centre Hospitalier Lyon Sud, 69495 Pierre Benite Cedex, France Vemurafenib, the first selective BRAF inhibitor, is indicated to treat patients with unresectable or metastatic melanoma with the BRAFV600E mutation [1]. This drug is associated with remarkable dermatological adverse effects (skin rash, photosensitivity, squamous-cell [...]

Results A facial edema in DRESS was associated with a definite case of DRESS (p=0.005) and a liver involvement (p=0.045). A younger age (50 years vs 66 years) was associated with a liver involvement (p=0.013). A severe neutropenia was associated with severe DRESS (p=0.012). Spongiosis and keratinocyte damage are the 2 most frequent epidermal changes noticed 55% and 53%. Pustules are not rare (26%). In the dermis a vascular alterations were frequent (88%) with a true leukocytoclastic vasculitis in 28%, a mild lymphocytic vasculitis in 13% and minor alterations in 44% of cases. In the dermis, there was a constant lymphocytic infiltrate mainly moderate in a perivascular distribution. In 57% the infiltrate is polymorphous with association of eosinophils neutrophil or atypical lymphocyte. In two third of cases, the changes are polymorphous and numerous, with no specific clear pattern. In the other one third of cases with few alterations, the presence of eosinophils, keratinocyte damage and spongiosis are usually present. A spongiosis was associated with non severe form of DRESS (p=0.041) and the absence of kidney involvement (p=0.023). A a higher of alterations per slides was associated a liver involvement (p=0.018). Our study do not support a prognostic value of keratinocyte damage.

Background Depigmentation therapy can be an option in adults with extensive and refractory vitiligo. Remaining pigmented patches can be removed using depigmentation creams (monobenzyl ether of hydroquinone 20%), laser therapy or cryotherapy. In contrast to cream treatment, laser therapy and cryotherapy are fast and targeted methods, capable of destroying melanocytes selectively on one specific area. Up till now, controlled trials comparing laser and cryotherapy as depigmenting treatment in vitiligo are lacking. Material and methods We performed a retrospective comparative study in 22 generalized vitiligo patients. Thirty-one pigmented test regions were exposed to cryotherapy and 20 to 755 nm laser therapy. The mean surface area per test region was 3.55 cm² and number of treatments per test region was limited to one single session in 84.3% and varied up to four sessions (2.0%). Results Overall no significant difference in the capacity to induce depigmentations was observed between cryotherapy (46.7%) and laser therapy (42.9%) after one treatment. The percentage of induced depigmentation was significantly different according to the body location (P = 0.005) with best results on the trunk, followed by the arms, face, neck and less on the hands. Variables that positively influenced depigmentation results were a younger age of vitiligo onset (P = 0.012), skin type V (P

Summary Background Although most mucosal pigmented macules are benign, it can be clinically challenging to rule out an early melanoma. Reflectance confocal microscopy (RCM) is a noninvasive imaging technique useful in discriminating between benign and malignant skin lesions. Objectives To describe the confocal aspects of benign and malignant mucosal pigmented macules with histopathological correlations. Methods We retrospectively reviewed the confocal images of 56 labial or genital pigmented macules including 10 macular melanomas. According to the retrospective nature of the study, we evaluated the recorded images chosen by the physicians that performed the RCM examination for each case. Results In benign macules, the most frequently observed pattern was a ringed pattern characterized by round or polycyclic papillae, with a hyper-reflective basal layer; another pattern was characterized by sparse bright dendritic cells in the basal layer, the basal epithelial cells being otherwise less reflective. Roundish cells, a high density of dendritic cells with atypias and intraepithelial bright cells were clues to the presence of malignancy. Conclusions Reflectance confocal microscopy seems to be a valuable tool to noninvasively differentiate benign from malignant mucosal pigmented macules and target biopsies in cases of equivocal features.

Other than the classic skin necrosis induced by oral anticoagulants (OAC) in patients with protein C and S deficiencies, other types of OAC induced-skin ulcers are little known. Herein, we describe an original case of recurrent pyoderma gangrenosum (PG)-like ulcers induced by OAC.A 70-year-old female heart-transplant recipient presented deep, hyperalgesic and quickly-spreading necrotic ulceration of the right leg 6 weeks after starting oral anticoagulant therapy with fluindione. Histological analysis revealed dermal infiltrate containing polynuclear neutrophils, which accords with the histopathological diagnosis of leukocytoclastic vasculitis or PG. Infectious, autoimmune and thrombophilic causes were ruled out. Fluindione was withdrawn and the ulcer healed completely within a month. Six months later, right leg ulceration recurred two weeks after the patient resumed fluindione but healed within 1 month of discontinuation of the drug. An OAC from another chemical family (warfarin) was then introduced, with further recurrence of ulceration after 2 weeks of treatment.The chronology of events and the negativity of aetiological explorations allowed a diagnosis to be made of OAC-induced skin ulcer, a rare complication of which the pathophysiology is unclear. This is the first case of PG-like ulcers induced by OAC.

New primary melanomas arising in patients with stage IV melanoma and receiving BRAF inhibitors have recently been reported. This raises the question of the nature of the earliest cellular events identifiable within pre-existing moles.To use reflectance confocal microscopy (RCM) to investigate changing moles in patients using vemurafenib.In the first part of the study 23 lesions were examined by RCM before excision (performed because of digital dermoscopy changes) and histopathological examination. In the second part, 10 randomly chosen lesions in two patients were examined before and after 3 months of vemurafenib treatment.The first step permitted the highlighting of an unusual RCM pattern identified in five lesions characterized by areas of marked atypia in otherwise nondysplastic lesions. In the second step, four initially nondysplastic lesions developed focal or multifocal areas of marked atypia under treatment, which were not always correlated with digital dermoscopy changes, but did correlate with histopathology. All four lesions were finally diagnosed as melanomas.Although the clinical relevance of such findings remains questionable, RCM allowed us to observe, at the cellular level, the earliest events occurring within vemurafenib-induced changing moles. Moreover, repeated RCM examinations permitted to confirm that microscopic marked atypia that led to the histopathological diagnosis of melanoma appeared under treatment and were not pre-existing.

Although dermoscopy of the nail plate is helpful to discriminate between benign and malignant causes of nail pigmentations, there remain ambiguous cases in which a matricial biopsy is required. When a subungual melanoma is diagnosed histopathologically, a complementary surgical treatment is performed secondarily, the duration of postoperative disability being accordingly prolongated.The purpose of our study was to evaluate the feasibility of an intraoperative diagnosis by reflectance confocal microscopy (RCM).Our series included nine consecutive patients who underwent a matricial biopsy for an acquired melanonychia (one benign lentigo and eight melanomas). RCM examination was performed in vivo on the nail matrix after reclination of the nail plate, and/or ex vivo on the fresh tissue biopsy. RCM data were compared with histopathology.There was a good correlation between confocal and histopathological features. Seven melanoma cases were unequivocally diagnosed intraoperatively according to the confocal features, whereas the lentigo was correctly classified as a benign lesion according to RCM. The remaining lesion could not be unequivocally classified by RCM and corresponded histopathologically to an early melanoma that required immunostaining to be diagnosed.Intraoperative RCM examination of the nail matrix is an efficient diagnostic approach of melanonychia striata that permits an extemporaneous diagnosis of malignancy and therefore a one-step surgical treatment of in situ or minimally invasive melanoma, reducing dramatically the duration of postoperative disability.

The 'dermoscopic island' is a term that was recently proposed to design an area of a pigmented lesion with a uniform dermoscopic pattern different from the remainder of the lesion. The positive predictive value of this sign for the diagnosis of melanoma is about 50%.The purpose of our study was to see if reflectance confocal microscopy (RCM) permitted to accurately distinguish between nevi and melanoma in such lesions.Five lesions of five consecutive unselected patients, with a dermoscopic island but no feasible clear cut diagnosis on the basis of dermoscopy alone were examined by RCM before excision for histopathological evaluation.Two lesions corresponded to nevi, and three lesions were early melanomas arising on a benign naevus in one case, and on a dysplastic naevus in two cases. In all five cases, RCM permitted to make the correct diagnosis, with a very good correlation with conventional histopathology.Reflectance confocal microscopy appears as a promising tool not only to enhance the early diagnosis of melanoma but also to avoid unnecessary excisions of lesions with a dermoscopic island.

The present study's purpose was to probe into the reliability and validity measurement of dynamic balance for individuals with IQs below 29. The 91 subjects were asked to complete the Papcsy-DePaepe test and the Bruininks test according to each test's protocol. Correlations of odd-even scores produced a reliability of .98 for the Papcsy-DePaepe test. Concurrent validity was indicated by a Pearson product-moment correlation of .64 between the two tests. Subsequent 3 × 2 × 2 multivariate analyses of variance confirmed a significant difference between the two tests and that retardation was associated with balance performance although age and gender were not.

We report two new cases of cutaneous indeterminate cell histiocytosis (ICH), clinically characterized by a profuse papular eruption, without systemic involment. The first patient, a 59-year-old man, was evaluated for a diffuse, mildly pruritic papular rash of 6 months duration, associated with an impaired general condition. His clinical history was remarkable for a hepatocellular carcinoma (HCC) on NASH treated by hepatic chemoembolization 4 months before the first consultation. No new drug had been [...]

Recent efforts undertaken to improve the quality of teachers in the state of Washington, have resulted in the development of pedagogical performance standards for student teachers. These standards are the result of a collaborative effort between the Washington Association of Colleges for Teacher Education (WACTE) and the Office of the Superintendent (OSPI). These two groups have specifically attempted to create an instrument/standards that would enforce the "No Child Left Behind Act of 2001" and decrease the achievement gap. Student teachers are required to meet all of the standards while teaching p-12 students. Based on teacher preparation programs and the stage of teacher preparation of student teachers, an intermediary step is deemed necessary to ensure success in meeting the standards. Therefore the purpose of this paper is to 1) describe the Washington Performance Based Assessment; 2) examine the literature related to student teachers' perceptions, beliefs, educational needs, and pedagogical needs; 3) describe the development process and content validation of a formative assessment and its congruence with the state standards; and 4) describe the use and implementation process of the assessment using a laptop.

Introduction Les exanthemes induits par les medicaments (EIM) se presentent le plus souvent comme un exantheme maculopapuleux isole avec guerison rapide et plus rarement comme un DRESS. Entre ces 2 formes, certains patients presentent des signes systemiques, mais avec un score de Kardaun – EIM simple (EIMS) ; – EIM complique (EIMC) ; – DRESS. Patients et methodes Il s’agit d’une etude retrospective (2008–2013) basee sur le registre du CCR2A. Les medicaments en cause, les atteintes viscerales et l’evolution etaient colligees. L’analyse histologique histologique etait faite en double insu. Observations Soixante et onze patients etaient inclus : 13 EIMS, 13 EIMC et 45 DRESS. Resultats Un œdeme facial etait trouve principalement dans les DRESS (p Discussion Nos resultats suggerent que les EIMC peuvent etre differencies des DRESS par une moindre frequence de l’œdeme facial, de la fievre et des ganglions peripheriques, par un taux d’eosinophiles plus faible et l’absence de lymphocytes atypiques. La necrose keratinocytaire, la densite de l’infiltrat, la presence de lymphocytes actives dans l’infiltrat, et le nombre d’alterations par biopsie voient leur frequence augmentee avec la gravite de la reaction medicamenteuse. L’atteinte du derme profond et la presence de vasculite leucocytoclasique est en faveur du DRESS. Conclusion La presence de nombreuses modifications, de necrose keratinocytaire, d’un infiltrat dermique dense sont en faveur d’une reaction systemique et doivent alerter pour un DRESS, surtout en cas de vasculite leucocytoclasique ou d’atteinte du derme profond.