Dermoscopy and reflectance confocal microscopy of solitary flat pink lesions: A new combined score to diagnose amelanotic melanoma.

BACKGROUND: Differential diagnosis of amelanotic/hypomelanotic melanoma among solitary flat pink lesions is challenging, due to limited clinical and dermoscopic clues. Dermoscopy and reflectance confocal microscopy assessments improve diagnostic accuracy, but their combined capacity among solitary flat pink lesions is yet to be defined. OBJECTIVES: To determine (i) whether diagnostic accuracy is improved with combined dermoscopy and reflectance confocal microscopy, (ii) a model to estimate probability of flat amelanotic/hypomelanotic melanoma among solitary flat pink lesions. METHODS: A retrospective single-centre study of solitary flat pink lesions, excised for suspected malignancy between 2011 and 2022 was performed. Images were independently evaluated by two dermatologists, blinded to histopathological diagnosis. Diagnostic performance was evaluated on the receiver operating characteristic curve and the area under the curve. Predictive features were identified by univariate and multivariate logistic regression analyses. A final predictive nomogram of independent risk factors was calculated by backward likelihood ratio. Hypothesis being tested was formulated before data collection. RESULTS: A total of 184 patients (87 females, 47.3%) were included; mean age was 57.6 years (19-95). Combined dermoscopy and reflectance confocal microscopy was more sensitive (83%, CI 69.2-92.4 and 91.5%, CI 79.6-97.6) than dermoscopy alone (76.6%, CI 62.0-87.7 and 85.1%, CI 71.7-93.8). Predictive features defined the new model, including linear irregular vessels (4.26-folds, CI 1.5-12.1), peripheral pigment network (6.07-folds, CI 1.83-20.15), remnants of pigmentation (4.3-folds, CI 1.27-14.55) at dermoscopy and atypical honeycomb (9.98-folds, CI 1.91-51.96), disarranged epidermal pattern (15.22-folds, CI 2.18-106.23), dendritic pagetoid cells in the epidermis (3.77-folds, CI 1.25-11.26), hypopigmented pagetoid cells (27.05-folds, CI 1.57-465.5), and dense and sparse nests (3.68-folds, CI 1.24-10.96) in reflectance confocal microscopy. Diagnostic accuracy of the model was high (AUC 0.91). CONCLUSIONS: Adjunctive reflectance confocal microscopy increases diagnostic sensitivity of flat amelanotic/hypomelanotic melanoma differential diagnosis. The proposed model requires validation.

The presence of eccentric hyperpigmentation should raise the suspicion of melanoma.

BACKGROUND: Melanocytic lesions with eccentric hyperpigmentation (EH), even though without other dermatoscopic features of melanoma, are often excised. OBJECTIVE: Aiming to understand whether the EH in a pigmented lesion is an accurate criterion of malignancy, we evaluated the capability of two evaluators, with different expertise, to correctly diagnose a melanoma when analysing a given lesion in toto versus a partial analysis, with only the EH or the non-hyperpigmented portion (non-EH) visible. METHODS: Dermatoscopic images of 240 lesions (107 melanomas and 133 nevi) typified by EH were selected. Facial, acral, mucosal lesions and lesions showing clear-cut features of melanoma (except for atypical network) were excluded. Clinical and dermoscopic features (main pattern and numbers of colours) were described for all cases. Each image was split in two through a software so that only the EH or the non-EH was visible. Two blinded evaluators examined three sets of images, two with customized images and one with the non-modified ones: they were asked to give a dichotomous diagnosis (melanoma or nevus) for each image. RESULTS: Melanomas were significantly more frequently typified by colour variegation (3 colours in 44.8% and 4 colours in 41.1% of cases) and atypical network (88.1% in the EH). No significant differences in diagnostic accuracy emerged between the two evaluators. Sensitivity improved in the evaluation of the whole lesions (mean sensitivity 89.7%) in comparison with the evaluation of EH or non-EH alone (72.7-62.6%). Specificity increased when evaluating the EH (54.1%). Positive predictive value (PPV) and likelihood ratio (LR+) of EH resulted 52.3% and 1.4, meaning that in one case out of two with EH is a melanoma. CONCLUSIONS: Lesions with EH are challenging, regardless of dermoscopic experience. The EH is a robust criterion for malignancy, since the evaluation of the whole lesion, through an intralesional comparative approach, increases sensitivity.

LAI versus oral: A case-control study on subjective experience of antipsychotic maintenance treatment.

BACKGROUND: To present real-world evidence on the differences between long-acting injectable (LAI) and oral antipsychotic maintenance treatment (AMT) in terms of subjective well-being, attitudes towards drug and quality of life in a sample of remitted schizophrenic subjects. METHODS: Twenty outpatients with remitted schizophrenia treated with either olanzapine or paliperidone and switching from the oral to the LAI formulation of their maintenance treatment were recruited before the switch (LAI-AMT group). A group of 20 remitted schizophrenic subjects with oral AMT and matching main sociodemographic, clinical and treatment variables made up the control group (oral-AMT group). All participants were assessed in terms of objective (PANSS, YMRS, MADRS) and subjective (SWN-K, DAI-10, SF-36) treatment outcomes at baseline (T0) and after 6 months (T1). RESULTS: Between T0 and T1, general psychopathology of the PANSS, DAI-10, and all but one of the SWN-K dimensions (except for social integration), showed significantly higher percentages of improvement in the LAI-AMT group compared to the oral-AMT group. A generalized expansion of health-related quality of life, with better functioning in almost all areas of daily living, was reported by the LAI-AMT group after the 6-month period. In contrast, the oral-AMT group reported a significant worsening of health-related quality of life in the areas of emotional role and social functioning in the same period. CONCLUSIONS: Our study indicates possible advantages of LAI over oral antipsychotic formulation in terms of subjective experience of maintenance treatment in remitted schizophrenic patients. Size and duration of this study need to be expanded in order to produce more solid and generalizable results.

The effects of music on cardiac patients on bed rest.

Hospitalizations that require invasive cardiac procedures or support with an intra-aortic balloon pump can be unsettling. This study was undertaken to measure the effect of a music intervention on physiologic and psychological responses of patients on bed rest due to procedural sheaths or an intra-aortic balloon pump. A randomized, two-group, pretest/post-test design was utilized to measure the effect of a 30-minute music intervention on heart rate, blood pressure, respiratory rate, skin temperature, pain perception, and mood states. One hundred forty subjects participated, 65 in the control group and 75 in the treatment group. There were no significant differences between the groups in demographic, clinical, or baseline variables, except for respiratory rate. After the music intervention, there were reductions in blood pressure, respiratory rate, and psychological distress, as measured by the Profile of Mood States (p < 0.05). Music appeared to affect selected physiologic responses and reduce psychological distress in patients on bed rest.

Effect of trimetazidine on 99Tcm-tetrofosmin uptake in patients with coronary artery disease.

Myocardial uptake of 99Tcm-tetrofosmin in vivo is determined by a combination of flow and metabolic status of myocytes. The accumulation of tetrofosmin in the mitochondria is related to their ability to transduce metabolic energy into electronegative membrane potential. Trimetazidine (TMZ), an anti-ischaemic drug, appears to have a metabolic cytoprotective effect related to mitochondrial function, since it does not induce systemic or coronary haemodynamic changes. In this study, we evaluated the effects of TMZ on tetrofosmin uptake in hypoperfused myocardial regions in patients with coronary artery disease (CAD). Twenty-two patients, 14 with previous myocardial infarction (group A) and eight with a history of angina (group B), with angiographically documented CAD were studied. All patients underwent two tetrofosmin SPET studies at rest, before (baseline) and 1 week after TMZ administration (post-TMZ). On quantitative analysis, 131 segments showed less tetrofosmin uptake at baseline. In these segments, tetrofosmin uptake was 51 +/- 13% at baseline and 55 +/- 15% post-TMZ (P < 0.001 vs control). In the 86 hypoperfused segments of group A, tetrofosmin uptake was 48 +/- 14% at baseline and 52 +/- 17% post-TMZ (P < 0.001 vs control). In the 45 hypoperfused segments of group B, tetrofosmin uptake was 56 +/- 9% at baseline and 60 +/- 10% post-TMZ (P < 0.001 vs control). In the remaining 309 segments, no significant difference in tetrofosmin uptake before and after TMZ was observed. In conclusion, our results suggest that TMZ administration may increase myocardial uptake of tetrofosmin in hypoperfused regions at rest in patients with CAD, based on its metabolic effect.

Accuracy of reagent strips in detecting hypoglycemia in the emergency department.

STUDY OBJECTIVE: Although reagent strips are commonly used, their reliability to estimate blood glucose concentration and guide administration of dextrose solutions in the emergency department environment has not been proved. We determined the accuracy of visually interpreted reagent strips (Chemstrip bG, Boehringer Mannheim Corp, Indianapolis, IN) and their ability to identify hypoglycemic patients in the ED. METHODS: We conducted a prospective, nonrandomized blinded clinical study of the visual estimation of blood glucose values by ED personnel using Chemstrip bG reagent strips during a 4-month period. Simultaneously obtained blood samples sent for laboratory glucose determination served as controls. The study was conducted at a large university hospital ED with an urban patient population. A convenience sample of 215 adult ED patients underwent serum glucose determination with data form completion. No study intervention was tested, although timing of administration of dextrose solutions, if given, was recorded. RESULTS: Hypoglycemia was defined as a glucose concentration less than 60 mg/dL on standard laboratory analysis. Reagent strips identified 28 of 29 of these patients (sensitivity=97%), and 171 of 182 patients without hypoglycemia (specificity=94%, negative predictive value=99%) compared with control samples. The 1 false-negative reagent strip reading of 80 mg/dL was obtained from blood stored in a serum separator tube and had a laboratory glucose value of 39 mg/dL. Eighty-seven percent of the reagent strips were within +/-60 mg/dL of the control value for the laboratory glucose reference range less than 350 mg/dL. CONCLUSION: Visually interpreted Chemstrip bG reagent strips provide an acceptable estimation of blood glucose concentration in the ED and are highly sensitive in detecting hypoglycemia.

Proper depth placement of oral endotracheal tubes in adults prior to radiographic confirmation.

OBJECTIVE: To determine whether a certain distance measurement on the oral endotracheal tube (ETT) at the corner of the mouth could reasonably ensure proper depth of placement in critically ill patients, without the immediate need for a confirming chest x-ray (CXR). METHODS: A prospective observational cross-sectional design was used to compare ETT mark distance and radiographic location of the ETT tip. The measurement marking on the ETT at the level of the corner of the mouth was noted at the time of intubation. The relationship of the tip of the ETT to the tracheal carina on the postintubation CXR was then determined. The ETT placement was deemed correct if the tip was at least 2 cm cephalad to the carina on the CXR. RESULTS: Of 83 intubated patients assessed, 52 were men and 31 women. The mean measurement of the ETT at the corner of the mouth was 22.2 cm for the women and 23.1 cm for the men. The mean distance from the tip of the ETT to the carina was 3.45 cm for the women and 4.13 cm for the men. Seventy-five of the 83 patients (90.4%; 95% CI 81.9-95.7%) had correct ETT positions on the initial CXR. If the ETT position had been adjusted at the corner of the mouth to 21 cm for the women and 23 cm for the men, the ETT would have been in correct position for 81 of the 83 patients (97.6%; 95% CI 89.6-95.7%). This represents a significant improvement in tube placement (p < 0.025; the McNemar chi-square). CONCLUSION: Proper depth of ETT placement in the critically ill adult patient can be estimated by the technique of this study. In this adult patient population, corner-of-the-mouth placement of the ETT using the 21-cm tube mark for the women and the 23-cm mark for the men would have led to proper placement for most patients.

Salsalate intoxication and ramifications of utilizing nonspecific analytical methods in estimating quantitative blood concentrations.

In a case involving poisoning with salsalate, a salicylate analogue, the initial blood concentration of the parent drug was underestimated because of the low cross-reactivity of the immunoassay used for the analysis. This resulted in unnecessary additional clinical and laboratory evaluations to find the cause of metabolic acidosis exhibited by the patient. Additional findings led to the conclusion that parent salsalate contributed to patient toxicity. For testing purposes, all salicylate compounds should not necessarily be classified into one salicylic acid category, and there must be detailed communication between the caregiver and the laboratory regarding the specific drug history.

Use of amrinone and glucagon in a case of calcium channel blocker overdose.

Hypotension resulting from calcium channel blocker ingestion often is refractory to standard therapeutic modalities. Amrinone and glucagon have been used separately and in combination with other agents in the treatment of calcium channel blocker overdose. We report the successful use of both amrinone and glucagon in the treatment of a 30-year-old woman who ingested 3.6 g of verapamil and presented with refractory hypotension. The use of the two agents together may provide improved inotropic support with minimal increases in myocardial oxygen consumption. In this case, the combination of amrinone and glucagon was safe and effective in the management of the hemodynamic instability associated with calcium channel blocker overdose.

Cinchonism: two case reports and review of acute quinine toxicity and treatment.

Two cases of acute quinine toxicity are presented, one from self-poisoning and the other from an unidentified source. Both patients presented with acute bilateral blindness. They also experienced the classic symptoms of cinchonism, including nausea, vomiting, and tinnitus. Prolongation of the Q-T interval developed in both patients. Serum quinine levels of 5.3 mg/L and 13 mg/L were measured. Although their visual acuity improved, both patients had some residual deficit at follow-up. A review of the literature, including clinical presentation and emergency medicine diagnosis and management, is also presented.

Diastolic perfusion time at ischemic threshold in patients with stress-induced ischemia.

BACKGROUND: To evaluate the relevance of diastolic perfusion time on the mechanisms underlying stress-induced ischemia, 16 patients with coronary artery disease and seven patients with syndrome X underwent five randomized stress tests (upright and supine exercise with and without therapy, transesophageal atrial pacing). METHODS AND RESULTS: Exercise duration Time to 0.1 mV ST segment depression, heart rate, rate-pressure product, and diastolic perfusion time were evaluated for each patient during stress tests. In both groups, variability coefficients of the above-mentioned parameters were not different at rest. At ischemic threshold (0.1 mV ST segment depression) in patients with coronary artery disease, the variability coefficient of exercise duration (40.1 +/- 22.2) was significantly higher (p less than 0.0001) than those of heart rate (12.8 +/- 2.9), rate-pressure product (14.8 +/- 3.3), and diastolic perfusion time (0.39 +/- 0.1). The variability coefficient of diastolic perfusion time was also significantly (p less than 0.0001) lower than those of heart rate and rate-pressure product. Similarly, the variability coefficient of diastolic perfusion time (0.44 +/- 0.1) in syndrome X patients was significantly lower (p less than 0.0001) than those of exercise duration (28.2 +/- 9.4), heart rate (12 +/- 1.4), and rate-pressure product (14.6 +/- 1.3). CONCLUSIONS: Fixed diastolic perfusion time at ischemic threshold, despite different kinds of stress tests and variability of heart rate and rate-pressure product, indicates the relevant role of diastolic perfusion time in determining myocardial ischemia.

Diastolic time at ischemic threshold in patients with syndrome X.

The patients with so-called syndrome X experience true myocardial ischaemia in spite of their anatomically normal coronary arteries. The pathogenetic mechanism of the effort-induced ischaemia in these patients should be obviously different from that of patients with atherosclerotic coronary artery lesions. An inadequate coronary dilatory capacity in response to increased oxygen demand has been proposed as mechanism responsible of ischaemic response to effort (Canon et al., 1983; Canon et al., 1985). Since diastolic duration expressed as percentage of the cardiac cycle has implications with the myocardial oxygen demand/supply ratio (Boudoulas et al., 1982; Maseri et al., 1977), the purpose of this study has been to evaluate the behaviour of this parameter at the outcome of the ischaemic electrocardiographic changes during stress testing in the patients with syndrome X.

Exercise-induced impairment of diastolic time in patients with X syndrome.

Since an abnormal shortening of diastolic duration during exercise in the patients with coronary artery disease was demonstrated, time course of diastolic period (cardiac cycle minus electromechanical systole) calculated from polycardiographic recording has been assessed in patients with X syndrome and in normal age-matched subjects during supine ergometer exercise. All patients with X syndrome had positive exercise stress response (more than 0.1 mV of ST segment depression). Duration of diastole expressed as percent of cardiac cycle was significantly shorter at the intermediate steps and at the peak of exercise in patients with X syndrome compared with normal subjects (p less than 0.05). When the relationship between heart rate and diastolic time was examined, an inverse nonlinear regression was found both in normal subjects and in patients with X syndrome. The exercise values of diastolic time observed in patients with X syndrome were significantly shorter than those predicted as normal diastolic time heart rate relation. Thus the patients with X syndrome demonstrated abnormalities in the decrement of diastolic time with exercise. We hypothesized that this disproportionate shortening, by reducing subendocardial blood flow, might induce a worsening of ischemic response to exercise.

Alinidine in chronic stable angina: the effect on diastolic perfusion time.

The present study has been performed to assess the effects of alinidine on diastolic duration during exercise in chronic coronary artery disease. Twelve male patients with stable effort angina and without previous myocardial infarction were studied. They received alinidine or placebo in a double-blind randomized crossover trial for 3 days after a wash-out period of 4 days. Alinidine was administered at a dosage of 30 mg 3 times a day. At the end of each treatment the patients underwent upright bicycle exercise. Left ventricular time intervals were obtained by means of carotid thermistor plethysmography. Diastolic duration was calculated by subtracting the electromechanical systole from the R-R interval and expressed as a percentage of the cardiac cycle (%D). Alinidine increased both total exercise duration from 246.7 +/- 120.7 to 346.6 +/- 114.1 s (p less than 0.05) and time to 0.1-mV ST segment depression from 98.3 +/- 53 to 187.2 +/- 105 s (p less than 0.05). Similarly the drug induced a reduction of the rate-pressure product and of the extent of ischemic ST segment depression during exercise. %D was increased by alinidine both at rest and during exercise. A direct linear regression between R-R and %D was found after both alinidine and placebo treatments either at rest or during exercise. Nevertheless, no difference was observed between both slopes and intercepts. Therefore, since the relationship between R-R interval and %D was unaffected by alinidine, it was possible to hypothesize that the changes in diastolic duration were due only to the bradycardic action of the drug.

Non-invasive assessment of left ventricular performance in patients with coronary artery disease after chronic diltiazem therapy.

To evaluate the effects of diltiazem (240 mg/day) on the left ventricular function, we studied 13 patients with coronary artery disease (CAD). Comparison with placebo was made in a double-blind randomized crossover study. Both placebo and diltiazem were administered for 5 weeks. We assumed left ventricular systolic time intervals assessed by polycardiography as parameter of ventricular function. Diltiazem induced a significant decrease in pre-ejection period (p less than 0.01) as well as pre-ejection period/left ventricular ejection time ratio (p less than 0.01). Thus, our results suggest that diltiazem improves the contractile state of ischemic myocardium in CAD patients.

[Influence of posture on exercise-induced electrocardiographic and hemodynamic changes in patients with stable effort angina pectoris]. / Influenza della postura sulle modificazioni elettrocardiografiche ed emodinamiche incruente indotte dall'esercizio in pazienti con angina stabile da sforzo.

The present work was performed in order to assess the differences in electrocardiographic and hemodynamic responses to supine and upright dynamic exercise of patients with coronary artery disease. Changes in heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure, rate-pressure product (RPP) and ST segment depression during supine and upright bicycle stress test were compared in twenty patients suffering from stable effort angina and without previous myocardial infarction. In the supine posture lower values of HR were observed at rest, during stress test and during three minutes of the recovery period. Conversely, in all patients both SBP and DBP were higher during the stress test in the supine position decubitus. No significant changes in RPP was observed between the two different postures. Finally, ST segment didn't show differences at rest between the upright and supine position. All the patients had a lower ischemic threshold during exercise in the supine position than in the upright one. In fact an ST segment depression greater than 1 mm was observed during stress test in the supine position at lower work-load levels and at lesser HR values. Consequently for given HR, SBP and DBP ST segment, depression was greater in the supine rather than in the upright position.