Characteristics and management of skin cancers in very elderly patients: A real-world challenge for clinicians.

The increase life expectancy led to an expected increase in skin cancer incidence in older patients. Their treatment can require a complex decision-making process. Limited data are available on characteristics, management and outcome of skin tumours in nonagenarian and centenarian patients. The aim of our study was to describe epidemiology, clinical-pathological features and treatment strategies of skin cancers in a cohort of patients aged ≧95 years. A total of 116 patients ≧95 years of age presented for the evaluation of 225 skin lesions (mean of 1.94 lesions per patient). The mean age was 97.4 years, 57.8% were women. Most patients had an ECOG score of 3 (49.3%) or 4 (32%). Lesions were mainly located on the head and neck area (74.2%), upper (7.1%) and lower (6,2%) limbs. The majority of patients presented with non-melanoma skin cancers (183/225; 81.3%), 25/225 (11.1%) had actinic keratosis, 5 (2.2%) melanoma and 2 (0.9%) atypical fibroxanthoma. Forty-eight lesions (21.3%) were treated with surgery, 58 (25.8%) with radiotherapy. The management of 73 lesion (32.4%) was discussed at the multidisciplinary tumour board meeting. One patient died for the progression of a squamous cell carcinoma; 74 patients died for causes unrelated to skin tumours, 36 are still alive after a mean follow-up of 27.27 months. This cohort study confirms that age is not per se a contraindication for treatment of skin cancers in elderly patients. Our results support the importance of a patient-centred care approach that should take into consideration patient's preferences, comorbidities, compliance and possible adverse events.

Sentiment and Emotional Analysis of Risk Perception in the Herculaneum Archaeological Park during COVID-19 Pandemic.

This paper proposes a methodology for sentiment analysis with emphasis on the emotional aspects of people visiting the Herculaneum Archaeological Park in Italy during the period of the COVID-19 pandemic. The methodology provides a valuable means of continuous feedback on perceived risk of the site. A semantic analysis on Twitter text messages provided input to the risk management team with which they could respond immediately mitigating any apparent risk and reducing the perceived risk. A two-stage approach was adopted to prune a massively large dataset from Twitter. In the first phase, a social network analysis and visualisation tool NodeXL was used to determine the most recurrent words, which was achieved using polarity. This resulted in a suitable subset. In the second phase, the subset was subjected to sentiment and emotion mapping by survey participants. This led to a hybrid approach of using automation for pruning datasets from social media and using a human approach to sentiment and emotion analysis. Whilst suffering from COVID-19, equally, people suffered due to loneliness from isolation dictated by the World Health Organisation. The work revealed that despite such conditions, people's sentiments demonstrated a positive effect from the online discussions on the Herculaneum site.

Dermoscopy of syringocystadenoma papilliferum.

Syringocystadenoma papilliferum is a benign adnexal neoplasm frequently seen in association with other adnexal tumours. We report the dermoscopic features of three cases of syringocystadenoma papilliferum developing in naevus sebaceus. Clinically the lesions were characterised by exophytic papillary structures. Dermoscopically, polymorphous vessels were the prevalent feature.

Dermoscopic Features of Basal Cell Carcinoma on the Lower Limbs: A Chameleon!

BACKGROUND: Lower limbs represent an uncommon location for basal cell carcinoma (BCC) and only few reports have described dermoscopic features of BCC in this body site. Since BCCs of the lower limbs frequently display nonclassic BCC dermoscopic criteria, they can simulate other benign or malignant lesions. OBJECTIVE: Our aim was to describe the dermoscopic features of BCC located on lower limbs and to define which criteria were more associated with their benign- or malignant-looking appearance. METHODS: We conducted a retrospective study enrolling consecutive patients with histologically confirmed BCCs of the lower limbs. Lesions were classified in 7 categories according to the clinical and dermoscopic global appearance. Clear BCC, squamous cell carcinoma (SCC) or Bowen disease-like, Kaposi disease-like, melanoma-like, and aspecific pattern were considered malignant-looking lesions; however, seborrheic keratosis-like and dermatofibroma-like were considered benign-looking. To define which dermoscopic criteria were independently associated with benign- or malignant-looking appearance, we conducted a multivariate logistic regression analysis. RESULTS: A total of 81 BCCs were enrolled: 18 (22%) were benign-looking lesions (of which 11 were seborrheic keratosis-like and 7 dermatofibroma-like) and 63 (78%) were malignant-looking BCCs (of which 24 were clear-cut BCCs, 23 SCC-like, 2 Kaposi disease-like, 9 melanoma-like, and 5 had aspecific pattern). Multivariate regression analysis showed that erosions/ulceration and vessels were independently associated with malignant-looking appearance. The most represented vessels were glomerular and polymorphic, which are more frequently encountered in SCC, together with ulceration. CONCLUSION: BCC of the lower legs frequently simulates other benign or malignant lesions, with SCC being the main differential diagnosis.

Reasons for excision of skin tumors: a one-year prospective study in a tertiary skin cancer unit.

BACKGROUND: Biopsies and surgical excisions represent routine procedures in clinical settings dealing with skin cancer. OBJECTIVE: To evaluate the impact of clinical examination, dermoscopy, reflectance confocal microscopy and digital monitoring on the decision to excise or biopsy a lesion in routine practice. METHODS: Patients scheduled for biopsy or excision of a skin lesion were prospectively enrolled. The expert dermatologist was asked to select the main factor that prompted him/her to excise or biopsy the lesion. RESULTS: The most common reason for melanoma excision was clinical and dermoscopic morphology (70.3%), followed by dermoscopy (11.4%), monitoring (8.9%) and clinical context (8.2%). Most basal and squamous cell carcinomas were recognized both clinically and dermoscopically, while 18.6 and 15.0%, respectively, could only be detected with dermoscopic examination. CONCLUSION: Each part of the clinical examination has a contributory role in the diagnosis of melanoma and other skin cancers.

Self-reported measure of subjective distress in response to COVID-19 pandemic in patients referred to our skin cancer unit during the first wave.

During the Italian first wave of the COVID-19 pandemic, social restrictions and bad news spread daily by mass media inevitably had a huge influence on the mental state of the population. To assess how much the COVID-19 outbreak impacted the psychologic state of patients referring to our Skin Cancer Unit from March 9 to May 31, 2020, we administered to them a self-report questionnaire, the Impact of Event Scale-Revised (IES-R). To evaluate the trend of the IES-R score over time, we set a temporal cutoff of March 27 (the day with the highest number of deaths for COVID-19 in Italy during the first wave). Three hundred fifty-five patients completed the questionnaire, reporting an average IES-R score of 25.5 (±16.4); 32.4% of participants reached a total IES-R score >32. Patients who visited after March 27, 2020 reported a higher psychologic impact, since the IES-R score significantly increased from 23.6 (±15.6) to 28.3 (±17.2). A group reported higher scores (of participants reaching an IES-R score >32, 57.4% were women and 33.9% were men). We gathered that, at an early stage of events of this magnitude, it could be useful to submit the IES-R questionnaire in high-risk and oncologic patients: we could potentially identify individuals at risk of developing post-traumatic stress disorders, who might be tempted to postpone necessary medical consultations. This could be also the basis for increasing targeted psychologic support in selected patients.

Inverse association between dietary vitamin D and risk of cutaneous melanoma in a northern Italy population.

The possibility of an inverse association between vitamin D and risk of cancer and, in particular, of cutaneous malignant melanoma has been suggested, but results of epidemiologic studies are still conflicting. We examined the relation between dietary vitamin D intake and melanoma risk through a population-based case-control study (380 cases, 719 controls) in a northern region of Italy, a country with an average vitamin D intake lower than that in northern Europe or the United States. We assessed average daily intake of vitamin D from foodstuffs using the European Prospective Investigation into Cancer and Nutrition (EPIC) semiquantitative food frequency questionnaire. In this population, levels of vitamin D intake were considerably lower than those observed in recent U.S. studies. We found an inverse relation between dietary vitamin D and melanoma risk in the sample as a whole, in both crude and adjusted analyses. In sex- and age-specific analyses, this association appeared to be stronger among males and among older subjects. These findings suggest that, at the relatively low levels of intake observed in this sample, an inverse relation between dietary vitamin D and risk of cutaneous malignant melanoma may exist.

The vast majority of lymphocytes infiltrating primary cutaneous melanoma express the CD27 costimulatory receptor: implications for melanoma progression.

Melanoma progression is favoured by prevalence, within the micro-environment of primary cutaneous melanoma, of suppressive forces, e.g. exerted by CD4(+) CD25(+) FOXP3(+) regulatory T lymphocytes, over anti-melanoma immunity, e.g. exerted by CD8(+) cytolytic T lymphocytes. The CD27 glycoprotein is crucial because it is able to identify regulatory T cells endowed with strong suppressive ability, whilst CD8(+) T cells endowed with actual cytolytic ability become CD27(-). The present in situ quantitative immunohistochemical study, including a series of double labelling experiments and morphometrical cell analyses, shows that the vast majority of lymphocytes infiltrating primary cutaneous melanoma express CD27. Specifically, virtually the entire CD4(+) CD25(+) FOXP3(+) T subset infiltrating primary cutaneous melanoma also co-expressed CD27; CD27 was, moreover, co-expressed even by the vast majority of the CD8(+) T cells, and, conversely, effector/cytotoxic CD8(+)CD27(-) cells were very scarcely represented. The overwhelming CD27 co-expression may confer on the CD4(+)CD25(+)FOXP3(+) T subset a consistent capacity to suppress anti-melanoma immunity, whereas the too low CD8(+) CD27(-) cell proportion may presumably be insufficient to confer on the CD8(+) T subset a satisfactory anti-melanoma cytotoxic activity. We therefore propose that these CD27-discriminated pathways may trigger a functional imbalance within the microenvironment of primary cutaneous melanoma, thus favouring melanoma progression.

The role of ultrasound examination for early identification of lymph-node metastasis of cutaneous squamous cell carcinoma: results from a single institutional center.

BACKGROUND: Metastasis from cutaneous squamous cell carcinoma (cSCC) mainly involve the regional nodal basin, with an incidence ranging from 2-4% until 15% in case of high-risk tumors. When dealing with high-risk cSCC, ultrasound examination is recommended every 3-4 months during follow-up. We aimed to determine the role of US examination in the early diagnosis of nodal metastasis from cSCC. METHODS: We conducted a retrospective cohort study enrolling consecutive cases of histopathologically verified cSCCs from January 2007 to March 2018. All the enrolled cases were followed for at least one year and all cases of histopathologically verified metastasis were registered. We also reported if ultrasound of the regional basin was performed between the primary diagnosis and metastasis and how the latter was identified, through ultrasounds or clinically. A Kaplan-Meier survival analysis was conducted on patients undergoing ultrasounds during follow-up. RESULTS: A total of 1881 cases, belonging to 1441 patients were included. Thirty-one cases of nodal metastasis diagnosed after the primary tumor, in as many patients, were identified. All of the selected metastasis derived from high-risk primary cSCCs. Only in 19 cases ultrasound examination was performed during follow-up; of these, 10 were diagnosed through ultrasounds and 9 clinically. Survival analysis demonstrated that the time interval between primary tumor and metastasis was significantly lower for patients with metastasis diagnosed by ultrasounds than clinically (P=0.036). CONCLUSIONS: Our study highlighted the need to optimize the use of nodal ultrasound examination for high-risk cSCCs in order to early detect metastasis.

NOSACQ-50 for Safety Climate Assessment in Agricultural Activities: A Case Study in Central Italy.

Safety climate assessment has been recognized as a powerful tool to bring to light workers' perceptions related to safety practices, attitudes and behaviors at the workplace. Accordingly, its investigation can provide useful information about safety problems within a company before accidents occur. In literature, numerous studies can be found investigating safety climates in different types of industry. However, safety climate assessment in agricultural activities is addressed scarcely, even though agriculture represents a very hazardous sector. To reduce this gap, the present study proposes an investigation of safety climate among farmers by means of the Nordic Safety Climate Questionnaire (NOSACQ-50). The results of the survey brought to light a low level of safety perception of the interviewed sample, especially as concerns safety commitment and risk-taking attitudes. In particular, a different attitude toward safety issues has been registered depending on both the position and gender of the interviewed farmers. Overall, the output of this cross-sectional analysis adds to the current literature by expanding knowledge of safety climate among farmers, representing a baseline for further investigations based on human-centered approaches to enhance safety in agriculture and consequently social and workplace aspects of sustainable agricultural systems.

Hazard function deployment: a QFD-based tool for the assessment of working tasks - a practical study in the construction industry.

Despite the efforts made, the number of accidents has not significantly decreased in the construction industry. The main reasons can be found in the peculiarities of working activities in this sector, where hazard analysis and safety management are more difficult than in other industries. To deal with these problems, a comprehensive approach for hazard analysis is needed, focusing on the activities in which a working task is articulated since they are characterized by different types of hazards and thus risk levels. The study proposes a methodology that integrates quality function deployment (QFD) and analytic network process methods to correlate working activities, hazardous events and possible consequences. This provides more effective decision-making, while reducing the ambiguity of the qualitative assessment criteria. The results achieved can augment knowledge on the usability of QFD in safety research, providing a basis for its application for further studies.

A dataset for automatic violence detection in videos.

The automatic detection of violence and crimes in videos is gaining attention, specifically as a tool to unburden security officers and authorities from the need to watch hours of footages to identify event lasting few seconds. So far, most of the available datasets was composed of few clips, in low resolution, often built on too specific cases (e.g. hockey fight). While high resolution datasets are emerging, there is still the need of datasets to test the robustness of violence detection techniques to false positives, due to behaviours which might resemble violent actions. To this end, we propose a dataset composed of 350 clips (MP4 video files, 1920 × 1080 pixels, 30 fps), labelled as non-violent (120 clips) when representing non-violent behaviours, and violent (230 clips) when representing violent behaviours. In particular, the non-violent clips include behaviours (hugs, claps, exulting, etc.) that can cause false positives in the violence detection task, due to fast movements and the similarity with violent behaviours. The clips were performed by non-professional actors, varying from 2 to 4 per clip.

Clinical and Dermoscopic Features Associated With Difficult-to-Recognize Variants of Cutaneous Melanoma: A Systematic Review.

Importance: The clinical and dermoscopic features of the vast majority of uncommon variants of cutaneous melanoma have been rarely reported, leading to difficulty in making accurate diagnoses. Objective: To define the main clinical and dermoscopic features of the most frequently reported but uncommon histologic variants of cutaneous melanoma. Evidence Review: A 2-step systematic review of the literature was performed (from inception to November 2018) using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The first step identified those uncommon variants of melanoma for which at least 1 case reporting dermoscopy was described in the literature. The keywords searched were melanoma, uncommon, rare, dermoscopy, and dermatoscopy. In the second step, each previously identified uncommon variant was searched for in the same databases by combining the following terms with melanoma, dermoscopy, and dermatoscopy: amelanotic, hypopigmented, animal, melanocytoma, balloon, desmoplastic, follicular, nested, nevoid, dermal, spitz*, spindle, and verrucous. The institution's database was also searched from January 2012 to September 2019 for histopathologically confirmed cases of the same melanoma variants. Each reviewer also assessed the quality of reporting in the included articles based on previously described guidelines. Findings: In total, 62 articles met the inclusion criteria, reporting 433 melanoma cases. An additional 56 cases of uncommon melanoma variants were retrieved from the institution's database for a total of 489 cases: 283 cases of amelanotic superficial spreading melanoma, 18 cases of animal-type and pigmented epithelioid melanocytoma, 7 cases of balloon cell melanoma, 71 cases of desmoplastic melanoma, 3 cases of follicular melanoma, 10 cases of nested melanoma, 33 cases of nevoid melanoma, 2 cases of primary dermal melanoma, 57 cases of spitzoid melanoma, and 5 cases of verrucous melanoma. These variants of melanoma occurred more frequently in women than men (147 cases vs 132 cases). Clinically, these tumors were mainly palpable (162 of 217 [74.7%]) or amelanotic (283 of 489 [57.9%]) lesions that could resemble other benign or malignant skin conditions; dermoscopy typically revealed a homogeneous pinkish background, white structures, and polymorphic vessels. The mean age of all included was 58 years (range, 1-89 years). Conclusions and Relevance: Uncommon melanoma variants may resemble both inflammatory disorders and other cutaneous neoplasms, representing a diagnostic pitfall even for the most experienced dermatologist. The purpose of this systematic review was to provide an extensive and detailed overview of specific clinical and dermoscopic features of each uncommon melanoma variant, highlighting the main criteria for differentiating these variants from other benign or malignant skin lesions.

Digital dermoscopic changes during follow-up of de-novo and nevus-associated melanoma: a cohort study.

BACKGROUND: Nevus-associated melanoma (NAM) has been regarded as a distinct biological entity from de-novo melanoma (DNM); however, static dermoscopy often fails in differentiating these entities. Digital dermoscopic monitoring allows to identify dynamic changes occurring during follow-up; this may improve diagnostic accuracy and potentially our knowledge on NAM biology. We aimed to define main independent factors associated with NAM diagnosis and those influencing follow-up time in a population of melanomas excised at follow-up. METHODS: A cohort of melanomas excised at follow-up was retrospectively and consecutively selected. NAMs and DNMs were compared according to baseline features and main dermoscopic changes occurring during follow-up. Univariate and multivariable logistic and Cox's regression analysis were performed to respectively define factors associated with NAM diagnosis and those influencing the risk for excision. RESULTS: Eighty-six melanomas were enrolled, of which 21 (24.4%) were nevus-associated. During follow-up NAMs mainly underwent atypical network modifications (47.6%), followed by inverse network (28.6%) and dermoscopic island (23.8%) worsening or appearance. DNMs were also mainly characterized by atypical network modifications (47.7%), however, a significant proportion of cases underwent irregular pigmentation/dots/globules or regression changes (29.2%), which were rarely seen among NAMs. Furthermore, both multivariable logistic and Cox's regression analysis demonstrated a significant association between NAM and a longer follow-up. CONCLUSIONS: We demonstrated that among melanomas excised at follow-up, different patterns of dermoscopic changes may be found between NAMs and DNMs. This finding, together with the association of NAM with a longer follow-up time, supports the hypothesis of different biological behavior of these two entities.

Risk Profiling from the European Statistics on Accidents at Work (ESAW) Accidents' Databases: A Case Study in Construction Sites.

The number of accidents and victims in the construction sector has not decreased significantly despite the increasingly stricter laws and regulations. The analysis of accidents, as well as their root causes and determinants can certainly contribute to the development of more effective preventive interventions. The present study proposes a methodology for the analysis and synthesis of data provided by accidents statistics with the goal of defining specific risk profiles based on the accidents determinants, their variables, and how they interact with one another in influencing the occurrence of an accident. For this purpose, a procedure capable of extracting this type of information from the European Statistics on Accidents at Work (ESAW) database was developed. In particular, data processing and aggregation are performed by means of the synergic use of the Matrix of Descriptors (MoD) and cluster analysis. To validate such a procedure, the analysis of fatalities due to electrical shocks was carried out. The results achieved allowed us to elicit valuable information for both safety managers and decision makers. The proposed methodology can facilitate a systemic analysis of accidents databases reducing the difficulties in managing reports and accident statistics.

The Safe Use of Pesticides: A Risk Assessment Procedure for the Enhancement of Occupational Health and Safety (OHS) Management.

The attention paid to the use of pesticides has increased notably in recent years as demonstrated by the issue of laws and regulations requiring their safe and environmentally-conscious use (e.g. Directive 2009/128/EC and Regulation (EC) no. 1272/2008). Despite the benefits that can be achieved by pursuing the targets of stricter legislative framework, the difficulties for farmers in complying with it are remarkable, especially for small-sized companies. In fact, in contrast to other occupational health and safety (OHS) contexts, in the case of pesticides even a preliminary analysis on the relationship between pesticide use and the consequent exposure risks for the workers is a complex task. In order to reduce the above-mentioned gap, the present study is focused on the development of an easy-to-use tool for carrying out occupational risk assessment of agricultural activities related to the use of pesticides. The procedure was developed by starting from the Agricultural Health Study (AHS) approach and its improvements, and continuing to the thorough development of a tool for preliminary risk assessment, providing a simplified model for its practical application by farmers. A case study concerning olive cultivation was used for its first verification. The results achieved should be considered as an initial step for the promotion of safer practices when using pesticides, providing a consistent base for their further validation.

Merkel cell carcinoma arising on a pre-existing Bowen's disease: is it just by chance?

Merkel cell carcinoma (MCC) is a cutaneous carcinoma with neuroendocrine differentiation. It arises typically on sun-exposed areas of elderly men as an asymptomatic, rapidly growing, red nodule. Although it is usually found as a solitary nodule, in almost one third of cases MCC may be associated with other malignancies such as basal cell or squamous cell carcinomas. Merkel cell carcinoma should be considered as differential diagnosis every time we have a rapidly growing, red nodule, arising in an elderly patient with signs of sun-damage. We report a case of MCC developing in association with a pre-existing Bowen's disease. The association between MCC and Bowen's disease is quite common and their area of occurrence is usually a sun-exposed area. Ultraviolet radiation contributes to the etiology of both the malignancies.