RESUMO
We call on dermatologists and dermatopathologists to include nail clipping histopathology as an essential component of the routine evaluation of melanonychia. This manuscript demonstrates a case where an adult woman with broad melanonychia of the right thumbnail declined a nail matrix biopsy, but was amenable to a nail clipping.The nail clipping showed pigmentation, melanocyte remnants, and small cavities in the nail plate. These features have been published previously by our group as a clue to nail unit melanoma within nail clippings.This patient was rapidly triaged for nail matrix biopsy, which demonstrated nail unit melanoma in situ. Every patient with melanonychia can benefit from a nail clipping by examination of the location of the pigmentation within the nail plate for surgical planning, and if melanocyte remnants are detected, the nail clipping also serves as a rapid triage mechanism for nail matrix biopsy to evaluate for nail unit melanoma. Fontana-stained sections will highlight the pigmentation in the nail plate, and its location in the nail plate can easily be described by the dermatopathologist. Nail clippings performed in the setting of clinically apparent melanonychia may show helpful histopathologic findings of pigmented fungi, hemorrhage, external pigmentation, features of other pigmented nail unit tumors, as well as other entities. Nail clipping histopathology can provide extensive information in the evaluation of melanonychia with minimal discomfort for a patient, and little disruption to a physician's clinic flow. With this additional case of a nail unit melanoma diagnosed after initial concern found in a nail clipping, as well as other information in the literature, it is clear that melanocyte remnants found in nail clippings are reliable concerning features related to nail unit melanoma in adults. With knowledge of these histopathologic features in nail clippings and the significance of melanocyte remnants, the dermatopathologist can play a crucial role in the use of a nail clipping as a life-saving diagnostic maneuver. Accordingly, given the potential benefit to patients in this setting, as well as other uses of a nail clipping in the evaluation of melanonychia, we call on dermatologists and dermatopathologists to innovate the routine evaluation of melanonychia through the routine employment of nail clippings for histopathologic evaluation.
Assuntos
Melanoma , Doenças da Unha , Transtornos da Pigmentação , Neoplasias Cutâneas , Adulto , Feminino , Humanos , Triagem , Doenças da Unha/diagnóstico , Doenças da Unha/cirurgia , Doenças da Unha/patologia , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/cirurgia , Neoplasias Cutâneas/patologia , Unhas/cirurgia , Unhas/patologia , Melanoma/diagnóstico , Melanoma/cirurgia , Melanoma/patologia , Transtornos da Pigmentação/patologiaRESUMO
A 26-year-old male presented with a 2-year history of a hyperkeratotic growth from the left index finger. Histopathology was consistent with an acquired digital fibrokeratoma with changes of a pleomorphic fibroma. Lesional cells were negative for CD34, Rb, and p53, and were positive for FXIIIa. We introduce the pleomorphic acquired digital fibrokeratoma as a novel clinicopathologic entity.
Assuntos
Fibroma , Neoplasias Cutâneas , Masculino , Humanos , Adulto , Neoplasias Cutâneas/patologia , Dedos/patologia , Fibroma/patologia , Antígenos CD34RESUMO
Melanoma of the nail apparatus is challenging to diagnose for both dermatologists and dermatopathologists. Misdiagnosis or delayed diagnosis of nail unit melanoma can have fatal consequences and legal ramifications. This review educates dermatopathologists on challenges and traps they should be aware of to avoid misdiagnosis of nail unit melanoma. We present illustrative difficult cases that introduce several themes regarding challenges in the diagnosis of nail unit melanoma: specimens with subtle histopathologic findings, challenges in immunoperoxidase interpretation, and how clinical knowledge and surgical procedural knowledge are mandatory to make the diagnosis. Dermatopathologists will be aware of when and how to suspect nail unit melanoma in unusual circumstances.
Assuntos
Melanoma , Doenças da Unha , Neoplasias Cutâneas , Humanos , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/patologia , Doenças da Unha/diagnóstico , Doenças da Unha/patologia , Melanoma/diagnóstico , Melanoma/patologia , Unhas/patologia , Erros de Diagnóstico , SíndromeRESUMO
OBJECTIVE: To the authors' knowledge, no data have been reported on dopamine fluctuations on subsecond timescales in humans with alcohol use disorder (AUD). In this study, dopamine release was monitored in 2 patients with and 2 without a history of AUD during a "sure bet or gamble" (SBORG) decision-making task to begin to characterize how subsecond dopamine responses to counterfactual information, related to psychological notions of regret and relief, in AUD may be altered. METHODS: Measurements of extracellular dopamine levels were made once every 100 msec using human voltammetric methods. Measurements were made in the caudate during deep brain stimulation electrode implantation surgeries (for treatment of movement disorders) in patients who did (AUD, n = 2) or did not (non-AUD, n = 2) have a history of AUD. Participants performed an SBORG decision-making task in which they made choices between sure bets and 50%-chance monetary gamble outcomes. RESULTS: Fast changes were found in dopamine levels that appear to be modulated by "what could have been" and by patients' AUD status. Positive counterfactual prediction errors (related to relief) differentiated patients with versus without a history of AUD. CONCLUSIONS: Dopaminergic encoding of counterfactual information appears to differ between patients with and without AUD. The current study has a major limitation of a limited sample size, but these data provide a rare insight into dopaminergic physiology during real-time decision-making in humans with an addiction disorder. The authors hope future work will expand the sample size and determine the generalizability of the current results.
Assuntos
Alcoolismo , Humanos , Alcoolismo/terapia , Dopamina , EmoçõesRESUMO
Large neurofibromas often cause significant patient morbidity and present a unique challenge to dermatologists and surgeons. Radical resection offers the lowest rate of recurrence but is not often pursued due to the high risk of intraoperative hemorrhage and difficulty in repairing large defects. Subtotal resection and debulking are more frequently performed, leading to higher rates of recurrence. This case highlights a particularly large neurofibroma and demonstrates how surgical techniques like preoperative embolization and advancement flaps can improve outcomes in the radical resection of large neurofibromas.
Assuntos
Neurofibroma , Cirurgiões , Humanos , Neurofibroma/cirurgia , Retalhos CirúrgicosRESUMO
BACKGROUND: Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs. OBJECTIVE: This review systematically analyzes the use of chemical peels for treatment of AKs. MATERIALS AND METHODS: A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs. RESULTS: Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas. CONCLUSION: Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.
Assuntos
Cáusticos/administração & dosagem , Abrasão Química/estatística & dados numéricos , Ceratose Actínica/cirurgia , Carcinoma Basocelular/epidemiologia , Carcinoma Basocelular/patologia , Carcinoma Basocelular/prevenção & controle , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/prevenção & controle , Cáusticos/efeitos adversos , Abrasão Química/efeitos adversos , Humanos , Ceratose Actínica/patologia , Recidiva , Prevenção Secundária/métodos , Prevenção Secundária/estatística & dados numéricos , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/prevenção & controle , Resultado do TratamentoRESUMO
Pigmented epithelioid melanocytoma (PEM) represents a group of rare, heavily pigmented melanocytic tumors encompassing lesions previously designated as "animal-type melanomas" and "epithelioid blue nevi." Despite the association of multiple such tumors in the setting of Carney complex, most cases of PEM occur spontaneously as solitary neoplasms in otherwise healthy patients. PEM may arise in both children and adults, and has a known propensity to spread to the regional lymph nodes. Despite this latter finding, recurrence at the biopsy site or spread beyond the lymph node basin is exceptionally uncommon. Although the molecular basis for PEM continues to be characterized, findings to date suggest that this category of melanocytic neoplasia has genetic alterations distinct from those seen in common nevi, dysplastic nevi, Spitz nevi, and melanoma. Herein, we present an in-depth clinical, histopathologic, and molecular analysis of a case of PEM occurring on the scalp of a young African American girl found to have a novel NTRK3-SCAPER gene fusion.
Assuntos
Proteínas de Transporte , Aberrações Cromossômicas , Cromossomos Humanos Par 15 , Cromossomos Humanos Par 17 , Receptor com Domínio Discoidina 2 , Neoplasias de Cabeça e Pescoço , Nevo Azul , Proteínas de Fusão Oncogênica , Proteínas de Transporte/genética , Proteínas de Transporte/metabolismo , Pré-Escolar , Cromossomos Humanos Par 15/genética , Cromossomos Humanos Par 15/metabolismo , Cromossomos Humanos Par 17/genética , Cromossomos Humanos Par 17/metabolismo , Receptor com Domínio Discoidina 2/genética , Receptor com Domínio Discoidina 2/metabolismo , Feminino , Neoplasias de Cabeça e Pescoço/genética , Neoplasias de Cabeça e Pescoço/metabolismo , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Nevo Azul/genética , Nevo Azul/metabolismo , Neoplasias Cutâneas/genética , Neoplasias Cutâneas/metabolismo , Neoplasias Cutâneas/patologiaAssuntos
Doenças da Unha , Unhas , Humanos , Fenômenos Magnéticos , Doenças da Unha/patologia , Unhas/patologiaRESUMO
Primary care visits provide an opportunity for skin examinations with the potential to reduce melanoma mortality. The INFORMED (INternet curriculum FOR Melanoma Early Detection) Group developed a Web-based curriculum to improve primary care providers' (PCPs') skin cancer detection skills. This study details feedback obtained from participant focus groups, including the feasibility of implementing in other PCP practices. Practicing PCPs at Henry Ford Health System and Kaiser Permanente Northern California completed the curriculum. Feedback sessions were conducted with standardized questions focusing on four domains: (1) overall impressions of the curriculum, (2) recommendations for improvement, (3) current skin examination practices, and (4) suggestions for increasing skin screening by PCPs. Discussions at each site were audio recorded, transcribed verbatim, and de-identified. Providers (N = 54) had a positive impression of the Web-based curriculum, with suggestions to provide offline teaching aids and request assistance. Despite having improved confidence in diagnosing malignant lesions, many providers felt a lack of confidence in performing the screening and time constraints affected their current practices, as did institutional constraints. Providers intended to increase discussion with patients about skin cancer. The accessibility, effectiveness, and popularity of the curriculum indicate potential for implementation in the primary care setting. Participating providers noted that institutional barriers remain which must be addressed for successful dissemination and implementation.
Assuntos
Currículo , Pessoal de Saúde/educação , Intenção , Internet , Melanoma/diagnóstico , Neoplasias Cutâneas/diagnóstico , California , Educação Médica Continuada , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Melanoma/prevenção & controle , Atenção Primária à Saúde , Neoplasias Cutâneas/prevenção & controle , Fatores de TempoAssuntos
Hipopigmentação , Micose Fungoide , Criança , Família , Humanos , Hipopigmentação/diagnósticoRESUMO
Timing behaviour and the perception of time are fundamental to cognitive and emotional processes in humans. In non-human model organisms, the neuromodulator dopamine has been associated with variations in timing behaviour, but the connection between variations in dopamine levels and the human experience of time has not been directly assessed. Here, we report how dopamine levels in human striatum, measured with sub-second temporal resolution during awake deep brain stimulation surgery, relate to participants' perceptual judgements of time intervals. Fast, phasic, dopaminergic signals were associated with underestimation of temporal intervals, whereas slower, tonic, decreases in dopamine were associated with poorer temporal precision. Our findings suggest a delicate and complex role for the dynamics and tone of dopaminergic signals in the conscious experience of time in humans.
RESUMO
Impulse Control Disorder (ICD) in Parkinson's disease is a behavioral addiction induced by dopaminergic therapies, but otherwise unclear etiology. The current study investigates the interaction of reward processing variables, dopaminergic therapy, and risky decision-making and subjective feelings in patients with versus without ICD. Patients with (n = 18) and without (n = 12) ICD performed a risky decision-making task both 'on' and 'off' standard-of-care dopaminergic therapies (the task was performed on 2 different days with the order of on and off visits randomized for each patient). During each trial of the task, participants choose between two options, a gamble or a certain reward, and reported how they felt about decision outcomes. Subjective feelings of 'pleasure' are differentially driven by expectations of possible outcomes in patients with, versus without ICD. While off medication, the influence of expectations about risky-decisions on subjective feelings is reduced in patients with ICD versus without ICD. While on medication, the influence of expected outcomes in patients with ICD versus without ICD becomes similar. Computational modeling of behavior supports the idea that latent decision-making factors drive subjective feelings in patients with Parkinson's disease and that ICD status is associated with a change in the relationship between factors associated with risky behavior and subjective feelings about the experienced outcomes. Our results also suggest that dopaminergic medications modulate the impact expectations have on the participants' subjective reports. Altogether our results suggest that expectations about risky decisions may be decoupled from subjective feelings in patients with ICD, and that dopaminergic medications may reengage these circuits and increase emotional reactivity in patients with ICD.
Assuntos
Transtornos Disruptivos, de Controle do Impulso e da Conduta , Doença de Parkinson , Humanos , Motivação , Doença de Parkinson/tratamento farmacológico , Emoções , Dopamina , RecompensaAssuntos
Acne Vulgar/induzido quimicamente , Alopecia/induzido quimicamente , Hirsutismo/induzido quimicamente , Dispositivos Intrauterinos Medicados , Levanogestrel/efeitos adversos , Menorragia/tratamento farmacológico , Acne Vulgar/epidemiologia , Alopecia/epidemiologia , Feminino , Hirsutismo/epidemiologia , Humanos , Incidência , Levanogestrel/administração & dosagem , Levanogestrel/uso terapêutico , Inquéritos e QuestionáriosRESUMO
PURPOSE: To determine the anatomic characteristics and pharmacokinetic properties of intravitreally placed bevacizumab and ranibizumab after pars plana lensectomy or pars plana vitrectomy and to compare these with nonoperated control eyes in a rabbit model. METHODS: Three groups of six Dutch-belted rabbits each underwent pars plana vitrectomy, pars plana lensectomy, or served as nonsurgical controls. Twelve days after surgery, 3 rabbits from each group underwent intravitreal injection in one eye with 1.25 mg/0.05 mL I-124-bevacizumab or 0.5 mg/0.05 mL I-124-ranibizumab. Serial imaging with integrated positron emission and computed tomography (PET/CT) were obtained on Days 0, 2, 5, 7, 14, 21, 28, and 35. Measured radioactivity emission in becquerels/milliliter was used to calculate the half-lives for each agent. RESULTS: The intravitreally placed radiolabeled agents were contained within the vitreous cavity for the duration of the study. The average clearance half-lives with standard error for bevacizumab and ranibizumab after correction for radioactive decay were, respectively, 4.22 ± 0.07 days and 2.81 ± 0.05 days in unoperated eyes, 2.30 ± 0.09 days (P < 0.0001) and 2.13 ± 0.05 days (P < 0.0001) after vitrectomy, and 2.08 ± 0.07 days (P = 0.0001) and 1.79 ± 0.05 days (P < 0.0001) after lensectomy. CONCLUSION: Intravitreal retention was longer for bevacizumab than ranibizumab within all study groups and was significantly reduced after vitrectomy and lensectomy for both agents. Consideration for more frequent intravitreal anti-vascular endothelial growth factor dosing regimens may be made for patients whose treated eyes have undergone previous vitrectomy or who are aphakic.
Assuntos
Inibidores da Angiogênese/farmacocinética , Anticorpos Monoclonais Humanizados/farmacocinética , Extração de Catarata , Vitrectomia , Inibidores da Angiogênese/administração & dosagem , Animais , Anticorpos Monoclonais Humanizados/administração & dosagem , Bevacizumab , Injeções Intravítreas , Taxa de Depuração Metabólica , Modelos Animais , Coelhos , RanibizumabRESUMO
The eye is a model organ for the local delivery of therapeutics. This proves beneficial when treating vitreous inflammation and other ophthalmic pathologies. The chronicity of certain diseases, however, limits the effectiveness of locally administered drugs. To maintain such treatments often requires frequent office visits and can result in increased risk of infection and toxicity to the patient. This paper focuses on the implantable devices and particulate drug delivery systems that are currently being implemented and investigated to overcome these challenges. Implants currently on the market or undergoing clinical trials include those made of nonbiodegradable polymers, containing ganciclovir, fluocinolone acetonide, triamcinolone acetonide, and ranibizumab, and biodegradable polymers, containing dexamethasone, triamcinolone acetonide, and ranibizumab. Investigational intravitreal implants and particulate drug delivery systems, such as nanoparticles, microparticles, and liposomes, are also explored in this review article.