Accuracy of a smartphone application for triage of skin lesions based on machine learning algorithms.

BACKGROUND: Machine learning algorithms achieve expert-level accuracy in skin lesion classification based on clinical images. However, it is not yet shown whether these algorithms could have high accuracy when embedded in a smartphone app, where image quality is lower and there is high variability in image taking scenarios by users. In the past, these applications were criticized due to lack of accuracy. OBJECTIVE: In this study, we evaluate the accuracy of the newest version of a smartphone application (SA) for risk assessment of skin lesions. METHODS: This SA uses a machine learning algorithm to compute a risk rating. The algorithm is trained on 131 873 images taken by 31 449 users in multiple countries between January 2016 and August 2018 and rated for risk by dermatologists. To evaluate the sensitivity of the algorithm, we use 285 histopathologically validated skin cancer cases (including 138 malignant melanomas), from two previously published clinical studies (195 cases) and from the SA user database (90 cases). We calculate the specificity on a separate set from the SA user database containing 6000 clinically validated benign cases. RESULTS: The algorithm scored a 95.1% (95% CI, 91.9-97.3%) sensitivity in detecting (pre)malignant conditions (93% for malignant melanoma and 97% for keratinocyte carcinomas and precursors). This level of sensitivity was achieved with a 78.3% (95% CI, 77.2-79.3%) specificity. CONCLUSIONS: This SA provides a high sensitivity to detect skin cancer; however, there is still room for improvement in terms of specificity. Future studies are needed to assess the impact of this SA on the health systems and its users.

Temperature-dependent impact of thermal aminolaevulinic acid photodynamic therapy on apoptosis and reactive oxygen species generation in human dermal fibroblasts.

BACKGROUND: Actinic keratoses (AKs) are generally accepted as common precursor lesions to invasive squamous cell carcinoma. Photodynamic therapy (PDT) is a common, in-office, field therapy modality used in the treatment of AKs. Clinical and laboratory observations have demonstrated that temperature modulation can affect PDT efficacy. OBJECTIVES: To demonstrate thermal PDT increases apoptotic cell death, and to investigate the mechanistic role of reactive oxygen species (ROS) free radicals in an in vitro human skin fibroblast model. METHODS: This study was completed using commercially available primary human skin fibroblasts treated with aminolaevulinic acid (ALA) at specific concentrations and controlled temperatures. Cell death, apoptosis and superoxide ROS levels were quantified. RESULTS: We found that thermal PDT with 0·5 mmol L(-1) ALA resulted in significant temperature-dependent increases in total apoptosis and superoxide ROS generation between 33 °C and 42 °C. CONCLUSIONS: Our results indicate that thermal PDT significantly increases apoptotic cell death through increased generation of superoxide ROS in a temperature-dependent manner.

Long-term effects of a middle school- and high school-based human immunodeficiency virus sexual risk prevention intervention.

OBJECTIVE: To determine the longer-term effect (mean +/- SD, 41.2 +/- 15.3 weeks; range, 14.1-80.5 weeks) of a middle school (MS)- and high school (HS)-based human immunodeficiency virus and sexuality intervention (Rochester AIDS Prevention Project for Youth [RAPP]) on knowledge, self-efficacy, behavior intention, and behaviors. DESIGN: Quasi-experimental design with 3 intervention groups and 1 control group. SETTING: Urban, predominantly ethnic, minority MS and HS health classes. PARTICIPANTS: Middle school and HS students (N = 4001) enrolled in health classes in 10 schools. Fifty percent were African American; 16%, Hispanic; 20%, white; and 14%, other. Less than 10% of the students refused participation. INTERVENTIONS: There were 4 study conditions: (1) control, usual health education curriculum taught by a classroom teacher; (2) RAPP adult health educator, intervention curriculum implemented by highly trained health educators; (3) RAPP peer educator, intervention implemented by extensively trained HS students; and (4) a comparison of the RAPP intervention curriculum taught by regular health teachers, implemented with MS students only. MAIN OUTCOME MEASURE: A confidential questionnaire was administered to all study subjects before and at long-term follow-up after the intervention, containing scales to measure knowledge, self-efficacy, behavior intention, and behaviors, including onset of sexual intercourse experience and engagement in risky sexual behaviors. RESULTS: Rates of baseline sexual activity in the sample were comparable to those found in other urban school-based surveys. Long-term knowledge (MS females, P<.001; and MS males, P<.01) and sexual self-efficacy (MS females, P<.05; and HS females, P<.01) scores were higher among the intervention groups (male and female are used in this study to describe those aged 9(1/2)-23 years). Intention to remain safe regarding sexual behavior was also greater among intervention groups in MS but not HS. However, subjects who were already sexually active at pretest were less likely to show a positive intervention effect. An intervention effect for the onset of intercourse and risky sexual behavior was found most significantly among MS females. CONCLUSIONS: A positive long-term effect from the RAPP intervention was observed, particularly for youth who were involved in less risk (eg, not yet sexually active) at study enrollment. Thus, we propose that the most appropriate time for intervention implementation is earlier in adolescence, before the onset of risky behaviors.

Artificial skin for closure and healing of wounds created by skin cancer excisions.

BACKGROUND: A dermal regeneration template indicated for life-threatening third-degree burn injuries is a product with potential application to smaller wounds to aid in healing and closure of complex excision sites. OBJECTIVE: To assess the effectiveness of dermal regeneration template for closure of skin cancer excision sites that would have otherwise required complicated closures. METHODS: Five patients, 61-84 years old, with skin cancer surgery yielding a total of six wounds were treated with the dermal regeneration template to close and heal their wounds. RESULTS: Four of five patients had complete healing (five of six wounds) with cosmetically acceptable results. The one treatment failure was application of the dermal regeneration template over exposed skull where inadequate neodermis formed. Successful healing was observed in five complex skin cancer excision sites including two wounds in previously irradiated grafted skin, a large and deep temporal defect, a wide excision in the supraclavicular region, and an excision down to cartilage on the antihelix of the ear. No infections were noted, although in four of five patients prophylactic oral antibiotics (either erythromycin or cephalexin) were prescribed postoperatively for 1-2 weeks. CONCLUSION: The product simplified wound care, subjectively appeared to decrease pain and postoperative bleeding, and yielded cosmetically acceptable wound repair. Autografting was not necessary; wounds healed in 2-4 months by epithelialization over neodermis after removal of the silicone layer. Furthermore, the product was a convenient long-term dressing and healing device for wounds where complex repairs, autografts, and/or flaps would otherwise be considered for closure.

Contact sensitivity and recalcitrant wounds.

Allergic contact dermatitis is a common and under-recognized phenomenon in patients with recalcitrant wounds. There are many possible causes including components of numerous agents used to treat these wounds, such as topical antibiotics, adhesives in dressings, emollients, emulsifiers, and self-administered medicaments. Considering allergic contact dermatitis when a wound is recalcitrant is important in the management of wounds. Etiologic agents, controversies, pathogenesis, diagnosis, and management of contact sensitivity are discussed.

Myofibroblast phenotype and apoptosis in keloid and palmar fibroblasts in vitro.

Keloid formation is a wound healing response, which fails to resolve and leads to formation of a raised collagen mass extending beyond the original wound margins. Keloids are typically excluded from palms and soles. Therefore we compared keloid and palmar fibroblasts in vitro using fibroblasts from nonaffected individuals as controls. Collagen I, alpha-smooth muscle actin and thrombospondin-1 were found at higher levels in keloid than in palmar fibroblasts. These differences were ameliorated by addition of TGFbeta1. The potential for resolution of the wound healing response was estimated analyzing apoptosis during serum starvation. Annexin V and TUNEL assays showed that palmar fibroblasts underwent faster apoptosis, than did the keloid fibroblasts, and started detaching. Addition of TGFbeta1 counteracted this effect. The weak expression of the myofibroblast phenotype and the advanced apoptosis of palmar fibroblasts suggest mechanisms for the exclusion of keloids from palmar sites.

Sexual behavior, contraception, and risk among college students.

PURPOSE: To characterize the differences and similarities among college freshmen, sophomores, juniors, and seniors regarding their sexual behavior including contraception choices and human immunodeficiency virus (HIV) risk. METHODS: A 41-item sexual behavior questionnaire designed for this study was administered to a convenience sample (N = 797) of a college population. RESULTS: Levels of sexual activity were found to be comparable to other college-based surveys. Notable trends included an increased level of oral contraceptive use among partners reported by seniors, as compared to freshmen, without a corresponding increase in condom use; an increased reliance among seniors, as compared to freshmen, on women to provide contraception; and a low level of self or partner HIV testing either before or after initiating sexual intercourse. Gender differences also revealed greater partner relationship duration, intensity, and communication prior to initiating sexual intercourse among women versus men (p < or = .001). CONCLUSIONS: Sexual behavior among college students differs across the 4 years with regard to rates of intercourse, contraception choice, and responsibility, as well as HIV testing and partner trust. University- and college-based health care programs should address sexual behavior with an awareness of the differences that exist in the four cohorts of students.

PIP: This study aimed to describe the differences and similarities among college freshmen, sophomores, juniors, and seniors concerning their sexual behavior, including contraception choices and HIV risk. The sample (N = 797; mean age = 19 years) were taken from a private 4-year undergraduate college and represented 17% of the college population. It consisted of 474 (60%) females and 318 (40%) males. They were interviewed through the use of a 41-item questionnaire administered in a cross-sectional survey design. In the results, levels of sexual activity were similar to other college-based surveys with 72% reporting ever having had sexual intercourse. The average age of first sexual intercourse was 16.8 years for females and 16.7 for males; 358 (45%) were currently sexually active. Condoms were the most common contraception used, followed by oral contraceptives. The primary purpose in choosing a contraceptive was prevention of both pregnancy and disease. Seniors had increased level of oral contraceptive use and increased reliance on women to provide contraception as compared to freshmen. The percentage of students who had undergone HIV testing also increased from freshman (16%) to senior (32%) years. As to gender differences, women reported greater partner relationship duration, intensity, and communication prior to initiating sexual intercourse as compared to men. In conclusion, college-based health care programs should address sexual behavior with an awareness of the differences that exist in the 4 cohorts of students.

Prefilled syringes: safe and effective.

BACKGROUND: Preloaded syringes are time savers, but questions have arisen anecdotally about the risk of infection from this procedure and the possible loss of potency, especially when performed with buffered syringes. OBJECTIVE: To show that preloaded syringes do not develop colonies of bacterial organisms and to confirm that anesthetic potency is maintained for at least 2 weeks. METHODS: Thirty-six syringes were stored for a period of 2 weeks on a shelf in our clinical procedure area with no protection from heat or light. The majority of these were then cultured for bacteria and fungi and one of them was used on one of the authors to determine the potency of the anesthetic. RESULTS: Preloaded syringes do not appear to be prone to the development of bacterial contamination for at least a 2-week period and potency of the anesthetic is maintained. CONCLUSION: Preloaded syringes are time savers and are a safe modality for use in the practicing dermatology office.

Early effects of a school-based human immunodeficiency virus infection and sexual risk prevention intervention.

OBJECTIVE: To determine the short-term effect of a middle and high school-based human immunodeficiency virus and sexuality intervention (Rochester AIDS Prevention Project for Youth [RAPP]) on knowledge, self-efficacy, and behavior intention. DESIGN: Nonrandomized intervention study with 2 intervention groups and 1 control group. SETTING: Middle and high school health classes in an urban, predominantly minority school district. PARTICIPANTS: Middle and high school students (N = 3635) enrolled in health classes in 9 schools; 50% African American, 16% Hispanic, 20% white, and 14% other. Less than 10% of students refused participation. INTERVENTION: There were 3 study conditions: (1) Control, usual health education curriculum taught by classroom teacher; (2) RAPP adult health educator, intervention curriculum implemented by ethnically diverse male-female pairs of highly trained health educators; and (3) RAPP peer educator, intervention implemented by male-female pairs of extensively trained high school students. Health classes within schools were assigned to 1 of the 3 conditions each semester, and simultaneous implementation of the control program with health educators or peer educators in the same school and during the same semester was not permitted. MAIN OUTCOME MEASURE: A confidential questionnaire administered to all study subjects before and immediately after the intervention, containing scales to measure knowledge, sexual self-efficacy, and safe behavior intention. RESULTS: Preintervention data indicated that the study population was involved in sexual activity and other risk behaviors at rates comparable to those of other urban adolescent populations. Examination of 3 outcome constructs as dependent variables (knowledge, sexual self-efficacy, and safe behavior intention) revealed that the health educators and peer educators increased students' knowledge significantly more than did the control condition for both middle (females, P<.01; males, P<.01) and high (females, P<.001; males, P<.001) school. Comparisons of self-efficacy changes across intervention groups did not reach statistical significance, and safe behavior intention changes differed significantly by intervention group for high school but not for middle school students. For all analyses, the preintervention scores for each outcome variable were the most powerful predictors of postintervention scores, and analysis of variance models predicted substantial overall variance. CONCLUSIONS: At short-term follow-up, the RAPP intervention had a powerful effect on knowledge for all students and a moderate effect on sexual self-efficacy and safe behavior intention, particularly for high school students. The peer educators were found to be equally and, for some variables, more effective than the highly trained adult educators. The substantial effect of the baseline scores and the high prevalence of risk behavior already evident by seventh grade indicate the importance of early implementation of school-based sexuality programs.

Experimental rationale for treatment of high-risk human melanoma with zinc chloride fixative paste. Increased resistance to tumor challenge in murine melanoma model.

BACKGROUND: Fixed-tissue micrographic surgery (Mohs) of melanoma has been shown by retrospective analysis to improve 5-year survival. OBJECTIVES: To determine whether zinc chloride fixative paste acts as an immune adjuvant to increase host resistance to melanoma. METHODS: We performed a murine study using the poorly immunogenic B16 melanoma of C57Bl6J mice, and the more immunogenic K1735p melanoma of C3H/HeN mice. Tumors were treated with zinc chloride paste and excised 24 hours later (Group 1), or simply excised (Group 2). Mice were challenged 7 days later with injection of melanoma cells at a distant site, and tumor growth in this second site was followed. RESULTS: K1735p melanomas developed at the challenge site in 69% of mice treated with excision versus 32% of mice treated with zinc chloride fixation (P < 0.025). Development of B16 melanoma was not altered by zinc chloride fixation. CONCLUSION: Zinc chloride fixation of the more immunogenic K1735p melanoma increased resistance to subsequent tumor challenge, suggesting that zinc chloride fixative paste acts as an immune adjuvant.

Self-reported honesty among middle and high school students responding to a sexual behavior questionnaire.

PURPOSE: To determine self-reported honesty in completing a sexual and other risk behavior questionnaire among middle and high school students, and to relate honesty scores to sexual behavior item responses as a method to detect bias in reporting. METHODS: A self-administered questionnaire measuring overall honesty (7-point rating scale), sexual honesty (5-category scale), and selected sex behaviors was used. Urban, predominantly minority middle and high schools (Grades 7-12) were examined, and participants were 3144 male and female students in middle (mean age = 13.7 +/- 2.0) and high (17.3 +/- 1.6) school health classes. RESULTS: The majority of students stated that they had been very or completely honest in responding to items on the questionnaire. Seventy-eight percent of middle school males (lowest rate), and 94% of high school females (highest rate) reported honesty. Middle school males were most likely to declare dishonesty regarding sexual behavior items, overstating their actual behavior (14%), while middle school girls were most likely to understate (8%) their behavior. Self-reported sexual honesty and reports of behavior were most consistent for understaters. That is, those subjects who answered that their questionnaire responses underreported their true sexual behavior did, in fact, report lower sexual activity on selected survey items. CONCLUSION: Middle and late adolescents reported high levels of honesty in responding to a sexuality-related questionnaire. When interpreting such questionnaire data, correction for the tendency to overstate among middle school males and understate among middle school females should be considered; conclusions about self-reports of sexual behavior among young adolescents need to take into account degree of honesty. However, the presence of some overreported and some underreported behavior does not invalidate interpretation of the overall survey findings.

Fibromyalgia syndrome in children and adolescents: clinical features at presentation and status at follow-up.

OBJECTIVES: To 1) describe the characteristic features of fibromyalgia syndrome (FS) in a pediatric population, 2) note similarities and differences with FS in adults, and 3) determine outcome after treatment. SETTING AND DESIGN: The Pediatric Rheumatology Clinic at the University of Rochester Medical Center is staffed by two pediatric rheumatologists and serves as a regional subspecialty referral service with approximately 450 annual patient visits, of which approximately 120 are initial evaluations. A retrospective medical record review from 1989 to 1995 was used to identify and describe the study population, and a structured telephone interview served to determine current status and response to treatment. RESULTS: A total of 45 subjects were identified (41 female; 42 white; mean age, 13.3 years), of whom 33 were available for telephone interview at a mean of 2.6 years from initial diagnosis (0.1 to 7.6 years). Of a possible 15 symptoms associated with FS, subjects reported a mean of 8, with >90% experiencing diffuse pain and sleep disturbance. Less frequent were headaches (71%), general fatigue (62%), and morning stiffness (53%). The mean cumulative number of tender points summed over all visits was 9.7 (of 18). Telephone interviews showed improvement in most patients, with a mean positive change of 4.8 on a self-rating scale of 1 to 10 comparing current status to worst-ever condition. CONCLUSIONS: FS in patients referred to a pediatric rheumatology clinic is characterized by diffuse pain and sleep disturbance, the latter being more common than that in adults. The mean number of tender points summed over all visits is fewer than the criterion of 11 established for adults at a single visit. The majority of patients improved over 2 to 3 years of follow-up.

Drug treatment of juvenile arthritis: accepted therapeutic options.

Juvenile arthritis (JA) is classified into 3 subtypes based primarily on clinical characteristics (sign and symptoms) at onset. For all patients with JA, drug therapy begins with nonsteroidal antiinflammatory drugs (NSAIDs) from which there are a number of pediatric approved compounds to choose. If disease activity persists after an adequate NSAID trial, a second-line agent, typically methotrexate, is added. In patients with a small number of resistant joints, in the absence of other illness manifestations, intraarticular corticosteroids (triamcinolone hexacetonide) can be used to induce remission. Some children with severe JA, particularly systemic onset disease, will require the addition of systemic corticosteroids for symptom control. Further treatment has been less well evaluated but includes intravenous immunoglobulin, drug combination cytotoxic therapy and biologic agents. The latter will be increasingly studied in the pediatric population in the future, but are currently reserved for severely unresponsive disease. Management of JA extends beyond drugs, to incorporate occupational and physical therapy, appropriate mental health care and a family centered strategy that seeks to achieve the highest attainment and quality of life for these patients and their families.