Reflectance confocal microscopy diagnostic accuracy for malignant melanoma in different clinical settings: systematic review and meta-analysis.

BACKGROUND: The diagnostic accuracy of reflectance confocal microscopy (RCM) of cutaneous malignant melanoma (MM) seems promising. However, clinical scenarios in which RCM is most useful are still to be established. OBJECTIVES: To assess the diagnostic accuracy of RCM for MM diagnosis according to study design, lesion type and diagnostic modality. Secondary outcomes include a comparison with dermoscopy. METHODS: A systematic literature search was conducted on PubMed, Embase, Scopus and Cochrane Public Library Databases for English articles published prior to January 2019. Statistical analyses were conducted with Meta-Disc v. 1.4, STATA 14.0 software and the QUADAS-2 tool. RESULTS: A total of 32 studies (7352 lesions) were included in the meta-analysis. Pooled sensitivity and specificity resulted 92% (95% CI: 0.91-0.93) and 70% (95% CI: 0.69-0.71), respectively. According to study design, diagnostic sensitivity was high for all study types, confirming a lower specificity for prospective interventional studies. Diagnostic accuracy remained high for all lesion types, with the highest specificity obtained for consecutive lesions of 77% (95% CI: 0.75-0.78) vs. 65% (95% CI: 0.63-0.66) for lesions highly suspicious for MM. RCM diagnostic accuracy was superior to dermoscopy, most notably in terms of specificity of 56% (95% CI: 0.52-0.60) vs. 38% (95% CI: 0.34-0.42), respectively. Studies were generally assessed across all domains as low or unclear risk of bias with a mainly low concern regarding applicability of evidence. Publication bias was asymmetrical (11.2 ± 4.0; 95% CI 2.97-19.43; P < 0.01). CONCLUSIONS: Independent of study design, RCM has a high diagnostic power for MM detection, and unnecessary excisions are reduced compared to dermoscopy. This reduction is most evident in non-decisional RCM scenarios and for lesions analysed at RCM consecutively compared to those selected highly suspicious for MM. However, the scarcity, heterogeneity and bias associated with the data in literature should be considered when interpreting present conclusions.

Seborrheic keratoses mimicking melanoma unveiled by in vivo reflectance confocal microscopy.

BACKGROUND: Seborrheic keratoses (SebK) with atypical dermoscopy presentation are increasingly reported. These lesions do not exhibit typical dermoscopy features of SebK and sometimes mimic melanoma, thus complicating the differential diagnosis. Reflectance confocal microscopy (RCM) is a non-invasive tool, which allows an in vivo imaging of the skin. The study objectives were to evaluate the agreement between RCM classification and histological diagnoses, and the reliability of well-known RCM criteria for SebK in the identification of SebK with atypical dermoscopy presentation. MATERIALS AND METHODS: We retrospectively analysed at RCM excised lesions presenting in dermoscopy ≥1 score at revisited 7-point checklist. The study population consisted of cases showing no melanocytic RCM findings. Lesions were investigated for distinct non-melanocytic RCM features, blinded from histopathology diagnoses. Histopathology matching was then performed before statistical analysis. RESULTS: The study consisted of 117 cases, classified at RCM as SebK (71 cases), dermatofibroma (18 cases), basal cell carcinoma (13 cases), squamous cell carcinoma (2 cases), and "non-specific" (13 cases). Overall K strength of agreement at histopathology matching proved 0.76. Of the 71 cases classified at RCM with SebK, agreement was achieved in 97%. CONCLUSION: Reflectance confocal microscopy classification proved high agreement with histopathology for SebK with atypical dermoscopy presentations, allowing an early differential diagnosis. RCM features in this group of lesions were similar to those described for typical cases of SebK, and may assist clinician therapy decision making, whilst avoiding unnecessary excisions.

Drug-induced panniculitides.

A substantial number of all panniculitides fails to recognize a specific etiology, and that is true also for a relatively frequent type of panniculitis, such as erythema nodosum (EN). Between the recognized causative factors of panniculitides, infectious, physical agents, autoimmune mechanisms and neoplastic disorders are well known. On the contrary, the role of drugs as inducers of panniculitides is marginally considered, and their report limited to anecdotal observations, often without due histopathological support. Since the clinical and histopathological features of drug-induced panniculitides are indistinguishable from those caused by other agents, the causative relationship may be demonstrated by the history of previous drug intake and by clinical improvement after drug discontinuation. We reviewed the currently reported descriptions of drug-induced panniculitis, including a few exemplificative original observations. EN results as the most frequently reported drug-induced panniculitis. Among the causative drugs of EN a variety of medications, with disparate, or even opposite, mechanisms of action are reported, thus limiting the understanding of the pathogenesis. Common causative drugs include oral contraceptives, nonsteroidal anti-inflammatory drugs, antiobiotics and leukotriene-modifying agents. Unfortunately, in several cases, the diagnosis of drug-induced EN is done on clinical findings alone. In those cases, the lack of histopathological support does not allow to define a precise clinicopathological correlation on etiologic grounds. Drug-induced lobular and mixed panniculitides, including eosinophilic panniculitis, are even more rarely described. Reported causative agents are glatiramer acetate, interferon beta and heparin (at sites of injections), and systemic steroids, tyrosine kinase inhibitors and BRAF with subcutaneous fat involvement at distance. In view of the recent introduction of new classes of drugs, attention should be paid to disclose their possible etiologic role in inducing among other side effects, also panniculitides.

Histopathologic spectrum of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): a diagnosis that needs clinico-pathological correlation.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is characterized by an heterogeneous group of severe dermatologic manifestations and systemic involvement, due to several groups of medicaments. A series of 9 consecutive cases, observed from 2008 to 2013 in the Department of Dermatology, University of Pavia, is reported, all satisfying the clinical, hematological and systemic diagnostic criteria of DRESS. Clinically, 4 out of 9 patients had an urticarial and papular eruption, 2 an erythema-multiforme-like (EM-like) pattern, 2 erythroderma and 1 had an erythematous and macular reaction. Aim of the study was to describe the histopathologic features of DRESS and to trace a possible correlation between the four clinical recognized types of the syndrome and the histopathological patterns. Predominantly, a superficial perivascular lymphocytic infiltrate, extravasation of erythrocytes, and focal interface changes characterized DRESS cases. Less frequently, histopathology revealed the presence of necrotic keratinocytes; surprisingly, only in 2 cases the presence of rare dermal eosinophils was detected, even if all the patients had significant peripheral eosinophilia. A histopathological diagnosis of DRESS seems per se, according to our data, not feasible, since the main histopathological changes (interface changes, superficial perivascular dermatitis, focal spongiosis, lichenoid infiltrate, rare presence of necrotic keratinocytes) can be interpreted generically as a drug induced dermatitis. The above mentioned histopathological changes, however, when associated with clinical information on cutaneous and systemic involvement of the patient, allow the pathologist or the dermatopathologist to make a diagnosis of DRESS with a reliable margin of certainty.

Post-surgical lipophagic panniculitis: a specific model of traumatic panniculitis and new histopathological findings.

Aim of this work was to define the histopathological features of post-surgical panniculitis. Dermal and hypodermal changes will be analyzed in detail, to understand the cascade of events that characterize the tissue response to surgical trauma. Cutaneous re-excision specimens of cases of basal cell carcinoma, squamous cell carcinoma, and melanoma consecutively seen from January 1, 2011 to June 30, 2011 at the Department of Dermatology, University of Pavia, were included in this study. Only the cases in which the first surgical procedure included the subcutaneous fat, were considered. In addition, the time elapsed from the first surgical procedure and the re-excision had to be included in a period of time from one to three months. All the specimens were stained with hematoxylin and eosin. Thirty cutaneous re-excision specimens were studied. Histopathologic examination revealed changes of epidermis, ranging from slight atrophy to moderate hyperplasia. In two cases focal ulceration was seen, with transfollicular elimination of foreign body material. The main dermal changes observed were the: 1) scar with well defined vertical orientation along the dermal suture line; 2) rounded cicatricial areas with radial branching septa of scarring tissue; 3) foreign body granuloma formation; 4) alignment of hystiocytes at the dermo-hypodermal border; 5) traumatic neuromas. The subcutaneous fat changes included: 1) lobular panniculitis with consistent presence of foam cells; 2) striking anisocytosis with pseudocystic degeneration and necrosis of adipocytes; 3) eritrocyte extravasation, mainly at the dermo-hypodermal border; 4) deep seated phlebitis. Post-surgical panniculitis is a lobular foam cell panniculitis characterized by simultaneous dermal and hypodermal changes, expression of the multi-faceted tissue response to a surgical trauma. This type of peculiar lipophagic response puts post-surgical panniculitis into the wider chapter of lipophage tissue response seen in atherosclerosis, glomerulosclerosis and some infectious models such as Mycobacterium tuberculosis and Chlamydia pneumoniae infections. Furthermore it may be seen as a reliable and convenient model for laboratory investigation on foam cell tissue response.

First record of Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) from Brazil and description of the female of Conostigmus binasutus Dessart & Cancemi, 1986.

Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) is reported for the first time from Brazil. Here, we provide a diagnosis of Conostigmus binasutus Dessart & Cancemi, 1986 and the description and illustration of the female, previously unknown. The analyzed material was collected utilizing Malaise traps, in Manaus, Amazon, Brazil and deposited at the Invertebrate collection of INPA (Instituto Nacional de Pesquisas da Amazônia) of Manaus. A identification key and distribution map to the Neotropical species of Conostigmus is provided.

First record of Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) from Brazil and description of the female of Conostigmus binasutus Dessart & Cancemi, 1986 / Primeiro registro de Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) para o Brasil e descrição da fêmea de Conostigmus binasutus Dessart & Cancemi, 1986

Abstract Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) is reported for the first time from Brazil. Here, we provide a diagnosis of Conostigmus binasutus Dessart & Cancemi, 1986 and the description and illustration of the female, previously unknown. The analyzed material was collected utilizing Malaise traps, in Manaus, Amazon, Brazil and deposited at the Invertebrate collection of INPA (Instituto Nacional de Pesquisas da Amazônia) of Manaus. A identification key and distribution map to the Neotropical species of Conostigmus is provided.

Resumo Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) é relatado pela primeira vez no Brasil. Aqui, nós fornecemos a diagnose de Conostigmus binasutus Dessart & Cancemi, 1986 e descrição e ilustração da fêmea, desconhecida anteriormente. O material analisado foi coletado utilizando armadilha Malaise, em Manaus, Amazonas, Brasil, e está depositado na Coleção de invertebrados do INPA (Instituto Nacional de Pesquisas da Amazônia) de Manaus. Além disso, é apresentada uma chave de identificação e mapa de distribuição das espécies Neotropicais de Conostigmus.

Cardiac and respiratory function after bone marrow transplantation in children with leukaemia.

Late cardiac and respiratory function changes were evaluated in children surviving disease-free more than 2 years after bone marrow transplantation (BMT) performed for haematological malignancies. Forty-one children received allogeneic and 10 autologous BMT. In all cases studied shortening fraction (SF) was always within normal limits from before BMT up to 4 years after BMT. SF, though still normal, was slightly lower in the group with higher pre-BMT cumulative anthracycline dose. Twenty-eight children underwent respiratory function tests regularly at all scheduled times (pre-BMT, +6 months, +1, +2, +3, +4 years after BMT). Vital capacity and total lung capacity showed a slight continuous decrease which was significant at 4 years after BMT (P = 0.015 and P = 0.003 respectively). The decline of forced expiratory volume in 1 s observed 1 year after BMT (P = 0.002) was roughly maintained over time. However, no children complained of symptoms attributable to respiratory dysfunction, and all indices studied were always within normal limits in almost all patients. So far late cardiac and lung changes following BMT in children seem to be negligible. However, whether such abnormalities could further worsen and impair adult quality of life remains to be ascertained.

[The use of urokinase and ammonium chloride in unblocking a central venous catheter in a child with acute lymphoblastic leukemia]. / Uso dell'urokinasi e del cloruro d'ammonio nella disostruzione di un catetere venoso centrale in un bambino con leucemia linfoblastica acuta.

Central venous catheter (C.V.C.) mechanical obstruction in immunocompromised patients can yield several complications sometime life-threatening and can be promptly solved by thrombolytic treatment. The authors describe a case of a child affected by acute lymphoblastic leukemia and experiencing an obstruction of his C.V.C. very difficult to treat with conventional urokinase treatment. Thinking the lack of success to be attributed to a calcium thrombus, the Authors before pulling out the C.V.C., made use of ammonium chloride solution in order to obtain the disappearance of the little bag covering the tip of C.V.C. The treatment was successful as confirmed by the contrast medium examination and the use of C.V.C. lasted for several months without other mechanical obstruction. In our best knowledge this is one of the first attempts with such ammonium chloride solution which have been used successful and rather safely. The only drug induced symptoms were constituted by mild and transient vomiting. Owing to this positive experience the authors believe useful to confirm this treatment in other cases. In this contest an experienced hematoncology team must take care of C.V.C. related complications.

First record of Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) from Brazil and description of the female of Conostigmus binasutus Dessart & Cancemi, 1986

Abstract Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) is reported for the first time from Brazil. Here, we provide a diagnosis of Conostigmus binasutus Dessart & Cancemi, 1986 and the description and illustration of the female, previously unknown. The analyzed material was collected utilizing Malaise traps, in Manaus, Amazon, Brazil and deposited at the Invertebrate collection of INPA (Instituto Nacional de Pesquisas da Amazônia) of Manaus. A identification key and distribution map to the Neotropical species of Conostigmus is provided.

Resumo Conostigmus Dahlbom, 1858 (Hymenoptera: Megaspilidae) é relatado pela primeira vez no Brasil. Aqui, nós fornecemos a diagnose de Conostigmus binasutus Dessart & Cancemi, 1986 e descrição e ilustração da fêmea, desconhecida anteriormente. O material analisado foi coletado utilizando armadilha Malaise, em Manaus, Amazonas, Brasil, e está depositado na Coleção de invertebrados do INPA (Instituto Nacional de Pesquisas da Amazônia) de Manaus. Além disso, é apresentada uma chave de identificação e mapa de distribuição das espécies Neotropicais de Conostigmus.

Final height of patients who underwent bone marrow transplantation during childhood.

OBJECTIVE: To determine the impact on final adult height of bone marrow transplantation. METHODS: The final height of 28 long term survivors (18 males; 10 females), allografted before or at the onset of puberty, at a median age of 10.8 years (range 6.3 to 14.6) and who did not receive growth hormone (GH) treatment or other growth promoting agents, was evaluated. Median follow up period after bone marrow transplantation was 7.9 years (range 3.2 to 11.4), and age at the most recent evaluation 18.1 years (range 15.6 to 24.5). Height values were expressed in standard deviation score (SDS) from the mean of the normal population. Height at bone marrow transplantation was compared with final height as well as with parental genetic height. Patients were divided into three groups: severe aplastic anaemia (SAA): three patients given no radiotherapy; leukaemia-total body irradiation (TBI): 14 patients with acute or chronic leukaemia conditioned with chemotherapy and TBI; leukaemia-TBI with previous cranial radiation therapy (CRT): 11 patients. None of the patients had solid tumour. RESULTS: There was a decrease in final height SDS compared to pre-transplantation height SDS (paired t test, p < 0.0001). All patients except one reached an adult height above -2.0 SDS. A significant decrease in height SDS was found in the TBI and the CRT groups (paired t test, p = 0.02 and p = 0.0002, respectively). Whereas height SDS value at the time of transplant was higher than the genetic height SDS, final height SDS values were lower. CONCLUSIONS: Despite the decrease in height SDS found after bone marrow transplantation, 27 of the 28 patients spontaneously achieved what is considered to be a normal height SDS (above -2.0 SDS). This should be taken into account when considering GH treatment in children who underwent bone marrow transplantation for malignant haematological diseases.

Immunity to polioviruses and tetanus after bone marrow transplantation in children.

Immunity to tetanus toxoid and polioviruses was studied in 34 (27 allografted, 7 autografted) children who underwent bone marrow transplantation (BMT). At a median time of 3 years after BMT, only one recipient was seronegative for tetanus toxoid. On the contrary 73% of children were seronegative for at least one of the three poliovirus types and 30% for all virus types. Undetectable antibody titers were more frequently found against type 3 than the other two types. We recommend that reimmunizations of children after BMT be based on serologic tests for antibody titers.

Mechanical and infective central venous catheter-related complications: a prospective non-randomized study using Hickman and Groshong catheters in children with hematological malignancies.

The aim of this study was to compare the Hickman and Groshong central venous catheters (CVCs) for incidence and severity of catheter-related complications in children. Seventy-three patients with hematological malignancies were observed, 42 with Groshong CVCs and 31 with Hickman CVCs. The number of infective episodes per 100 CVC-days was not significantly different (0.25 in the Hickman group versus 0.13 in the Groshong group; P = 0.24). The most frequent type of CVC-related infection in both groups was microbiologically documented sepsis; in most cases Gram-positive bacteria were isolated. Neutropenia (P < 0.001 for both CVCs) and hospital CVC management (P = 0.0047 for the Hickman group, P < 0.001 for the Groshong group) emerged as the major risk factors for the outbreak of infections. The rate of mechanical complication episodes per 100 CVC-days was similar in both groups (1.01 in the Hickman group versus 1.1 in the Groshong group: P = 0.58). Some complications (fissures, ruptures, total lumen obstruction by clots) occurred only in the Groshong group. Our study did not demonstrate any statistically significant difference in the incidence of mechanical and infective CVC-related complications between these two types of catheter.