Automated Prediction of Photographic Wound Assessment Tool in Chronic Wound Images.

Many automated approaches have been proposed in literature to quantify clinically relevant wound features based on image processing analysis, aiming at removing human subjectivity and accelerate clinical practice. In this work we present a fully automated image processing pipeline leveraging deep learning and a large wound segmentation dataset to perform wound detection and following prediction of the Photographic Wound Assessment Tool (PWAT), automatizing the clinical judgement of the adequate wound healing. Starting from images acquired by smartphone cameras, a series of textural and morphological features are extracted from the wound areas, aiming to mimic the typical clinical considerations for wound assessment. The resulting extracted features can be easily interpreted by the clinician and allow a quantitative estimation of the PWAT scores. The features extracted from the region-of-interests detected by our pre-trained neural network model correctly predict the PWAT scale values with a Spearman's correlation coefficient of 0.85 on a set of unseen images. The obtained results agree with the current state-of-the-art and provide a benchmark for future artificial intelligence applications in this research field.

First Ex Vivo Animal Study of a Biological Heart Valve Prosthesis Sensorized with Intravalvular Impedance.

IntraValvular Impedance (IVI) sensing is an innovative concept for monitoring heart valve prostheses after implant. We recently demonstrated IVI sensing feasible in vitro for biological heart valves (BHVs). In this study, for the first time, we investigate ex vivo the IVI sensing applied to a BHV when it is surrounded by biological tissue, similar to a real implant condition. A commercial model of BHV was sensorized with three miniaturized electrodes embedded in the commissures of the valve leaflets and connected to an external impedance measurement unit. To perform ex vivo animal tests, the sensorized BHV was implanted in the aortic position of an explanted porcine heart, which was connected to a cardiac BioSimulator platform. The IVI signal was recorded in different dynamic cardiac conditions reproduced with the BioSimulator, varying the cardiac cycle rate and the stroke volume. For each condition, the maximum percent variation in the IVI signal was evaluated and compared. The IVI signal was also processed to calculate its first derivative (dIVI/dt), which should reflect the rate of the valve leaflets opening/closing. The results demonstrated that the IVI signal is well detectable when the sensorized BHV is surrounded by biological tissue, maintaining the similar increasing/decreasing trend that was found during in vitro experiments. The signal can also be informative on the rate of valve opening/closing, as indicated by the changes in dIVI/dt in different dynamic cardiac conditions.

Percutaneous ablation or minimally invasive partial nephrectomy for cT1a renal masses? A propensity score-matched analysis.

OBJECTIVE: Local tumor ablation to treat small renal mass is increasing. The aim of the present study was to compare oncologic outcomes among patients with T1 renal mass treated with partial nephrectomy and local tumor ablation. METHODS: To reduce the inherent differences between patients undergoing laparoscopic or robot-assisted partial nephrectomy (n = 405) and local tumor ablation (n = 137), we used a 1:1 propensity score-matched analysis. Local tumor ablation consisted of radiofrequency ablation and cryoablation. Disease-free survival, overall survival and other causes mortality-free survival rates were estimated using the Kaplan-Meier method. Multivariable logistic regression and competing-risk regression models were used to identify predictors of complications, recurrence and other causes mortality, respectively. RESULTS: Partial nephrectomy had higher disease-free survival estimates, as compared with local tumor ablation (92.8% vs 80.4% at 5 years, P = 0.02), with no significant difference between radiofrequency ablation and cryoablation (P = 0.9). Ablation showed comparable overall survival estimates to partial nephrectomy (91% vs 95.8% at 5 years, P = 0.6). The 5-year recurrence rates were 7.9% versus 23.8% for patients aged ≤70 years, and 2.5% versus 11.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively; the 5-year other causes mortality rates were 0% and 2.2% for patients treated with partial nephrectomy and ablation aged ≤70 years, and 3% versus 10.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively. At multivariable analysis, ablation was associated with fewer complications (odds ratio 0.41; P = 0.01). At competing risks analysis, age (hazard ratio 0.96) and ablation (hazard ratio 4.56) were independent predictors of disease recurrence (all P ≤ 0.008). CONCLUSIONS: Local tumor ablation showed a higher risk of recurrence and lower risk of complications compared with partial nephrectomy, with comparable overall survival rates.

Innovative IntraValvular Impedance Sensing Applied to Biological Heart Valve Prostheses: Design and In Vitro Evaluation.

Subclinical valve thrombosis in heart valve prostheses is characterized by the progressive reduction in leaflet motion detectable with advanced imaging diagnostics. However, without routine imaging surveillance, this subclinical thrombosis may be underdiagnosed. We recently proposed the novel concept of a sensorized heart valve prosthesis based on electrical impedance measurement (IntraValvular Impedance, IVI) using miniaturized electrodes embedded in the valve structure to generate a local electric field that is altered by the cyclic movement of the leaflets. In this study, we investigated the feasibility of the novel IVI-sensing concept applied to biological heart valves (BHVs). Three proof-of-concept prototypes of sensorized BHVs were assembled with different size, geometry and positioning of the electrodes to identify the optimal IVI-measurement configuration. Each prototype was tested in vitro on a hydrodynamic heart valve assessment platform. IVI signal was closely related to the electrodes' positioning in the valve structure and showed greater sensitivity in the prototype with small electrodes embedded in the valve commissures. The novel concept of IVI sensing is feasible on BHVs and has great potential for monitoring the valve condition after implant, allowing for early detection of subclinical valve thrombosis and timely selection of an appropriate anticoagulation therapy.

Effectiveness of Semi-Supervised Active Learning in Automated Wound Image Segmentation.

Appropriate wound management shortens the healing times and reduces the management costs, benefiting the patient in physical terms and potentially reducing the healthcare system's economic burden. Among the instrumental measurement methods, the image analysis of a wound area is becoming one of the cornerstones of chronic ulcer management. Our study aim is to develop a solid AI method based on a convolutional neural network to segment the wounds efficiently to make the work of the physician more efficient, and subsequently, to lay the foundations for the further development of more in-depth analyses of ulcer characteristics. In this work, we introduce a fully automated model for identifying and segmenting wound areas which can completely automatize the clinical wound severity assessment starting from images acquired from smartphones. This method is based on an active semi-supervised learning training of a convolutional neural network model. In our work, we tested the robustness of our method against a wide range of natural images acquired in different light conditions and image expositions. We collected the images using an ad hoc developed app and saved them in a database which we then used for AI training. We then tested different CNN architectures to develop a balanced model, which we finally validated with a public dataset. We used a dataset of images acquired during clinical practice and built an annotated wound image dataset consisting of 1564 ulcer images from 474 patients. Only a small part of this large amount of data was manually annotated by experts (ground truth). A multi-step, active, semi-supervised training procedure was applied to improve the segmentation performances of the model. The developed training strategy mimics a continuous learning approach and provides a viable alternative for further medical applications. We tested the efficiency of our model against other public datasets, proving its robustness. The efficiency of the transfer learning showed that after less than 50 epochs, the model achieved a stable DSC that was greater than 0.95. The proposed active semi-supervised learning strategy could allow us to obtain an efficient segmentation method, thereby facilitating the work of the clinician by reducing their working times to achieve the measurements. Finally, the robustness of our pipeline confirms its possible usage in clinical practice as a reliable decision support system for clinicians.

3D Patient-Specific Virtual Models for Presurgical Planning in Patients with Recto-Sigmoid Endometriosis Nodules: A Pilot Study.

Background and Objective: In recent years, 3D printing has been used to support surgical planning or to guide intraoperative procedures in various surgical specialties. An improvement in surgical planning for recto-sigmoid endometriosis (RSE) excision might reduce the high complication rate related to this challenging surgery. The aim of this study was to build novel presurgical 3D models of RSE nodules from magnetic resonance imaging (MRI) and compare them with intraoperative findings. Materials and Methods: A single-center, observational, prospective, cohort, pilot study was performed by enrolling consecutive symptomatic women scheduled for minimally invasive surgery for RSE between November 2019 and June 2020 at our institution. Preoperative MRI were used for building 3D models of RSE nodules and surrounding pelvic organs. 3D models were examined during multi-disciplinary preoperative planning, focusing especially on three domains: degree of bowel stenosis, nodule's circumferential extension, and bowel angulation induced by the RSE nodule. After surgery, the surgeon was asked to subjectively evaluate the correlation of the 3D model with the intra-operative findings and to express his evaluation as "no correlation", "low correlation", or "high correlation" referring to the three described domains. Results: seven women were enrolled and 3D anatomical virtual models of RSE nodules and surrounding pelvic organs were generated. In all cases, surgeons reported a subjective "high correlation" with the surgical findings. Conclusion: Presurgical 3D models could be a feasible and useful tool to support surgical planning in women with recto-sigmoidal endometriotic involvement, appearing closely related to intraoperative findings.

Tailored Sac Embolization During EVAR for Preventing Persistent Type II Endoleak.

BACKGROUND: Persistent type II endoleaks (ELIIp) occur in 8-23% of patients submitted to endovascular aneurysm repair (EVAR) and may lead to aneurysm progression and rupture. Intraoperative embolization of the abdominal aortic aneurysm (AAA) sac is effective to prevent their occurrence, however a method to achieve complete sac thrombosis has not been standardized yet. Aim of our study was to identify factors associated with prevention of ELIIp after intraoperative embolization, in order to optimize technical details. METHODS: Patients at high risk for ELIIp, who underwent EVAR with AAA - sac coil embolization were prospectively collected into a dedicated database from January 2012 to March 2015. The endoluminal residual sac volume (ERV), not occupied by the endograft [ERV= AAA total volume (TV) - (AAA-thrombus volume (THV) + endograft volume (EgV)] was calculated on preoperative computed tomography and the concentration of coils implanted (CCoil= n coils implanted/ERV) for each patient was evaluated. AAA volumetric evaluation was conducted by dedicated vessels analysis software (3Mensio). ELIIp presence was evaluated by contrast-enhanced ultrasound at 6 and 12-month. Patients with ELIIp at 12 months (Group 1) were clustered and compared to patients without ELIIp (Group 2), in order to evaluate the incidence of ELIIp in patients undergone to preventive AAA-sac embolization, and identify the predictors of ELIIp prevention. Morphological potential risk factors for ELIIp such as TV, THV, VR% and EgV were also considered in all patients. Statistical correlation was assessed by Fisher Exact Test. RESULTS: Among 326 patients undergone to standard EVAR, 61 (19% - M: 96.7%, median age: 72 [IQR: 8] years, median AAA diameter: 57 [IQR: 7] mm) were considered at high risk for ELIIp and were submitted to coil embolization. The median AAA total volume (TV) and median ERV were 156 (IQR: 59) cc and 46 (IQR: 26) cc, respectively. The median number and concentration of coils (IMWCE-38-16-45 Cook M-Ray) positioned in AAA-sac were 5 (IQR: 1) coils and 0.17 coil/cm3 (range 0.02-1.20). Among this high-risk population, the incidence of ELIIp was 29.5% and 23% at 6 and 12-month, respectively. Fourteen patients (23%) were clustered in Group1 and 47 (77%) in Group 2. Both groups were homogeneous for clinical characteristics and preoperative morphological risk factors. There were no differences in the preoperative median TV, AAA-thrombus volume (THV), %VR, EgV and number of implanted coils between Group1 and Group2. Patients in Group1 had a significantly higher ERV (59 [IQR: 13] cm3 vs. 42 [IQR: 27] cm3, P = 0.002) and lower CCoil (0.09 [IQR: 0.03] vs. 0.18 [IQR: 0.21], P = 0.006) than patients of Group2. ELIIp was significantly related to the presence of ERV > 49 cm3 (86 % vs. 42 %, Group1 and Group2 respectively, P = 0.006) and CCoil < 0.17coil/ cm3 (100% vs. 68%, Group1 e Group2 respectively, P = 0.014). CONCLUSION: According with our results, Coil concentration and endoluminal residual volume can affect the efficacy of the AAA - sac embolization in the prevention of ELIIp, moreover CCoil ≥0.17coil/ cm3 maight be considered to determine the tailored number of coils.

Development of a CO2 Sensor for Extracorporeal Life Support Applications.

Measurement of carbon dioxide (CO2) in medical applications is a well-established method for monitoring patient's pulmonary function in a noninvasive way widely used in emergency, intensive care, and during anesthesia. Even in extracorporeal-life support applications, such as Extracorporeal Carbon Dioxide Removal (ECCO2R), Extracorporeal Membrane Oxygenation (ECMO), and cardiopulmonary by-pass (CPB), measurement of the CO2 concentration in the membrane oxygenator exhaust gas is proven to be useful to evaluate the treatment progress as well as the performance of the membrane oxygenator. In this paper, we present a new optical sensor specifically designed for the measurement of CO2 concentration in oxygenator exhaust gas. Further, the developed sensor allows measurement of the gas flow applied to the membrane oxygenator as well as the estimation of the CO2 removal rate. A heating module is implemented within the sensor to avoid water vapor condensation. Effects of temperature on the sensor optical elements of the sensors are disclosed, as well as a method to avoid signal-temperature dependency. The newly developed sensor has been tested and compared against a reference device routinely used in clinical practice in both laboratory and in vivo conditions. Results show that sensor accuracy fulfills the requirements of the ISO standard, and that is suitable for clinical applications.

Basal Cell Carcinoma: A Comprehensive Review.

Basal cell carcinoma (BCC) is the most common type of carcinoma worldwide. BCC development is the result of a complex interaction between environmental, phenotypic and genetic factors. However, despite the progress in the field, BCC biology and mechanisms of resistance against systemic treatments have been poorly investigated. The aim of the present review is to provide a revision of BCC histological and molecular features, including microRNA (miRNA) dysregulation, with a specific focus on the molecular basis of BCC systemic therapies. Papers from the last ten years regarding BCC genetic and phenotypic alterations, as well as the mechanism of resistance against hedgehog pathway inhibitors vismodegib and sonidegib were included. The involvement of miRNAs in BCC resistance to systemic therapies is emerging as a new field of knowledge.

How does 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography impact the management of patients with prostate cancer recurrence after surgery?

OBJECTIVE: To evaluate the clinical impact of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography on the planned management of prostate cancer patients with biochemical recurrence after surgery. METHODS: We enrolled 276 prostate cancer patients referred to 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography due to biochemical recurrence after surgery (two consecutive prostate-specific antigen assays ≥0.2 ng/mL). First, the detection rate of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography was assessed according to different prostate-specific antigen levels. Second, the independent predictors of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography positive results were assessed. Finally, the intended treatment before revision of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography was assessed by a multidisciplinary team based on the European Association of Urology guidelines, patient clinical condition and clinical parameters. Then, re-assessment of the treatment plan was prospectively recorded by the same board after revision of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography. The effective clinical impact of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography was rated as major (change in therapeutic approach), minor (same treatment, but modified therapeutic strategy) or none. RESULTS: The overall detection rate of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography was 47.5%. Prostate-specific antigen at 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (odds ratio 3.52) and prostate-specific antigen doubling time <3 months (odds ratio 3.98) were independent predictors of positive 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography results (all P ≤ 0.03). 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography led to a major treatment change in 177 cases (64.1%), with a minor clinical impact of 2.5%. The overall clinical impact of 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography was 42.4%, 27.7%, 21.2% and 8.7% in men with prostate-specific antigen at 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography of 0.2-0.4, 0.5-1, 1.1-2 and >2 ng/mL, respectively. CONCLUSIONS: 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography allows clinicians to radically change the intended treatment approach before imaging evaluation, in roughly two out three individuals.

An Implantable Sensorized Lead for Continuous Monitoring of Cardiac Apex Rotation.

Changes in the pattern or amplitude of cardiac rotation have been associated with important cardiovascular diseases, including Heart Failure (HF) which is one of the major health problems worldwide. Recent advances in echocardiographic techniques have allowed for non-invasive quantification of cardiac rotation; however, these examinations do not address the continuous monitoring of patient status. We have presented a newly developed implantable, transvenous lead with a tri-axis (3D) MEMS gyroscope incorporated near its tip to measure cardiac apex rotation in the three-dimensional space. We have named it CardioMon for its intended use for cardiac monitoring. If compared with currently proposed implantable systems for HF monitoring based on the use of pressure sensors that can have reliability issues, an implantable motion sensor like a gyroscope holds the premise for more reliable long term monitoring. The first prototypal assembly of the CardioMon lead has been tested to assess the reliability of the 3D gyroscope readings. In vitro results showed that the novel sensorized CardioMon lead was accurate and reliable in detecting angular velocities within the range of cardiac twisting velocities. Animal experiments will be planned to further evaluate the CardioMon lead in in vivo environments and to investigate possible endocardial implantation sites.

A Novel Sensorized Heart Valve Prosthesis: Preliminary In Vitro Evaluation.

BACKGROUND: Recent studies have shown that subclinical valve thrombosis in heart valve prosthesis (HVP) can be responsible for reduced leaflet motion detectable only by advanced imaging diagnostics. We conceived a novel sensorized HVP able to detect earlier any thrombus formation that may alter the leaflets motion using an electric impedance measurement, IntraValvular Impedance (IVI). METHODS: For IVI measurement, dedicated electrodes are embedded in the structure of the HVP to generate a local electric field that is altered by the moving valve leaflets during their cyclic opening/closing. We present preliminary in vitro results using a first prototype of sensorized mechanical heart valve connected to an external impedance measurement system. The prototype was tested on a circulatory mock loop system and the IVI signals were recorded during both normal dynamics and experimentally induced altered working of the leaflets. RESULTS: Recordings showed a very repetitive and stable IVI signal during the normal cyclic opening/closing of the HVP. The induced alterations in leaflet motion were reflected in the IVI signal. CONCLUSIONS: The novel sensorized HVP has great potential to give early warning of possible subclinical valve thrombosis altering the valve leaflet motion, and to help in tailoring the anticoagulation therapy.

Effect of intermediate ZrO2-CaO coatings deposited by cold thermal spraying on the titanium-porcelain bond in dental restorations.

STATEMENT OF PROBLEM: Metal ceramic systems are used for the majority of dental crowns and fixed dental prostheses. However, problems with porcelain bonding are encountered when titanium is used as the substrate. PURPOSE: The purpose of this study was to evaluate the effect of intermediate calcium oxide-stabilized zirconia (ZrO2-CaO) coatings deposited by cold thermal spraying on the titanium-porcelain bonding in dental restorations. MATERIAL AND METHODS: Two different types of ZrO2-CaO coatings obtained by oxyacetylene cold thermal spraying deposition were applied on commercially pure titanium bars before adding the porcelain layer. Type 1 was obtained by directly spraying the ZrO2-CaO powder on the titanium substrate. Type 2 was obtained by spraying a bond coat of nickel-aluminum-molybdenum alloy before spraying the ZrO2-CaO powder. Three-point bend tests according to International Organization of Standardization 9693-1:2012 were carried out to evaluate the debonding strength for the ZrO2-CaO-coated specimens (types 1 and 2) in comparison with a noncoated group (control), which received a traditional bonder-based adhesive technique. The results were compared with ANOVA, followed by the Student-Newman-Keuls test for pairwise comparisons. Scanning electron microscopy and energy dispersion spectroscopy were used to examine the interfacial properties and the failure mode of each group. RESULTS: Mean (±standard deviation) debonding strength values for type 1 coating (25.97 ±2.53 MPa) and control (23.51 ±2.94 MPa) were near the acceptable lower limit of 25 MPa indicated by the International Organization of Standardization 9693-1:2012 and were not significantly different (Student-Newman-Keuls test, P>.05). Type 2 coating produced an improved titanium-porcelain bonding (debonding strength=39.47 ±4.12 MPa), significantly higher than both type 1 (Student-Newman-Keuls test, P<.05) and control (Student-Newman-Keuls test, P<.05). Scanning electron microscopy-energy dispersion spectroscopy analysis confirmed these findings, which revealed a predominant cohesive failure mode for type 2. CONCLUSIONS: An intermediate coating layer of ZrO2-CaO plus a substrate of bonding nickel-aluminum-molybdenum alloy applied by oxyacetylene cold thermal spraying deposition provided an improved titanium-porcelain bond.

Morpho-functional analysis of the temporomandibular joint following mandible-first bimaxillary surgery with mandible-only patient-specific implants.

The aim of this study was to evaluate condylar and glenoid fossa remodeling after bimaxillary orthognathic surgery guided by patient-specific mandibular implants. In total, 18 patients suffering from dentofacial dysmorphism underwent a virtually planned bimaxillary mandibular PSI-guided orthognathic procedure. One month prior to surgery, patients underwent a CBCT scan and optical scans of the dental arches; these datasets were re-acquired 1 month and at least 9 months postsurgery. Three-dimensional models of the condyles, glenoid fossae, and interarticular surface space (IASS) were obtained and compared to evaluate the roto-translational positional discrepancy and surface variation of each condyle and glenoid fossa, and the IASS variation. The condylar position varied by an average of 4.31° and 2.18 mm, mainly due to surgically unavoidable ramus position correction. Condylar resorption remodeling was minimal (average ≤ 0.1 mm), and affected skeletal class III patients the most. Later condylar remodeling was positively correlated with patient age. No significant glenoid fossa remodeling was observed. No postoperative orofacial pain was recorded at clinical follow-up. The procedure was accurate in minimizing the shift in relationship between the bony components of the TMJ and their remodeling, and was effective in avoiding postoperative onset of orofacial pain. An increase in sample size, however, would be useful to confirm our findings.

Post-printing processing and aging effects on Polyjet materials intended for the fabrication of advanced surgical simulators.

Material Jetting (MJ) 3D printing technology is promising for the fabrication of highly realistic surgical simulators, however, the changes in the mechanical properties of MJ materials after post-printing treatments and over time remain quite unknown. In this study, we investigate the effect of different post-printing processes and aging on the mechanical properties of a white opaque and rigid MJ photopolymer, a white flexible MJ photopolymer and on a combination of them. Tensile and Shore hardness tests were conducted on homogeneous 3D-printed specimens: two different post-printing procedures for support removal (dry and water) and further surface treatment (with glycerol solution) were compared. The specimens were tested within 48 h from printing and after aging (30-180 days) in a controlled environment. All groups of specimens treated with different post-printing processes (dry, water, glycerol) exhibited a statistically significant difference in mechanical properties (i.e. elongation at break, elastic modulus, ultimate tensile strength). Particularly, the treatment with glycerol makes the flexible photopolymer more rigid, but then with aging the initial elongation of the material tends to be restored. For the rigid photopolymer, an increase in deformability was observed as a major effect of aging. The hardness tests on the printed specimens highlighted a significant overestimation of the Shore values declared by the manufacturer. The study findings are useful for guiding the material selection and post-printing processing techniques to manufacture realistic and durable models for surgical training.

Dissecting human anatomy learning process through anatomical education with augmented reality: AEducAR 2.0, an updated interdisciplinary study.

Anatomical education is pivotal for medical students, and innovative technologies like augmented reality (AR) are transforming the field. This study aimed to enhance the interactive features of the AEducAR prototype, an AR tool developed by the University of Bologna, and explore its impact on human anatomy learning process in 130 second-year medical students at the International School of Medicine and Surgery of the University of Bologna. An interdisciplinary team of anatomists, maxillofacial surgeons, biomedical engineers, and educational scientists collaborated to ensure a comprehensive understanding of the study's objectives. Students used the updated version of AEducAR, named AEducAR 2.0, to study three anatomical topics, specifically the orbit zone, facial bones, and mimic muscles. AEducAR 2.0 offered two learning activities: one explorative and one interactive. Following each activity, students took a test to assess learning outcomes. Students also completed an anonymous questionnaire to provide background information and offer their perceptions of the activity. Additionally, 10 students participated in interviews for further insights. The results demonstrated that AEducAR 2.0 effectively facilitated learning and students' engagement. Students totalized high scores in both quizzes and declared to have appreciated the interactive features that were implemented. Moreover, interviews shed light on the interesting topic of blended learning. In particular, the present study suggests that incorporating AR into medical education alongside traditional methods might prove advantageous for students' academic and future professional endeavors. In this light, this study contributes to the growing research emphasizing the potential role of AR in shaping the future of medical education.

Italian National Registry of Alopecia Areata: an epidemiological study of 699 Italian patients.

BACKGROUND: Alopecia areata (AA) is an organ-specific autoimmune disease that affects the hair follicles of the scalp and the rest of the body causing hair loss. Due to the unpredictable course of AA and the different degrees of severity of hair loss, only a few well-designed clinical studies with a low number of patients are available. Also, there is no specific cure, but topical and systemic anti-inflammatory and immune system suppressant drugs are used for treatment. The need to create a global registry of AA, comparable and reproducible in all countries, has recently emerged. An Italian multicentric electronic registry is proposed as a model to facilitate and guide the recording of epidemiological and clinical data and to monitor the introduction of new therapies in patients with AA. METHODS: The aim of this study was to evaluate the epidemiological data of patients with AA by collecting detailed information on the course of the disease, associated diseases, concomitant and previous events, and the clinical response to traditional treatments. Estimate the impact on the quality of life of patients. RESULTS: The creation of the National Register of AA has proven to be a valid tool for recording, with a standardized approach, epidemiological data, the trend of AA, response to therapies and quality of life. CONCLUSIONS: AA is confirmed as a difficult hair disease to manage due to its unpredictable course and, in most cases, its chronic-relapsing course, capable of having a significant impact on the quality of life of patients.