Human surface anatomy terminology for dermatology: a Delphi consensus from the International Skin Imaging Collaboration.

BACKGROUND: There is no internationally vetted set of anatomic terms to describe human surface anatomy. OBJECTIVE: To establish expert consensus on a standardized set of terms that describe clinically relevant human surface anatomy. METHODS: We conducted a Delphi consensus on surface anatomy terminology between July 2017 and July 2019. The initial survey included 385 anatomic terms, organized in seven levels of hierarchy. If agreement exceeded the 75% established threshold, the term was considered 'accepted' and included in the final list. Terms added by the participants were passed on to the next round of consensus. Terms with <75% agreement were included in subsequent surveys along with alternative terms proposed by participants until agreement was reached on all terms. RESULTS: The Delphi included 21 participants. We found consensus (≥75% agreement) on 361/385 (93.8%) terms and eliminated one term in the first round. Of 49 new terms suggested by participants, 45 were added via consensus. To adjust for a recently published International Classification of Diseases-Surface Topography list of terms, a third survey including 111 discrepant terms was sent to participants. Finally, a total of 513 terms reached agreement via the Delphi method. CONCLUSIONS: We have established a set of 513 clinically relevant terms for denoting human surface anatomy, towards the use of standardized terminology in dermatologic documentation.

Tuning of polyurethane foam mechanical and thermal properties using ball-milled cellulose.

Cystalline-Cc and ultra-milled Amorphous-Ca cellulose were used as reactive filler to tune the performances of composite polyurethane-cellulose-foams, PUC. The effect of Cc and Ca on chemo-physical and mechanical properties of PUC was analysed through FTIR, morphological analysis, thermal conductivity and compression measurements. FTIR results show that, both Cc and Ca react with isocyanate through the OH functional groups contributing to the formation of a tough cellulose-polyurethane network. Morphological observations show that the addition of both Cc and Ca induces a decrease of average cell-size compared to the pristine-PU, thus confirming that they act as nucleating agent. In addition, the better dispersion of the Ca in the polyol, with respect to Cc induces, a finer cell leading to a reduction of the thermal conductivity around 33 % (for the composite loaded with 20 %wt-Ca) with respect to pristine-PU. Finally, the addition of Ca highly reactive modifies the mechanical behaviour from rigid-brittle to semi-rigid.

Characterization of sustainable polyhydroxyls, produced from bio-based feedstock, and polyurethane and copolymer urethane-amide foams.

This manuscript presents data related to the research article entitled "Synthesis and characterization of sustainable polyurethane foams based on polyhydroxyls with different terminal groups" (DOI: 10.1016/j.polymer.2018.06.077) [1]. We provide Supplementary data on the chemical properties, in terms of FTIR characterization, of polyhydroxyls produced starting from bio-based feedstock (biosuccinic acid and 1,4 butandiol) and thermal properties (glass transition temperature-Tg and thermal degradation behavior) of polyurethane and copolymer urethane-amide foams manufactured from the aforementioned polyhydroxyls. The FTIR characterization elucidates the chemical structure of polyhydroxyls and allows to make some hypothesis on their reaction routes with the isocyanate molecules. The thermal characterization revealed that the addition of bio-based polyhydroxyls to the sample formulations improves both the glass transition and degradation temperature of the foams. These foamed products exhibit potential performances to be applied as a substitute for conventional polyurethane foams.

Genotoxic and cytotoxic effects of ZnO nanoparticles for Dunaliella tertiolecta and comparison with SiO2 and TiO2 effects at population growth inhibition levels.

The increasing use of oxide nanoparticles (NPs) in commercial products has intensified the potential release into the aquatic environment where algae represent the basis of the trophic chain. NP effects upon algae population growth were indeed already reported in literature, but the concurrent effects at cellular and genomic levels are still largely unexplored. Our work investigates the genotoxic (by COMET assay) and cytotoxic effects (by qualitative ROS production and cell viability) of ZnO nanoparticles toward marine microalgae Dunaliella tertiolecta. A comparison at defined population growth inhibition levels (i.e. 50% Effect Concentration, EC50, and No Observed Effect Concentration, NOEC) with SiO2 and TiO2 genotoxic effects and previously investigated cytotoxic effects (Manzo et al., 2015) was performed in order to elucidate the possible diverse mechanisms leading to algae growth inhibition. After 72h exposure, ZnO particles act firstly at the level of cell division inhibition (EC50: 2mg Zn/L) while the genotoxic action is evident only starting from 5mg Zn/L. This outcome could be ascribable mainly to the release of toxic ions from the aggregate of ZnO particle in the proximity of cell membrane. In the main, at EC50 and NOEC values for ZnO NPs showed the lowest cytotoxic and genotoxic effect with respect to TiO2 and SiO2. Based on Mutagenic Index (MI) the rank of toxicity is actually: TiO2>SiO2>ZnO with TiO2 and SiO2 that showed similar MI values at both NOEC and EC50 concentrations. The results presented herein suggest that up to TiO2 NOEC (7.5mg/L), the algae DNA repair mechanism is efficient and the DNA damage does not result in an evident algae population growth inhibition. A similar trend for SiO2, although at lower effect level with respect to TiO2, is observable. The comparison among all the tested nanomaterial toxicity patterns highlighted that the algae population growth inhibition occurred through pathways specific for each NP also related to their different physicochemical behaviors in seawater.

Accuracy of in vivo confocal microscopy for diagnosis of basal cell carcinoma: a comparative study between handheld and wide-probe confocal imaging.

BACKGROUND: Reflectance confocal microscopy (RCM) increases specificity of identification of basal cell carcinoma (BCC). A smaller-diameter handheld RCM (HH-RCM) allows better access to limited anatomic locations. OBJECTIVE: To compare accuracy of HH-RCM in identification of BCC to that of traditional wide-probe RCM (TWP-RCM). METHODS: Patients presenting at least one lesion clinically and dermoscopically suspicious for BCC, were recruited from two dermatology skin cancer clinics. Prior to excision, we attempted to image all lesions with HH-RCM and TWP-RCM using a standardized protocol. RCM images were retrospectively evaluated, jointly by two blinded readers. For purposes of comparative RCM, sensitivity and specificity analysis, we used a threshold of ≥3 RCM criteria to identify BCC, whereby at least one criterion had to be presence of 'dark silhouettes' or 'bright tumor islands'. RESULTS: Among 54 lesions imaged with both RCM devices, 45 were biopsy-proven BCCs. Comparison between TWP-RCM vs. HH-RCM was as follows: sensitivity (100% vs. 93%), specificity (78% for both probes), positive predictive value (96% vs. 95%), and negative predictive value (100% vs. 70%) respectively. Notably, both TWP-RCM and HH-RCM demonstrated the presence of 'dark silhouettes' or 'bright tumor islands' in all 45 BCCs. CONCLUSION: Both RCM probes demonstrate high PPV. TWP-RCM shows higher NPV, since its broader field-of-view probably allows more exhaustive search for BCC criteria. The RCM criteria threshold for BCC identification should be further tested.

Dermoscopy and reflectance confocal microscopy of pigmented actinic keratoses: a morphological study.

BACKGROUND: Actinic keratoses (AKs) are very common lesions on sun damaged skin and, when pigmented, represent a challenge in the differential diagnosis with early melanoma. Non-invasive diagnostic methods, such as dermoscopy and reflectance confocal microscopy (RCM) have been shown to improve the diagnostic accuracy of melanoma and non-melanoma skin cancer, however, only one case report described confocal findings of pigmented AKs up to now. OBJECTIVES: The aim of our retrospective morphological study was to analyse dermoscopic and confocal images of a series of histopathologically proven pigmented AKs, located on the face and other body sites, to define peculiar features of these "difficult to diagnose" lesions. METHODS: Clinical, dermoscopic and RCM images of 17 histopathologically confirmed pigmented AKs were retrospectively collected from the databases of four skin lesion clinics in Italy and USA. Dermoscopic and RCM images were analysed for prevalent morphological features. RESULTS: The majority of the lesions were located on the face (n = 8); followed by scalp (n = 4) and trunk (n = 4); and one lesion was located on the lower limbs. On dermoscopy the majority of lesions were characterized by grey dots/globules/granularity and structureless brown pigmentation. The main RCM feature of pigmented AKs was as follows: (i) the presence of epidermal changes (atypical keratinocytes, parakeratosis, scaling); (ii) increased epidermal thickness; (iii) bright, small, dermal papillae with enlarged interpapillary space; and (iv) intraepidermal dendritic cells referrable to Langherans cells. Features suggestive of melanocytic lesions, such as nesting, meshwork pattern or atypical cells infiltrating the junction, were never detected in our case series at the dermal epidermal junction (DEJ) level. CONCLUSION: Larger case series with adequate control population are warranted to validate these findings and to test their value in clinical setting.

[A model of the arterial aneurysm of the brain for microneurosurgical training].

Clipping of arterial aneurysms of the brain is one of technically complex neurosurgical interventions. In the available literature, there is no information about simulation models of aneurysm clipping that have tactile properties similar to the real ones. The study presents a technical rationale for the development of a new model for the aneurysm on human placental vessels to train skills of isolating and clipping under ruptured and unruptured aneurysm conditions.

Dermoscopy of acral melanoma: a multicenter study on behalf of the international dermoscopy society.

BACKGROUND: Most studies on dermoscopy of acral lesions were conducted in Asian populations. In this study, we analyzed these features in a predominantly Caucasian population. OBJECTIVE: Estimate the prevalence of dermoscopic features in acral lesions, and assess their level of agreement between observers. METHODS: In this retrospective multicenter study, 167 acral lesions (66 melanomas) were evaluated for 13 dermoscopic patterns by 26 physicians, via a secured Internet platform. RESULTS: Parallel furrow pattern, bizarre pattern, and diffuse pigmentation with variable shades of brown had the highest prevalence. The agreement for lesion patterns between physicians was variable. Agreement was dependent on the level of diagnostic difficulty. CONCLUSION: Lesions with a diameter >1 cm were more likely to be melanoma. We found as well that a benign pattern can be seen in parts of melanomas. For this reason one should evaluate an acral lesion for the presence of malignant patterns first.

Multiple primary melanomas: do they look the same?

BACKGROUND: A series of studies has investigated epidemiological, clinical and genetic characteristics of patients with multiple primary melanoma (MPM). However, comparison of the clinical and dermoscopic features of MPM within a given individual has been described only in case reports. OBJECTIVES: To describe the dermoscopic features of MPM for each given patient, and to evaluate the characteristics eventually associated with similar or dissimilar appearance. METHODS: From the databases of three skin-lesion clinics in the U.S.A., Italy and Spain we collected the dermoscopic images of melanomas in patients diagnosed with MPM. RESULTS: Among 58 patients with MPM, we found that 53% of patients had dermoscopically similar melanomas and 47% of patients had dermoscopically different melanomas. In older patients 59% of melanomas were dermoscopically similar vs. 47% in younger patients (P=0·377). Similar thickness was associated with the occurrence of dermoscopically similar melanomas (19/30 cases, 63%; P=0·039). Most (65%) of the synchronous lesions were similar, compared with 36% of nonsynchronous lesions (P=0·029), and most (69%) of the melanomas on sun-damaged skin were similar, vs. 37% of melanomas on nonsun-damaged skin (P=0·015; odds ratio 3·88, 95% confidence interval 1·11-13·98). The percentage of dermoscopically different melanomas was higher in patients with a family history of melanoma (67% vs. 48%). CONCLUSIONS: MPMs in a given patient have almost the same chance of looking dermoscopically similar or different. However, a subset of elderly patients with sun-damaged skin may present multiple, similar, thin melanomas characterized by pigment-network and regression structures.

Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the 'gold standard'?

BACKGROUND: The 'gold standard' for the diagnosis of melanocytic lesions is dermatopathology. Although most of the diagnostic criteria are clearly defined, the interpretation of histopathology slides may be subject to interobserver variability. OBJECTIVES: The aim of this study was to determine the variability among dermatopathologists in the interpretation of clinically difficult melanocytic lesions. METHODS: This study used the database of MelaFind®, a computer-vision system for the diagnosis of melanoma. All lesions were surgically removed and sent for independent evaluation by four dermatopathologists. Agreement was calculated using kappa statistics. RESULTS: A total of 1,249 pigmented melanocytic lesions were included. There was a substantial agreement among expert dermatopathologists: two-category kappa was 0.80 (melanoma vs. non-melanoma) and three-category kappa was 0.62 (malignant vs. borderline vs. benign melanocytic lesions). The agreement was significantly greater for patients ≥40 years (three-category kappa = 0.67) than for younger patients (kappa = 0.49). In addition, the agreement was significantly lower for patients with atypical mole syndrome (AMS) (kappa = 0.31) than for patients without AMS (kappa = 0.76). LIMITATIONS: The data were limited by the inclusion/exclusion criteria of the MelaFind® study. This might represent a selection bias. The agreement was evaluated using kappa statistics. This is a standard method for evaluating agreement among pathologists, but might be considered controversial by some statisticians. CONCLUSIONS: Expert dermatopathologists have a high level of agreement when diagnosing clinically difficult melanocytic lesions. However, even among expert dermatopathologists, the current 'gold standard' is not perfect. Our results indicate that lesions from younger patients and patients with AMS may be more problematic for the dermatopathologists, suggesting that improved diagnostic criteria are needed for such patients.

Reflectance confocal microscopy criteria of lichen planus-like keratosis.

BACKGROUND: Lichen planus-like keratosis (LPLK) may be difficult to differentiate from melanoma and other skin cancers on sun-damaged skin based on clinical and dermoscopic examination. Reflectance confocal microscopy (RCM) allows evaluation of skin lesions at high resolution. OBJECTIVES: The aim of this study was to identify criteria for specific diagnosis of LPLK using in vivo RCM. METHODS: Lesions included in the study were derived from patients presenting for skin examination at a private dermatology practice specializing in skin cancer. We retrospectively analysed RCM features of 28 biopsy-proven LPLK and compared them to RCM findings in skin cancers on sun-damaged skin, including five in situ squamous cell carcinomas, six actinic keratoses, seven superficial basal cell carcinomas and eight melanomas. RESULTS: The main RCM features of LPLK and their relative frequencies were: (i) typical honeycomb pattern of the spinous layer (78.6%); (ii) elongated cords and/or bulbous projections at the dermal-epidermal junction (75%); and (iii) numerous plump-bright cells and/or bright stellate spots in the superficial dermis (92.9%). These RCM features correlated with the following histopathological findings respectively: (i) spinous-granular layers without significant atypia of keratinocytes; (ii) elongated, bulbous rete ridges; and (iii) dense infiltration of melanophages and lymphocytes in superficial dermis. We propose diagnostic criteria that classify correctly 71.4% of LPLK, while avoiding misclassification of any of the skin cancers in the present series as LPLK. CONCLUSIONS: We identified RCM criteria for diagnosis of LPLK that correlate well with histopathological findings and that allow differentiation of LPLK from skin cancer.

Cloudy and starry milia-like cysts: how well do they distinguish seborrheic keratoses from malignant melanomas?

BACKGROUND: Seborrheic keratoses are the most common skin lesions known to contain small white or yellow structures called milia-like cysts (MLCs). Varied appearances can sometimes make it difficult to differentiate benign lesions from malignant lesions such as melanoma, the deadliest form of skin cancer found in humans. OBJECTIVE: The purpose of this study was to determine the statistical occurrence of MLCs in benign vs. malignant lesions. METHODS: A medical student with 10 months experience in examining approximately 1000 dermoscopy images and a dermoscopy-naïve observer analysed contact non-polarized dermoscopy images of 221 malignant melanomas and 175 seborrheic keratoses for presence of MLCs. RESULTS: The observers found two different types of MLCs present: large ones described as cloudy and smaller ones described as starry. Starry MLCs were found to be prevalent in both seborrheic keratoses and melanomas. Cloudy MLCs, however, were found to have 99.1% specificity for seborrheic keratoses among this group of seborrheic keratoses and melanomas. CONCLUSION: Cloudy MLCs can be a useful tool for differentiating between seborrheic keratoses and melanomas.

Design of porous polymeric scaffolds by gas foaming of heterogeneous blends.

One of the challenges in tissue engineering scaffold design is the realization of structures with a pre-defined multi-scaled porous network. Along this line, this study aimed at the design of porous scaffolds with controlled porosity and pore size distribution from blends of poly(epsilon-caprolactone) (PCL) and thermoplastic gelatin (TG), a thermoplastic natural material obtained by de novo thermoplasticization of gelatin. PCL/TG blends with composition in the range from 40/60 to 60/40 (w/w) were prepared by melt mixing process. The multi-phase microstructures of these blends were analyzed by scanning electron microscopy and dynamic mechanical analysis. Furthermore, in order to prepare open porous scaffolds for cell culture and tissue replacement, the TG and PCL were selectively extracted from the blends by the appropriate combination of solvent and extraction parameters. Finally, with the proposed combination of gas foaming and selective polymer extraction technologies, PCL and TG porous materials with multi-scaled and highly interconnected porosities were designed as novel scaffolds for new-tissue regeneration.

The significance of multiple blue-grey dots (granularity) for the dermoscopic diagnosis of melanoma.

BACKGROUND: The presence of multiple blue-grey dots (MBGD) is widely used by clinicians to decide if a pigmented lesion should be removed, but only little is known about their significance. OBJECTIVES: To evaluate the significance of MBGD for the dermoscopic diagnosis of melanoma. METHODS: In part 1 we retrospectively evaluated 340 pigmented lesions for the presence and morphological appearance of granularity. One hundred and seventy melanomas were included and matched with 170 benign and dysplastic naevi which were randomly chosen from our collection. In part 2, 3773 lesions were examined prospectively in at-risk patients: all lesions with granularity were recorded, surgically removed and subjected to histopathological examination. RESULTS: In part 1, granularity was found in 26.5% of the benign lesions and 93.5% of melanomas. The presence of granularity, granularity at the periphery, irregularly distributed granularity and granularity in association with red and white colour were statistically highly significant for the diagnosis of melanoma (P < 0.001). In part 2, granularity was found in 1.08% of the 3773 lesions and more frequently in sun-damaged skin. Sensitivity for the diagnosis of melanoma was 85% and specificity 99%. CONCLUSIONS: After the revision of many lesions with MBGD, we concluded that the term 'granularity' better describes this entity. Lesions with irregular granularity (periphery, irregularly distributed) should be removed especially if they are associated with red, blue or white colour. Lesions with a benign dermoscopy pattern which have granularity with a regular appearance and involving only a small portion of the lesion do not require surgical excision.

Dermoscopy of facial nonpigmented actinic keratosis.

BACKGROUND: The accuracy of clinical diagnosis of nonpigmented, facial actinic keratosis (AK) is often suboptimal, even for experienced clinicians. OBJECTIVES: To investigate the dermoscopic features of nonpigmented AK located on the head/neck that may assist the clinical diagnosis. METHODS: Forty-one nonpigmented AKs on facial sites were examined by dermoscopy for any consistent underlying features. Lesions were gathered from skin cancer centres in Australia, Austria, Italy and the U.S.A. All cases were diagnosed histopathologically. RESULTS: Four essential dermoscopic features were observed in facial AK: (i) erythema, revealing a marked pink-to-red 'pseudonetwork' surrounding the hair follicles (95%); (ii) white-to-yellow surface scale (85%); (iii) fine, linear-wavy vessels surrounding the hair follicles (81%); and (vi) hair follicle openings filled with yellowish keratotic plugs (66%) and/or surrounded by a white halo (100%). These features combined, in 95% of cases, to produce a peculiar 'strawberry' appearance. CONCLUSIONS: A dermoscopic model of 'strawberry' pattern is presented, which may prove helpful in the in vivo diagnosis of nonpigmented, facial AK. A limitation of this study is the lack of testing of the specificity of the described dermoscopic criteria in differentiating nonpigmented AKs from other nonpigmented skin lesions at this site.

Impairment of coronary circulation by acute hyperhomocysteinaemia and reversal by antioxidant vitamins.

OBJECTIVE: To evaluate the effect of acute hyperhomocysteinaemia with and without antioxidant vitamins pretreatment on coronary circulation and circulating chemokine levels. DESIGN: Observer-blinded, randomized crossover study. SETTING: This study was conducted at a university hospital and at a general hospital in Italy. SUBJECTS: Sixteen healthy hospital staff volunteers (nine men, seven women), aged 26-40 years. INTERVENTIONS: Subjects were given each three loads in random order at 1-week intervals: oral methionine, 100 mg kg(-1) in fruit juice; the same methionine load immediately following ingestion of antioxidant vitamin E, 800 IU, and ascorbic acid, 1000 mg; and methionine-free fruit juice (placebo). MAIN OUTCOME MEASURES: Coronary flow velocity reserve (CFVR), assessed by noninvasive transthoracic Doppler echocardiography, blood pressure, heart rate, lipid and glucose, monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) parameters evaluated at baseline and 4 h following ingestion of the loads. RESULTS: The oral methionine load increased plasma homocysteine from 12.8 +/- 1.8 to 33.3 +/- 3.4 micromol L(-1) at 4 h (P < 0.001). A similar increase was observed with same load plus vitamins (P < 0.001) but not with placebo (P = 0.14). Circulating MCP-1 and IL-8 levels rose after the methionine load (P < 0.001), but not after placebo or methionine plus vitamins. The methionine load significantly reduced CFVR (decrease, 26 +/- 8.2%; P < 0.001). The methionine load with ingestion of vitamins partially prevented the impairment of CFVR (decrease, 11 +/- 4%; P < 0.001). CONCLUSION: Our data suggest that acute hyperhomocysteinaemia reduces CFVR and increases plasma MCP-1 and IL-8 levels in healthy subjects. Pretreatment with antioxidant vitamin E and ascorbic acid prevents the effects of hyperhomocysteinaemia, suggesting an oxidative mechanism.

[Dermatoscopy of pigmented lesions]. / Dermatoscopie des lésions pigmentées.

Dermoscopy is a simple to use in vivo method for the early diagnosis of malignant melanoma and the differential diagnosis of pigmented skin lesions. It has been shown to increase diagnostic accuracy over clinical visual inspection in the hands of an experienced physician. This paper is a review of the principles of Dermoscopy as well as recent technological developments.

Automatic differentiation of melanoma from melanocytic nevi with multispectral digital dermoscopy: a feasibility study.

BACKGROUND: Differentiation of melanoma from melanocytic nevi is difficult even for skin cancer specialists. This motivates interest in computer-assisted analysis of lesion images. OBJECTIVE: Our purpose was to offer fully automatic differentiation of melanoma from dysplastic and other melanocytic nevi through multispectral digital dermoscopy. METHOD: At 4 clinical centers, images were taken of pigmented lesions suspected of being melanoma before biopsy. Ten gray-level (MelaFind) images of each lesion were acquired, each in a different portion of the visible and near-infrared spectrum. The images of 63 melanomas (33 invasive, 30 in situ) and 183 melanocytic nevi (of which 111 were dysplastic) were processed automatically through a computer expert system to separate melanomas from nevi. The expert system used either a linear or a nonlinear classifier. The "gold standard" for training and testing these classifiers was concordant diagnosis by two dermatopathologists. RESULTS: On resubstitution, 100% sensitivity was achieved at 85% specificity with a 13-parameter linear classifier and 100%/73% with a 12-parameter nonlinear classifier. Under leave-one-out cross-validation, the linear classifier gave 100%/84% (sensitivity/specificity), whereas the nonlinear classifier gave 95%/68%. Infrared image features were significant, as were features based on wavelet analysis. CONCLUSION: Automatic differentiation of invasive and in situ melanomas from melanocytic nevi is feasible, through multispectral digital dermoscopy.