[Main Types of Cysts in Dermatopathology: Part 2]. / Principales tipos de quistes en dermatopatología: Parte 2.

This is the second article in a two-part series published in this journal, in which we examine the histopathological characteristics, as well as the differential diagnosis, of the main entities that present as cystic and pseudocystic structures in cutaneous biopsy. In this second article, we address ciliated cutaneous cysts, branchial cysts, Bartholin's cysts, omphalomesenteric cysts, thymic cysts, thyroglossal duct cysts, synovial cysts, and median raphe cysts, as well as mucocele, ganglion, and auricular and digital myxoid pseudocysts.

Neuroprotective effects of VCE-004.8 in a rat model of neonatal stroke.

BACKGROUND: Currently there is no effective treatment for neonatal stroke, an acute neurologic syndrome with sequelae, due to focal ischemic, thrombotic, or hemorrhagic event occurring in the perinatal period. VCE-004.8, an aminoquinone exhibiting activity on CB2 and PPARγ receptors, is neuroprotective in adult mice models of acute and chronic brain damaging conditions. We hereby aimed to study VCE-004.8 neuroprotection in a rat model of neonatal stroke. METHODS: 7-day-old (P7) Wistar rats of both sexes were submitted to Middle Cerebral Artery Occlusion (MCAO), receiving i.p. 30 min after vehicle (MCAO + VEH) or VCE-004.8 5 mg/kg (MCAO + VCE). Non-occluded rats served as controls (SHAM). MCAO consequences were assessed at P14 by MRI, histological (TUNEL staining), biochemical (lactate/n-acetyl aspartate ratio by 1H-NMR spectroscopy) and motor studies (grasp test), and at P37 assessing myelination (MBP signal), hemiparesis and hyperlocomotion. Effects of VCE-004.8 on excitotoxicity (glutamate/n-acetyl aspartate, 1H-NMR), oxidative stress (protein nitrosylation, Oxyblot) and neuroinflammation (Toll-like receptor 4 and TNFa expression, Western blot) were assessed at P14. Therapeutic window was assessed by delaying drug administration for 12 or 18 h. RESULTS: Post-MCAO administration of VCE-004.8 reduced the volume of infarct and histological and biochemical brain damage, reducing hyperlocomotion, restoring motor performance and preserving myelination, in a manner linked to the modulation of excitotoxicity, oxidative stress and neuroinflammation. VCE-004.8 was still effective being administered 12-18 h post-insult. CONCLUSIONS: These data suggest that this drug could be effective for the treatment of stroke in newborns.

Relationship between appendicular muscular mass index and physical function in older people.

This study aimed to establish the relationship between the appendicular muscle mass index (AMMI), assessed from anthropometric variables, and the physical function of older people. Seventy-six older people participated in this study (72.03 ± 7.03 years). The participants underwent evaluations to determine their AMMI using anthropometry (weight, calf circumference, hip circumference, and knee height) and manual grip strength. Additionally, their physical function was evaluated using the 5-chair stand test, the 3-meter walk test, and the timed up and go test (TUG) to determine the strength of the lower limbs, the gait speed, and the dynamic balance, respectively. The results show that the AMMI did not present a significant relationship with the 5-chair stand test in both women (r = -0.135; p = 0.204) and men (r = -0.067; p = 0.349). The AMMI was moderately correlated with the gait speed in both women (r = 0.542; p < 0.001) and men (r = 0.556; p < 0.001). Finally, a statistical significance was observed in the relationship between the AMMI and the TUG test in women (r = -0.273; p = 0.047) and older men evaluated in this study (r = -0.284; p = 0.042). In conclusion, there is a relationship between the AMMI and both the dynamic balance and the gait speed. Therefore, the AMMI emerges as a potential public health assessment by enabling the clinical quantification of muscle mass and an estimation of physical function in the elderly population.

Effects of active exergames on physical performance in older people: an overview of systematic reviews and meta-analysis.

This overview assessed the available body of published peer-reviewed systematic reviews and meta-analyses related to the effects of active exergames compared with active/passive control on physical performance outcomes in older people. The methodological quality and certainty of evidence were assessed using PRISMA, AMSTAR 2, and GRADE. The protocol was registered in PROSPERO (code: CRD42023391694). The main outcomes indicate that 4,477 records, five systematic reviews, and 10 meta-analyses were included. The AMSTAR-2 reported six meta-analyses with high methodological quality, four moderate quality, two systematic reviews with low quality, and three very-low quality. Meta-analysis was performed on balance using the Berg Balance Scale (BBS) and Timed Up-and-Go (TUG) tests, on cardiorespiratory fitness using the 6-min walk test, and on upper and lower limbs muscle strength using the handgrip strength, knee extension, and 30-s chair stand tests. Significant differences in favor of the active exergames groups concerning active/passive groups were reported in BBS (SMD = 0.85; 95% CI = 0.12-1.58; I2 = 96%; p = 0.02), TUG (SMD = 1.44; 95% CI = 0.71-2.16; I2 = 97%; p < 0.0001), and 30-s chair stand test (SMD = 0.79; 95% CI = 0.33-1.25; I2 = 88%; p = 0.0008). However, no significant differences were reported in favor of the active exergames groups in 6-min walk (SMD = 0.93; 95% CI = -0.64 to 2.50; I2 = 95%; p = 0.24), handgrip strength (SMD = 0.67; 95% CI = -0.04 to 1.38; I2 = 84%; p = 0.06), and knee extension tests (SMD = 0.20; 95% CI = -0.05 to 0.44; I2 = 95%; p = 0.12) compared to active/passive control. However, it was impossible to perform a meta-analysis for the variables of walking speed as a fall risk due to the diversity of instruments and the small number of systematic reviews with meta-analysis. In conclusion, interventions utilizing active exergames have shown significant improvements in the static and dynamic balance and lower limb muscle strength of apparently healthy older people, compared to control groups of active/inactive participants, as measured by BBS, TUG, and 30-s chair stand tests. However, no significant differences were found in the 6-min walk, HGS, and knee extension tests. Systematic review registration: PROSPERO, CRD42023391694.

Frailty, Seasonal Sensitivity and Health-related Quality of Life in Older People Living in High Southern Latitudes: a Bayesian Analysis.

Background: In older people, a notable research gap exists regarding the intricate dynamics between frailty, seasonal sensitivity, and health-related quality of life (HRQoL). This study aimed to determine the association between frailty, seasonal sensitivity, and HRQoL in older people from high southern latitudes. Methods: A cross-sectional observational study was conducted. Frailty, seasonal sensitivity, and HRQoL measurements were self-reported by participants through questionnaires. A total of 118 older people were recruited from a local community. The participants were selected through intentional non-probabilistic sampling. Results: The adjusted models showed a trend where lower education was associated with a higher risk of frailty (BF = 0.218). For frailty and HRQoL, we observed a trend suggesting that HRQoL decreases with increasing severity of frailty (BF = 1.76). In addition, we observed a linear effect based on the severity of seasonal sensitivity, meaning that older people with higher perceived severity report a proportional decrease in HRQoL (BF = 6.66). Conclusion: Sociodemographic factors, such as lower education levels, have increased the risk of frailty. At the same time, frailty and seasonal sensitivity perceived severity were associated with a lower HRQoL in older people.

Quadriceps muscle reaction time in obese children.

This study aimed to determine the influence of obesity, according to body mass index (BMI) and fat mass percentage, on quadriceps muscle reaction times. The study utilized a cross-sectional design. The sample size consisted of 42 schoolchildren (54.5% girls) aged 11 to 12 years old. Participant measurements included weight and height, which were used to categorize individuals based on BMI. Additionally, the electrical bioimpedance technique was employed to categorize participants based on their body fat percentage. A sudden destabilization test of the lower limb was performed to assess the reaction time of the rectus femoris, vastus medialis, and vastus lateralis muscles. The results show that overweight/obese children have a longer muscle reaction time for both the rectus femoris (ß = 18.13; p = 0.048) and the vastus lateralis (ß = 14.51; p = 0.042). Likewise, when the children were classified by percentage of body fat the results showed that overfat/obese children have a longer muscle reaction time for both the rectus femoris (ß = 18.13; p = 0.048) and the vastus lateralis (ß = 14.51; p = 0.042). Our results indicate that BMI and fat mass classification negativity alter the muscle reaction time in children. Overweight/obese or overfat/obese children showed longer reaction times in the rectus femoris and vastus lateralis muscles compared to children with normal weight. Based on these findings, it is suggested that in overweight and obese children, efforts not only focus on reducing body weight but that be complemented with training and/or rehabilitation programs that focus on preserving the normal physiological function of the musculoskeletal system.

Extensive and deep granulomatous ulcers as an atypical manifestation of cartilage-hair hypoplasia syndrome: A diagnostic and therapeutic challenge.

Cartilage hypoplasia syndrome is a primary immunodeficiency disease characterized by short stature, hypoplastic hair and a variable degree of immunodeficiency. Noninfectious cutaneous granulomas represent an uncommon yet well-recognized manifestation within the spectrum of primary immunodeficiency diseases. However, cutaneous granulomas as a manifestation of cartilage-hair hypoplasia syndrome, are extremely rare. We present a case of a middle-aged man with cartilage hypoplasia syndrome featuring cutaneous granulomas, manifesting as chronic, extensive and deep cutaneous ulcers. The patient was treated with anti-TNF-alpha adalimumab with partial improvement. Our case underscores the broad spectrum of clinical manifestations associated with cartilage hypoplasia syndrome and adds new evidence to the potential therapeutic efficacy of anti-TNF-alpha drugs in its treatment.

AMPK Activation by Cimicifuga racemosa Extract Ze 450 Is Associated with Metabolic Effects and Cellular Resilience against Age-Related Pathologies in Different Tissue Cell Types.

Cimicifuga racemosa extracts (CREs) have gained well-established use for the treatment of menopausal symptoms such as hot flushes and excessive sweating, and weight gain. While the clinical effects of CREs have been well documented, the mechanisms underlying these effects are largely unknown. More recently, the metabolic effects of the CRE Ze 450 were demonstrated in cultured cells in vitro and in mouse models of obesity in vivo. At the molecular level, metabolic regulation, enhanced insulin sensitivity, and increased glucose uptake were linked to the activation of AMP-activated protein kinase (AMPK). Therefore, we tested the effects of Ze 450 on AMPK phosphorylation and thus activation in cells from different tissues, i.e., murine C2C12 myoblast cells, human HEPG2 liver cells, mouse HT22 neuronal cells, and in murine 3T3L1 adipocytes. Using a FRET-based HTRF-assay, we found that Ze 450 induced AMPK phosphorylation and the activation of this key enzyme of metabolic regulation in cells from various different tissues including C2C12 (muscle), HEPG2 (liver), HT22 (hippocampal), and 3T3-L1 (adipocyte) cells. In C2C12 muscle cells, enhanced AMPK activation was accompanied by reduced mitochondrial respiration and enhanced glucose uptake. Further, Ze 450 enhanced the resilience of the cells against oxidative death induced by ferroptosis inducers erastin or RSL3. Our findings suggest a general effect of Cimicifuga racemosa on AMPK activation in different tissues and across species. This may have a significant impact on expanded therapeutic applications of Ze 450, since AMPK activation and the related metabolic effects have been previously associated with anti-aging effects and the prevention of the metabolic syndrome.

Pain neuroscience education for patients with chronic pain: A scoping review from teaching-learning strategies, educational level, and cultural perspective.

OBJECTIVE: (1) To identify the characteristics of PNE programs in terms of teaching-learning strategies, session modality, content delivery format, number of sessions, total minutes and instructional support material used in patients with chronic musculoskeletal pain, (2) to describe PNE adaptations for patients with different educational levels or cultural backgrounds, and (3) to describe the influence of the patient's educational level or cultural background on the effects of PNE. METHODS: The PRISMA guideline for scoping reviews was followed. Nine databases were systematically searched up to July 8, 2023. Articles that examined clinical or psychosocial variables in adults with chronic musculoskeletal pain who received PNE were included. RESULTS: Seventy-one articles were included. Studies found benefits of PNE through passive/active teaching-learning strategies with group/individual sessions. However, PNE programs presented great heterogeneity and adaptations to PNE were poorly reported. Most studies did not consider educational level and culture in the effects of PNE. CONCLUSIONS: Despite the large number of studies on PNE and increased interest in this intervention, the educational level and culture are poorly reported in the studies. PRACTICAL IMPLICATIONS: It is recommended to use passive and/or active teaching-learning strategies provided in individual and/or group formats considering the patient's educational level and culture.

Exploring gastric cancer genetics: A turning point in common variable immunodeficiency.

Background: Gastric cancer (GC) stands as a prominent cause of cancer-related mortality and ranks second among the most frequently diagnosed malignancies in individuals with common variable immunodeficiency (CVID). Objective: We sought to conduct a comprehensive, large-scale genetic analysis to explore the CVID-associated germline variant landscape within gastric adenocarcinoma samples and to seek to delineate the transcriptomic similarities between GC and CVID. Methods: We investigated the presence of CVID-associated germline variants in 1591 GC samples and assessed their impact on tumor mutational load. The progression of GC was evaluated in patients with and without these variants. Transcriptomic similarities were explored by matching differentially expressed genes in GC to healthy gastric tissue with a CVID transcriptomic signature. Results: CVID-associated germline variants were found in 60% of GC samples. Our analysis revealed a significant association between the presence of CVID-related genetic variants and higher tumor mutational load in GC (P < .0001); high GC mutational load seems to be linked to immunotherapy response and worse prognosis. Transcriptomic similarities unveiled key genes and pathways implicated in innate immune responses and tumorigenesis. We identified upregulated genes related to oncogene drivers, inflammation, tumor suppression, DNA repair, and downregulated immunomodulatory genes shared between GC and CVID. Conclusions: Our findings contribute to a deeper understanding of potential molecular modulators of GC and shed light on the intricate interplay between immunodeficiency and cancer. This study underscores the clinical relevance of CVID-related variants in influencing GC progression and opens avenues for further exploration into novel therapeutic approaches.

[Main Types of Cysts in Dermatopathology: Part 1]. / Principales tipos de quistes en dermatopatología: parte 1.

Cystic structures represent one of the most common findings in dermatopathology. These encompass both cystic tumors and pseudocysts resulting from the accumulation of certain substances, such as mucin. In a two-part series (of which this is the first part), we have reviewed the principal types of cysts and pseudocysts that may be observed in cutaneous biopsies, examining their histopathological features and primary differential diagnoses. This first part encompasses infundibular cysts, eruptive dermoid cysts, pigmented follicular cysts, pilonidal cysts, tricholemmal cysts, milium cysts, hybrid cysts, bronchogenic cysts, as well as steatocystoma, hydrocystoma, and comedones.

Comparative Electromyographic Study of Scapular Stabilizing Muscles During Five Main Rehabilitation Exercises.

OBJECTIVE: The aim of the study is to compare the surface electromyographic amplitude, activation ratio, and onset latency of the main scapular stabilizing muscles between five typical rehabilitative exercises. DESIGN: Twenty-seven healthy participants performed five scapular exercises (wall slide, wall push-up plus, prone horizontal abduction with external rotation, external rotation in side lying, and low row) while simultaneously recording surface electromyographic of serratus anterior, middle trapezius, lower trapezius, and upper trapezius. Surface electromyographic amplitudes, onset latencies, and activation ratios were calculated. RESULTS: Prone horizontal abduction with external rotation showed an excellent upper trapezius/middle trapezius (0.43) and upper trapezius/lower trapezius (0.30) muscle balance with high (>50% maximum voluntary isometric contraction) middle trapezius and lower trapezius amplitudes, a low (<20% maximum voluntary isometric contraction) upper trapezius amplitude, and an early activation of the scapular stabilizing muscles (-474.7 to 89.9 ms) relative to upper trapezius. External rotation in side lying showed excellent upper trapezius/serratus anterior (0.26), upper trapezius/middle trapezius (0.32), and upper trapezius/lower trapezius (0.21) activation ratios and, along with low row and wall slide, showed early activation of the scapular stabilizing muscles (-378.1 to -26.6 ms). CONCLUSIONS: Prone horizontal abduction with external rotation presented optimal scapular neuromuscular control. Although external rotation in side lying, low row, and wall slide did not meet all the criteria associated with optimal scapular neuromuscular control, these exercises could be used in early stages of shoulder rehabilitation because they favor early activation of the scapular stabilizing muscles.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age.

INTRODUCTION: The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age. MATERIALS AND METHODS: This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS). RESULTS: A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results. CONCLUSIONS: Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Effects of different plyometric training frequencies on physical performance in youth male volleyball players: a randomized trial.

This study aimed to analyze the effect of plyometric training (PT) at different frequencies on jump performance, running sprint speed, and service speed in youth male volleyball players. The participants were randomly assigned to one PT session per week (Experimental Group 1, EG1, n = 15), two PT sessions per week (Experimental Group 2, EG2, n = 14), and a control group (CG, n = 13). The total weekly jumping ranged between 98 and 196 jumps (equalized between, EG1 and, EG2). The assessments performed were squat jump (SJ), countermovement jump (CMJ), CMJ-arms, drop jump (DJ), 5-m sprint, 10-m sprint, and service speed. The intragroup comparisons showed that, EG1 significantly (p < 0.001) improved SJ (Δ = 12.74%; d = 1.30), CMJ (Δ = 11.94%; d = 1.71), CMJ-arms (Δ = 12.02%; d = 1.47), DJ (Δ = 10.93%; d = 1.30), 5-m sprint (Δ = -4.61%; d = 0.29), 10-m sprint (Δ = -3.95%; d = 0.40) and service speed (Δ = 8.17%; d = 1.53). Similarly, EG2 significantly (p˂ 0.001) improved SJ (Δ = 11.52%; d = 1.25), CMJ (Δ = 11.29%; d = 1.38), CMJ-arms (Δ = 11.42%; d = 1.26), DJ (Δ = 13.90%; d = 2.17), 5-m sprint (Δ = -3.85%; d = 0.25), 10-m sprint (Δ = -2.73%; d = 0.25) and service speed (Δ = 6.77%; d = 1.44). The CG significantly (p < 0.05) improved SJ (Δ = 2.68; d = 0.28), CMJ-arms (Δ = 2.30; d = 0.35), 5-m sprint (Δ = -1.27; d = 0.10) and service speed (Δ = 1.42; d = 0.30). Intergroup comparisons revealed significantly greater improvements in all variables (p < 0.001) in, EG1 and, EG2 concerning to CG. However, no significant differences were found between, EG1 and, EG2. A moderate weekly PT volume, distributed in one or two sessions per week, seems equally effective.

Effects of Olympic Combat Sports on Cardiorespiratory Fitness in Non-Athlete Population: A Systematic Review of Randomized Controlled Trials.

This systematic review aimed to assess the available body of published peer-reviewed articles related to the effects of Olympic combat sports (OCS) on cardiorespiratory fitness (CRF) in the non-athlete population. The methodological quality and certainty of evidence were evaluated using PRISMA, TESTEX, RoB, and GRADE scales. The protocol was registered in PROSPERO (code: CRD42023391433). From 4133 records, six randomized controlled trials were included, involving 855 non-athletes (mean age = 27.2 years old). The TESTEX scale reported all studies with a ≥ 60% (moderate-high quality) score. The GRADE scale indicated moderate to low certainty of evidence. It was only possible to perform a meta-analysis on direct methods to maximum oxygen consumption (VO2max). The main results indicated significant differences in favor of OCS compared to active/passive controls in VO2max (SMD = 4.61; 95%CI = 1.46 to 7.76; I2 = 99%; p = 0.004), while the individual results of the studies reported significant improvements in favor of the OCS on the indirect methods of the CRF. OCS improved CRF in a healthy non-athlete population of different ages, specifically showing a significant improvement in VO2max with direct tests, such as cardiopulmonary tests. However, moderate to low certainty of evidence is reported, so no definitive recommendations can be established.

The optimal dose of pain neuroscience education added to an exercise programme for patients with chronic spinal pain: A systematic review and dose-response meta-analysis.

ABSTRACT: Pain neuroscience education (PNE) has shown promising results in the management of patients with chronic spinal pain (CSP). However, no previous review has determined the optimal dose of PNE added to an exercise programme to achieve clinically relevant improvements. The aim was to determine the dose-response association between PNE added to an exercise programme and improvements in pain intensity and disability in patients with CSP. A systematic search of PubMed/MEDLINE, Embase, Web of Science, Scopus, and the Cochrane Library was conducted from inception to April 19, 2023. The exposure variable (dosage) was the total minutes of PNE. Outcome measures included pain intensity, disability, quality of life, pressure pain thresholds, and central sensitization inventory. Data extraction, risk-of-bias assessment, and certainty of evidence were performed by 2 independent reviewers. The dose-response relationship was assessed using a restricted cubic spline model. Twenty-six randomised controlled trials with 1852 patients were included. Meta-analysis revealed a statistically significant effect in favour of PNE on pain intensity and disability. In addition, a dose of 200 and 150 minutes of PNE added to an exercise programme was estimated to exceed the minimum clinically important difference described in the literature for pain intensity (-2.61 points, 95% CI = -3.12 to -2.10) and disability (-6.84 points, 95% CI = -7.98 to -5.70), respectively. The pooled effect of the isolated exercise was small. These findings may be useful in optimising the most appropriate PNE dose to achieve clinically relevant improvements in patients with CSP.

Efficacy of cupping therapy in individuals with fibromyalgia. A systematic review of randomized clinical trials.

BACKGROUND: Fibromyalgia is a chronic and idiopathic condition and is among the most common causes of generalized chronic pain, even affecting psychological and cognitive aspects. AIM: To evaluate the efficacy of cupping therapy on pain, quality of life, sleep disorders, and the impact of the disease in subjects with fibromyalgia. METHODS: We searched the Pubmed, CINAHL, Epistemonikos, Scopus, and Web of Science databases. Randomized controlled trials involving adults with fibromyalgia undergoing cupping were included. Pain intensity, quality of life, sleep disturbances, and the impact of fibromyalgia were assessed. We have reported the results using descriptive statistics and narrative synthesis. RESULTS: Two articles with a total of 155 participants were included. Large effect sizes were found for pain intensity, moderate for quality of life, and low for the impact of fibromyalgia and sleep disorders. However, the certainty of the evidence is low for most outcomes except for sleep disorders. CONCLUSIONS: There is a discrepancy in the efficacy of cupping therapy in improving pain intensity, quality of life, sleep disturbances, and disease impact in people with fibromyalgia. Future high-quality randomized clinical trials are required.

Approach to the so-called "Invisible Dermatosis": When Subtle Histopathological Findings Guide Diagnosis.

ABSTRACT: Invisible dermatosis is a concept that can be applied either to clinical or histopathological findings. We will focus on the dermatopathological aspect of this invisible dermatosis that can be seen as dermatosis with subtle histopathological findings that are mandatory to known to stablish the diagnosis. With a proper approach facing in depth the different skin layers from stratum corneum to subcutaneous tissue combined with some especial stains, special investigations and mostly a proper clinicopathological correlation, the problem of missing out a diagnosis can be decreased. We will review the general aspects for diagnosis and the peculiar findings of an in-depth review of them because it is important to note that minor changes on a skin biopsy do not mean it is disease free. We will review classic clues, we will add some new useful ones, and we will also provide a guide on the special stains helpful, such as periodic acid-Schiff when facing fungi, orcein-Giemsa and van Gieson when altered elastic fibers are suspected, or Pearl and Masson Fontana when an altered skin pigmentation is suspected.