Dermoscopy and reflectance confocal microscopy of solitary flat pink lesions: A new combined score to diagnose amelanotic melanoma.

BACKGROUND: Differential diagnosis of amelanotic/hypomelanotic melanoma among solitary flat pink lesions is challenging, due to limited clinical and dermoscopic clues. Dermoscopy and reflectance confocal microscopy assessments improve diagnostic accuracy, but their combined capacity among solitary flat pink lesions is yet to be defined. OBJECTIVES: To determine (i) whether diagnostic accuracy is improved with combined dermoscopy and reflectance confocal microscopy, (ii) a model to estimate probability of flat amelanotic/hypomelanotic melanoma among solitary flat pink lesions. METHODS: A retrospective single-centre study of solitary flat pink lesions, excised for suspected malignancy between 2011 and 2022 was performed. Images were independently evaluated by two dermatologists, blinded to histopathological diagnosis. Diagnostic performance was evaluated on the receiver operating characteristic curve and the area under the curve. Predictive features were identified by univariate and multivariate logistic regression analyses. A final predictive nomogram of independent risk factors was calculated by backward likelihood ratio. Hypothesis being tested was formulated before data collection. RESULTS: A total of 184 patients (87 females, 47.3%) were included; mean age was 57.6 years (19-95). Combined dermoscopy and reflectance confocal microscopy was more sensitive (83%, CI 69.2-92.4 and 91.5%, CI 79.6-97.6) than dermoscopy alone (76.6%, CI 62.0-87.7 and 85.1%, CI 71.7-93.8). Predictive features defined the new model, including linear irregular vessels (4.26-folds, CI 1.5-12.1), peripheral pigment network (6.07-folds, CI 1.83-20.15), remnants of pigmentation (4.3-folds, CI 1.27-14.55) at dermoscopy and atypical honeycomb (9.98-folds, CI 1.91-51.96), disarranged epidermal pattern (15.22-folds, CI 2.18-106.23), dendritic pagetoid cells in the epidermis (3.77-folds, CI 1.25-11.26), hypopigmented pagetoid cells (27.05-folds, CI 1.57-465.5), and dense and sparse nests (3.68-folds, CI 1.24-10.96) in reflectance confocal microscopy. Diagnostic accuracy of the model was high (AUC 0.91). CONCLUSIONS: Adjunctive reflectance confocal microscopy increases diagnostic sensitivity of flat amelanotic/hypomelanotic melanoma differential diagnosis. The proposed model requires validation.

Responding to a school SARS-CoV-2 outbreak: Insights and policy implications emerging from the pandemic.

Background: The SARS-CoV-2 pandemic has affected also the school environment. Prolonged closures and the weakness of available data prevent a definitive answer to the question of school transmission. We report our experience of responding to COVID-19 cases in the school setting, presenting a case study of the management of an outbreak in a large school. Methods: The LHA/ASL Roma 1 has organized the School Units with a structure firmly rooted in the territory. At the local level, the District Unit mainly manages the relationship with schools, while the Hygiene and Public Health Service of the Prevention Department holds a coordinating and facilitating role. The HPHS carries out contact tracing activities facilitated by the schools, through the figure of the COVID-19 Contact Person, who is specifically trained to manage the preliminary stages of the reports. Results: Following several reports of COVID-19 suspect cases from two schools and, after a complex phase of contact tracing, it was possible to identify the major transmission chains. Furthermore, we performed a population-based screening on the entire school. Beyond the known transmission chains, for which quarantine was already in place, only five additional cases emerged, all asymptomatic, out of 1,231 swabs tested with RT-PCR. Conclusions: Our experience confirms that an active interaction between the school and the School Unit made it possible to quickly control a potentially dangerous outbreak. The large-scale screening test demonstrated the substantial absence of collateral transmission chains. Effective contact tracing allowed to set forth a successful response. Our model of intervention can be used to support public health protocols regarding school outbreaks.

Fractional 1064 nm picosecond laser and skin photoaging: in vivo evaluation of treatment effects with reflectance confocal microscopy.

Few studies showed the role of picosecond laser (PLS) in the treatment of skin photoaging signs. However, no studies have explored the microscopic effects of PSL in photoaging. The aim of this study is to preliminarily identify clinical variations induced by a 1,064 nm Nd:YAG PSL on the décolleté area, then to apply the treatment protocol to treat facial photoaging and estimate the clinical and microscopic outcomes. A total of 10 consecutive patients with cutaneous photoaging were enrolled. Patients were treated 3 times at monthly intervals with the fractionated 1,064 nm Nd:YAG PSL. In a preliminary phase, PSL treatment was performed on the décolleté to establish its efficacy and safety. Then, the same treatment protocol was applied to all the face and clinical and reflectance confocal microscopy (RCM) were analyzed, comparing baseline (T0) pictures and 4 months after the treatment (T1) ones. On the face, a reduction of dyschromia and wrinkles was observed at T1. Furthermore, the underlying RCM variations were revealed at different skin levels. Our results show the clinical and microscopic effectiveness and safety of the 1,064-nm Nd:YAG PSL in the treatment of skin photoaging signs.

Development and calibration of a new mathematical model for the description of an ion-exchange process for ammonia removal in the presence of competing ions.

Ammonia ion removal and recovery via an ion-exchange process using zeolites is a promising alternative to traditional biological treatments. The analysis of its efficiency is not straightforward as it depends on various factors, such as the cation exchange capacity of the zeolite, amount of zeolite available, initial ammonia concentration, contact time, ammonia speciation depending on pH or the presence of competing ions. Mathematical modelling and simulation tools are very useful to analyse the effect of different operational conditions on the efficiency and optimal operation of the process. This paper experimentally analyses the effect that the presence of competing ions has on the efficiency of ammonia removal. This experimental work has shown a reduction of around 21% of ammonia removal efficiency in the presence of competing ions. The main contribution of this paper is the development new mathematical model able to describe the ion-exchange process in the presence of competing ions. The mathematical model developed is able to analyse the performance of the IEX process under different empty bed contact times, influent loads, pH and concentrations of competing ions. The capability of the model to reproduce real data has been proven comparing the experimental and simulation results. Finally, an exploration by simulation has been undertaken to show the potential of the mathematical model developed.

A validated photonumeric cellulite severity scale for the area above the knees: the knee cellulite severity score.

BACKGROUND: Treatment for cellulite above the knees is increasingly requested. However, a classification of cellulite of this area has not yet been developed. OBJECTIVE: To validate the proposed knee cellulite severity score (KCSS) for the assessment of cellulite and skin laxity above the knee. MATERIALS AND METHODS: Based on standardized photographs of cellulite and skin laxity above the knees of 57 females (114 knees), three key morphological aspects of cellulite were identified. A photonumeric KCSS was developed and validated by three independent assessors. RESULTS: The three key cellulite morphological features (number of depressions, depth of depressions and presence of laxity) are each graded from 0 to 3, producing a classification of no lesions (0), mild (1-3), moderate (4-6) and severe (7-9). Evaluators at different time points repeated similar classifications (intraclass correlation coefficient >0.9), which were also similar among the assessors (inter-observer reliability >0.9). All three key morphological aspects were deemed necessary, and positively contributed, to the overall scale (item-total correlation analysis values >0.89, P < 0.05). CONCLUSIONS: The KCSS is a consistent, comprehensive, reliable, and reproducible tool for standardized and objective assessment of the severity of cellulite and skin laxity above the knees.

Permanent implants for lip augmentation: Results from a retrospective study and presentation of tips and tricks.

BACKGROUND: Requests for lip augmentation are increasing because of expanding media exposure and consumer needs. Temporary effects can be obtained by several techniques, but a recent procedure consisting of lip prosthesis implantation, offering a permanent result, is emerging. Accordingly, the implantation of solid lip prosthesis represents an innovation in the field of esthetic medicine and surgery. METHODS: A total of 100 women with atrophic or hypoplastic lips were treated with lip implants. The treatment was performed in a single session, and controls were scheduled at fixed time intervals. A standard digital photo was used for measurement and analysis. Data concerning patient satisfaction and complications of the technique were collected and analyzed. Variations to the original technique were also discussed. RESULTS: Patient evaluation revealed that a permanent and natural result without discomfort for the patient and/or the partner was reached with the implantation of silicone prosthesis in the upper and/or lower lip. Swelling, bruising, and malpositions were the most frequent adverse events. A case of severe edema was reported. Practical tricks acquired through experience were discussed to prevent complications. CONCLUSIONS: One of the most widespreading methods for lip remodeling is hyaluronic acid injections. Nevertheless, hyaluronic acid has a variable duration, and it is not always the first choice. This context allowed for the development of other techniques such as the implantation of silicone prosthesis. The advantages of this prosthesis are as follows: safety, definitive result, and reversibility considering the possibility to remove the implanted prosthesis in the case of a request.

Telangiectasia of the face: risk factors for reappearance in patients treated with dye laser.

BACKGROUND: Lasers can be successfully used in the treatment of facial telangiectasias. Nevertheless, reappearance of telangiectasias after successful laser treatment is a significant problem. Risk factors involved in the reappearance have not been previously investigated. OBJECTIVE: To evaluate whether personal, clinical and behavioural factors can influence the recurrence or new appearance of telangiectasias after treatment. METHODS: Four hundred and fifteen women and 69 men obtaining complete clearance after laser treatment were included in the study and the role of different risk factors in the reappearance of telangiectasias was analysed. Immunocompromised patients were excluded. A statistical analysis was then performed. RESULTS: Twenty four percent of women and 14.5% of men enrolled showed a persistent clearance after treatment. In women in whom telangiectasias reappeared, logistic regression highlighted the importance of tanning addiction, aesthetic medicine and surgery procedures as risk factors, while therapy for menopause was found to be a protective factor. Hypertension was found to be a risk factor in men. CONCLUSIONS: The efficacy of laser for treatment of telangiectasias of the face has been previously proven. Nevertheless, this is the first study presenting an analysis of risk factors involved in the new appearance of telangiectasias after the clearance induced by therapy.

Risk factors for recurrence after successful treatment of warts: the role of smoking habits.

BACKGROUND: Several therapies have been proposed for cutaneous warts without results concerning factors affecting recurrences. OBJECTIVE: To determine the importance of individual characteristics and different therapy modalities in the occurrence of relapses. METHODS: Observational prospective cohort study including 199 patients affected by multiple plantar warts treated as follows: 49 with keratolytics, 50 with CO2 laser, 50 with pulsed dye laser (PDL) and 50 with cryotherapy. Personal data were evaluated through a questionnaire, and treatment information was collected. A Cox regression analysis was performed to identify independent factors for relapse occurrence. RESULTS: Of patients, 57.8% showed a persistent clearance of warts after treatment with a higher recurrence-free interval when treated with PDL. Accordingly, the risk of recurrence was increased with CO2 laser [hazard ratio (HR) 2.92, 95% confidence interval (CI) 1.49-5.74] and keratolytic treatment (HR 3.23, 95% CI 1.60-6.54), as compared to PDL. Furthermore, the multivariate analysis highlighted a higher risk of recurrence in patients between 26 and 35 years (HR 1.88, 95% CI 1.03-3.45), older than 35 (HR 2.23, 95% CI 1.23-4.07) and smokers (HR 4.90, 95% CI 3.09-7.78). CONCLUSIONS: Pulsed dye laser is characterized by the lowest rate of recurrence. Furthermore, our study highlights that the risk of warts relapse is 5-fold higher in smokers compared to non-smokers, revealing the importance of the effects of smoking on inflammation and immune response.

Spitz naevi and melanomas with similar dermoscopic patterns: can confocal microscopy differentiate?

BACKGROUND: Differentiating Spitz naevi from melanomas can be difficult both clinically and dermoscopically. Previous studies have reported the potential role of in vivo reflectance confocal microscopy (RCM) in increasing diagnostic accuracy. OBJECTIVES: To define RCM criteria that can differentiate 'false twins', namely Spitz naevi and melanomas sharing similar dermoscopic appearance. METHODS: Lesions histopathologically diagnosed as Spitz naevi or melanomas were retrospectively retrieved. They were selected to cover all dermoscopic types and were put into couples sharing similar aspects. Lesions were classified into three main dermoscopic categories: globular and starburst pattern, spitzoid with dotted vessels, and multicomponent or aspecific pattern. RESULTS: RCM findings revealed that striking cell pleomorphism within the epidermis, widespread atypical cells at the dermoepidermal junction and marked pleomorphism within nests were significantly associated with the diagnosis of melanoma, while spindled cells and peripheral clefting were found exclusively with and pathognomonic of Spitz naevi. Furthermore, the analysis of a dermoscopic subgroup highlights the importance of striking pleomorphism and spindled cells as clues to differentiate 'false twins' with globular or starburst patterns. CONCLUSIONS: The current study highlights the role of RCM in discriminating 'false twins' of Spitz naevi and melanomas for lesions showing starburst and globular patterns on dermoscopy, whereas RCM is not useful in the other dermoscopic subgroups.

Generosity motivated by acceptance--evolutionary analysis of an anticipation game.

We here present both experimental and theoretical results for an Anticipation Game, a two-stage game wherein the standard Dictator Game is played after a matching phase wherein receivers use the past actions of dictators to decide whether to interact with them. The experimental results for three different treatments show that partner choice induces dictators to adjust their donations towards the expectations of the receivers, giving significantly more than expected in the standard Dictator Game. Adding noise to the dictators' reputation lowers the donations, underlining that their actions are determined by the knowledge provided to receivers. Secondly, we show that the recently proposed stochastic evolutionary model where payoff only weakly drives evolution and individuals can make mistakes requires some adaptations to explain the experimental results. We observe that the model fails in reproducing the heterogeneous strategy distributions. We show here that by explicitly modelling the dictators' probability of acceptance by receivers and introducing a parameter that reflects the dictators' capacity to anticipate future gains produces a closer fit to the aforementioned strategy distributions. This new parameter has the important advantage that it explains where the dictators' generosity comes from, revealing that anticipating future acceptance is the key to success.

Update on the use of confocal microscopy in melanoma and non-melanoma skin cancer.

Reflectance confocal microscopy (RCM) is a new technique enabling the visualization of the skin at a quasi-histological resolution, allowing the identification of clues for the diagnosis of skin diseases. The aim of this analysis was to provide new insights into the role of RCM in the diagnosis of skin cancers. Data comes from the most recent literature, taking into account previous essential reported information in this field. The study eligibility criteria were: studies providing update information, focusing on RCM findings in melanoma and non-melanoma skin cancers (NMSC), without restrictions for age, sex, ethnicity. Duplicated studies and single case report were excluded from this study. A search concerning the role of RCM in melanoma and NMSC was performed on the Medline. RCM clues were analyzed for different skin cancers, in particular melanoma and NMSC, in association with clinical, dermoscopic and histopathologic findings. Diagnostic accuracy, sensibility and specificity of the technique were reviewed. Furthermore, some new findings have been described and recent applications have been discussed. The selection of articles was limited in order to provide an up-to-date revision. In conclusion, several RCM features were implemented for the diagnosis of melanoma and NMSC, leading to a confocal-based classification in most cases.

Update on non-invasive imaging techniques in early diagnosis of non-melanoma skin cancer.

UNLABELLED: Non-melanoma skin cancer (NMSC) is the most common malignancy in fair skinned populations. Dermoscopy, reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) are non-invasive imaging techniques that play an important role in diagnosis of skin tumors. The aim of this study was to provide new insights into the role of non-invasive tecniques in the diagnosis of non-melanoma skin cancers, concentrating especially on dermoscopy, RCM and OCT. The analysis of the studies obtained from the most recent literature, taking into account previous essential reported information in this field. A search concerning the role of dermoscopy, RCM and OCT in the diagnosis of NMSC was performed on PubMed. EXCLUSION CRITERIA: duplicated studies, single case report, and papers with language other than English New and old literature about early diagnosis of NMSC through non-invasive imaging techniques were analyzed. The role and the diagnostic accuracy of dermoscopy, RCM and OCT for the diagnosis of NMSC were reported according to the data given by literature. The development of non-invasive diagnostic devices (especially dermoscopy, RCM and OCT) allows tissue imaging in-vivo contributing to a more accurate diagnosis of skin cancer, sparing time for the patient and costs for the public health system.