Diagnostic agreement and interobserver concordance with teledermoscopy referrals.

BACKGROUND: Malignant melanoma and non-melanoma skin cancers are among the fastest increasing malignancies in many countries. With the help of new tools, such as teledermoscopy referrals between primary health care and dermatology clinics, the management of these patients could be made more efficient. OBJECTIVE: To evaluate the diagnostic agreement and interobserver concordance achieved when assessing referrals sent through a mobile teledermoscopic referral system as compared to referrals sent via the current paper-based system without images. METHODS: The referral information from 80 teledermoscopy referrals and 77 paper referrals were evaluated by six Swedish dermatologists. They were asked to answer questions about the probable diagnosis, the priority, and a management decision. RESULTS: Teledermoscopy generally resulted in higher diagnostic agreement, better triaging and more malignant tumours being booked directly to surgery. The largest difference between the referral methods was seen for invasive melanomas. Referrals for benign lesions were significantly more often correctly resent to primary health care with teledermoscopy. However, referrals for cases of melanoma in situ were also incorrectly resent five times. The interobserver concordance was moderate with both methods. CONCLUSION: By adding clinical and dermoscopic images to referrals, the triage process for both benign and dangerous skin tumours can be improved. With teledermoscopy, patients with melanoma especially can receive treatment more swiftly.

Stage-specific direct health care costs in patients with cutaneous malignant melanoma.

BACKGROUND: Clinical stage at diagnosis is a strong prognostic factor for death in cutaneous malignant melanoma (CMM), with worse prognosis at higher stages. However, few studies have investigated how direct health care cost per patient varies with clinical stage. OBJECTIVE: The aim of this study was to determine the stage-specific direct health care costs for CMM patients compared to the health care costs in the general population in the County of Östergötland, Sweden. METHODS: Cutaneous malignant melanoma patients in the County of Östergötland diagnosed 2005-2012 were identified from the Swedish cancer registry. Information on clinical stage was collected from the Swedish Melanoma Register (SMR) and cost data from the Cost per Patient database (CPP) for 1075 CMM patients in Östergötland. CPP contains costs associated with all health care contacts per patient including inpatient, outpatient and primary care. The CMM-related costs were defined as the difference in mean health care costs between CMM patients and general population. RESULTS: The first year after CMM diagnosis, the average health care costs for CMM patients were 2.8 times higher than in the general population. The health care cost ratio varied from 2.0 (stage I) to 10.1 (stage IV) and the CMM-related costs per patient-year varied from €2 670 (stage I) to €29 291 (stage IV). The mean health care costs decreased over time but remained significantly higher than in the general population for all clinical stages. During the first year after diagnosis, patients in clinical stage III-IV (7% of CMM patients) accounted for 27% of the total CMM-related health care costs. CONCLUSIONS: The direct health care costs for CMM patients were significantly higher than in the general population independent of clinical stage. CMM patients diagnosed in clinical stage III-IV were associated with particularly high costs and the health care system may save resources by finding CMM patients in earlier stages.

Daylight photodynamic therapy with methyl aminolevulinate cream is effective and nearly painless in treating actinic keratoses: a randomised, investigator-blinded, controlled, phase III study throughout Europe.

BACKGROUND: Unmet needs exist in actinic keratosis (AK) treatment. Daylight photodynamic therapy (DL-PDT) has shown good efficacy and safety results compared to conventional PDT (c-PDT) in a recent Phase III multi-centre randomised controlled trial in Australia among 100 subjects with AKs. OBJECTIVES: Demonstrate non-inferior efficacy and superior safety of DL-PDT compared to c-PDT in treating multiple mild and/or moderate facial/scalp AKs. METHODS: Phase III, 12 week, multi-centre, randomised, investigator-blinded, controlled, intra-individual study conducted at different latitudes in Europe. AKs of adult subjects were treated once with methyl aminolevulinate (MAL) DL-PDT on one side of the face and MAL c-PDT contralaterally. Endpoints for DL-PDT concerned efficacy (non-inferiority regarding complete lesion response at week 12) and safety (superiority regarding subject's assessment of pain after treatment, on an 11-point numeric rating scale). Safety evaluation also included incidence of adverse events. Subject satisfaction was described using a questionnaire at baseline and last visit. RESULTS: At week 12, the total lesion complete response rate with DL-PDT was similar (non-inferior) to c-PDT (70% vs. 74%, respectively; 95% CI [-9.5; 2.4] in PP analysis, confirmed in ITT analysis). In addition, efficacy of DL-PDT was demonstrated regardless of weather conditions (sunny or cloudy). DL-PDT was nearly painless compared to c-PDT (0.7 vs. 4.4, respectively; P < 0.001), better tolerated and resulted in higher subject satisfaction. CONCLUSION: DL-PDT in comparison with c-PDT was as effective, better tolerated and nearly painless with high patient satisfaction, and may be considered a treatment of choice to meet needs of patients with mild or moderate facial/scalp AKs.

Low risk of melanoma in patients with atopic dermatitis.

BACKGROUND: There is a possible association between atopy and cancer based on the concept of atopic diseases as a hyper-reactive state of the immune system. Melanoma is an immunogenic tumour, and since patients with atopic dermatitis (AD) are subjected to local and systemic immunosuppressives, it would be expected to find an influence of AD on the melanoma risk. There is a positive correlation between the number of naevi and melanoma risk, and children and adults with AD have fewer naevi than controls although many patients receive ultraviolet treatment. OBJECTIVE: This study aims to investigate the melanoma risk in a retrospective cohort of AD patients compared with the population. STUDY DESIGN: 6280 AD patients born 1935-1979 visited five Dermatology clinics during 1986-2004. Mean follow-up time was 36.7 years (SD 6.9) corresponding to 230 742 person-years at risk. The cohort file was linked to the National Cancer register. RESULTS: Six AD patients with melanoma were identified, and the Poisson regression analysis adjusted for age group, sex and year resulted in an incidence rate ratio of 0.49 (95% confidence interval: 0.27-1.35, P = 0.08) for the AD group compared with the total population in the region. CONCLUSION: A low risk to develop melanoma was found in AD patients. However, the results must be interpreted with caution since the small number of expected cases of melanoma makes the risk estimate sensitive to chance effects. We hypothesize that formation of naevi and progression to melanoma is counteracted by the inflammatory process in the skin of AD patients.

Frequency and distribution pattern of melanocytic naevi in Estonian children and the influence of atopic dermatitis.

BACKGROUND: There is a strong correlation between naevus number and prospective melanoma risk. Melanoma is one of the most rapidly increasing cancers in Estonia and primary prevention programmes for melanoma that target risk behaviour in the sun have so far not been launched. METHODS: The naevus profile was examined in 549/700 9-year-old Estonian children (282 boys and 267 girls) and the presence of active atopic dermatitis (AD) was registered. RESULTS: There was a wide range of naevi (4-121) and a median total body count of 26. There was no difference in naevus count between boys and girls. No dysplastic naevi were found. Thirty-nine of 549 children (7%) had at least one lesion clinically diagnosed as a congenital naevus. Boys had more naevi on the face (median 4) and trunk (median 12) than girls (median 3 and 9, respectively, P < 0.001). Girls had more naevi on the legs compared with boys (median 4 and 3, respectively, P < 0.01). Fifty-four out of 549 (9.8%) had naevi on the palms and 18/549 (3.3%) on the soles. Children with fair skin, freckles and light hair and eye colours had significantly more naevi than those with darker colours. Thirty-one of 549 (6%) children had AD diagnosed on the examination day and they had a lower total naevus count (median 20) compared with children with no AD (median 27, n = 518, P < 0.05). CONCLUSIONS: The naevus situation in Estonian children today might constitute a starting point for evaluating the efficiency of coming preventive measures as a change of naevus number in children might serve as an early marker for a change in melanoma incidence.

Intraluminal acid and gastric mucosal integrity: the importance of blood-borne bicarbonate.

The acid-secreting gastric mucosa resists intraluminal acid better than the nonsecreting. Here we investigated pH at the epithelial cell surface, mucosal permeability, and blood flow during intraluminal administration of acid (100 mM) in acid-stimulated and nonstimulated gastric corpus mucosae. Surface pH (H(+)-selective microelectrodes), permeability (clearance of (51)Cr-EDTA), and mucosal blood flow (laser-Doppler flowmetry) were studied in Inactin-anesthetized rats. Acid secretion was stimulated with pentagastrin (40 microg. kg(-1). h(-1)) or impromidine (500 microg. kg(-1). h(-1)), or HCO(3)(-) (5 mmol. kg(-1). h(-1)) given intravenously. Surface pH was only slightly reduced by intraluminal acid in acid secretion-stimulated or HCO(3)(-)-treated rats but was substantially lowered in nonstimulated rats. Clearance increased threefold and blood flow increased by approximately 75% in nonstimulated rats. During stimulated acid secretion or intravenous infusion of HCO(3)(-), clearance was unchanged and blood flow increased by only approximately 30% during intraluminal acid. Increased epithelial transport of HCO(3)(-) buffering the mucus gel is most probably the explanation for the acid-secreting mucosa being less vulnerable to intraluminal acid than the nonsecreting.

Acid transport through channels in the mucous layer of rat stomach.

BACKGROUND & AIMS: We have reported previously that secreted acid moves through the mucous layer in restricted areas above the gastric crypts. The aim of this study was to visualize and study the dynamics of this event. METHODS: Anesthetized rats prepared for intravital microscopy of the gastric mucosa were divided in the following groups with respect to acid secretion: spontaneous; stimulated (pentagastrin, 40 microg. kg(-1). h(-1)); transiently inhibited (omeprazole, 400 micromol. kg(-1) for 7 days); and totally inhibited (omeprazole, 3 x 200 micromol. kg(-1) for 7 days). The mucus was stained with Congo red (blue, pH < 3; red, pH > 5.2), and photographs were taken through a stereomicroscope. RESULTS: During acid secretion, blue-colored crypt openings with attached thread-like (5-7 microm wide) structures (designated channels) were seen passing from the crypt openings through the mucus to the lumen. Red-colored channels and crypt openings were observed when acid secretion was transiently inhibited. Red-colored crypt openings but no channels were found after total inhibition of acid secretion for a week. CONCLUSIONS: The results suggest that secreted acid is transported through channels within the mucus. These channels are probably created by the high intraglandular pressure pushing acid and glandular mucus into the gel.

Prostaglandin E2 and aggressive factors increase the gland luminal pressure in the rat gastric mucosa in vivo.

BACKGROUND & AIMS: The gastroprotective properties of prostaglandins in low concentrations are still unclear. In this study, we investigated the effects of prostaglandin E2 (PGE2), indomethacin, and intraluminally applied HCl or ethanol on intraglandular pressure, mucus thickness, acid secretion, and gastric mucosal blood flow. METHODS: Glandular pressure and mucous gel thickness were measured with microelectrodes during intravital microscopy in thiobutabarbital sodium-anesthetized rats. Gastric blood flow was measured with laser Doppler flowmetry. RESULTS: In pentagastrin-treated rats, glandular pressure increased significantly in response to topical (1 micrograms/mL) or intra-arterial (12 micrograms.kg-1.h-1) PGE2 from approximately 17 to 69 and 18 to 57 mm Hg, respectively, whereas blood flow, mucus thickness, and acid secretion were unaltered. Indomethacin (3 mg/kg intravenously) significantly decreased glandular pressure from approximately 20 to 11 mm Hg. Intraluminal application of 10 and 100 mmol/L HCl or 20% and 40% ethanol significantly increased glandular pressure but had no effect after indomethacin pretreatment. CONCLUSIONS: Endogenous PGE2 is important for maintaining a high glandular pressure, and exogenous PGE2 potently increases glandular pressure at concentrations not altering blood flow, mucus thickness, or acid secretion. This suggests that high intraglandular pressures might be involved in gastroprotection.

Gastric mucosal smooth muscles may explain oscillations in glandular pressure: role of vasoactive intestinal peptide.

BACKGROUND & AIMS: Oscillating (3-7 cycles/min) high pressures in gastric glands during acid secretion suggest the existence of rhythmically contracting mucosal muscles. The aim of this study was to study vasoactive intestinal peptide (VIP), an inhibitory neurotransmitter in the gastrointestinal tract, in relation to mucosal muscles, glandular pressure, and blood flow. METHODS: Rat, dog, and human mucosae were examined immunocytochemically for smooth muscle actin and VIP. Glandular pressure was measured using microelectrodes, red blood cell velocity (V[RBC]) was measured using a cross-correlation technique, and blood flow was measured using laser Doppler flowmetry in exposed gastric mucosa of thiobutabarbital sodium-anesthetized rats. RESULTS: Actin immunostaining showed muscle strands arising from muscularis mucosae, extending toward the gastric pits. VIP-immunoreactive nerve fibers were found in close relation to these muscles. VIP, administered intra-arterially close to the stomach (2 microg/kg bolus, followed by 10 microg x kg[-1] x h[-1]), significantly decreased glandular pressure from 18.2 +/- 1.6 to 8.9 +/- 1.6 mm Hg and almost eliminated the pressure oscillations. VIP infusion also abolished the oscillations in V(RBC) and significantly increased blood flow by approximately 35%. CONCLUSIONS: Contracting mucosal muscles may be responsible for oscillations in glandular pressure and possibly also in V(RBC). VIP probably relaxes these muscles.

Effect of inhibition of pentagastrin-stimulated acid secretion on gastric mucosal gland luminal pressure.

We demonstrated previously that hydrochloric acid secreted from the gastric glands traverses the mucus layer in channels above the gland openings. The driving force for creation of these channels is most probably the hydrostatic pressure generated in the gastric gland lumen during stimulation of acid secretion. Here we investigated the effect of total inhibition of acid secretion on gland luminal pressure. Glandular pressure was measured in vivo with a pressure-sensitive microelectrode technique in Inactin-anaesthetized Sprague Dawley or Lewis x DA F1 rats. Glandular pressure was significantly reduced after ranitidine inhibition of acid secretion, from 17.2 +/- 2.1 mmHg during pentagastrin stimulation to 11.2 +/- 1.2 mmHg. This was also true when pentagastrin infusion was continued after inhibition of secretion with ranitidine. Omeprazole, however, did not significantly alter gland luminal pressure although it totally inhibited acid secretion. With continuation of pentagastrin infusion after omeprazole inhibition, glandular pressure increased significantly from 17.6 +/- 3.4 to 20.1 +/- 3.3 mmHg. In conclusion, total inhibition of acid secretion with ranitidine reduces but does not abolish gland luminal pressure. After omeprazole inhibition of acid secretion the gastric gland luminal pressure persisted or even increased. Since the volume secretion is lower after omeprazole administration than during pentagastrin stimulation, the outflow resistance most probably had increased after omeprazole injection. Suggestions for increased outflow resistance are narrowing in the upper part of the gland lumen by conformational changes of the cells or muscle contractions, and/or an increase in mucus secretion or viscosity.

Omeprazole induces high intraglandular pressure in the rat gastric mucosa.

BACKGROUND & AIMS: In a few patients receiving high doses of omeprazole for a prolonged period, cystic changes have developed in the gastric mucosa, possibly consisting of enlarged gland lumina. To investigate this question, the luminal pressure in gastric glands was studied after omeprazole treatment in Inactin-anesthetized rats. METHODS: The gland luminal pressure and mucus thickness were measured with microelectrodes. For pressure measurements (servo-null technique) the microelectrode was inserted into a gland at an angle of approximately 30 degrees to the mucosal surface. RESULTS: Animals given omeprazole by gavage, 400 micromol/kg daily for 1 week, showed high gland luminal pressures (27.4 +/- 2.4 mm Hg). Similar values were found in animals given an intravenous omeprazole injection (40 micromol/kg). Much lower pressures were noted after vehicle or pentagastrin infusion. The thickness of the lower, firm mucus layer was not altered by omeprazole treatment. CONCLUSIONS: The significantly higher gland luminal pressure after treatment with omeprazole, compared with the values during pentagastrin or vehicle infusion, cannot be explained by increased mucus thickness. The results suggest accumulation of fluid in the gland lumen caused by increased resistance to outflow from the gland. This might explain the proposed enlargement of gland lumina.