Poor agreement between the automated risk assessment of a smartphone application for skin cancer detection and the rating by dermatologists.

BACKGROUND: Several smartphone applications (app) with an automated risk assessment claim to be able to detect skin cancer at an early stage. Various studies that have evaluated these apps showed mainly poor performance. However, all studies were done in patients and lesions were mainly selected by a specialist. OBJECTIVES: To investigate the performance of the automated risk assessment of an app by comparing its assessment to that of a dermatologist in lesions selected by the participants. METHODS: Participants of a National Skin Cancer Day were enrolled in a multicentre study. Skin lesions indicated by the participants were analysed by the automated risk assessment of the app prior to blinded rating by the dermatologist. The ratings of the automated risk assessment were compared to the assessment and diagnosis of the dermatologist. Due to the setting of the Skin Cancer Day, lesions were not verified by histopathology. RESULTS: We included 125 participants (199 lesions). The app was not able to analyse 90 cases (45%) of which nine BCC, four atypical naevi and one lentigo maligna. Thirty lesions (67%) with a high and 21 with a medium risk (70%) rating by the app were diagnosed as benign naevi or seborrhoeic keratoses. The interobserver agreement between the ratings of the automated risk assessment and the dermatologist was poor (weighted kappa = 0.02; 95% CI -0.08-0.12; P = 0.74). CONCLUSIONS: The rating of the automated risk assessment was poor. Further investigations about the diagnostic accuracy in real-life situations are needed to provide consumers with reliable information about this healthcare application.

Needs and preferences of patients regarding basal cell carcinoma and cutaneous squamous cell carcinoma care: a qualitative focus group study.

BACKGROUND: Despite the high and rising incidence rate of keratinocyte cancer (KC) and the importance of incorporating patient values into evidence-based care, few studies have focused on the perspectives of patients with KC. OBJECTIVES: To identify the needs and preferences of patients with basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) regarding care. METHODS: A qualitative study was conducted consisting of three focus groups with patients with BCC and three focus groups with patients with SCC. In total 42 patients participated. In each focus group, the patients' needs and preferences regarding treatment and follow-up were discussed, using a predefined topic list. All sessions were transcribed verbatim and analysed by two researchers. RESULTS: The following needs and preferences were identified: (i) the need to receive all relevant, tailored information; (ii) a physician who takes you seriously and communicates well; (iii) a short waiting period and the best treatment with direct results; (iv) to be seen by the same physician; a preference for a dermatologist during (v) treatment and (vi) follow-up; (vii) a general need for structured follow-up care and (viii) a full-body skin examination during follow-up. Patients with BCC additionally expressed the need for openness and transparency and wanting to participate in shared decision making. CONCLUSIONS: It is advocated to organize skin cancer care that is better tailored to the needs of patients with KC, providing patient-centred care. This should include investing in the patient-physician relationship, and personalizing the type and form of information and the follow-up schedules. Adding the patient's perspective to current guidelines could facilitate this process.

[Guideline on 'The treatment of recurrent varicose veins'Supplement to the Dutch Guideline on Venous disease]. / Richtlijn 'Behandeling bij neo-varices'.

The Dutch Guideline on Venous disease was lacking a section on recurrent varicose veins. The newly issued supplement on recurrent varicose veins fills this gap and provides clinicians with solutions concerning the management of patients with recurrent varicose veins following earlier treatment. Because venous disease is nowadays considered to be an ongoing disease, patients with this disorder will often require life-long care and different treatment than patients who have never been treated before.

Randomized clinical trial of endovenous laser ablation versus steam ablation (LAST trial) for great saphenous varicose veins.

BACKGROUND: The aim was to compare endovenous laser ablation (EVLA) and endovenous steam ablation (EVSA) for great saphenous varicose veins in a non-inferiority study. METHODS: Patients with primary great saphenous vein reflux were randomized to EVLA (940 nm) or EVSA (SVS™). Primary outcomes were treatment success (vein obliteration or abolition of reflux) [corrected] at 52 weeks, and Venous Clinical Severity Score (VCSS) at 12 weeks. Secondary outcomes were pain, satisfaction with treatment, duration of analgesia use and days lost from daily activities, changes in Aberdeen Varicose Vein Questionnaire (AVVQ) and EQ-5D™ scores after 12 weeks, and complications at 2 and 12 weeks. RESULTS: A total of 227 legs were treated (EVSA, 117; EVLA, 110); 36 legs treated with EVSA received a low dose and the remaining 81 a higher dose. At 1 year, the treatment success rate after high-dose EVSA was not inferior to that of EVLA: 92 (95 per cent confidence interval (c.i.) 86 to 98) versus 96 (92 to 100) per cent respectively. Changes in VCSS after 12 weeks were similar: -2·69 (95 per cent c.i. -2·34 to -3·04) and -2·51 (-2·10 to -2·93). AVVQ, EQ-5D™ and EQ VAS scores improved equally 12 weeks after both treatments. Patients treated with EVSA reported less postprocedural pain, fewer days of analgesia use, were more satisfied with therapy, and had a shorter convalescence. Complication rates were comparable. CONCLUSION: The 1-year treatment success of high-dose EVSA was not inferior to that of EVLA. Several secondary outcomes were in favour of EVSA. Registration number NCT02046967 (http://www.clinicaltrials.gov).

[Universal Dutch guideline on 'Venous disease']. / Overkoepelende richtlijn 'Veneuze pathologie'.

- The Dutch guideline on 'Venous disease' comprises four parts: two revised guidelines ('Varicose veins' and 'Venous leg ulcer') and two new guidelines ('Deep venous disease' and 'Compression therapy').- These guidelines were drawn up by a working party made up of representatives from the Dutch Association of Surgeons, the Dutch Society of Vascular Surgery and the Dutch Society of Dermatology and Venereology.- We will discuss the most important parts of the guideline here.

Ulcer recurrence after in-hospital treatment for recalcitrant venous leg ulceration.

BACKGROUND: Leg ulceration caused by chronic venous disease occurs in 1% of the adult Western population. A majority of these patients is successfully treated in the outpatient setting. A minority of patients is hospitalized, most frequently because of the lack of healing tendency. The literature provides recurrence rates for ulcer disease, but lacks specific data on recurrence rates after in-hospital treatment of recalcitrant venous leg ulcers. OBJECTIVES: To investigate time to ulcer recurrence after in-hospital treatment of venous leg ulceration. METHODS: A multicentre, retrospective cohort study of patients admitted for leg ulceration between 1996 and 2007 was conducted. RESULTS: Data could be collected for 107 of the patients. Of these, 27 had conservative treatment (bed rest, local wound care, pain management) and 48 patients underwent surgical ulcer treatment with (n = 19) or without (n = 29) initial vacuum-assisted closure (VAC) treatment. The treatment method was 'miscellaneous' in the remaining 32 patients. Median admission time was 30 days, median percentage of closure at discharge was 95%, and median time to ulcer recurrence 60 days. The Mann-Whitney U-test showed significant differences between the conservative group and the surgery group, the latter having a longer length of hospital stay (P < 0.0001) and a higher percentage of ulcer closure (P < 0.0001), but there was no difference in time to ulcer recurrence (P = 0.273). Comparable differences were demonstrated between the conservative group and the VAC plus surgery group. No significant differences could be demonstrated between the surgically treated patients and those treated by VAC and surgery. CONCLUSIONS: Hospital stay is significantly shorter in cases of surgical treatment of recalcitrant venous leg ulcers. Most ulcers recur within 2 months after hospital discharge. Recurrence of venous leg ulcers after hospital admission is independent of the method of treatment and cause of ulceration.

[Echo-guided compression sclerotherapy using foam: an improvement in the treatment of varicose veins]. / Echogeleide sclerocompressietherapie met schuim: een aanwinst bij de behandeling van varices.

Recently, echo-guided compression sclerotherapy (ECST) using foam was introduced as an efficient and patient-friendly therapy for the treatment of varicose veins. ECST enables operation under either spinal or general anaesthetic to be avoided. Foam for phlebological use is a volatile mixture of a gas, usually air, and a small quantity of liquid with the characteristics of a detergent or soap, such as polidocanol. The product that is injected has deterging properties. It reduces the surface tension of endothelial cells resulting in the destruction of the vascular wall. The treated vessel is subsequently reduced to a fibrous cord. For small calibre varicose veins, sclerosing fluids are used. In The Netherlands, until relatively recently branch varicosities of the long and short saphenous veins were treated surgically, but ECST using foam can be successfully used to treat wide calibre varicosities. Caution is advised in treating patients who are known to have a history of open foramen ovale because of the higher risk of the occurrence of scotoma and transient cerebral ischaemia.

Expression of retinoic acid 4-hydroxylase (CYP26) during mouse and Xenopus laevis embryogenesis.

Retinoids are important signal molecules during vertebrate embryonic development and their synthesis as well as catabolism should therefore be strictly regulated. The retinoic acid (RA) 4-hydroxylase, belonging to the cytochrome P450 family CYP26, is an enzyme catalyzing the 4-hydroxylation of RA, thereby regulating RA homeostasis. Here we describe the temporal and spatial expression patterns of mouse (mCYP26) and Xenopus laevis (xCYP26) homologues. In mouse, expression is detected in uterine crypt, around differentiating cartilage, several regions of the head, regions of the pharynx, the neural retina, and several regions of the trunk. In Xenopus, Northern blot analysis shows presence of xCYP26 transcripts before the MBT and an increased expression level during gastrulation. Whole-mount in situ hybridization shows a specific expression pattern arising at onset of gastrulation, with a ring around the blastopore. By mid gastrulation there is an anterior and a posterior expression domain, each of which gets more complex later in development. There are some important similarities and differences in expression pattern between Xenopus and mouse.

Long cotton wool rolls as compression enhancers in macrosclerotherapy for varicose veins.

BACKGROUND: Macrosclerotherapy in combination with compression has proven to be safe and effective in the treatment of varicose veins. Local compression is increased by pads, according to Laplace law. Firm rolls of cotton wool are fixed over the course of the entire vein to increase local compression and to reduce complications. Additional compression is given by a combination of a class I (daytime and nighttime) and class II (daytime only) medical compression hosiery. PURPOSE: To evaluate the effectiveness and side effects of sclerocompression therapy with cotton wool rolls in combination with medical compression hosiery. METHOD: Prospective study with 100 patients (120 legs) with primary varicose veins, which are treated with polidocanol as sclerosant with the empty vein technique. Immediately after the injection, a long cotton wool roll is placed over the entire vein and fixed. Additional compression is obtained with class I and class II medical compression hosiery. The interface pressure on the skin, just under the cotton wool roll, is measured on 12 legs with the aid of an interface pressure measuring instrument (Oxford Pressure Monitor). RESULTS: Good sclerosing results are obtained in all patients. Side effects are classified as early and late. In 16 patients, minor side effects which needed no treatment are observed. In only 3 cases (2.5%), intravascular blood clots (2) and phlebitis (1) needed incision and expression. The mean interface pressure of all measuring sensors under the cotton wool roll is 84 mm/Hg (68 to 122 mm/Hg). CONCLUSION: This study proves the high effectiveness of a cotton wool roll compression right at the place of treatment. By using these long cotton wool compression rolls, the compression part of sclerocompression therapy becomes more effective and much easier to perform.

Muller's ambulatory phlebectomy for varicose veins of the foot.

BACKGROUND: Ambulatory phlebectomy is an accepted therapy for varicose veins. It has also been used for ankle and foot varicosities with success although the anatomy of the venous system of the foot is poorly described in the literature. OBJECTIVE: To review the relevant literature on the anatomy of the veins of the foot. Also to form an opinion on safe possibilities for the treatment of foot varicosis. METHODS: The English, French, German, and Dutch language literature was reviewed for anatomy and treatment of varicose veins of the foot. Fourteen patients (19 feet) were treated for varicose veins of the foot with ambulatory phlebectomy. RESULTS: Literature concerning the venous anatomy of the foot is very limited. Venous surgery, sclerotherapy, and ambulatory phlebectomy have all been used for the treatment of varicose veins of the foot. The former two have resulted in serious complications. All treated patients showed excellent results with ambulatory phlebectomy. No serious side effects were seen. CONCLUSIONS: The venous anatomy of the foot does not indicate major restrictions in the treatment of its varicosities. Ambulatory phlebectomy is the safest and most elegant treatment option for varicose veins of the foot. Venous surgery and sclerotherapy may be used successfully in special cases only.

Muller's ambulatory phlebectomy and compression.

BACKGROUND: Compression therapy will relieve patients of symptoms of venous disease, if not prevent the occurrence of complications, and is used either alone or in combination with other treatment options. OBJECTIVE: To describe the use of compression in the two main therapy modalities: sclerocompression and ambulatory phlebectomy. METHODS: Aim and mechanism of compression therapy are analyzed and clinical implications are discussed. RESULTS: A modification of compression therapy after ambulatory phlebectomy is suggested based on empirical evidence. CONCLUSIONS: The use of broad compression pads after ambulatory phlebectomy reduces hemorrhage and enhances resorption.

Developmental expression and differential regulation by retinoic acid of Xenopus COUP-TF-A and COUP-TF-B.

COUP-TFs (Chicken Ovalbumin Upstream Promoter Transcription Factors) have been proposed to be negative regulators of retinoid receptor-mediated transcriptional activation. In a previous paper we reported the cloning of a Xenopus (x) COUP-TF (Matharu, P.J. and Sweeney, G.E. (1992) Biochim. Biophys. Acta 1129, 331-334). Here we describe the cloning of a second xCOUP-TF. Amino acid sequence comparison between these two Xenopus COUP-TFs revealed a high level of similarity. Extensive amino acid sequence conservation was found among all Drosophila, Xenopus, zebrafish and mammalian COUP-TF genes examined. Phylogenetic tree analyses indicate that the vertebrate COUP-TFs fall into three classes. The two Xenopus COUP-TF genes show similar temporal expression patterns: both are expressed from the end of gastrulation. In situ hybridization studies reveal complex expression patterns in the developing central nervous system (CNS), besides expression in the eye and in some mesodermal tissues. Retinoic acid (RA) treatment enhances xCOUP-TF-A expression in neurula stage embryos, whereas the expression of xCOUP-TF-B is inhibited during the same developmental period. The strictly conserved amino acid sequences and the strong similarities between the expression patterns of the two different xCOUP-TFs on the one hand, and other vertebrate COUP-TF homologues on the other, make it likely that COUP-TFs have a conserved role in patterning the nervous system.

Vein biopsy. A new indication for Muller's phlebectomy.

BACKGROUND: Histology can be essential for certain diagnoses. In venous diseases, especially in some syndromes and angiodysplasia, a vein biopsy can be helpful as well. OBJECTIVE: To describe an easy method of vein biopsy. METHOD: In Muller's phlebectomy, a micro incision is made in the skin overlining the vein. The vein is hooked with a special hook. Skin is closed with a steristrip. RESULTS: Muller's phlebectomy turned out to be an excellent method for harvesting material from veins. CONCLUSIONS: With the described method it is possible to harvest enough material for histologic diagnosis with little or no discomfort to the patient and excellent cosmesis.

Traumatic neuroma. A rare complication following Muller's phlebectomy.

BACKGROUND: Complications following ambulatory surgical phlebectomy are rare, and to our knowledge, traumatic neuromas have never been reported. OBJECTIVE: To present a case of traumatic neuroma in a 48-year-old woman after ambulatory minisurgical phlebectomy. METHODS: The ambulatory minisurgical phlebectomy as described by Muller. RESULTS: In a 48-year-old woman who developed persisting nodules after phlebectomy, histopathology confirmed the clinical diagnosis of traumatic neuroma.