Skin Markers Research Articles

Skin Marks on the Indus River Dolphin (Platanista minor) and their Implications for Conservation

Skin Marks on the Indus River Dolphin (Platanista minor) and their Implications for Conservation

Commentary: A technical revisit to the glabellar flap.

We have read an interesting article by Balchev et al. published in the current issue of IJO. They included 15 patients who were followed up over 36 months. The authors have described the use of glabellar flap (GF) to reconstruct medial canthal region defects. They have categorized the medial canthal region into the upper, medial, and lower zone in reference to the medial canthal tendon. They used V-Y glabellar rotation, advancement, or combined transposition flap techniques. By definition, the glabella is a region between the eyebrows that has potential skin to reconstruct surrounding areas like the medial canthus and nose.[1] The glabellar myocutaneous flap is a simple, safe, and effective procedure that provides anterior lamellae and vascular supply to the reconstructed region.[12] The advantages being similar skin color, texture, and thickness with minimal postoperative flap shrinkage or contracture.[123] Moreover, the vascular supply leads to faster healing with minimal collateral damage. Maloof and Leatherbarrow[4] (2000) provided a detailed description of the GF. They conceptualized the idea of anatomical and surgical medial canthus, the latter being much larger in area. The surgical medial canthus extended from the subbrow region (superior) to the upper cheek (inferior) and medially up to the midline over the nose. They believed that any reconstruction of surgical medial canthus could be performed using a glabellar V-Y flap. The critical factors in preoperative planning of GF include[4]: Size, depth, and location of the defect Orientation and alignment of the V-Y flap Depth of the medial canthus or nasal bridge prominence Age and skin texture of the patient. The smaller, shallower, and medial defects have favorable outcomes. The prominent nasal bridge or deep medial canthus will need a longer flap to reach up to the lateral edge of the defect. Younger patients have tighter skin that may have intraoperative implications. Skin marking is a vital part of the GF harvesting process. After the surgical excision of the lesion and determining its tumor-free margins, a surgical marker pen is used to draw the triangular or rectangular GF. The flap size depends on the size of the defect, distance from the glabella, and the depth of the medial canthus.[1234] The first arm of the V-shaped GF, arises tangentially from the superolateral edge of the defect, passes superomedial toward the midline apex. The second arm (preferably curved in shape) is fashioned at an acute angle, and its length is kept slightly longer to accommodate the bend of flap tissue [Fig. 1]. The flap should have a broad base for better vascular supply. The dissection should be limited to the skin and subcutaneous tissue, avoiding the involvement of corrugators and procerus muscles. The suture fixation of the flap base to the underlying periosteum prevents traction and preserves canthal concavity. The donor site should be closed in two layers—the deeper muscular layer (4-0 or 5-0 absorbable sutures) and the skin with 4-0 or 5-0 prolene or nylon (preferably horizontal mattress sutures). For larger defects, the extended, modified advancement flap, rotational flap, or bilobed GF can be used.[145]Figure 1: A glabellar flap fashioned for the reconstruction of left medial canthus lesion showing the first and second arms with a broad baseThe complex scenarios that may compromise the outcomes of GF include[4]: Young patients with tight forehead and facial skin Very deep medial canthus Dense hairs in-between eyebrows (synophrys) Large and irregular defect extending more laterally or inferiorly. The limitations of GF include consecutive midline forehead scar, medialization of the eyebrows, lymphedema, and flap uptake-related complications (necrosis, infection, etc.).[45] Nevertheless, the GF and its modifications constitute a simple, reproducible, and efficient technique providing excellent skin color match with satisfactory aesthetic and functional outcomes.[3]

Comparison of Effectiveness and Safety of Immunotherapy of Warts with Intralesional Versus Subcutaneous MMR Vaccine: An Open Label Randomized, Parallel Group, Clinical Trial.

Common wart, also known as verruca vulgaris is characterized by focal proliferation of keratinocytes caused by multiple strains of human papilloma virus (HPV). Conventional treatments like chemical cautery, cryotherapy, electro-cautery, etc often fail to cure verruca satisfactorily. The present work was a randomized, parallel-group, non-inferiority clinical trial with an objective of comparing the effectiveness and safety of subcutaneous MMR versus intralesional MMR vaccine in the treatment of multiple warts.Method:Consenting patients of both sexes of 18-65 years age, who have viral warts and did not receive anti-wart treatment in the last 4 weeks and devoid of any active bacterial or viral skin diseases were included in the study.Interventions:Eligible patients were randomized into either group A (receiving 0.3 ml of intralesional MMR) or group B (receiving 0.5 ml of subcutaneous MMR). A total of three injections were administered at two weeks interval.Outcome Measure:The response was considered complete if there was disappearance of the wart(s) and return of the normal skin markings, partial if the wart(s) was regression in size by 50-99% and no response if there was be 0-49% decrease in wart size.Results:Thirty patients were recruited in each group; 5 of group A and 3 of group B were lost to follow up. Modified intention to treat analysis was performed, so, the last observation of such patients was carried forward and all 60 participants were analysed. Number of warts and size of the largest wart were declined significantly (P < 0.001 and P = 0.001 respectively) in both the treatment arms. No significant difference between two groups were seen. Complete clearance including distant lesions was achieved in 22 patients; 12 (48%) in group A and 10 (37.04%) in group B, but the final outcome at the end of the study showed no significant difference between the two t groups. (P = 0.64).Adverse Events:Only one patient had developed mild fever with tender, enlarged parotid gland after first injection of subcutaneous MMR which resolved within two weeks.Conclusion:Efficacy and safety profile of Subcutaneous and intralesional MMR were almost same. Both can be considered as safe and cost effective treatment of warts while the subcutaneous route may be easier to administer.

The Case of a Scaly Hand: Burrowing into a Diagnosis.

A 60-year-old female patient, housewife, belonging to the upper-middle class, hailing from Kerala, India, presented with complaints of itching and scaling, solely involving the left hand for 3 months. She gave a history of aggravation of symptoms after exposure to detergents. There was no contact with other irritants/allergens prior to the onset of the lesions. There were no similar complaints in other family members. She gave a history of applying a topical preparation composed of salicylic acid 3% and clobetasol propionate 0.05% on and off for 1 month with no improvement in lesions. On examination, the patient had scaling, desquamation, and accentuation of skin markings predominantly involving the left palm extending to involve the dorsum of the fingers. The patient also had underlying erythema and mild edema of the affected hand [Figure 1a and b]. Minimal scaling was noted over the right hand.Figure 1: (a) Scaling, desquamation, accentuation of skin markings over the left palm with erythema and mild edema. (b) Scaling, desquamation over the dorsum of fingers of the left hand with mild edemaThe lesions were nontender. No nail changes were seen. Soles were normal. No other lesions were present on the body. With a provisional diagnosis of Tinea manuum and hand eczema, 10% potassium hydroxide mount was done to arrive at a final diagnosis. The image we found through the lens caught us by surprise. We expected to find fungal hyphae, but surprisingly we found an eight-legged arthropod, the Sarcoptes scabiei mite with scybala! [Figure 2].Figure 2: 10% potassium hydroxide mount showing mite of Sarcoptes scabiei and scybalaThe patient was treated with permethrin 5% cream and antihistamines. The patient was reviewed back after 2 weeks with complete improvement in her symptoms and lesions [Figure 3].Figure 3: After treatment, the scaling and desquamation over the left hand has resolvedScabies, a parasitic infestation of the skin is caused by the mite Sarcoptes scabiei.[1] Burrows are the primary lesions in scabies. Secondary lesions include papules, vesicles, pustules, and excoriations.[2] The typical distribution of lesions includes web spaces of fingers, the wrists, axillae, groins, buttocks, genitals, and the breasts in women.[3] Scabies can also manifest with atypical morphological forms such as bullae, crusting, ecchymoses, urticaria, and eczema. Scabies surrepticius is a term that has been proposed to describe the atypical morphological presentations of this infestation.[4] Wilson et al.[5] reported an atypical appearance of scabies in the form of papulosquamous lesions among inmates of a nursing home. Usually, in chronic infestation and use of long-term topical steroids, eczematous lesions may be the presenting picture as was in our case.[6] We would also like to emphasize the predominantly unilateral involvement of the left hand in this patient. Such atypical presentations often confound the diagnosis of scabies and hence this case emphasizes the importance of potassium hydroxide mount, a very simple but essential tool to confirm the diagnosis in doubtful cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Atrophic Lingual Plaque in Father-Son Duo.

Dear editor, A 24-year-old male presented with a tongue lesion present since adolescence. On examination, he had a single large, sharply demarcated, irregular, depressed plaque on the dorsum of the tongue. Blackish discoloration of the papillae within the lesion was noted. [Figure 1a]. Also, there were multiple, asymptomatic, annular plaques all over the body, slowly increasing in number and size with age. Most of these plaques had a hyperkeratotic double-edged border with a gutter in between with a thread-like margin with atrophy at the center in a few. Similar plaques were present in the buccal mucosa, hard palate, labial commissures, scrotum, glans, and penile shaft. His father also had multiple similar plaques on the tongue as the son, but the center was more atrophic and glazy [Figure 1c]. Furthermore, his father had similar lesions over the body and limbs [Figure 2].Figure 1: Shows (a) clinical picture of son showing a sharply demarcated large irregular plaque with bluish-grey papillae inside the border; (b) mucoscopy of the same lesion of the son with incomplete white peripheral keratotic tract with a double-free edge with few areas showing white radiating lines; (c) clinical picture of the father showing multiple sharply-demarcated plaques with atrophic papillae; (d) mucoscopic picture showing white peripheral keratotic tract with a double-free edge, dotted vessels in irregular distribution and clusters inside the plaque, loss of papillae with brown clods, and white lines in the centerFigure 2: Multiple large annular plaques with double-edged border of classic porokeratosis of Mibelli on back (a) and legs (b) and upper limb (c)Mucoscopy (DermLite DL4; Contact polarized; 10× magnification; ultrasound gel as interface media) of the tongue plaque of the son [Figure 1b] showed incomplete, peripheral, white, double-edged, keratotic tract with few areas showing white radiating lines and brown clods. In contrast, the father [Figure 1d] showed a white peripheral, double-edged, keratotic track with a center showing dotted vessels in irregular distribution and clusters inside the plaque, loss of papillae, brown clods, and white lines. Dermoscopy of the cutaneous lesion of both father and son showed the hyperkeratotic double-edged margin with the characteristic gutter in between and decreased skin markings at the center, which indicated a clinical diagnosis of classic porokeratosis of Mibelli (CPM). Biopsy and histopathological [Figure 3a and b] examination of the tongue lesion of the son showed moderately dense superficial perivascular patchy lichenoid lymphocytic infiltrate with focal interface vacuolar change. In a few places, the epidermis showed an invagination of the floor, which lacked a granular layer, whereas the walls showed hypergranulosis, and the center had a column of dyskeratotic and parakeratotic cells, the cornoid lamellae. It confirmed our clinical diagnosis of multifocal CPM.Figure 3: Showing histopathological findings {Hematoxylin and Eosin, 10 × (a) and 40 × (b)} – moderately dense superficial perivascular patchy lichenoid lymphocytic infiltrate with focal interface vacuolar change, the epidermis showed an invagination of the floor, which lacks granular layer, whereas the walls showed hypergranulosis, and the center had a column of dyskeratotic and parakeratotic cellsAlthough Pororkeratosis is clinically classified as localized and generalized, they are unified by a common histopathological finding of a column of parakeratotic cells with an absent granular layer at the base. Dermoscopy of cutaneous lesions helps diagnose as it accentuates the gutter as white track,[1] which is characteristic of porokeratosis, especially in CPM, as was seen in our case. Ahmed et al.[2] described 26 cases of primary genital porokeratosis in their review. Our literature search of PubMed and Google (till April 2021) and review of reported cases having mucosal porokeratosis [electronic supplement Table e-1] found 18 reports. Out of 21 cases, ten had labial lesions, nine cases had buccal mucosa lesions, and only six had lesions on their tongue (including the present report), making the tongue rarest of the three sites. Only labial porokeratosis was present in isolated form (seven cases), whereas the buccal mucosa lesions always presented with cutaneous lesions. In cases where the lesions were generalized with mucosal involvement (14 cases), buccal mucosal lesions were present in nine cases, six in the tongue, and only two on the lips, making buccal mucosa most common to be affected in generalized forms. Of these 14 cases, eight were of CPM, three each of disseminated superficial porokeratosis (DSP) and porokeratosis palmaris et plantaris disseminata (PPEPD). A total of six cases (including ours) had lingual porokeratosis. Previously, tongue plaque has been seen in two cases of CPM,[34] and one each in PPEPD,[5] and DSP.[6] Our case with widespread mucosal involvement is very rare. Furthermore, we could not find any literature describing the dermoscopic and histopathologic findings of lingual porokeratosis. The mucoscopic findings will help clinicians make outpatient-based spot diagnoses. Consent Consent for publication of the image is taken. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Supplement Table

Optical skin marker based augmented reality navigation during percutaneous pedicle screw placement: Clinical results from a prospective study

Optical skin marker based augmented reality navigation during percutaneous pedicle screw placement: Clinical results from a prospective study

The not so familiar silent joint killer: Ochronosis – A case report with review of literature

Ochronosis is rarely considered a cause for knee synovitis due to its rare occurrence. It starts affecting the joint from the third decade onward causing premature joint damage. The damaged joint and surrounding tissue present as blackish decolorated mass and can surprise the operating surgeon, unless diagnosed beforehand. Prior diagnosis helps both the anesthetist and operating surgeon to better handle the associated complications of ochronosis during surgery. Diagnosis is essentially based on prior knowledge of the disease and its markers. Here, we report a rare case of ochronosis of the knee that was treated elsewhere previously as tuberculosis of the knee. A history evaluation along with intraoperative findings helped arrive at the possible diagnosis of ochronosis. Total synovectomy was done. Postoperative improvement of visual analog scale score was significant and the patient was satisfied with the pain relief attained through treatment. Early diagnosis and timely management is critical to avoid unwanted complication related to both anesthesia and surgery pertaining to the disease. Knowledge of skin markers and urine darkening helps in identifying the disease early.

Effects of Botulinum Toxin A on the Blood Flow in Expanded Rat Skin

Background Poor blood supply can easily lead to expander extrusion and necrosis at the distal expanded flap. Botulinum toxin A (BTX-A) has been previously found to improve pedicled flap blood flow perfusion, but its effects on the blood supply of expanded skin remain unclear. Therefore, this study aimed to evaluate the effects of BTX-A on blood flow perfusion during and after expansion. Methods Eighteen Sprague-Dawley rats were randomly divided into a BTX-A group and a control group. BTX-A or normal saline was injected intradermally into the marked skin on the back immediately. Then expanders were implanted in the rats. One week later, inflation of the expander with normal saline was started and performed twice a week to reach an intracapsular pressure of 8 kPa. The skin blood flow was measured before each injection. After 4 weeks of expansion, the sample was harvested for histological staining to measure the diameter and density of blood vessels; meanwhile, a 2 cm× 8 cm expanded random flap was elevated and sutured in situ. Blood flow perfusion and flap survival were observed. Results Compared with the control group, the BTX-A group had more blood flow, a larger blood vessel diameter, and higher blood vessel density in the expanded skin. Additionally, the flap of the BTX-A group had good blood flow perfusion and a high proportion of flap survival area within 7 days after expanded flap transfer. Data were analyzed using an independent t-test. Conclusion Pre-surgical BTX-A treatment may increase angiogenesis and vasodilatation, with subsequent blood perfusion elevation during and after expansion, and obtain a greater proportion of survival area of the transferred expanded flap.

Cryoneurolysis for Digital Neuralgia in Professional Baseball Players: A Case Series

We describe a non-surgical approach to refractory digital neuralgia using cryoneurolysis in a series of 3 professional baseball players. Thumb injuries are common in baseball players and can sometimes be challenging to effectively manage. Depending on the injury, current treatments include anti-inflammatories, immobilization, physical therapy, corticosteroid injections, and/or surgery. A subset of patients, however, fail nonoperative management yet do not have a clear indication for surgery. Cryoneurolysis or cyroanalgesia is an FDA-approved form of neuromodulation, which has been used safely and effectively on a variety of peripheral nerves. The mechanism of action involves percutaneous introduction of a small probe under local anesthetic to nerve tissue using ultrasound guidance. The probe is then cooled to -88°C using nitrous oxide, which results in secondary Wallerian degeneration. Axonal and myelin regeneration occurs completely in 3-6 months. Visualization of the superficial radial sensory and ulnar digital nerve were obtained under ultrasound. The skin was prepared in sterile fashion. A 22-gauge 1-½ inch needle was then advanced with ultrasound guidance, and local anesthetic was applied. Both treatment sites were marked with skin marker. Cryoneurolysis was employed using a 5 mm tip. 60-second treatment cycles were performed at each site. Each of the cycles resulted in a 5 × 7 mm lesion visible as hypoechoic signal. All 3 players endorsed significant and prolonged relief and were able to return to an elite level of play. This manuscript is subject to all of the limitations of a case series, and larger rigorous studies are needed to illuminate causal inferences. Novel, complex technologies may also be more susceptible to placebo effect. Nonetheless, we are able to report marked efficacy and safety from cryoneurolysis of the ulnar digital nerve and the superficial radial sensory nerve in a small group of elite baseball players with refractory digital neuralgia.

Kinematics-vis: A Visualization Tool for the Mathematics of Human Motion.

Kinematic analysis studies characterize human motion in healthy, pathologic, and rehabilitated subjects. These studies provide rich datasets which enable clinicians and researchers to understand disease progression, and the effects of surgical intervention and physical therapy. A variety of techniques - ranging from optical skin marker tracking to biplane fluoroscopy - are utilized to collect these datasets. The quantification and physical interpretation of these motion capture datasets (i.e. kinematic analysis) are predominantly conducted using Euler/Cardan angles (Diebel, 2006; Wikipedia, 2021; Zatsiorsky, 1998), whose output - time series of 3 angles - is presented in peer-reviewed manuscripts in 2D graphs (Ludewig et al., 2009). This rudimentary presentation, however, obscures the physical meaning behind Euler/Cardan analysis. As other authors have noted, the visualization of these angles enables meaningful discussion between biomechanics researchers and clinicians (Baker, 2011). A ubiquitous open-source method to concurrently visualize recorded human motion and the results of kinematic analysis is presently lacking in the biomechanics community. 'Kinematics-vis' is a JavaScript web application that visualizes kinematic analysis output resulting from motion capture studies.

The Art and life of Alàgbà Fálétí – A Pic torial, Art and Artifacts Exhibition in Honor of Alàgbà Adébáyọ̀ Fálétí (1921- 2017) curated by Akinsola Adejuwon and Seyi Ogunjobi

Alàgbà Adébáyọ Fálétí to generations both in “town and gown” is a Yorùbá ̀ iconic cultural statement. His life was a window to different historical epochs in Nigeria. A life that spanned and recorded historical trajectories of early colonial, decolonisation, independent movement, First and Second World Wars, and Nigerian Civil War, Military and Civilian Rules experiences of Nigeria, is worth studying. The Institute of Cultural Studies, Obafemi Awolowo University Ile Ife in recognition of the deep engraving of the footprints of Fálétí in the sands of Yorùbá, indeed African times, called for befitting academic and cultural activities. Among these are this art and artifacts exhibition, a Colloquium, a Playlet and Documentary Film Show. Fálétí’s intense dedication to the promotion of the Yorùbá ọmọlúàbí cultural ethos and his deployment of his God-given talents and acquired capabilities in the promotion of Yorùbá literary and visual arts, history, poetry, orature, cinema and indeed 1 This is a review of the 2-week pictorial, art and artifacts exhibition in Honor of Alagba Adebayo Faleti in 2017 at the Institute of Cultural Studies, Obafemi Awolowo University, Ile-Ife, Nigeria, curated by Akinsola Adejuwon and Seyi Ogunjobi.&#x0D; &#x0D; Reviews 192 Akinsola Adejuwon African arts in general, is not lost on all Fálétí enthusiasts. Furthermore, his remarkable service as Senior Art Fellow at the Institute of Cultural Studies OAU completes the Institute’s resolution to capture the worthy legacy in the appropriate location even with the inauguration of an Alàgbà Adébáyọ Fálétí ̀ Library, Institute of Cultural Studies. Within a lifetime of close to one century, Fálétí delivers perhaps unique classical Yorùbá messages in words matched with action, first to Africa and then the world. This review looks at the pictorial and art exhibition covering the world of Alàgbà Adébáyọ̀ Akande Fálétí. It is an assessment of a thematic display of selected pictures and objects which probably placed the observer within the environment and with people Fálétí related with. The images, pictures, artworks and objects in the display were segmented into five major parts. These focused mainly on Alàgbà Fálétí’s parentage, early childhood, education within pristine Yorùbá-driven legacies of the Ọyọ̀ -́ Yorùbá type, Family life over-written from data flowing from core Yorùbá ethical and artistic ‘motherboard.’ Represented also are years of adolescence and expressions of early youthful forays under various tutelary influences, variegated working periods, writing and acting plus public service careers. Alàgbà Fálétí’s childhood coincided with the period when the British Colonial Government had taken over administration of entire geographical space known as Nigeria. In spite of introduction of foreign culture and customs into Nigeria by the Europeans, Yorùbá culture remained resilient. Hence, we could imagine that the childhood of Alàgbà Fálétí was not radically different from Samuel Johnson’s description of features of Yorùbá childhood as characterised by ‘freedom’ (Johnson: 2009, pp.98-100). These facets of life are arranged in a flow of one hundred and thirty-two frames of pictures and images appropriately hanged on the gallery wall boards, awards, artworks and objects displayed on individual stands. The montage produced by the flow of images on exhibition probably rallied to install both the titular and tutelar toga of ‘Alàgbà’ on Fálétí. Perhaps this also developed from a character evincing deep and cultured qualities over the last century. Qualities projectable only from such roundly home-grown dignitary. An all-round Yorùbá man from the core to the marked skin on his face.

Dermoscopy of Small Diameter Melanomas with the Diagnostic Feasibility of Selected Algorithms-A Clinical Retrospective Multicenter Study.

Simple SummaryThe early detection of melanoma determines the recovery of the patient. Dermoscopy, which is one of the diagnostic tools for pigmented lesions, is characterized by high sensitivity and specificity, giving the clinician the possibility to detect the presence of abnormal structures before their clinical presentation. There are a small number of dermoscopic analyses of pigmented lesions of less than 6 mm in diameter in the published literature. The authors attempted to identify characteristic dermoscopic structures typical for melanomas of less than 5 mm in diameter in comparison with a group of melanomas exceeding this dimension at an identical clinical stage. It was found that dermoscopy in the secondary prevention of micromelanomas (appearing mainly as brown lesions) revealed the presence of dotted or polymorphous vessels, with architectural disorder in half of cases. Moreover, spitzoid, multicomponent asymmetric or nonmelanoma-specific patterns prevailed. Knowledge of these dermoscopic features brings the clinician closer to an early diagnosis of melanoma with a diameter of 5 mm or less.Objective: The aim of the study was to verify two hypotheses. The first concerned the possibility of diagnostic dermoscopic differentiation between cutaneous melanomas of the histopathological category in situ (pTis) and thin melanomas (pT1a) in terms of their diameter. The second assessed the diagnostic feasibility of two dermoscopic algorithms aiming to detect ≤ 5.0 mm-sized melanomas histopathologically confirmed as pTis and pT1a. Methods: Dermoscopic images of consecutive cases of histopathologically confirmed melanomas were evaluated by three independent investigators for the presence of the predefined criteria. The melanomas were subdivided according to their diameter into small melanomas, so-called micromelanomas (microM)—sized ≤ 5.0 mm and >5.0 mm, according to published definitions of small melanocytic lesions. The Triage Amalgamated Dermoscopic Algorithm (TADA) and the revisited 7-point checklist of dermoscopy (7-point) algorithm were chosen for the diagnostic feasibility. Odds ratios and corresponding 95% confidence limits (CL) were calculated using the logistic regression adjusted for age for the melanoma-specific dermoscopic structures, the dermoscopic patterns and the diagnostic feasibility of the 7-point checklist and TADA algorithms. The p-values of the results were corrected using the Bonferroni method. Results: In total, 106 patients with 109 melanomas, 50 sized ≤ 5.0 mm and 59 exceeding the diameter of 5.0 mm, were retrospectively analyzed. The prevalent general pattern of microM was the spitzoid one (48% vs. 11.86%, p = 0.0013). Furthermore, 40% of microM vs. 6.78% melanomas sized > 5.0 mm (p = 0.0023) did not present melanoma-specific patterns. The asymmetric multicomponent pattern was present in 64.41% melanomas sized > 5.0 mm and in 26.00% microM (p = 0.0034). The asymmetry of structures or colors was detected in 56% microM vs. 89.83% (p = 0.0020) and 56% microM and 94.92% (p = 0.000034) melanoma sized > 5.0 mm, respectively. The differences in frequency of the detected dermoscopic structures specific to melanomas revealed that microM are almost deprived of negative networks (p = 0.04), shiny white structures (p = 0.0027) and regression features (p = 0.00003). Neither prominent skin markings nor angulated lines were found in the entire study group. Out of the vascular structures, microM presented only dotted (32%) or polymorphous (28%) vessels, although more rarely than melanomas sized > 5.0 mm (66.1% p = 0.017 and 49% p > 0.05, respectively). The diagnostic feasibility revealed a score ≥ 3 of the 7-point algorithm (indicative for malignancy) in 60% microM and 98.31% melanomas sized > 5.0 mm (p = 0.000006). The TADA algorithm revealed melanoma-specific patterns in 64% microM and 96.61% > 5.0 mm-sized melanomas (p = 0.00006) and melanoma-specific structures in 72% and 91.53% (p > 0.05), respectively. Conclusion: In the dermoscopy, 40% of micromelanomas histopathologically staged as pTis and pT1a did not reveal melanoma-specific patterns. Among the general melanocytic patterns, the spitzoid one was the most frequently found in melanomas sized ≤ 5.0 mm. The 7-point checklist and TADA dermoscopic algorithms were helpful in the identification of the majority of melanomas sized ≤ 5.0 mm.

Effect of the soft tissue artifact on marker measurements and on the calculation of the helical axis of the knee during a gait cycle: A study on the CAMS-Knee data set

The soft tissue artifact (STA) is a phenomenon occurring when the motion of bones or anatomical segments is measured by means of skin markers: the biological tissues between the markers and the bone produce a relative motion bone-markers that leads to inaccuracies in the estimation of rigid body poses or kinematics. The aim of this study was to quantify the STA by exploiting a recently published gait analysis dataset. The dataset was composed of six adult subjects with a total knee arthroplasty who underwent gait analysis trials. The motion of the knee was concurrently recorded by means of (i) fluoroscopy imaging and (ii) an optoelectronic system and redundant markers attached to the thigh and shank. The STA was studied by comparing the results calculated on the marker sets with the results obtained from the fluoroscopy data. The stance and swing phases were considered separately. Rigid STA motion and local STA deformation were studied separately. In addition to previous studies, the instantaneous helical axis (IHA) of the knee was calculated and the effect of the STA on its calculation was assessed.The largest rigid-motion STA effect was observed on the thigh cluster (~10 deg. and ~ 18 mm). The shank cluster was mainly affected during the swing phase (~7 deg. and ~ 17 mm). The local STA deformation affected differently the markers. The largest effect was ~16 mm and the lowest was ~4 mm. The estimation of the IHA was not reliable when based only on markers, having an estimation error of ~17 deg. and ~ 25 mm. A high variability of results across subjects was observed.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine.

Analysis of Macrophages and Peptidergic Fibers in the Skin of Patients With Painful Diabetic Polyneuropathy.

Background and ObjectivesThe mechanisms of pain in patients with diabetic polyneuropathy are unknown. Studies have suggested a role of inflammation and increased neuropeptides peripherally in pain generation. This study examined the possible skin markers of painful diabetic polyneuropathy (P-DPN): macrophages, substance P (SP), and calcitonin gene-related peptide (CGRP).MethodsThe participants were included from a large Danish cross-sectional clinical study of type 2 diabetes. We diagnosed definite diabetic polyneuropathy using the Toronto criteria and used the Neuropathic Pain Special Interest Group classification for defining P-DPN. We included 60 skin biopsies from patients with diabetic polyneuropathy—30 with P-DPN and 30 with nonpainful diabetic polyneuropathy (NP-DPN)—and 30 biopsies from healthy controls of similar age and sex. The biopsies were stained using PGP 9.5, IbA1, and SP and CGRP primary markers.ResultsThere was increased macrophage density in patients with P-DPN (8.0%) compared with that in patients with NP-DPN (5.1%, p < 0.001), and there was increased macrophage density in patients with NP-DPN (5.1%) compared with that in healthy controls (3.1%, p < 0.001). When controlling for neuropathy severity, body mass index, age, and sex, there was still a difference in macrophage density between patients with P-DPN and patients with NP-DPN. Patients with P-DPN had higher median nerve fiber length density (274.5 and 155 mm−2 for SP and CGRP, respectively) compared with patients with NP-DPN (176 and 121 mm−2 for SP and CGRP, respectively, p = 0.009 and 0.04) and healthy controls (185.5 and 121.5 mm−2 for SP and CGRP, respectively), whereas there was no difference between patients with NP-DPN and controls without diabetes (p = 0.64 and 0.49, respectively). The difference between P-DPN and NP-DPN for SP and CGRP was significant only in female patients, although a trend was seen in male patients.DiscussionThe findings point to a possible involvement of the innate immune system in the pathogenesis of neuropathic pain in patients with DPN, although markers of activated macrophages were not measured in this study.

A Simplified Method for Considering Achilles Tendon Curvature in the Assessment of Tendon Elongation.

The consideration of the Achilles tendon (AT) curvature is crucial for the precise determination of AT length and strain. We previously established an ultrasound-kinematic-based method to quantify the curvature, using a line of reflective foil skin markers covering the AT from origin to insertion. The current study aimed to simplify the method by reducing the number of markers while maintaining high accuracy. Eleven participants walked (1.4 m/s) and ran (2.5, 3.5 m/s) on a treadmill, and the AT curvature was quantified using reflective foil markers aligned with the AT between the origin on the gastrocnemius myotendinous-junction (tracked by ultrasound) and a marker on the calcaneal insertion. Foil markers were then systematically removed, and the introduced error on the assessment of AT length and strain was calculated. We found a significant main effect of marker number on the measurement error of AT length and strain (). Using more than 30% of the full marker-set for walking and 50% for running, the of the AT length error saturated, corresponding to average errors of <0.1 mm and <0.15% strain. Therefore, a substantially reduced marker-set, associated with a marginal error, can be recommended for considering the AT curvature in the determination of AT length and strain.

Augmented Reality Assisted Surgical Navigation System for Epidural Needle Intervention.

An augmented reality (AR)-assisted surgical navigation system was developed for epidural needle intervention. The system includes three components: a virtual reality-based surgical planning software, a patient and tool tracking system, and an AR-based surgical navigation system. A three-dimensional (3D) path plan for the epidural needle was established on the preoperative computed tomography (CT) image. The plan is then registered to the intraoperative space by 3D models of the target vertebrae using skin markers and real-time tracking information. In the procedure, the plan and tracking information are transmitted to the head-mounted display (HMD) through a wireless network such that the device directly visualizes the plan onto the back surface of the patient. The physician determines the entry point and inserts the needle into the target based on the direct visual guidance of the system. An experiment was conducted to validate the system using two torso phantoms that mimic human respiration. The experimental results demonstrated that the time and the number of X-rays required for needle insertion were significantly decreased by the proposed method (43.6±20.55sec, 2.9±1.3times) compared to those of the conventional fluoroscopy-guided approach (124.5 ± 46.7s, 9.3±2.4times), whereas the average targeting errors were similar in both cases. The proposed system may potentially decrease ionizing radiation exposure not only to the patient but also to the medical team.

Therapeutic Breast Reduction in Upper Quadrant Breast Tumor

Introduction: Breast conserving surgery plus radiation therapy and mastectomy procedures has equal results in terms of survival. Oncoplastic surgery principles along with breast reduction techniques allow for very good aesthetic results in immediate breast reconstruction with local tissues in several well-defined clinical scenarios. Nevertheless, we still find several limitations to their use regarding the location of the tumor or the need for inconvenient skin resections out of the standard markings of breast reduction. We present a case where traditional breast reduction techniques were inadequate and technical modifications of standard markings and pedicle design were developed to avoid the need to undergo a mastectomy. Methods: We present a patient diagnosed with breast cancer where the clinical characteristics of the tumor (location, skin excision needed) precluded the use of traditional oncoplastic breast reduction techniques. Modifications to the traditional breast reduction techniques were used to cope with the oncological resections needed. Results: A good global symmetry and aesthetic result were achieved. Scar pattern obtained was considered relatively camouflaged and patient satisfaction was high. Conclusion: Breast reduction procedures can be the solution for the treatment of breast cancer. The location of the tumor in the superior quadrants outside standard markings and the need to include skin in the tumor resection can be sidetracked by using enlarged NAC pedicles with modifications to classic skin markings without compromising oncologic safety. The final aesthetic results obtained are considered very good and the patient is very satisfied.

Surface-Guided Radiotherapy Feedback: Improvement and Change of Practices

Surface imaging systems are becoming a reference in radiotherapy treatments to improve patient setup. Thanks to an important database of patient positioning, a clinical retrospective evaluation of the system has been realized. For this evaluation, three relevant endpoints have been identified and analyzed: the time-saving setup, the accuracy setup, the number of additional X-Ray images performed to validate the patient setup.Two groups of patients have been defined including all localizations except head & neck treatments. Patients have been all treated on the same Linac following the same positioning and imaging protocol. The first group, the reference one, includes 700 patients with a treatment positioning based on skin marks using lasers. The second group includes 250 patients with treatment positioning based on surface imaging system. In parallel, clinical data (BMI, age, localization etc.) and treatment data (immobilizing system, treatment technique etc.) have been extracted from the Hospital Information System (HIS) and Treatment Planning System (TPS) databases thanks to homemade program. Afterwards, statistical analyses have been carried out for both groups in order to correlate the clinical and technical data with the three defined endpoints.Different correlations have been pointed out. First results confirm that the surface imaging system gives relevant and better set-up information for different sub-groups (breast, skinny pelvis etc.). Nevertheless, for others sub-groups, no correlation nor improvements have been observed (pelvic high BMI etc.) in comparison to laser positioning.Different changes in our patient positioning practices have been defined with the help of surface imaging system. For many patients, we improved our imaging workflow efficiency. For several sub-groups of patients, we still have to investigate the system and its best use.

Combination of LINAC Auto-Go and SGRT Auto-Positioning as a New Positioning Method for Thoracic Radiotherapy Patients

There are many studies findings on patient positioning efficiency using SGRT. In our clinic, we have 80 patients in average per linear accelerator. Hence, we would like to further develop the positioning method by combining the functions from both LINAC and SGRT system to investigate its potential in positioning accuracy and setup time.There was 40 thoracic cancer patients were selected randomly and divided into 2 groups. Controlled group (Group A) with a total of 20 patients who were aligned based on skin marking. The patient was aligned to the CT reference plane by the therapists using hands. Then, the therapists did the manual calculations for each patient for the isocenter shifts. The other 20 patients, the experimental group (Group B), who were first aligned to the reference plane along their nipples across the vac-bag marking to ensure patient's position in longitudinal direction and patient was nicely fit into the vac-bag. Next, the therapist introduced the first step of auto-positioning and second step with 'move couch' function to the isocenter position. CBCT images were taken in both groups and shifts in translational and rotational were recorded. All systematic and random errors were analyzed as well as setup time.Total of 208 and 199 CBCT images in group A and B were analyzed. The mean shifts errors for group A and B were 0.36cm, 0.27cm and 0.44cm (lat, lng and vrt) and 0.89˚, 0.98˚ and 0.76˚ (pitch, roll and rtn) and 0.23cm, 0.10cm and 0.16cm (lat, lng and vrt) and 0.63˚, 0.5˚ and 0.57˚ (pitch, roll and rtn) respectively. Group B is superior in positioning accuracy than Group A in all directions. The results also shown the average setup time for Group A and B were 118 second and 89 seconds respectively. It is statistical significance (P < 0.05).New positioning method using combination of auto-positioning by both LINAC and SGRT system has proven to improve our workflow efficiency and setup accuracy greatly. It eliminates the need of isocenter shift manual calculation, which substantially reduced the potential of human error-induced radiation incidence. This new positioning method is adapted in our clinic to replace the current patient positioning workflow.Z. Cui: None.