Automated melanoma recognition

A system for the computerized analysis of images obtained from ELM has been developed to enhance the early recognition of malignant melanoma. As an initial step, the binary mask of the skin lesion is determined by several basic segmentation algorithms together with a fusion strategy. A set of features containing shape and radiometric features as well as local and global parameters is calculated to describe the malignancy of a lesion. Significant features are then selected from this set by application of statistical feature subset selection methods. The final kNN classification delivers a sensitivity of 87% with a specificity of 92%.

Metabolism of amiodarone (part I): identification of a new hydroxylated metabolite of amiodarone

Amiodarone (AMI) is a potent antiarrhythmic drug, but its metabolism has not yet been fully documented. Mono-N-desethylamiodarone (MDEA) is its only known metabolite. Our preliminary investigations using rabbit liver microsomes had shown that in vitro AMI was biotransformed to MDEA, and the latter was rapidly further biodegraded to other unknown products. The aim of the present study was to investigate the chemical structure of the biotransformed compound of MDEA. Upon incubation of MDEA with rabbit liver microsomes and NADPH as cofactor, MDEA was biotransformed into three unknown products: X1, X2, and X3. The products were purified using chromatography. The chemical structure of the major product, X1, was investigated in detail. HPLC-ESI-MS revealed that MDEA had been oxygenated. Hydrogen-deuterium exchange experiments showed that the X1 molecule contained one exchangeable hydrogen atom more than its precursor MDEA, indicating that MDEA had been hydroxylated. Further results from ESI-MS/MS analysis indicated that the site of hydroxylation was the n-butyl side chain. NMR analysis (1H NMR, one-dimensional-total correlation spectroscopy, and heteronuclear multiple-bond correlation spectroscopy) established the 3-position (omega-1) of the butyl moiety as the specific carbon atom that is hydroxylated. Rat liver microsomes were also able to catalyze MDEA hydroxylation. Compound X1, as analyzed by HPLC-ESI-MS and ESI-MS/MS, was detected in the liver, heart, lung, and kidney tissue of four rats receiving AMI, suggesting that the hydroxylated MDEA was a secondary metabolite of AMI.

CONCLUSION

in mammals, MDEA is hydroxylated to the secondary metabolite of AMI [2-(3-hydroxybutyl)-3-[4-(3-ethylamino-1-oxapropyl)-3,5-diiodobenzoyl]-benzofuran].

Computer-aided epiluminescence microscopy of pigmented skin lesions: the value of clinical data for the classification process

Early melanoma is often difficult to differentiate from benign pigmented skin lesions (PSLs). Digital epiluminescence microscopy (DELM) and automated image analysis could represent possible aids for inexperienced clinicians. We designed an automated computerized image analysis system that has the potential for use as an additional tool for the differentiation of melanoma from dysplastic naevi and common naevi. The PC-based pilot system was attached to a common DELM system as the image source. Digital images of PSLs were automatically segmented and a panel of 107 morphological parameters were measured. Additionally, seven clinical parameters were evaluated and used as an additional source of information. Neural networks were then trained to distinguish melanoma from benign PSLs. One class of networks was trained solely based on the morphometric features, whereas the second class of networks was trained on the combination of morphometric and clinical features. The automatic segmentation algorithm was correct in 96% of cases. Using three-way receiver operating characteristic (ROC) analysis, for networks trained solely on morphometric features the volume under surface (VUS) was 0.617 (SD 0.036). The performance was significantly better for networks trained on the combination of both morphometric and clinical features (VUS = 0.682, SD 0.035). In a dichotomous model, distinguishing benign lesion (common naevi + dysplastic naevi) from melanoma, the area under the curve (AUC) from two-way ROC analysis was 0.942 (SD 0.018) for networks trained solely on morphometric features and 0.968 (SD 0.012) for those trained on the combination of clinical and morphometric data (P= NS). Automated feature extraction from PSLs and the training of neural networks as classifiers has thus shown satisfactory performance in a large scale experiment. The addition of clinical data significantly increases the diagnostic performance for distinguishing three classes of lesions (i.e. common naevi, dysplastic naevi and melanoma). Such integrated systems hold promise as a decision aid for the diagnosis of PSLs.

Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi

BACKGROUND

Digital epiluminescence microscopy (DELM) has been reported to be a useful technique for the follow-up of melanocytic nevi. One of the promises of this technique is to identify modifications over time that indicate impending or incipient malignancy and to facilitate surveillance of melanocytic skin lesions, particularly in patients with multiple clinically atypical nevi.

OBJECTIVE

Our purpose was to report on patterns of modifications over time observed in benign melanocytic skin lesions and melanoma.

METHODS

A total of 1862 sequentially recorded DELM images of melanocytic lesions from 202 patients (mean age, 36.1 years; 54.0% female patients) with multiple clinically atypical nevi were included in the analysis. The median follow-up interval was 12. 6 months. Melanocytic lesions with substantial modifications over time (enlargement, changes in shape, regression, color changes or appearance of ELM structures known to be associated with melanoma) were excised and referred to histopathologic examination.

RESULTS

A total of 75 melanocytic skin lesions (4.0%) from 52 patients (mean age, 33.3 years; 63.5% female patients) showed substantial modifications over time and were excised and referred to histopathologic examination. Eight changing lesions were histologically diagnosed as early melanomas. These lesions frequently showed focal enlargement associated with a change in shape as well as appearance of ELM structures that are known to be associated with melanoma. In contrast, the majority of benign changing lesions (common and atypical nevi) showed symmetric enlargement without substantial structural ELM changes. Six of the 8 patients in whom melanoma developed were unaware of the fact that the lesion had changed over time.

CONCLUSION

We demonstrate that follow-up of melanocytic lesions with DELM helps to identify patterns of morphologic modifications typical for early melanoma. DELM may therefore serve as a useful tool to improve the surveillance of patients with multiple atypical nevi.

Comparing three-class diagnostic tests by three-way ROC analysis

Three-way ROC surfaces are based on a generalization of dichotomous ROC analysis to three-class diagnostic tests. The discriminatory power of three-class diagnostic tests is measured by the volume under the ROC surface. This measure can be given a probabilistic interpretation similar to the equivalence of the c-index to the area under the ROC curve. This article presents a method to calculate nonparametric estimates of the variance of the volume under the surface using Mann-Whitney U statistics. As a simple extension of this result, it is possible to calculate covariance estimates for the volume under the surface. This allows the statistical comparison of two tests used for diagnostic tasks with three possible outcomes. The formulas derived are validated on synthetic data and applied to a three-class data set of pigmented skin lesions. It is shown that a neural network algorithm trained on clinical data and lesion features performs better than one trained on only the lesion features.

Isolation and expression of a novel member of the CITED family

Chicken CITED3 (cCITED3) is a novel gene, which is expressed in the pre-somitic mesoderm, the mesonephric tubules, the Wolffian ducts and collecting tubules of the developing urogenital system and in the cranial sensory ganglia. Sequence analysis revealed that cCITED3 encodes a protein which contains two conserved domains that have been described for members of the CITED family.

ASW: a gene with conserved avian W-linkage and female specific expression in chick embryonic gonad

Vertebrates exhibit a variety of sex determining mechanisms which fall broadly into two classes: environmental or genetic. In birds and mammals sex is determined by a genetic mechanism. In mammals males are the heterogametic sex (XY) with the Y chromosome acting as a dominant determiner of sex due to the action of the testis-determining factor, SRY. In birds females are the heterogametic sex (ZW); however, it is not known whether the W chromosome carries a dominant ovary-determining gene, or whether Z chromosome dosage determines sex. Using an experimental approach, which assumes only that the sex-determining event in birds is accompanied by sex-specific changes in gene expression, we have identified a novel gene, ASW (Avian Sex-specific W-linked). The putative protein for ASW is related to the HIT (histidine triad) family of proteins. ASW shows female-specific expression in genital ridges and maps to the chicken W chromosome. In addition, we show that, with the exception of ratites, ASW is linked to the W chromosome in each of 17 bird species from nine different families of the class Aves.

Increased blood pressure response to the cold pressor test in pregnant women developing pre-eclampsia

OBJECTIVES

Recent data indicate an increased vascular reactivity due to an overactivity of the sympathetic nervous system in women with pre-eclampsia. We therefore evaluated whether this increased vascular reactivity can be detected prior to the clinical manifestation of preeclampsia by the use of a physiological stimulus.

DESIGN

Prospective data collection.

SETTING

Clinic of Obstetrics and Gynecology in a 2000 bed tertiary care hospital.

PARTICIPANTS

One hundred and twenty-three pregnant women between the 16th to 20th week of gestation.

INTERVENTIONS

A cold pressor test was performed by positioning an ice-bag on the forehead of the woman for 3 min. Blood pressure and heart rate were monitored by a continuous, noninvasive blood pressure measurement device during the stimulus and after removal of the icebag. A clinical follow-up was carried out by review of the charts after delivery to identify those women who have developed pre-eclampsia.

RESULTS

Ten (8%) out of 123 pregnant women developed pre-eclampsia. During the cold pressor test systolic as well as diastolic blood pressure increased significantly and was more pronounced in women developing pre-eclampsia compared with healthy pregnant women (systolic blood pressure: 14.2 +/- 5.5 versus 8.5 +/- 7.2 mmHg, P= 0.02; diastolic blood pressure: 7.3 +/- 4.9 versus 3.9 +/- 4.7 mmHg, P=0.03). The change in heart rate was similar between both groups (8 +/- 2.6 versus 10.4 +/- 6.4 beats/min, not significant).

CONCLUSIONS

An increased vasoconstrictive response to a physiological stimulus is present in women with pre-eclampsia as a sign of an increased vascular reactivity prior to clinical manifestation of the disease. The cold pressor test may be a suitable diagnostic tool to identify women, who will develop pre-eclampsia. However, future studies in larger cohorts are required to establish the final value of this test.

Realization of a CPR using HL7 queries from communication server to information server

A communication server is often used in Germany to interface legacy systems. It handles the translation, duplication, and transmission of messages to all systems that might need this information. Based on the principles of "for every data there is only one master" and "information on demand" we have built an information server that reduces the messages required and simplifies the handling of messages, the update of data already sent compared to a communication server. It also allows to implement a security policy as required by the German data privacy legislature.

Frequency and characteristics of enlarging common melanocytic nevi

OBJECTIVE

To analyze the frequency and characteristics of enlarging common melanocytic nevi.

DESIGN

Cohort study using digital epiluminescence microscopy (ELM) for documentation and follow-up, with a median follow-up interval of 11.4 months.

SETTING

A dermatology department at a university hospital in Vienna, Austria.

PATIENTS

One thousand six hundred twelve melanocytic nevi appearing clinically as common nevi, obtained from 385 patients (mean [+/-SD] age, 34.2 +/- 14.8 y; 55.6% female).

INTERVENTIONS

Follow-up examination and documentation by digital ELM.

MAIN OUTCOME MEASURES

Frequency of enlarging nevi according to age and comparison of ELM features observed in enlarging and nonenlarging nevi.

RESULTS

Enlargement was found in 5.3% (n = 86) of nevi. The frequency of enlarging nevi was inversely related to age (P<.001), in that enlarging nevi were common in patients younger than 20 years and relatively rare in older age groups. Epiluminescence microscopy revealed a peripheral rim of brown globules in 48.8% (n = 42) of enlarging nevi. In contrast, a peripheral rim of brown globules was found in only 0.7% (n = 11) of nevi without enlargement (P<.001). Enlarging nevi that were excised in children and adolescents showed no histological signs of atypia. In older age groups, 48.1% of excised enlarging nevi that were clinically diagnosed as common nevi showed some histological signs of atypia. None of the excised enlarging lesions was histologically diagnosed as melanoma.

CONCLUSIONS

The frequency of enlarging common nevi is inversely related to age. In the absence of clinical signs of atypia, enlargement alone does not indicate malignancy. A peripheral rim of brown globules is a characteristic ELM feature of symmetrically enlarging melanocytic nevi.

The interpretation of test results

BACKGROUND

Dermatologists need to interpret an increasing number of research studies and diagnostic tests. Understanding the techniques for interpreting test results and making decisions based upon those tests represent important tools for decision making for both clinicians and researchers.

OBJECTIVE

This article focuses briefly on the key parameters of diagnostic tests: sensitivity, specificity, prevalence, predictive values, likelihood ratios, and the concept of receiver-operating-characteristic (ROC) curves. A simple example is presented in a step-by-step manner.

CONCLUSION

The principles of interpreting test results are easy to learn and applicable in daily clinical routine. Therefore, dermatologists should be familiar with the concepts outlined in this paper.

Function of human mitochondrial 2,4-dienoyl-CoA reductase and rat monofunctional Delta3-Delta2-enoyl-CoA isomerase in beta-oxidation of unsaturated fatty acids

Human 2,4-dienoyl-CoA reductase (2,4-reductase; DECR) and rat monofunctional Delta(3)-Delta(2)-enoyl-CoA isomerase (rat 3, 2-isomerase; ECI) are thought to be mitochondrial auxiliary enzymes involved in the beta-oxidation of unsaturated fatty acids. However, their function during this process has not been demonstrated. Although they lack obvious peroxisomal targeting signals (PTSs), both proteins have been suggested previously to also occur in the mammalian peroxisomal compartment. The putative function and peroxisomal location of the two mammalian proteins can be examined in yeast, since beta-oxidation of unsaturated fatty acids is a compartmentalized process in Saccharomyces cerevisiae requiring peroxisomal 2,4-dienoyl-CoA reductase (Sps19p) and peroxisomal 3, 2-isomerase (Eci1p). A yeast sps19Delta mutant expressing human 2, 4-reductase ending with the native C-terminus could not grow on petroselinic acid [cis-C(18:1(6))] medium but could grow when the protein was extended with a PTS tripeptide, SKL (Ser-Lys-Leu). We therefore reason that the human protein is a physiological 2, 4-reductase but that it is probably not peroxisomal. Rat 3, 2-isomerase expressed in a yeast eci1Delta strain was able to re-establish growth on oleic acid [cis-C(18:1(9))] medium irrespective of an SKL extension. Since we had shown that Delta(2,4) double bonds could not be metabolized extra-peroxisomally to restore growth of the sps19Delta strain, we postulate that rat 3,2-isomerase acted on the Delta(3) unsaturated metabolite of oleic acid by replacing the mutant's missing activity from within the peroxisomes. Immunoblotting of fractionated yeast cells expressing rat 3, 2-isomerase in combination with electron microscopy supported our proposal that the protein functioned in peroxisomes. The results presented here shed new light on the function and location of human mitochondrial 2,4-reductase and rat monofunctional 3,2-isomerase.

Oral terbinafine (Lamisil) in the short-term treatment of fungal infections of the skin: results of a post-marketing surveillance study

Oral terbinafine (Lamisil, Novartis Pharma AG, Basel, Switzerland) is an effective therapy for fungal infections of the skin and nails. A post-marketing surveillance study was undertaken to evaluate the clinical efficacy and safety of oral terbinafine. A total of 454 patients with clinically and mycologically confirmed superficial fungal infections of the skin were enrolled from 79 dermatology clinics. Patients received oral terbinafine (250 mg day-1) for 2 weeks. Specific signs and symptoms were assessed by standard questionnaire before, immediately after, and 4 weeks after treatment. Observed improvements in patients after 2 weeks treatment were: erythema 81%, blistering 33%, exudation 50%, scaling 89%, pruritus 83%. After 4 weeks treatment, erythema was absent in 85% of patients, blistering and exudation in 99.7%, scaling in 82%, and pruritus in 94%. Overall clinical efficacy was assessed as good to excellent in 97% of patients. Adverse effects--mainly gastrointestinal and minor skin rashes--were reported in 5.3% of patients. The results of this study confirm that oral terbinafine is safe and highly effective for the short-term treatment of fungal skin infections.

Complications following the use of the Combitube, tracheal tube and laryngeal mask airway

In a prospective, randomised trial, 75 patients scheduled for routine surgery were randomly allocated to one of three groups to evaluate trauma and postoperative complications after insertion of the Combitube, tracheal tube or laryngeal mask airway. Insertion of the Combitube was associated with a higher incidence of sore throat (48% vs. 16% vs. 12% [p < 0.01]) and dysphagia (68% vs. 12% vs. 8% [p < 0.01]) compared with tracheal intubation or insertion of the laryngeal mask airway, respectively. Hoarseness was significantly less common in both the Combitube and the laryngeal mask groups (both 12%) than in the tracheal tube group (44%; p < 0.01). Haematoma occurred in 36% of the Combitube group compared with 4% in both the laryngeal mask and the tracheal tube groups (p < 0.01). The higher incidence of complications should be considered when using the Combitube.

Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream

A 32-year-old man presented with a chronic rosacea-like dermatitis of the facial skin and the eyelids. The skin disorder had been present for 4 years and was unresponsive to multiple previous treatment attempts. Skin scrapings and a histologic examination of a biopsy specimen from the affected area revealed the presence of numerous Demodex mites. The patient was treated with oral ivermectin and subsequent topical permethrin resulting in complete and rapid clearing of the folliculitis. We believe that this case supports the view that Demodex mites may be pathogenic when they are present in large numbers. Oral treatment with 200 microg/kg ivermectin with subsequent weekly topical permethrin showed impressive treatment efficacy in a case refractory to conventional treatment.

Prognostic role of serum prostatic acid phosphatase for 103Pd-based radiation for prostatic carcinoma

PURPOSE

To establish the prognostic role of serum enzymatic prostatic acid phosphatase (PAP) in patients treated with palladium (103Pd) and supplemental external beam irradiation (EBRT) for clinically localized, high-risk prostate carcinoma.

METHODS AND MATERIALS

One hundred twenty-four consecutive patients with Stage T2a-T3 prostatic carcinoma were treated from 1992 through 1995. Each patient had at least one of the following risk factors for extracapsular disease extension: Stage T2b or greater (100 patients), Gleason score 7-10 (40 patients), pretreatment prostate specific antigen (PSA) >15 ng/ml (32 patients), or elevated serum PAP (25 patients). Patients received 41 Gy conformal EBRT to a limited pelvic field, followed 4 weeks later by a 103Pd boost (prescription dose 80 Gy). Biochemical failure was defined as a PSA greater than 1 ng/ml (normal <4 ng/ml).

RESULTS

The overall, actuarial freedom from biochemical failure at 4 years after treatment was 79%. In Cox-proportional hazard multivariate analysis, the strongest predictor of failure was elevated pretreatment acid phosphatase (p = 0.02), followed by Gleason score (p = 0.1), and PSA (p = 0.14).

CONCLUSION

PAP was the strongest predictor of long-term biochemical failure. It may be a more accurate indicator of micrometastatic disease than PSA, and as such, we suggest that it be reconsidered for general use in radiation-treated patients.

PCR and blood culture for detection of Escherichia coli bacteremia in rats

Critically ill patients often develop symptoms of sepsis and therefore require microbiological tests for bacteremia that use conventional blood culture (BC) techniques. However, since these patients frequently receive early empirical antibiotic therapy before diagnostic procedures are completed, examination by BC can return false-negative results. We therefore hypothesized that PCR could improve the rate of detection of microbial pathogens over that of BC. To test this hypothesis, male Wistar rats were challenged intravenously with 10(6) CFU of Escherichia coli. Blood was then taken at several time points for detection of E. coli by BC and by PCR with E. coli-specific primers derived from the uidA gene, encoding beta-glucuronidase. In further experiments, cefotaxime (100 or 50 mg/kg of body weight) was administered intravenously to rats 10 min after E. coli challenge. Without this chemotherapy, the E. coli detection rate decreased at 15 min and at 210 min after challenge from 100% to 62% of the animals with PCR and from 100% to 54% of the animals with BC (P, >0.05). Chemotherapy decreased the E. coli detection rate at 25 min and at 55 min after challenge from 100% to 50% with PCR and from 100% to 0% with BC (P, <0.05). Thus, at clinically relevant serum antibiotic levels, PCR affords a significantly higher detection rate than BC in this rat model. The results suggest that PCR could be a useful adjunct tool supplementing conventional BC techniques in diagnosing bacteremia.

Hemodynamic and catecholamine stress responses to insertion of the Combitube, laryngeal mask airway or tracheal intubation

In a prospective, randomized, and controlled trial, we compared the stress responses after insertion of the Combitube (CT; Kendall-Sheridan Catheter Corp., Argyle, NY), the laryngeal mask airway (LMA), or endotracheal intubation (ET). Seventy-five patients scheduled for routine urological or gynecological surgery were randomly allocated to one of three groups and were ventilated via either an ET, a LMA, or a CT. All three devices could be inserted easily and rapidly, providing adequate ventilation and oxygenation. Insertion of the CT was associated with a significant increase in mean maximal systolic arterial pressure (160+/-32 mm Hg) and diastolic arterial pressure (91+/-17 mm Hg) compared with ET (140+/-24, 78+/-11 mm Hg; P < 0.05, P < 0.01, respectively) or insertion of the LMA (115+/-33,63+/-22 mm Hg, both P < 0.001). The mean maximal epinephrine and norepinephrine plasma concentrations after insertion of the CT (37.3+/-31.1 and 279+/-139 pg/mL, respectively) were significantly higher than those after ET (35.8+/-89.8 and 195+/-58 pg/mL, respectively) or insertion of a LMA (17.3+/-13.3 and 158+/-67 pg/mL, respectively). This might be attributed to the pressure of the pharyngeal cuff of the CT on the anterior pharyngeal wall. We conclude that insertion of the CT causes a pronounced stress response and that precautions should be taken when used in patients at risk of hypertensive bleeding.

IMPLICATIONS

In this study, we showed that the hemodynamic and catecholamine stress responses after insertion of the Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY) were significantly higher compared with laryngeal mask airway or endotracheal intubation. We conclude that the increased stress response to insertion of a Combitube may represent a serious hazard to patients with cardiovascular disease.

Cbfa2 is required for the formation of intra-aortic hematopoietic clusters

Cbfa2 (AML1) encodes the DNA-binding subunit of a transcription factor in the small family of core-binding factors (CBFs). Cbfa2 is required for the differentiation of all definitive hematopoietic cells, but not for primitive erythropoiesis. Here we show that Cbfa2 is expressed in definitive hematopoietic progenitor cells, and in endothelial cells in sites from which these hematopoietic cells are thought to emerge. Endothelial cells expressing Cbfa2 are in the yolk sac, the vitelline and umbilical arteries, and in the ventral aspect of the dorsal aorta in the aorta/genital ridge/mesonephros (AGM) region. Endothelial cells lining the dorsal aspect of the aorta, and elsewhere in the embryo, do not express Cbfa2. Cbfa2 appears to be required for maintenance of Cbfa2 expression in the endothelium, and for the formation of intra-aortic hematopoietic clusters from the endothelium.

[Botulism caused by a commercially produced product]

Insufficient conserved home-made products are the main cause of botulism in Denmark. We present a case of botulism caused by a commercially produced vegetable pie conserved by traditional bottling without addition of preservatives. Clostridium botulinum was grown from faeces of the index case indicating an intestinal infection. An action plan set up by the medical and veterinarian authorities functioned well and further spread of the disease was avoided. More cases of botulism may be seen in the future, if procedures ensuring proper conservation in food production are not adhered to.