Methodological aspects of high-frequency ultrasound of skin in children

Unveiling the language of scars: A patient-centric themed framework for comprehensive scar morphology

BACKGROUND

Scarring, a pervasive issue spanning across medical disciplines, lacks a comprehensive terminology for effective communication, patient engagement, and outcome assessment. Existing scar classification systems are constrained by specific pathologies, physician-centric features, and inadequately account for emerging technologies. This study refrains from proposing yet another classification system and instead revisits the foundational language of scar morphology through a theme analysis of primary patient complaints.

METHOD

Data encompassing five years of a high-volume scar practice was analysed. Primary complaints were aggregated into collective descriptors and further organized into theme domains. The resulting hierarchical map of presenting complaints revealed five key domains: Loss of Function, Contour, Texture, Vector, and Colour Presenting complaints were codified into 42 items, which were then categorised into 14 collective descriptor terms. The latter were in turn organised into five overarching themes.

RESULT

Loss of Function, accounting for 10% of primary concerns, signifies reduced function attributed solely to the scar. Contour, encompassing 41% of concerns, pertains to scar height, shape, and depth. Texture, representing 12% of concerns, denotes tactile variations such as hardness, roughness, and moisture. Vector, comprising 13% of concerns, refers to scar tissue tension and associated distortions. Colour, the concern in 24% of cases, encompasses variations in pigmentation, vascularity, and exogenous pigments.

DISCUSSION

Standardized terminology enhances patient care, communication, and research. This study underscores the fundamental question of "what bothers the patient," reviving a patient-centred approach to scar management. By prioritizing themes based on patient complaints, this study innovatively integrates function, aesthetics, and patient experience. In conclusion, this study pioneers a paradigm shift in scar management by presenting a patient-driven theme framework that offers a common language for healthcare professionals and patients. Embracing this language harmonizes scar treatment, fosters innovation, and transforms scars from silent reminders into stories of resilience and healing.

Ultrasound Detected Subcutaneous Changes in a Pediatric Cohort After Initiation of a New Insulin Pump or Glucose Sensor

Objective: This study examined subcutaneous tissue changes at sites used by continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM), and tested whether these changes, if any, were associated with glycated hemoglobin (HbA1c). Research Design and Methods: This prospective study investigated recently used CSII or CGM sites in 161 children and adolescents during the first year after initiation of a new diabetes device. Subcutaneous changes such as echogenicity, vascularization, and the distance from the skin surface to the muscle at CSII and CGM sites were assessed by ultrasound. Results: The distance from skin surface to muscle fascia at both the upper arm and abdomen was influenced by age, body mass index z-score, and sex. Especially in boys and the youngest, the depth of many devices outreached the mean distance. The mean distance for boys at the abdomen and upper arm ranged from 4.5-6.5 mm and 5-6.9 mm for all ages, respectively. Hyperechogenicity at CGM sites was 4.3% after 12 months. The frequency of subcutaneous hyperechogenicity and vascularization at CSII sites increased significantly over time (41.2% to 69.3% and 2% to 16% respectively, P < 0.001 and P = 0.009). Hyperechogenicity in the subcutis was not a predictor of elevated HbA1c (P = 0.11). Conclusion: There is large variation in the distance from the skin surface to the muscle fascia and many diabetes devices reach even deeper. Hyperechogenicity and vascularization increased significantly over time at CSII sites, but not CGM sites. The importance of hyperechogenicity for insulin absorption is unclear and further investigations are needed. Clinical Trial Registration number: NCT04258904.

Dermal thickness and echogenicity using DermaScan C high frequency ultrasound: Methodology and reliability testing in people with and without primary lymphoedema

BACKGROUND

DermaScan C high frequency ultrasound was investigated for image capture and analysis of dermal measures in people with and without primary lymphoedema.

METHOD

Three repeated images were taken at six sites in people without lymphoedema (NLO). Intra-rater reliability was assessed by taking three sets of measures on images from 10 people and inter-session reliability by capturing three images, lifting the probe from the skin in between. Methods were adjusted, and repeated images from four sites were taken in people with primary lymphoedema (PLO) and reliability re-assessed.

RESULTS

Intra-rater reliability in NLO and PLO for echogenicity measures were excellent (NLO ICC_(3,1) : .989; PLO .997) across all sites and specific to each site (calf: ICC_(3,1) : .989; and foot: ICC_(3,1) : .999, respectively). Inter-session reliability was moderate for NLO (ICC_(3,1) : .727), improving after method modifications for PLO (ICC_(3,1) : .916). When investigated by site, inter-session reliability was good in the foot (ICC_(3,1) : .811) and moderate in the calf (ICC_(3,1) : .616). Mean thickness analysed by site resulted in good inter-session reliability only in the foot (ICC_(3,1) .838).

CONCLUSION

Intra-rater reliability was excellent using the DermaScan C for dermal measures in people with primary lymphoedema. Inter-session reliability required particular attention to method and gain settings.

Skin thickness measurements for optimal intradermal injections in children

BACKGROUND

In the context of precision medicine and in response to the highly needed capacity of rapid interventions towards new infectious diseases and pandemic outbreaks, intradermal immunization is gaining increased attention. However, the currently used Mantoux technique for ID injection is difficult to standardize and requires training, especially when used in children. To allow determining the maximum penetration depth and needle characteristics for the development of a platform of medical devices suited for intradermal injection, VAX-ID® and to ensure an accurate ID injection in children, the epidermal and dermal thickness at the proximal ventral and dorsal forearm (PVF & PDF) and at the deltoid region in children aged 8 weeks to 18 years were assessed. The lateral part of the upper leg was assessed as well in children aged 8 weeks to 2 years since it is a commonly used injection site in this population.

MATERIALS & METHODS

Mean thickness of the PVF, PDF, lateral part of the upper leg and deltoid were measured using high-frequency ultrasound. Association with gender, age and BMI was assessed using Mann-Whitney U Test, Spearman correlation and Wilcoxon Signed Ranks Test, respectively.

RESULTS

Results showed an overall mean skin thickness of 0.99 mm (SD: 0.14 mm) at the PVF, 1.20 mm (SD: 0.17) at the PDF, 1.28 mm (SD: 0.16) at the lateral part of the upper leg and increasing to 1.32 mm (0.25) at the deltoid region. Age and BMI correlated significantly (p < 0.001) with skin thickness at all investigated body sites. Gender did not affect skin thickness in the investigated population.

CONCLUSION

Significant differences in skin thickness at the PVF, PDF and deltoid region were seen according to age and BMI. An optimal needle length of 0.7 mm is advised to guarantee intradermal injection in children at all investigated injection sites. (NCT02727114).

Skin thickness as a potential marker of gestational age at birth despite different fetal growth profiles: A feasibility study

BACKGROUND

New methodologies to estimate gestational age (GA) at birth are demanded to face the limited access to obstetric ultrasonography and imprecision of postnatal scores. The study analyzed the correlation between neonatal skin thickness and pregnancy duration. Secondarily, it investigated the influence of fetal growth profiles on tissue layer dimensions.

METHODS AND FINDINGS

In a feasibility study, 222 infants selected at a term-to-preterm ratio of 1:1 were assessed. Reliable information on GA was based on the early ultrasonography-based reference. The thicknesses of the epidermal and dermal skin layers were examined using high-frequency ultrasonography. We scanned the skin over the forearm and foot plantar surface of the newborns. A multivariate regression model was adjusted to determine the correlation of GA with skin layer dimensions. The best model to correlate skin thickness with GA was fitted using the epidermal layer on the forearm site, adjusted to cofactors, as follows: Gestational age (weeks) = -28.0 + 12.8 Ln (Thickness) - 4.4 Incubator staying; R2 = 0.604 (P<0.001). In this model, the constant value for the standard of fetal growth was statistically null. The dermal layer thickness on the forearm and plantar surfaces had a negative moderate linear correlation with GA (R = -0.370, P<0.001 and R = -0.421, P<0.001, respectively). The univariate statistical analyses revealed the influence of underweight and overweight profiles on neonatal skin thickness at birth. Of the 222 infants, 53 (23.9%) had inappropriate fetal growths expected for their GA. Epidermal thickness was not fetal growth standard dependent as follows: 172.2 (19.8) μm for adequate for GA, 171.4 (20.6) μm for SGA, and 177.7 (15.2) μm for LGA (P = 0.525, mean [SD] on the forearm).

CONCLUSIONS

The analysis highlights a new opportunity to relate GA at birth to neonatal skin layer thickness. As this parameter was not influenced by the standard of fetal growth, skin maturity can contribute to clinical applications.

Skin and subcutaneous thickness at injecting sites in children with diabetes: ultrasound findings and recommendations for giving injection

BACKGROUND

Children who inject insulin need clear guidelines as to the length of needle best for them. We studied the distance from surface to muscle in children in order to make needle choices which are evidence-based.

METHODS

One hundred one children with type 1 diabetes were divided into three groups according to age: 2-6, 7-13, and 14-17 yr. The thickness of skin and subcutaneous (SC) tissue was measured by ultrasound in all injection sites.

RESULTS

Skin thickness varied from 1.58 mm in the arm of the youngest children to 2.29 mm in the buttocks of the adolescents. Values decreased progressively based on age (2-6 < 7-13 < 14-17) and on body site (arm < thigh < abdomen < buttocks). Skin + SC thickness varied in a similar fashion. The skin surface to muscle distances were <4 mm in nearly 10% of children, especially in the 2-6 yr group. In this group, the rate of intramuscular (IM) injections using the 4-mm pen needle when a pinch-up is not used would be 20.2%. This rate of IM injections doubles when using the 5-mm needle, and when injections are given under similar conditions it triples using the 6-mm needle.

CONCLUSIONS

It seems medically appropriate for all children to use short needles where possible to minimize inadvertent IM injections which may increase glycemic variability. Currently, the safest needle for all children appears to be the 4-mm pen needle. However, when used in children aged 2-6 yr, it should be used with a pinched skin fold.

Echographic measurement of skin thickness in sites suitable for intradermal vaccine injection in infants and children

Whereas the knowledge of skin thickness is essential to determine microneedle length and ensure proper administration of and better responses to intradermal vaccines, very few figures are available, especially in infants and children. Using ultrasound echography, we investigated skin thickness in 384 children aged 4-7, 12-18, and 54-66 months at potential body sites for intradermal vaccine delivery: deltoid, suprascapular, upper back, and lumbar area. The mean epidermis plus dermis thickness was significantly higher at the suprascapular than at the deltoid site (1.29mm vs. 1.22mm) and remained relatively unchanged whatever the BMI, age, sex, and skin phototype. In the 43 children aged 54-66 months, the mean skin thickness was significantly higher in the upper than in the lumbar area (1.39mm vs. 1.31mm). In this study setting, the heterogeneity in skin thickness cannot be considered sufficient to indicate various microneedle lengths for various ages or injection sites.

Study of superficial basal cell carcinomas and Bowen disease by qualitative and quantitative ultrasound biomicroscopy approach

In the present work the ultrasound biomicroscopy (UBM) technique is applied in the study of cutaneous cell carcinomas in vitro, including superficial basal cell carcinomas (BCC) and Bowen disease (BD) cases. The evaluation was made by qualitative observation of UBM images, and by quantitative computation of integrated backscatter coefficient (IBC), obtained with a system working at a central frequency of 45 MHz. The characteristic histological structures for each studied tumor type were well identified in the images. The IBC values observed in the two carcinoma types inside the affected region, were different between them, next to 10(-4) [Sr(-1).mm(-1)] for superficial BCC tissues, and to 10(-5) [Sr(-1).mm(-1)1] for BD tissues; moreover, in the deeper dermis (slight affected region) the backscatter was next to 10(-3) [Sr(-1).mm(-1)] for both tissue groups, and agrees with the values obtained for healthy skin both, in this study and in previous works. The results here obtained encourage the continuation of the work, with a higher number of samples, attempting to obtain more significant results.

Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendations

OBJECTIVE

During subcutaneous insulin therapy, inadvertent intramuscular (IM) injections may increase pain and/or adversely affect glucose control. The most appropriate needle length for patients depends on skin thickness (ST) and the distance to muscle fascia. ST and subcutaneous adipose layer thickness (SCT) were measured in adults with diabetes.

RESEARCH DESIGN AND METHODS

A total of 388 US adults with diabetes (in three BMI subgroups: <25, 25-29.9, and >or=30 kg/m(2)) with diverse demographic features were evaluated. Each subject had ultrasound measurements of ST and SCT at four injection sites.

RESULTS

Subjects had BMI 19.4-64.5 kg/m(2), age 18-85 years; 40% Caucasian, 25% Asian, 16% Black, 14% Hispanic; 28% type 1 diabetes. Mean ST (+/-95% CI) was: arm 2.2 mm (2.2, 2.3), thigh 1.9 mm (1.8, 1.9), abdomen 2.2 mm (2.1, 2.2) and buttocks 2.4 mm (2.4, 2.5). Multivariate analyses showed body site, gender, BMI, and race are statistically significant factors for ST but effects were small. Thigh ST was <0.6 mm thinner than the buttocks. Differences of 10 kg/m(2) account for 0.2 mm ST variation. Mean SCT was: arm 10.8 mm (10.2, 11.3), thigh 10.4 mm (9.8, 10.9), abdomen 13.9 mm (13.2, 17.7) and buttocks 15.4 mm (14.7, 16.2). Females had 5.1 mm greater SCT. Differences of 10 kg/m(2) account for 4 mm SCT variation.

ADVERSE EVENTS

A few mild hypo- or hyperglycemia events, unrelated to study procedure, were detected and treated before subject discharge from study visits.

LIMITATIONS

Only adults in the US were studied; some measurements could not be obtained on every subject, at every injection site.

CONCLUSIONS

Injection site ST does not differ by clinically significant degrees in demographically diverse adults with diabetes; SCT has a wider range. Needles >or=8 mm, inserted perpendicularly, may frequently enter muscle in limbs of males and those with BMI <25 kg/m(2). With 90 degrees insertion, needles 4-5 mm enter the subcutaneous tissue with minimal risk of IM injection in virtually all adults. These data will assist recommending appropriate length needles for subcutaneous insulin injections in adults.