Study of health outcomes in school children: key challenges and lessons learned from the Framingham Schools' Natural History of Nevi Study

Dermoscopic structures and patterns used in melanoma detection

Melanoma is the leading cause of skin cancer-related deaths. Yet, early detection remains the most cost-effective means of preventing death from melanoma. Early detection can be achieved by a physician and/or the patient (also known as a self-skin exam). Skin exams performed by physicians are further enhanced using dermoscopy. Dermoscopy is a non-invasive technique that allows for the visualization of subsurface structures that are otherwise not visible to the naked eye. Evidence demonstrates that dermoscopy improves the diagnostic accuracy for skin cancer, including melanoma; it decreases the number of unnecessary skin biopsies of benign lesions and improves the benign-to-malignant biopsy ratio. Yet, these improvements are contingent on acquiring dermoscopy training. Dermoscopy is used by clinicians who evaluate skin lesions and perform skin cancer screenings. In general, under dermoscopy nevi tend to appear as organized lesions, with one or two structures and colors, and no melanoma-specific structures. In contrast, melanomas tend to manifest a disorganized pattern, with more than two colors and, usually, at least one melanoma-specific structure. This review is intended to familiarize the reader with the dermoscopic structures and patterns used in melanoma detection.

Lessons Learned in Conducting Community Participatory School-Based Health Research on an American Indian Reservation

BACKGROUND

Describing lessons learned from using a community-based participatory research (CBPR) approach to conduct school-based child health research in a tribal community is an important contribution to the literature.

OBJECTIVES

To identify how CBPR principles shaped the process of conducting a school-based child health intervention, and to describe lessons learned.

METHODS

The study evaluates how CBPR principles guided a mixed-methods, school-based child health intervention to increase physical activity (PA).

RESULTS

Nine key lessons are identified, associated with CBPR principles.

CONCLUSIONS

This information can help researchers understand how to successfully navigate the challenges and opportunities of conducting CBPR-guided research in the context of a small, short-term project, including leadership turnover, multiple Institutional Review Board (IRB)s, and study design approaches amidst schools policy changes. Collectively, understanding the lessons learned through the perspective of CBPR principles may help others conduct meaningful research with schools and children in tribal communities.

Factors in Early Adolescence Associated With a Mole-Prone Phenotype in Late Adolescence

Importance

Nevi are important phenotypic risk factors for melanoma in adults. Few studies have examined the constitutional and behavioral factors associated with a mole-prone phenotype in adolescents.

Objective

To identify host, behavioral, and dermoscopic factors in early adolescence (age, 14 years) that are associated with a mole-prone phenotype in late adolescence (age, 17 years).

Design, Setting, and Participants

A prospective observational cohort study from the Study of Nevi in Children was conducted from January 1, 2009, to December 31, 2014, with a 2- to 3-year follow-up. A total of 569 students from the school system in Framingham, Massachusetts, were enrolled in the 8th or 9th grade (baseline; mean [SD] age, 14.4 [0.7] years). The overall retention rate was 73.3%, and 417 students were reassessed in the 11th grade.

Main Outcome and Measures

Mole-prone phenotype in the 11th grade, defined as total nevus count of the back and 1 randomly selected leg in the top decile of the cohort or having any nevi greater than 5 mm in diameter.

Results

Of the 417 students assessed at follow-up in the 11th grade (166 females and 251 males; mean [SD] age, 17.0 [0.4] years), 111 participants (26.6%) demonstrated a mole-prone phenotype: 69 students (62.2%) with 1 nevus greater than 5 mm in diameter, 23 students (20.7%) with total nevus count in the top decile, and 19 students (17.1%) with both characteristics. On multivariate analysis, baseline total nevus count (adjusted odds ratio, 9.08; 95% CI, 4.0-23.7; P < .001) and increased variability of nevus dermoscopic pattern (adjusted odds ratio, 4.24; 95% CI, 1.36-13.25; P = .01) were associated with a mole-prone phenotype.

Conclusions and Relevance

This study found clinically recognizable factors associated with a mole-prone phenotype that may facilitate the identification of individuals at risk for melanoma. These findings could have implications for primary prevention strategies and help target at-risk adolescents for higher-intensity counseling about sun protection and skin self-examination.

The study of nevi in children: Principles learned and implications for melanoma diagnosis

Melanocytic nevi are a strong phenotypic marker of cutaneous melanoma risk. Changes in nevi during childhood and adolescence make these prime periods for studying nevogenesis. Insights gained by the study of nevi in childhood have implications for melanoma detection in both adults and children. A more comprehensive understanding of the morphologic characteristics of nevi in different anatomic locations, in association with the patient's age and pigmentary phenotype may aid in the identification of melanomas. When monitoring melanocytic lesions over time, it is essential to differentiate normal from abnormal change. This review summarizes the rapidly expanding body of literature relevant to nevus phenotype, particularly in the context of our experience with the Study of Nevi in Children (SONIC) Project.

Growth-Curve Modeling of Nevi With a Peripheral Globular Pattern

Importance

Although nevi with a peripheral rim of globules (peripheral globular nevi [PGN]) observed with dermoscopy are associated with enlarging melanocytic nevi, their actual growth dynamics remain unknown. Because change is a sensitive but nonspecific marker for melanoma, beginning to understand the growth patterns of nevi may improve the ability of physicians to differentiate normal from abnormal growth and reduce unnecessary biopsies.

Objective

To study the growth dynamics and morphologic evolution of PGN on dermoscopy.

Design, Setting, and Participants

A total of 84 participants with 121 PGN from September 1, 1999, through May 1, 2013, were identified retrospectively. Cohorts were recruited from the Memorial Sloan Kettering Cancer Center; Melanoma Unit of the Hospital Clinic, University of Barcelona; and Study of Nevi in Children. All 3 cohorts underwent longitudinal monitoring with serial dermoscopic imaging of their PGN. Data analysis was performed from May 1, 2014, through April 1, 2015.

Main Outcomes and Measures

Establishment of the natural growth curve of PGN. The secondary aim was to establish the median time to growth cessation in those PGN for which the size eventually stabilized and/or had begun to decrease during the study period.

Results

The median duration of follow-up was 25.1 (range, 2.0-114.4) months. Most of the nevi (116 [95.9%]) enlarged at some point during sequential monitoring. The rate of increase in the surface area of PGN varied among cohorts and ranged from -0.47 to 2.26 mm2/mo (mean rate, 0.25 [95% CI, 0.14-0.36] mm2/mo). The median time to growth cessation in the 26 PGN that stabilized or decreased in size (21.5%) was 58.6 months. All lesions changed in a symmetric manner and 91 (75.2%) displayed a decrease in the density of peripheral globules over time.

Conclusions and Relevance

Nevi displaying a peripheral globular pattern enlarged symmetrically with apparent growth cessation occurring during a span of 4 to 5 years. Our results reiterate the important concept that not all growth is associated with malignancy.

Cross-sectional analysis of the dermoscopic patterns and structures of melanocytic naevi on the back and legs of adolescents

BACKGROUND

Junctional (flat) naevi predominate on the extremities, whereas dermal (raised) naevi are found primarily on the head, neck and trunk. Few studies have investigated the anatomical site prevalence of melanocytic naevi categorized using dermoscopy.

OBJECTIVES

To identify the prevalence of dermoscopic patterns and structures of naevi from the back and legs of adolescents.

METHODS

Dermoscopic images of acquired melanocytic naevi were obtained from the back and legs of students from a population-based cohort in Framingham, Massachusetts. Naevi were classified into reticular, globular, homogeneous or complex dermoscopic patterns. Multinomial logistic regression modelling assessed the associations between dermoscopic pattern and anatomical location.

RESULTS

In total 509 participants (mean age 14 years) contributed 2320 back naevi and 637 leg naevi. Compared with homogeneous naevi, globular and complex naevi were more commonly observed on the back than the legs [odds ratio (OR) 29·39, 95% confidence interval (CI) 9·53-90·65, P < 0·001 and OR 6·8, 95% CI 2·7-17·14, P < 0·001, respectively], whereas reticular lesions were less likely to be observed on the back than on the legs (OR 0·67, 95% CI 0·54-0·84, P = 0·001). Naevi containing any globules were more prevalent on the back than on the legs (25% vs. 3·6%, P < 0·001). Naevi containing any network were more prevalent on the legs than on the back (56% vs. 40·6%, P < 0·001).

CONCLUSIONS

These findings add to a robust body of literature suggesting that dermoscopically defined globular and reticular naevi represent biologically distinct naevus subsets that differ in histopathological growth pattern, age- and anatomical-site-related prevalence, molecular phenotype and aetiological pathways.

Lessons learnt on recruitment and fieldwork from a pilot European human biomonitoring survey

Within the European Environment and Health Action Plan an initiative to establish a coherent human biomonitoring approach in Europe was started. The project COPHES (COnsortium to Perform Human biomonitoring on a European Scale ) developed recommendations for a harmonized conduct of a human biomonitoring (HBM) survey which came into action as the pilot study DEMOCOPHES (DEMOnstration of a study to COordinate and Perform Human biomonitoring on a European Scale). Seventeen European countries conducted a survey with harmonized instruments for, inter alia, recruitment, fieldwork and sampling, in autumn/winter 2011/2012. Based on the countries' experiences of conducting the pilot study, following lessons learnt were compiled: the harmonized fieldwork instruments (basic questionnaire, urine and hair sampling) turned out to be very valuable for future HBM surveys on the European scale. A school approach was favoured by most of the countries to recruit school-aged children according to the established guidelines and country specific experiences. To avoid a low participation rate, intensive communication with the involved institutions and possible participants proved to be necessary. The communication material should also include information on exclusion criteria and offered incentives. Telephone contact to the participants the day before fieldwork during the survey can prevent the forgetting of appointments and first morning urine samples. To achieve comparable results on the European scale, training of interviewers in all issues of recruitment, fieldwork and sampling through information material and training sessions is crucial. A survey involving many European countries needs time for preparation and conduct. Materials for quality control prepared for all steps of recruitment, fieldwork and sampling proved to be important to warrant reliable results.

Challenges and benefits of conducting environmental justice research in a school setting

Environmental justice (EJ) research requires attention to consequences for research participants beyond those typically considered by institutional review boards. The imbalance of power between impacted communities and those who create and regulate pollution creates challenges for participation, yet research can also benefit those involved. Our community-academic partnership designed the Rural Air Pollutants and Children's Health (RAPCH) study to provide positive impacts while measuring health effects at three low-resource public middle schools near concentrated animal feeding operations (CAFOs) in North Carolina. We evaluated perceived benefits and challenges of study involvement by interviewing school staff and community liaisons who facilitated data collection. Reported benefits included enhancement of students' academic environment and increased community environmental awareness; challenges were associated mainly with some participants' immaturity. Leadership from a strong community-based organization was crucial to recruitment, yet our approach entailed minimal focus on EJ, which may have limited opportunities for community education or organizing for environmental health.

Genetic factors associated with naevus count and dermoscopic patterns: preliminary results from the Study of Nevi in Children (SONIC)

BACKGROUND

Melanocytic naevi are an important risk factor for melanoma. Naevi with distinct dermoscopic patterns can differ in size, distribution and host pigmentation characteristics.

OBJECTIVES

We examined MC1R and 85 other candidate loci in a cohort of children to test the hypothesis that the development and dermoscopic type of naevi are modulated by genetic variants.

METHODS

Buccal DNAs were obtained from a cohort of 353 fifth graders (mean age 10·4 years). Polymorphisms were chosen based on a known or anticipated role in naevi and melanoma. Associations between single-nucleotide polymorphisms (SNPs) and baseline naevus count were determined by multivariate regression adjusting for sex, race/ethnicity and sun sensitivity. Dermoscopic images were available for 853 naevi from 290 children. Associations between SNPs and dermoscopic patterns were determined by polytomous regression.

RESULTS

Four SNPs were significantly associated with increasing (IRF4) or decreasing (PARP1, CDK6 and PLA2G6) naevus count in multivariate shrinkage analyses with all SNPs included in the model; IRF4 rs12203952 showed the strongest association with log naevus count (relative risk 1·56, P < 0·001). Using homogeneous naevi as the reference, IRF4 rs12203952 and four other SNPs in TERT, CDKN1B, MTAP and PARP1 were associated with either globular or reticular dermoscopic patterns (P < 0·05).

CONCLUSIONS

Our results provide evidence that subsets of naevi defined by dermoscopic patterns differ in their associations with germline genotypes and support the hypothesis that dermoscopically defined subsets of naevi are biologically distinct. These results require confirmation in larger cohorts. If confirmed, these findings will improve the current knowledge of naevogenesis and assist in the identification of individuals with high-risk phenotypes.

Dermatoscopic imaging of skin lesions by high school students: a cross-sectional pilot study

BACKGROUND

The ability of novices to perform imaging of skin lesions is not well studied.

OBJECTIVES

To determine the ability of 12th grade high school students without formal training to take clinical and dermatoscopic images of skin lesions on patient-actors.

PATIENTS/METHODS

Nineteen participants were divided into 11 gender-specific groups of 1-2 students. Groups were provided written instructions and assessed in their ability to (a) identify 8 pre-specified skin lesions, (b) take overview clinical images, and (c) take contact, polarized dermatoscopic images. Groups captured the same images twice using two different cameras [Nikon TM 1 J1 / VEOS HD1 and a VEOS DS3 (Canfield Scientific, Inc.)]. The sequence of camera use was determined using block randomization. If students made visibly poor skin contact during dermatoscopic imaging using their first camera, study investigators provided verbal instructions to place the second camera directly onto the skin. Students completed anonymous surveys before and after the imaging activity.

RESULTS

Students were proficient at identifying the correct pre-specified skin lesions (86/88, 98%), capturing sufficient quality overview clinical images of the back and legs (41/42, 98%), and taking dermatoscopic images of the entire skin lesion (174/176, 99%). Regarding dermatoscopic image quality, 116 of 175 (66%) images were in focus. Out of focus images were attributed to poor skin contact. Groups that received feedback (n=4) were able to obtain a significantly higher proportion of in focus dermatoscopic images using their second camera compared to their first camera (16% to 72%, P<0.001).

CONCLUSIONS

We identified several barriers that exist for participant-acquired dermatoscopic imaging. Instructions emphasizing the importance of skin contact are useful. Our results may help guide future patient-acquired teledermatoscopy efforts.

Recruitment and retention of urban schoolchildren into a randomized double-blind vitamin D supplementation trial

BACKGROUND

While rarely used for supplementation trials in the United States, schools present a practical alternative to a clinical setting.

PURPOSE

We describe the successful recruitment and retention of urban schoolchildren into a 6-month randomized, double-blind vitamin D3 supplementation trial.

METHODS

Boston-area urban schoolchildren, aged 8-15 years, were recruited in 2011-2012 through classroom and auditorium presentations. Informed consent forms in five languages were sent home to parents. Retention methods included regular telephone calls and gift cards for completed study visits.

RESULTS

In total, 691 schoolchildren enrolled. Their mean (standard deviation) age was 11.7 (1.4) years; 59% were racial/ethnic minorities and 68% qualified for free or reduced-price school meals. Multi-level, culturally sensitive, creative approaches contributed to success in recruitment and retention. Of 691 participants, 81% completed the 6-month intervention period. Reasons for attrition included missed appointments and fear of a blood draw. More children from households with higher incomes were retained than those from households with lower incomes (85% vs 79%, respectively, P = 0.04).

LIMITATIONS

The need for three fasting blood draws over the 6-month supplementation period was a limiting factor in the recruitment and retention of children in this study.

CONCLUSION

Recruitment of urban children into a school-based randomized controlled trial represents a feasible approach for a supplementation study. Particular attention to children of lower socioeconomic status may enhance participation and retention when conducting intervention studies among diverse populations.

Tanning and beauty: Mother and teenage daughters in discussion

Tanning increases dramatically through the teenage years, but the family context of this health risk behavior is relatively unstudied. We conducted videotaped conversations between teenage girls (10th and 11th grade) and their mothers. We developed a coding system for discussion content and highlight findings including inadequate knowledge concerning the harms of tanning and positive views of outdoor tanning over indoor tanning, yet agreement that all tans are attractive. Many teens believed that indoor tanning is sometimes necessary to achieve the tanned look. These findings can usefully guide intervention development regarding the harms of all tanning, rather than indoor or outdoor tanning specifically.

Do suncreens protect us?

Sunlight stimulates a multitude of important biological effects on skin, causing, amongst other pathological changes, photocarcinogenesis. Sunscreens are designed to provide protection against these harmful properties of ultraviolet radiation, and public health campaigns have been employed to encourage their use. Despite this, there has been a continued rise in the incidence and mortality of the most harmful skin cancer, malignant melanoma. This review article therefore looks at the role of ultraviolet radiation in causing skin cancer; summarizes the available evidence on both the beneficial and harmful effects of sunscreen use; and concludes with practical advice on how we might advise our patients to best protect themselves from photocarcinogenesis.

Skin cancer screening and primary prevention: facts and controversies

Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.

Prospective study of sunburn and sun behavior patterns during adolescence

OBJECTIVES

Early childhood UV light radiation (UVR) exposures have been shown to be associated with melanoma development later in life. The objective of this study was to assess sunburn and changes in sunburn and sun behaviors during periadolescence.

METHODS

A prospective, population-based study was conducted in fifth-grade children (∼10 years of age) from Framingham, Massachusetts. Surveys were administered at baseline (September-October 2004) and again 3 years later (September-October 2007). Surveys were analyzed to assess prevalence of reported sunburn and sun behaviors and to examine changes in response over the follow-up period.

RESULTS

Data were analyzed from 360 participants who had complete information regarding sunburn at both time points. In 2004, ∼53% of the students reported having at least 1 sunburn during the previous summer, and this proportion did not significantly change by 2007 (55%, P = .79), whereas liking a tan and spending time outside to get a tan significantly increased (P < .001). In 2004, 50% of students reported "often or always" use of sunscreen when outside for at least 6 hours in the summer; this proportion dropped to 25% at the follow-up evaluation (P < .001).

CONCLUSIONS

With at least 50% of children experiencing sunburns before age 11 and again 3 years later, targeting children in pediatric offices and community settings regarding unprotected UV exposure may be a practical approach. Because periadolescence is a time of volatility with regard to sun behaviors, learning more about children who receive sunburns versus those who avoid them is a critical research task.

Clinical and dermoscopic stability and volatility of melanocytic nevi in a population-based cohort of children in Framingham school system

Nevi are important risk markers of melanoma. The study aim was to describe changes in nevi of children using longitudinal data from a population-based cohort. Overview back photography and dermoscopic imaging of up to 4 index back nevi was performed at age 11 (baseline) and repeated at age 14 (follow-up). Of 443 children (39% females) imaged at baseline, 366 children (39% females) had repeated imaging three year later. At age 14, median back nevus counts increased by 2; 75% of students (n=274) had at least one new back nevus and 28% (n=103) had at least one nevus that disappeared. Of 936 index nevi imaged dermoscopically at baseline and follow-up, 69% (645 nevi) had retained the same dermoscopic classification from baseline evaluation. Only 4% (n=13) of nevi assessed as globular at baseline were classified as reticular at follow-up, and just 3% (n=3) of baseline reticular nevi were classified as globular at follow-up. Of 9 (1%) index nevi that disappeared at follow-up, none showed halo or regression at baseline. In conclusion, the relative stability of dermoscopic pattern of individual nevi in the face of the overall volatility of nevi during adolescence suggests that specific dermoscopic patterns may represent distinct biologic nevus subsets.

Dermoscopic patterns and subclinical melanocytic nests in normal-appearing skin

BACKGROUND

Dermoscopic patterns of normal-appearing skin have received little scrutiny. We have recently completed an analysis of dermoscopic patterns of naevi in children.

OBJECTIVES

To describe dermoscopic patterns in the normal-appearing skin surrounding naevi and to explore histological features of patterned background skin.

METHODS

Dermoscopic images of back naevi were obtained from a population-based sample of fifth grade students. The dermoscopic pattern of the background skin around the naevi was analysed. We examined histopathological features of background skin patterns in a convenience sample of seven specimens from six adult patients.

RESULTS

We observed a dermoscopic pattern in the background of normal-appearing skin in 41% of 1192 dermoscopic images from the backs of the 443 children. The background skin pattern was less frequent in individuals with a fair skin (P < 0.001). A globular pattern was observed in 201 images (17%) and a reticular pattern was seen in 287 images (24%), of which 112 images also showed globules. Inter-rater reliability between the two observers for a random sample of 100 images was excellent (kappa = 0.77). In four specimens with a globular background pattern, microscopic melanocytic nests were observed in the normal-appearing skin. No subclinical naevus nests were observed in three reticular pattern specimens.

CONCLUSIONS

Dermoscopically recognized patterns are commonly present in clinically normal skin of children. Microscopic melanocytic nests may be observed in normal-appearing skin with a globular skin pattern.

Study of Nevi in Children (SONIC): baseline findings and predictors of nevus count

The authors report baseline findings and predictors of nevus count (log total nevi) at the completion of year 1 (2004) of the first known population-based, prospective study of nevi in a US cohort of children. Overall, 64% (n = 443/691) of grade 5 students and their parents in Framingham, Massachusetts, completed surveys and underwent digital photography. Total nevus count was associated with skin and hair color and tendency to burn, as measured by a sun sensitivity index. In multivariate analyses, male gender (rate ratio (RR) = 1.38, 95% confidence interval (CI): 1.22, 1.55; P < 0.0001), spending 5-6 weekly hours outdoors between 10 AM and 4 PM (RR = 1.13, 95% CI: 1.00, 1.28; P = 0.051), getting a painful sunburn once (RR = 1.24, 95% CI: 0.98, 1.57; P = 0.073) and at least twice (RR = 1.34, 95% CI: 0.99, 1.82; P = 0.061), and wearing a shirt at the beach or pool rarely (RR = 1.29, 95% CI: 1.08, 1.54; P = 0.005), sometimes (RR = 1.26, 95% CI: 1.01, 1.57; P = 0.041), and often and always (RR = 1.32, 95% CI: 1.13, 1.54; P = 0.001) were associated with increased number of nevi. Identifying factors that predict the development of nevi will improve primary prevention efforts during early life.

Perceived barriers and benefits to research participation among school administrators

BACKGROUND

Gaining access to conduct research in schools can be challenging, but little has been done to directly assess school administrators' perceptions of research. The purpose of this qualitative study was to increase understanding of barriers and benefits of research participation as perceived by superintendents and principals in elementary, middle, and high school settings.

METHODS

Administrators (14 elementary, 14 middle, and 15 high school principals and 14 superintendents; total n = 57) were randomly selected from across a Midwestern state and were interviewed by phone following a semistructured guide of questions.

RESULTS

Six major themes were consistent across principals and superintendents and reached saturation. Themes indicated that administrators were interested in research projects that (1) provide tangible benefits to their school, (2) are consistent with their academic mission, (3) are not burdensome, (4) do not take place during state assessment time or other busy times, and (5) are credible and noncontroversial. Previous research experiences leave a lasting impression on administrators and influenced their future decisions.

CONCLUSIONS

Findings indicate that researchers should carefully frame their research in terms of how it will directly benefit the school, keeping in mind that academic performance is the top priority for school administrators. Researchers should be very clear and realistic about the time commitments, how the research results will be provided, and how the study may be used to improve the school's academic mission.