Multisource, Phase-controlled Radiofrequency for Treatment of Skin Laxity: Correlation Between Clinical and In-vivo Confocal Microscopy Results and Real-Time Thermal Changes

Objective: The objective of this study was to analyze the correlation between degrees of clinical improvement and microscopic changes detected using confocal microscopy at the temperature gradients reached in patients treated for skin laxity with a phase-controlled, multisource radiofrequency system. Design and setting: Patients with skin laxity in the abdominal area were treated in six sessions with radiofrequency (the first 4 sessions were held at 2-week intervals and the 2 remaining sessions at 3-week intervals). Patients attended monitoring at 6, 9, and 12 months. Participants: 33 patients (all women). Measurements: The authors recorded the following: variations in weight, measurements of the contour of the treated area and control area, evaluation of clinical improvement by the clinician and by the patient, images taken using an infrared camera, temperature (before, immediately after, and 20 minutes after the procedure), and confocal microscopy images (before treatment and at 6, 9, and 12 months). The degree of clinical improvement was contrasted by two external observers (clinicians). The procedure was performed using a new phase-controlled, multipolar radiofrequency system. Results: The results reveal a greater degree of clinical improvement in patients with surface temperature increases greater than 11.5oC at the end of the procedure and remaining greater than 4.5oC 20 minutes later. These changes induced by radiofrequency were contrasted with the structural improvements observed at the dermal-epidermal junction using confocal microscopy. Changes are more intense and are statistically correlated with patients who show a greater degree of improvement and have higher temperature gradients at the end of the procedure and 20 minutes later. Conclusion: Monitoring and the use of parameters to evaluate end-point values in skin quality treatment by multisource, phased-controlled radiofrequency can help optimize aesthetic outcome.     

Clinical Applicability of in vivo Reflectance Confocal Microscopy for the Diagnosis of Actinic Keratoses

BACKGROUND In vivo reflectance confocal microscopy (RCM) has been used for evaluation of the morphologic features of nonmelanoma skin cancer. The application of RCM for diagnosis of basal cell carcinoma has been reported; however, the evaluation of actinic keratoses (AKs) has only been the subject of preliminary studies.
STUDY GOAL The goal of this study was to evaluate the applicability of RCM in the diagnosis of AK in correlation with routine histology.
MATERIALS AND METHODS Forty-four Caucasians with a minimum of one AK participated in this study. Evaluation consisted of clinical examination, RCM, and routine histology, including a total of 46 AKs in the final analysis. Ten normal skin sites served as controls. RCM features of AK included parakeratosis, architectural disarray, and keratinocyte pleomorphism. Following blinded evaluations, sensitivity/specificity, kappa analysis, and Spearman's correlation were performed on all parameters.
RESULTS Sensitivity/specificity values of RCM features ranged from 80% to 98.6%. The presence of architectural disarray and cellular pleomorphism appeared to be the best predictor of AK.
CONCLUSION In summary, RCM may be a promising technology for the noninvasive detection of AK and as adjunct tool to clinical diagnosis and monitoring. However, the preliminary nature of this study warrants further investigations.     

Confocal Laser Scanning Microscopy: A Nondestructive Subsurface Histotomography of Healthy Human Bone

Microscopy of bony tissue usually requires special treatment for decalcification and processing of thin sections. Confocal laser scanning microscopy (CLSM) allows the nondestructive histotomography of organic hard tissue. The aim of this study was to visualize healthy human bone structures and to correlate identical areas in CLSM and conventional light microscopy. Each sample of healthy human lower jaw (n = 20) was divided into three parts: (1) fresh, untreated bony blocks studied by CLSM; (2) MMA-embedded thin sections (without decalcification), HE stained and studied by CLSM and conventional light microscopy (correlation of identical areas); (3) decalcificated, HE stained, histological sections studied by conventional light microscopy. In untreated bony blocks, microstructures such as osteocytes and lamellae were identified by CLSM. These structures could be correlated with conventional light microscopy. In CLSM, subcellular structures cannot yet be interpreted, whereas cytoplastic processes of osteocytes were seen with high contrast. With CLSM, nondestructive histology of cortical bone can be obtained. The risk of artifacts due to pretreatment is minimized, and subsurface visualization does not affect the interpretation. Received: 2 June 1998 / Accepted: 15 December 1998     

New Bone Formation and Microstructure Assessed by Combination of Confocal Laser Scanning Microscopy and Differential Interference Contrast Microscopy

Bone is a mineralized connective tissue that is continuously and microstructurally remodeled. Altered bone formation and microstructure arise in pathological bone conditions such as osteoporosis, osteonecrosis, fracture repair, and Paget disease of bone. A proper and objective assessment of bone formation and microstructure will provide insight into the understanding of bone pathogenesis and remodeling. Here, new bone formation ex vitro and its microstructure were evaluated in in vivo multiple sequential polychrome-labeled samples using confocal laser scanning microscopy (CLSM), which generated clearer and more reliable images of thick bone sections than conventional fluorescence microscopy (CFM). Intriguingly, fine details of the bone microstructural features, including the mineralization fronts, quiescent versus active osteons, and Volkmann’s channel, were elucidated using CLSM, which defines the relationship between morphological changes and function, when combined with differential interference contrast microscopy. Furthermore, CLSM provided objective evaluations of bone formation, such as the ratio of labeled areas of new bone formation in a rabbit model when compared with CFM. Altogether, new bone formation and its microstructure can be evaluated more adequately using a combination of CLSM and DIC microscopies.     

Adsorption of Complement, Cytokines, and Proteins by Different Dialysis Membrane Materials: Evaluation by Confocal Laser Scanning Fluorescence Microscopy

The membranes tested in the present study were cellulose triacetate (CTA), polymethylmethacrylate (PMMA), and polyacrylonitrile (PAN). The adsorption by each membrane of albumin, IgG, C3a, interleukin-1β (IL-1β), interleukin-6 (IL-6), human neutrophil elastase (HNE), and tumor necrosis factor α (TNFα) was examined and semiquantitatively graded by confocal laser scanning fluorescence microscopy (CLSFM). After clinical use the dialyzers were treated with antibodies for these proteins and cytokines. Then the samples were incubated with fluorescein isothiocyanate-labeled anti-IgG antibody and observed by CLSFM. The changes in the blood levels of C3a and cytokines were also studied. In the CTA membrane, the adsorption of these substances, except for albumin and HNE, was less than in the synthetic membranes. The PAN membrane revealed the most abundant adsorption, especially for IL-1β, IL-6, and TNFα. Although a marked elevation of C3a in the blood was observed in the CTA membrane, considerable adsorption was evident in the PMMA and the PAN membranes. Because the changes in the blood levels could be affected by membrane adsorption, both the blood levels and the adsorption of the biocompatibility parameters should be evaluated when membrane biocompatibility is discussed.     

Level of Confidence in Diagnosis: Clinical Examination Versus Dermoscopy Examination

BACKGROUND: Confidence is an important factor in decision making and may influence patient care. OBJECTIVES: To evaluate whether short-training-based dermoscopy increases confidence in the diagnosis of skin lesions. METHODS AND MATERIALS: After a 1-hour course on dermoscopy, 20 pairs of clinical and dermoscopic images of lesions were presented to 19 dermatology residents with little or no dermoscopy experience. After viewing the clinical image, they were asked to assess their confidence in the diagnosis in a seven-point scale, with 1 reflecting that the respondent was 100% confident that the lesion was benign, while number 7 reflected 100% confidence that it was malignant. The same technique was used for dermoscopic images. RESULTS: Ten of the 20 pairs of evaluations showed a significant difference (p<.05). The largest differences were observed in lesions where clinical scores suggested that participants were uncertain about the diagnosis, but tended to decide that the lesion was benign after dermoscopy. Dermoscopy did not improve confidence in the evaluation of dysplastic lesions as well as lesions with obvious clinical diagnoses. CONCLUSIONS: Short-training-based dermoscopy improved confidence in the diagnosis of clinically challenging skin lesions, but the impact was not demonstrable for clinically obvious lesions and dysplastic nevi.     

Confocal Microscopy Study of Nerves and Blood Vessels in Untreated and Treated Port Wine Stains: Preliminary Observations

BACKGROUND AND OBJECTIVE: Vascular ectasia in port wine stain birthmarks (PWS) might result from reduced innervation with loss of autonomic stimulation. We investigated this theory and evaluated nerve and blood vessel density, and mean blood vessel size in untreated and treated PWS skin. METHODS: Skin biopsy specimens were obtained from uninvolved skin, untreated PWS, PWS with a good response to laser treatment and PWS with a poor response to laser treatment. Confocal microscopy was performed to determine nerve and blood vessel density, and mean blood vessel size. RESULTS: Nerve density was significantly decreased in all PWS sites compared to uninvolved skin. Mean blood vessel diameter was larger in untreated compared to treated PWS. PWS with a good response to treatment had decreased nerve density but blood vessel density and mean diameter was relatively normal. PWS with a poor response to treatment had decreased nerve density but increased blood vessel density and mean blood vessel diameter compared to normal skin. CONCLUSION: Nerve density was decreased in all evaluated PWS sites and this may be a factor in lesion pathogenesis. PWS blood vessel size correlated with pulsed dye laser response and may prove to be a useful prognostic indicator of therapeutic outcome.     

Important Clinical Outcomes in Urogynecology: Views of Patients,Nurses and Medical Staff

We attempted to grade treatment outcomes in female urinary incontinence by the perceived importance of these outcomes for patients, nursing staff and medical staff. One hundred millimeter visual analog scales (VAS) quantifying the relative importance of five clinical outcomes were sent to 100 patients, 50 nursing staff and 135 medical staff involved in continence care and median VAS scores for each outcome were compared between groups. Subjective improvement and improvement in quality of life were rated most highly. Median scores for subjective cure were 93 (76–99) for nurses, 93 (11–100) for patients and 91 (50–100) for ICS (UK) members. Median quality of life improvement scores were 92 (67–100), 93 (3–100) and 93 (74–100), respectively (not significant). There was a striking concordance of opinion regarding the importance of subjective improvement and improvement in quality of life. We suggest that these should become primary outcome measures in all future clinical trials and audits of incontinence treatments.     

In Vivo Real-Time Confocal Reflectance Microscopy: A Noninvasive Guide for Mohs Micrographic Surgery Facilitated by Aluminum Chloride, an Excellent Contrast Enhancer

BACKGROUND: Mohs micrographic surgery (MMS) is based on microscopically controlled excision of cutaneous neoplasms and offers the highest cure rates with maximum tissue preservation. In vivo confocal microscopy (CM) allows noninvasive optical imaging of thin sections of living skin, in its native state, in real time, with high resolution and contrast. OBJECTIVE: To evaluate the feasibility of the use of in vivo CM as a surgical guide in MMS. METHODS: Five patients with a biopsy-proven basal cell carcinoma (BCC) were imaged by in vivo CM on one or two sites from the clinically visible skin cancer. The first Mohs layer was then excised, and the fresh-frozen sections were correlated with the CM findings. Aluminum chloride (AlCl) 20% was applied on the Mohs defect followed by in vivo CM on one site from each lesion. A second Mohs layer was subsequently excised, and fresh-frozen sections were correlated with CM findings. RESULTS: The findings of in vivo CM were confirmed by hematoxylin and eosin-stained frozen sections after excisions of the first and second Mohs layers. AlCl was found to provide an excellent contrast between BCC cells and the surrounding tissue, detected readily with both in vivo and ex vivo CM. The tumor cells with AlCl exhibited intensely bright nuclei with an excellent contrast as compared with the low-contrast dark nuclei without AlCl application. CONCLUSION: In vivo CM is a potential surgical guide for MMS, and AlCl provides an excellent exogenous agent to enhance tumor contrast for CM.     

Melanosis of the bladder: a rare endoscopic and histopathological finding

Melanosis of the bladder represents a rare condition characterized by anomalous deposits of melanin-containing pigment. To our knowledge, so far, just 5 cases have been reported in the literature. We describe a case of a simply melanosis of the bladder confirmed by histochemical stains and immunohistochemistry analysis.     

Giant-Cell Tumors of the Sphenoid Bone in Four Children: Radiological, Clinical, and Pathological Findings

We report the clinical pathological and radiological findings of giant cell tumor of the sphenoid bone in four children aged 10 to 16 years. The most common clinical finding was headache, followed by cranial nerve abnormalities. The computed tomographic findings of giant cell tumor consist of a lytic defect, sharply margmated with no sclerosis associated with an expansile, homogeneous mass (isodense with muscle). In the differential diagnosis, the lesion most similar to giant cell tumor is giant cell granuloma. The different histopathological features of the two lesions are discussed, along with other lesions, in the differential diagnosis. The magnetic resonance features consist of a mass with low signal intensities on T₁ and T₂ weighted images associated with moderate enhancement after introduction of gadolinium.