First prospective study of the recognition process of melanoma in dermatological practice

BACKGROUND: Early detection is crucial to improve melanoma prognosis. Different diagnostic guides such as the ABCD rule (asymmetry [A], irregularity of borders [B], unevenness of distribution of color [C], and diameter [D]) have been proposed to identify melanoma, but their efficacy in real life is questionable. We investigated the recognition process of melanoma by dermatologists to use as a model to improve self-detection in the general population and to train students and general practitioners. OBJECTIVES: To understand the major principles of the recognition process of nevi and melanoma unconsciously used by dermatologists. DESIGN: Prospective survey recording the immediate perceptions of dermatologists of the morphologic features of the lesion and intuitive diagnostic opinion about 4036 consecutive resected nevi and melanoma. SETTING: One hundred thirty-five volunteer dermatologists in their daily practices. MAIN OUTCOME MEASURES: Perceptions of the image best explaining the diagnostic opinion and best predicting the final diagnosis by univariate and multivariate analysis. RESULTS: The immediate diagnostic opinion of the dermatologist is mainly explained by an unconscious reference to the overall pattern compared with the common nevi, but also compared with the other nevi of the individual (the "ugly duckling sign"). The dermatologist's ability to discriminate between nevi and melanoma relies on the assessment of the overall pattern, the ugly duckling sign, and the knowledge of a recent change. A separate or combined analysis of individual morphologic criteria such as ABCD does not seem to play a major role in this recognition process. CONCLUSIONS: Persons most skilled at the clinical detection of melanoma seem to unconsciously rely on cognitive (overall pattern) and comparative (ugly duckling sign) processes rather than an algorithm of morphologic criteria (ABCD). These concepts could be tested in the medical training of general practitioners and education of the general population, where they might be more efficient than algorithms such as the ABCD criteria.     

Mood alterations during interferon-alfa therapy in patients with chronic hepatitis C: evidence for an overlap between manic/hypomanic and depressive symptoms

BACKGROUND: Psychiatric side effects are common during interferon-alfa (IFN-alfa) therapy and often responsible for early treatment discontinuation, thus limiting its therapeutic potential. Depression is considered the hallmark of these side effects. However, irritability, anger/hostility, and manic/hypomanic episodes have also been reported, suggesting that these symptoms are important features of IFN-alfa-induced neuropsychiatric side effects. OBJECTIVE: The aim of this prospective study was to use item-by-item analysis to thoroughly characterize neuropsychiatric symptoms occurring during early IFN-alfa therapy in a large cohort of patients with chronic hepatitis C. METHOD: Ninety-three previously IFN-alfa-naive patients treated with pegylated IFN-alfa plus ribavirin for chronic hepatitis C were studied. Neuropsychiatric assessments were conducted before initiation and after weeks 4 and 12 of antiviral therapy. They included the Mini-International Neuropsychiatric Interview, the 10-item Montgomery-Asberg Depression Rating Scale, the State-Trait Anxiety Inventory, and the Brief Fatigue Inventory. RESULTS: Psychiatric events occurred in 30 patients (32%). They consisted of mood disorders in all cases: mania in 3 cases (10%), irritable hypomania in 15 cases (50%), and depressive mixed states in 12 cases (40%). Neurovegetative symptoms appeared within 4 weeks in most patients. In patients who developed mood disorders, sadness and depressive thoughts were present but minimal in severity. In contrast, inner tension and anxiety symptoms increased significantly over time only in these patients. CONCLUSIONS: Our results suggest that IFN-alfa-induced mood disorders are common and consist of an overlap between depressive and manic symptoms rather than a mere depression. The impact of such findings on therapeutic management should be investigated.     

Comparison of fast Fourier transform and autoregressive spectral analysis for the study of heart rate variability in diabetic patients

INTRODUCTION: Impaired heart rate variability (HRV) is associated with poor outcome in diabetic patients. The present prospective study compared spectral components of HRV obtained by either fast Fourier transform (FFT) or autoregressive (AR) analyses in diabetic patients. METHODS: Thirty patients (49+/-12 years; 11 F/19 M; 60% with insulin-dependent type 1 diabetes) underwent 24-h ambulatory electrocardiographic recordings which comprised a 10-min resting period at the onset (n=30) and end (n=12) of the monitoring. Spectral analysis was applied to 5-min sequences at rest, and the total power and power spectra integrated over the very low (VLF), low (LF), and high (HF) frequency bands were obtained. RESULTS: Fifteen patients had moderately depressed HRV and two patients had highly depressed HRV (standard deviation of the RR intervals over 24-h<100 ms and <50 ms, respectively). Both raw data and ln-transformed data were significantly different between FFT and AR. All spectra component were obtained in each patient using FFT. Using AR, the LF/HF ratio could not be estimated or was zero in 4 and 11 patients, respectively. The AR results were more sensitive than FFT results to minor changes (+/-5%) in the timing of the onset of analysis. The day-to-day reproducibility of FFT was better than that of AR. Finally, using FFT, the LF/HF ratio, LFnu, and HFnu were essentially redundant (nu=normalized units). CONCLUSIONS: The spectral components of short-term HRV calculated by using the FFT and AR methods were not interchangeable and FFT analysis must be preferred in diabetic patients.     

A randomized formula controlled trial of Bifidobacterium lactis and Streptococcus thermophilus for prevention of antibiotic-associated diarrhea in infants

GOALS: This clinical trial was carried out to determine whether oral treatment with a commercial probiotic formula containing Bifidobacterium lactis and Streptococcus thermophilus would reduce the frequency of antibiotic-associated diarrhea (AAD) in infants. STUDY: In this double-bind formula controlled study, 80 infants, 6 to 36 months of age, were randomly assigned to receive a commercial formula containing 10 viable cells of B. lactis and 10 viable cells of S. thermophilus at the initiation of antibiotics for a duration of 15 days. The infants were assessed daily for formula intake, stool frequency, and stool consistency for a total duration of 30 days. Seventy-seven infants received nonsupplemented formula for the entire duration. RESULTS: There was a significant difference in the incidence of AAD in the children receiving probiotic-supplemented formula (16%) than nonsupplemented formula (31%). CONCLUSIONS: The present study shows that prevention against AAD in infants was obtained by oral treatment with daily dose of B. lactis and S. thermophilus.     

Screening mammography participation and invitational strategy: the Quebec Breast Cancer Screening Program, 1998-2000

In the Quebec Breast Cancer Screening Program, a personalized letter signed by a regional program physician is sent to every woman in the province 50 to 69 years of age, inviting her to have a screening mammogram. A reminder letter is also frequently sent. The aim of this study was to evaluate the influence of this screening invitational strategy on rates of participation. The population studied was comprised of 684,028 women in Quebec aged 50-69. The baseline (expected) monthly mammography screening rate was estimated from the rate of screening mammograms recorded between the date a woman became eligible for screening and the mailing date of her personalized invitational letter; the observed monthly mammography screening rate was calculated after the mailing of the letter. Compared to baseline (expected) screening rates, observed rates were substantially increased (p<.05). The ratios of observed to expected rates were respectively 3.05 and 2.23 in the second and fourth months, respectively, after the letter mailing, coinciding with the mailing of the initial and reminder letters. In the twelve months after the mailing, the ratio of observed to expected rates was 1.68 (95% CI: 1.67-1.69). Twelve months following the mailing, 30 percent of the women who were letter recipients had undergone a screening mammography, compared to an expected cumulative probability of 20 percent for women not receiving a letter. The strength of this effect was similar to one seen in randomised controlled trials.     

Effect of supplementation with antioxidants upon long-term risk of hypertension in the SU.VI.MAX study: association with plasma antioxidant levels

OBJECTIVE: To assess the effects of supplementation with a combination of antioxidant vitamins and trace elements, at nutritional doses, upon the 6.5-year risk of hypertension in the SU.VI.MAX trial. To describe the association between baseline plasma antioxidant levels and the same long-term risk using observational data from the study. SETTING: A total of 5086 adults from the SU.VI.MAX trial, a randomized primary prevention trial. RESULTS: Compared with the placebo group, no effect of supplementation upon the 6.5-year risk of hypertension could be detected (odds ratio, 1.04 and 95% confidence interval, 0.87-1.23 in men; and odds ratio, 1.10 and 95% confidence interval, 0.95-1.29 in women). Furthermore, compared with men in the first tertile, those in the second and third tertiles of serum baseline levels of beta-carotene presented a lower risk of hypertension in both the placebo and supplementation groups. Multivariate-adjusted odds ratios (95% confidence interval) were 0.70 (0.44-1.12) and 0.53 (0.33-0.86) in the placebo group, and were 0.59 (0.37-0.94) and 0.67 (0.42-1.07) in the supplementation group. In women, a decreasing trend was observed with vitamin C levels and risk of hypertension in the intervention group. No association could be shown between vitamin E and trace element plasma levels and the risk of hypertension. CONCLUSIONS: Despite an inverse association between baseline plasma levels of beta-carotene in men and the risk of developing hypertension, we could not demonstrate any beneficial effect of low-dose antioxidant supplementation upon the 6.5-year risk of hypertension in the randomized analysis.     

Renal functional contrast-enhanced magnetic resonance imaging: evaluation of a new rapid-clearance blood pool agent (p792) in sprague-dawley rats

OBJECTIVES: The objective of the present study was to compare P792, a new rapid clearance blood pool agent characterized by negligible interstitial diffusion but unrestricted glomerular filtration, with Gd-DOTA in both qualitative and quantitative aspects of renal functional magnetic resonance imaging. MATERIALS AND METHODS: Dynamic imaging was performed with a fast T1-weighted gradient-echo sequence on a 1.5-T magnet in 25 Sprague-Dawley rats, after injection of 13 micromol Gd/kg-1 of P792 (n = 10), 100 (n = 10), or 50 micromol Gd/kg-1 of Gd-DOTA (n = 5). Signal-time curves from 6 regions of interest (ROIs), including renal parenchyma and contents, were analyzed. RESULTS: Qualitative analysis depicted a typical pattern of temporal enhancement as previously described with extracellular gadolinium chelates, including early and brief enhancement of the aorta, renal vessels and cortex, quickly followed by enhancement of the medulla and then renal pelvis. However, a decrease in signal intensity was noted in the inner medulla and the renal pelvis approximately 90 seconds after bolus injection, being more marked when using the full dose of Gd-DOTA. Curve analysis showed a similar vascular phase within each parenchymal ROI, confirmed by similar upslopes, which ranged from 0.015 +/- 0.007 to 0.019 +/- 0.005. Following this initial phase, T1-enhancement appeared greater and longer within the medulla and renal pelvis, and subsequently in the whole kidney ROI with P792 (time to maximal enhancement (sec)/ enhancement rate: 85.5 +/- 15.9/3.1 +/- 0.4) as compared with Gd-DOTA full (53.0 +/- 18.9/ 2.7 +/- 0.3) or half dosage (65.2 +/- 20.1/ 2.2 +/- 0.2). The subsequent decrease in signal intensity, characterized by a downslope during the minute following maximal enhancement, was faster with Gd-DOTA (0.006 +/- 0.002) as compared either to P792 or half dosage Gd-DOTA (0.003 +/- 0.001). CONCLUSIONS: Due to its physicochemical and pharmacokinetic properties, P792 allows the use of a reduced dosage of gadolinium, resulting in less T2* effect without compromising T1 enhancement. Thus, P792 appears suitable for renal functional MR imaging.     

Endovascular treatment with coils of 149 middle cerebral artery berry aneurysms

PURPOSE: To retrospectively evaluate the immediate and long-term clinical results, as well as the angiographic results, of occlusion of middle cerebral artery (MCA) berry aneurysms with coils. MATERIALS AND METHODS: This retrospective study had institutional review board approval, and informed consent was obtained. One hundred fifty-four MCA aneurysms in 142 patients were intended to be treated. Complications, patient clinical outcomes, and immediate postprocedural and follow-up angiography results were retrospectively evaluated. RESULTS: One hundred forty-nine (96.8%) of 154 MCA aneurysms (72 ruptured, 77 unruptured) were occluded with coils in 137 patients (99 women and 38 men; age range, 28-76 years; mean, 48 years). Thromboembolic events occurred in 20 (13.4%) and aneurysm perforation occurred in seven (4.7%) of 149 procedures. Endovascular treatment (EVT) was performed without complications for 121 (81.2%) of the treated aneurysms. For ruptured aneurysms, the treatment-related mortality rate was 6% (four of 72 aneurysms) and the treatment-induced permanent morbidity rate was 1% (one aneurysm). For unruptured aneurysms, the treatment-induced mortality rate was 1% (one of 77 aneurysms) and the procedure-related permanent morbidity rate was 3% (two aneurysms). One hundred five (70.5%) of the 149 aneurysms were examined with follow-up angiography at least once. Recurrences were found for 21 (20%) of the 105 aneurysms that were followed up for a cumulative period of 1564 months (mean, 15 months). Of these 21 recurrent aneurysms, 10 increased in size in the interval between follow-up angiography examinations and 11 remained stable. A second treatment was required for 12 aneurysms, and a third treatment was required for one. After repeat EVT, total aneurysm occlusion was attained for nine aneurysms, and a residual neck was seen in two aneurysms. One recurrent aneurysm was surgically clipped. The nine other aneurysms with small recurrences were not candidates for additional treatment. CONCLUSION: EVT of MCA aneurysms with coils can be successfully performed without inducing neurologic deficits in most patients with ruptured or unruptured aneurysms.     

Selective endovascular treatment of intracranial aneurysms with a liquid embolic: a single-center experience in 39 patients with 41 aneurysms

BACKGROUND AND PURPOSE: Although embolization with detachable coils is an accepted alternative to surgical clipping, a major long-term problem is aneurysm recanalization due to coil compaction. Liquid embolic agents are a possible alternative as filling material that might decrease the recanalization rate. We evaluated the use of a liquid embolic for endovascular treatment of intracranial aneurysms. METHODS: During 1999-2003, 10 patients with 11 small aneurysms (group 1) and 29 patients with 30 large or giant aneurysms (group 2) were treated with a liquid embolic. Of 32 female and seven male patients, 20 had mass effect and two had subarachnoid hemorrhage; 17 were asymptomatic. All aneurysms were judged unsuitable for regular treatment; selective embolization was performed with a liquid embolic alone or with coils and liquid embolic. Stent placement was performed in 15 cases. Clinical and anatomic outcomes were assessed with the Modified Glasgow Outcome Scale and with angiography at 3, 12, and 24 months. RESULTS: In group 1, good or excellent outcome and complete occlusion were observed in all patients. In group 2, clinical outcome was good or excellent in 26 patients and fair in one, and death occurred in two patients (one procedure related and one disease related). Technical complications occurred in four patients in group 1 (one permanent neurologic deficit) and in four patients in group 2 (one patient died, two remain hemiparetic, one remains asymptomatic). Follow-up images showed two recanalizations in group 1 and nine in group 2. CONCLUSION: Selective embolization with a liquid embolic is useful to treat aneurysms unsuitable for coiling or for patients in whom previous treatment failed. This mostly applies to large and giant aneurysms in which morbidity and mortality rates are better than those associated with surgery, and the recanalization rate is lower than that previously described with coiling.