Ryan K. Rader

Biologically inspired skin lesion segmentation using a geodesic active contour technique.

Computer‐aided diagnosis of skin cancer requires accurate lesion segmentation, which must overcome noise such as hair, skin color variations, and ambient light variability.

Fuzzy logic color detection: Blue areas in melanoma dermoscopy images

Fuzzy logic image analysis techniques were used to analyze three shades of blue (lavender blue, light blue, and dark blue) in dermoscopic images for melanoma detection. A logistic regression model provided up to 82.7% accuracy for melanoma discrimination for 866 images. With a support vector machines (SVM) classifier, lower accuracy was obtained for individual shades (79.9-80.1%) compared with up to 81.4% accuracy with multiple shades. All fuzzy blue logic alpha cuts scored higher than the crisp case. Fuzzy logic techniques applied to multiple shades of blue can assist in melanoma detection. These vector-based fuzzy logic techniques can be extended to other image analysis problems involving multiple colors or color shades.

Diagnostic Inaccuracy of Smartphone Applications for Melanoma Detection: Representative Lesion Sets and the Role for Adjunctive Technologies

To the Editor The study by Wolf et al1 highlights the low accuracy of smartphone applications for melanoma self-detection, and correctly concludes that these applications could harm patients by delaying melanoma treatment through incorrect diagnosis. The article also found 98% sensitivity with 30.4% specificity for pigmented lesion evaluation by store-and-forward teledermatology. We question whether the teledermatology results can be reproduced in a real-world setting.

The Pink Rim Sign: Location of Pink as an Indicator of Melanoma in Dermoscopic Images

Background. In dermoscopic images, multiple shades of pink have been described in melanoma without specifying location of these areas within the lesion. Objective. The purpose of this study was to determine the statistics for the presence of centrally and peripherally located pink melanoma and benign melanocytic lesions. Methods. Three observers, untrained in dermoscopy, each retrospectively analyzed 1290 dermoscopic images (296 melanomas (170 in situ and 126 invasive), 994 benign melanocytic nevi) and assessed the presence of any shade of pink in the center and periphery of the lesion. Results. Pink was located in the peripheral region in 14.5% of melanomas and 6.3% of benign melanocytic lesions, yielding an odds ratio of 2.51 (95% CI: 1.7–3.8, P < 0.0001). Central pink was located in 12.8% of melanomas and 21.8% of benign lesions, yielding an odds ratio of 0.462 (95% CI: 0.67, P = 0.204). Pink in melanoma in situ tended to be present throughout the lesion (68% of pink lesions). Pink in invasive melanoma was present in 17% of cases, often presenting as a pink rim. Conclusions. The presence of pink in the periphery or rim of a dermoscopic melanocytic lesion image provides an indication of malignancy. We offer the “pink rim sign” as a clue to the dermoscopic diagnosis of invasive melanoma.

Extreme Pain From Brown Recluse Spider Bites: Model for Cytokine-Driven Pain

IMPORTANCE Bites from the brown recluse spider (BRS) can cause extreme pain. We propose cytokine release as a cause of the discomfort and a central mechanism through glial cell upregulation to explain measured pain levels and time course. OBSERVATIONS Twenty-three BRS bites were scored at a probable or documented level clinically, and an enzyme-linked immunosorbent assay was used to confirm the presence of BRS venom. The mean (SD) pain level in these cases 24 hours after the spider bite was severe: 6.74 (2.75) on a scale of 0 to 10. Narcotics may be needed to provide relief in some cases. The difference in pain level by anatomic region was not significant. Escalation observed in 22 of 23 cases, increasing from low/none to extreme within 24 hours, is consistent with a cytokine pain pattern, in which pain increases concomitantly with a temporal increase of inflammatory cytokines. CONCLUSIONS AND RELEVANCE These findings in BRS bites support the hypothesis of cytokine release in inflammatory pain. A larger series is needed to confirm the findings reported here. The extreme pain from many BRS bites motivates us to find better prevention and treatment techniques.

Analysis of clinical and dermoscopic features for basal cell carcinoma neural network classification.

Basal cell carcinoma (BCC) is the most commonly diagnosed cancer in the USA. In this research, we examine four different feature categories used for diagnostic decisions, including patient personal profile (patient age, gender, etc.), general exam (lesion size and location), common dermoscopic (blue‐gray ovoids, leaf‐structure dirt trails, etc.), and specific dermoscopic lesion (white/pink areas, semitranslucency, etc.). Specific dermoscopic features are more restricted versions of the common dermoscopic features.

Sector expansion and elliptical modeling of blue-gray ovoids for basal cell carcinoma discrimination in dermoscopy images

Blue‐gray ovoids (B‐GOs), a critical dermoscopic structure for basal cell carcinoma (BCC), offer an opportunity for automatic detection of BCC. Due to variation in size and color, B‐GOs can be easily mistaken for similar structures in benign lesions. Analysis of these structures could afford accurate characterization and automatic recognition of B‐GOs, furthering the goal of automatic BCC detection. This study utilizes a novel segmentation method to discriminate B‐GOs from their benign mimics.

Addressing the Crisis in the Treatment of Osteoporosis: Better Paths Forward

The report by Khosla and colleagues highlights a critical gap in osteoporosis management: Patients who need pharmacological therapy are either not being prescribed thesemedications or fail to take them, especially bisphosphonates. We suggest three changes to the paths proposed by the authors to further improve osteoporosis treatment: new ways to guide patient decisions, extending new drug development to include therapies from complementary and alternative medicine, and new efforts in osteoporosis research. With enhanced osteoporosis treatment and lifestyle options, we have a better chance to find an approach suitable for each individual. The first path forward offered by the authors is the most critical: patient and physician education to increase therapeutic compliance. Let’s pursue that direction further. We would like the authors to respond to this question: Why not use new ways to address patients’ false beliefs that osteoporosis treatment risks are likely and that without treatment, a fragility fracture is unlikely? The authors have not adequately addressed the primary problem; in spite of the positive benefits, patients refuse to comply with medication recommendations. New models in disease understanding can guide our counseling efforts; compliance depends on addressing all components of the disease perception model. Our goals are 1) increase perceived susceptibility to fragility fractures; 2) increase perceived severity of suffering from a fragility fracture; 3) increase the perceived benefits of medication compliance/ adherence; 4) decrease perceived barriers to medication compliance/adherence, such as inflated fear of atypical femoral fractures (AFFs); and 5) continue to monitor health beliefs to promote compliance. In this model, underlying emotional aspects have greater effects on behavior than do cognitive elements; narrative (anecdotal) evidence is more effective than statistical evidence. A graphic scenario of suffering and incapacitation after a hip fracture will enhance emotional perception of this threat. Although the growing impact of social media on patient decisions can contribute to flawed health beliefs, it also brings an avenue for physicians to participate in social media discussions to align physician and patient viewpoints. Other avenues for education should be pursued; when a patient enquires about duration of therapy, we can focus on what matters to an individual patient. Patients generally prefer weekly therapy over daily therapy—providing a chance to overcome one barrier. Newer educational techniques such as gamification bring benefits at any age. Gamified learning can be used in clinical waiting areas before the visit to improve flawed decision making. The authors recommended new drug development as a long-term approach; are they taking into account the economic gauntlet of conventional new molecule development? This narrow path should be widened to include potentially osteoprotective substances such as geraniin, dalbergin, echinocystic acid, and Achyranthes japonica extract. The National Center for Complementary and Integrative Health (NCCIH) website indicates two herbal medicines that have shown promise in laboratory studies, black cohosh and turmeric extract, the latter study funded by NCCIH. In the authors’ long-term approach, why did the authors not include research as another avenue to help resolve the crisis? The authors stated, “American Society for Bone and Mineral Research and its members have been very fortunate to have decades of strong support for basic and clinical research efforts by NIH from multiple Institutes.” Yet the American Society for Bone and Mineral Research estimates that only 1% of the NIH budget was allotted to bone research; osteoporosis research support is even less than this total and has fallen, from

Patient Concern as a Predictor of Cutaneous Malignancy

181 million in 2012 to

Region growing by sector analysis for detection of blue‐gray ovoids in basal cell carcinoma

151 million estimated for 2016, less than 0.5% of the NIH budget of