bluuebunny/crossref_metadata_2025 huggingface dataset:
PD08 Sun protection practices of men in the west of Ireland
Authors: Hynes Jason , Griffin Laoise , Laing Mary
Published: June 2023

Irish men get more skin cancer than women, especially of the head and neck area. They typically get more sun exposure and are less likely to wear sun protection factor (SPF). Little is known about the types of hats men wear, or photoprotective practices regarding the lips. We carried out an observational study, using a questionnaire, on men aged > 18 years attending dermatology for any reason. Fitzpatrick skin type and Norwood classification for male pattern baldness was documented. Sixty-one men [mean (SD) age 56 (16.9) years] were involved. Forty-nine per cent were attending for the assessment of skin lesions. Thirty-eight per cent were on immunosuppression. Sixty-four per cent worked outdoors currently or in the past, 79% have or had spent > 3 h outdoors daily. Twenty-six per cent had a Norwood classification of ≥ 3v (vertex of scalp showing). The majority (71%) was of Fitzpatrick skin types I and II. Seventy-nine per cent wore SPF, 19% daily and 17% during the summer. Only 15% of men reported wearing lip SPF. Sixty-eight per cent reported wearing a hat on a ‘sunny day’. Of these, 54% wear baseball (BB) caps, 20% wear a wide-brimmed hat (WBH), 20% a narrow-brimmed hat, 4% a wool or traditional cap and 2% a total face covering. Age did not influence whether a hat was worn, but it did influence the type, with younger men more likely to wear BB caps and older men more likely to wear WBH. Those with hair thinning were more likely to wear a hat (87% vs. 67%). Non-hat-wearers were also less likely to wear SPF. Despite the incidence of skin cancer in sun-exposed sites in men, few studies have focused on photoprotective practices of the head and neck. Our study demonstrates that while Irish men wear SPF, few wear SPF on their lips. Additionally, Irish men often wear a hat type that would not be considered to provide adequate photoprotection to the head and neck. Hat type varied with age, with younger patients wearing less photoprotective hats. When considering photoprotection campaigns, factors such as age, fashion trends and education regarding lip SPF should be considered.
PD11 Photodynamic therapy for treating acne vulgaris
Authors: Ralph James , Alani Angela , Markham Trevor , Murphy Annette
Published: June 2023

In recent years, photodynamic therapy (PDT) has been advised as a possible adjunct to conventional therapy for acne vulgaris (acne). Both the 2021 National Institute for Health and Care Excellence acne guidelines and the 2018 British Association of Dermatologists’ PDT guidelines include PDT as an option to consider for acne in those aged 18 and older and if other treatments are ineffective, not tolerated or contraindicated. There is, at present, insufficient evidence to suggest an exact dosage or treatment protocol. Herein, we present a case of successful use of PDT in a patient with difficult-to-manage acne and the protocol employed. A 21-year-old woman has been attending dermatology for 10 years for acne, with keloid scarring, which is most extensive on her back. She was previously treated with spironolactone and a combined oral contraceptive pill. Topical retinoids and antibiotics, including trimethoprim (to which she developed erythema multiforme), clindamycin, azithromycin and tetracyclines, had all been used for various periods without sustained successful clearance. The patient has a general anxiety disorder with low mood and is taking quetiapine. She is a social media advocate for people with mental health issues and has good insight into her mood. She is educated regarding isotretinoin and contraindications to its use. The patient was treated with a trial of two sessions of PDT 1 week apart. The target area was prepared 3 h in advance of light with methyl aminolaevulinate 16% (as hydrochloride) spread to a thickness of 1–5 mm beyond the area border. Red light (635 nm) with a total dose of 37 J cm−2 was provided for 7 min and 50 s each time. The patient has Fitzpatrick skin type I and experienced moderate postprocedural erythema, which later resolved. At both the 3- and 6-month clinical follow-up, the patient is effectively clear of active acne in the treated area. There is previous residual scarring. The patient is not using any topical or systemic acne treatments. Options for acne treatment are diverse. However, some patients experience ineffective clearance or tolerance, and are not good candidates for isotretinoin. Dermatology centres with PDT may help provide an alternative solution. This case illustrates the successful application of PDT for acne and adds to the body of literature to support its inclusion in the aforementioned guidelines.
PS08 Skin lightening product use among British Indian immigrants: a qualitative study exploring causes and consequences
Authors: Khanna Divya , de Wildt Gilles , Lindenmeyer Antje
Published: June 2023

Cosmetic, topical skin-lightening products (SLPs) containing steroids, hydroquinone and mercury are available to Indian consumers without dermatological supervision. The World Health Organization discourages such SLP use, recognizing scar tissue formation, skin atrophy, localized infection, chemical burn and renal/hepatic impairment as adverse effects. Despite legislation restricting the sale of unlicensed SLPs in the UK, they remain accessible to British Indians through illegal importation. The current literature focuses on the high prevalence of unsupervised SLP use in India, documenting its psychodermatological and physical harm. However, no research has explored the causes and consequences of its use among British Indian communities, despite notable variances in culture. This qualitative study addresses the research gap to inform future management of unsafe SLP use. After ethical approval was granted, 24 semi-structured, in-depth interviews were conducted. Participants were recruited using maximum variation and snowball sampling through national radio and social media advertising, to encourage generalizability. Transcripts and field notes were analysed using conventional thematic and deviant case analysis, using NVivo 12 software. Two interdependent sets of themes influencing SLP use emerged. The first set, titled ‘Causes of SLP use’, included the following themes: ‘British cultural influence’, ‘product accessibility’ and ‘Indian beauty standards’. The second set, titled ‘Consequences of SLP use’, included the following themes: ‘financial’, ‘social’, ‘intrapersonal’, ‘physical’, ‘societal’ and ‘psychological’. Participants felt the Indian beauty standard derives from caste, religion, colonialism, Ayurvedic medicine and Indian media, which together heavily depict fair skin as superior, encouraging SLP use. This was further facilitated by frequent advertising on Indian television channels and social media, and the abundance and affordability of SLPs in South Asian stores in the UK. Participants persistently used SLPs, despite experiencing burning and patchy dyspigmentation as common adverse effects. Open internalized racism within the community instilled shame and stigma against those with darker skin, encouraging SLP use. Participants believed this was less common among second- and third-generation British Indians, discouraging SLP use, due to increased assimilation into British culture and improved media representation of people of colour. Participants agreed that SLP use negatively impacts on personal identity but identified its potential to elevate social desirability. This study newly highlights the significant negative psychodermatological impact of unsupervised SLP use among the British Indian community. As a factor propagating internalized racism, this study identifies a need to control illegal SLP importation and provide community-wide education on unsafe SLP use. These management strategies should be evaluated in future research.
PS09 The raising of Lazarus: re-engagement of adults with atopic dermatitis following the advent of novel effective therapies
Authors: O’Connor Cathal , Murphy Michelle
Published: June 2023

Atopic dermatitis (AD) has a devastating impact on quality of life, and persistent AD affects at least 7% of adults. Until recently, options for severe AD beyond topical therapies were limited to phototherapy and conventional immunosuppressive systemic drugs. With the advent of highly effective targeted treatments such as dupilumab and Janus kinase inhibitors (JAKi), patients with AD who had been lost to follow-up in dermatology are now returning en masse for consideration of biologic treatment or JAKi. The aim of this study was to analyse qualitatively the recapture of adults with severe AD who had previously been lost to follow-up because of disillusionment with suboptimal therapies and care. Semi-structured interviews were performed with 12 adults with severe AD to discuss their pathway to return to dermatology. Thematic analysis divided concepts into two categories: experiences of losing contact with dermatology and experiences of re-engagement with dermatology. Themes related to leaving dermatology care included the ineffectiveness of older treatments, toxicity of older treatments, attendance futility, dermatologist fatigue and ‘fizzling out’. ‘The ciclosporin would work for a few weeks but then I would have a flare, and my kidneys nearly gave out’; ‘I could tell the dermatologist was sick of looking at me. Back then I thought I was the problem, but now I think he was embarrassed because he couldn’t help me’; ‘I never decided I was going to stop going, it just ended up fizzling out and never going back.’ Themes related to re-engaging with dermatology care included social media influence, novelty, exasperation with quality of life and the life-changing improvements seen with novel treatments. ‘I saw someone on Facebook showing pictures after a few weeks on the injection and I went straight to my GP for a referral back to the dermatologist’; ‘After 60 years with eczema I just wanted to try something new, even if it killed me!’; ‘A few days after starting the tablets I left like Lazarus, it was like standing up out of a wheelchair for the first time in my life.’ This study highlights the reasons why adults with AD left dermatology services, explains why they re-engaged and deeply explores the transformative effect that novel treatments have had on the AD landscape. As adults with AD continue to return to dermatology care, the implications of increasing patient numbers needing biologic and JAKi therapy should be factored into healthcare and finance planning.
PS14 Bimekizumab response up to 3 years in patients with moderate-to-severe plaque psoriasis who responded at week 16: post hoc results from the BE BRIGHT open-label extension trial
Authors: Warren Richard B , Strober Bruce , Lebwohl Mark , Foley Peter , Langley Richard G , Davis Leah , Hoepken Bengt , Szilagyi Balint , Ciaravino Valerie , Bewley Anthony
Published: June 2023

Treatment with the interleukin-17A/F inhibitor bimekizumab (BKZ) has demonstrated maintenance of efficacy and health-related quality of life (HRQoL) outcomes over 2 years. The objective of this analysis was to assess the long-term response in patients with moderate-to-severe plaque psoriasis who achieved Psoriasis Area and Severity Index (PASI) ≤ 2, a key treat-to-target outcome, after 16 weeks of BKZ treatment over 3 years. Patients who completed a 52- (BE VIVID) or 56-week (BE SURE and BE READY) phase III feeder study were eligible to enrol in the BE BRIGHT open-label extension (OLE) (NCT03370133, NCT03412747, NCT03410992 and NCT03598790). Upon OLE entry, patients received BKZ 320 mg Q4W or Q8W based on feeder study treatment and week 52/56 PASI 90 (≥ 90% improvement in PASI) response. Patients switched from BKZ Q4W to Q8W at OLE week 24 (based on investigator discretion and PASI 90 response), or OLE week 48/next scheduled visit (all patients). Achievement of body surface area (BSA) ≤ 1% and PASI 0 (all studies), and Dermatology Life Quality Index (DLQI)0/1 (BE SURE and BE READY only due to schedule differences) is reported among week 16 PASI ≤ 2 responders through year 1 (feeder study week 52/56) and year 3 (OLE week 96). Analysed patients were randomized to BKZ, received BKZ maintenance dosing from feeder study week 16 and entered the OLE, including a subset who received BKZ Q4W through to week 16 then continuous BKZ Q8W (Q4W/Q8W/Q8W). Missing data were imputed using modified nonresponder imputation (mNRI): patients who discontinued treatment due to lack of efficacy or treatment-related adverse events were considered nonresponders; multiple imputation was used for all other missing data. The week 16 responder rate is also reported (NRI). At baseline, 989 patients were randomized to BKZ; 87.8% (n = 868) achieved PASI ≤ 2 at week 16. Of these, 694 entered the OLE. Among week 16 PASI ≤ 2 responders (n = 694), 91.9% and 82.3% achieved BSA ≤ 1% and PASI 0 after year 1 (52 weeks), and 88.6% and 74.1% after year 3, respectively. Among week 16 PASI ≤ 2 responders (n = 445), 87.8% and 86.8% achieved DLQI 0/1 after year 1 (56 weeks) and year 3, respectively. Of the week 16 PASI ≤ 2 responders who received BKZ Q4W/Q8W/Q8W (n = 189), 95.2% and 87.6% achieved BSA ≤ 1% and PASI 0 after 1 year (52 weeks), and 93.4% and 79.7% after 3 years, respectively. Among the Q4W/Q8W/Q8W patients, 94.1% and 91.2% achieved DLQI 0/1 after year 1 (56 weeks) and year 3, respectively. The BKZ provided long-term efficacy and HRQoL benefits. Among week 16 PASI ≤ 2 responders, the vast majority sustained high levels of clinical and HRQoL responses through 3 years of BKZ treatment, including those who received BKZ Q4W/Q8W/Q8W.

Funding: UCB Pharma. Medical writing: Costello Medical.
BT05 Community and Locality Imaging Centres: innovation in the skin cancer care pathway
Authors: Muthiah Shareen , Coon Andrew , Bryden Alyson , Chin Gillian , Fleming Colin , Morton Colin
Published: June 2023

Timely management of patients referred with suspected skin cancer remains challenging due to demand that exceeds the capacity of dermatology departments. Encouraging the attachment of images and key metadata along with referrals from primary care helps promote enhanced clinical referral triage. We describe the process of establishing Community and Locality Imaging Centres (CLICs) that seek not only to promote efficient triage, but also to establish a national pipeline of anonymized images, with linked Digital Imaging and Communications in Medicine (DICOM®) data, to assess the potential for future use of artificial intelligence (AI) algorithms in clinical practice. General practitioners (GPs) can request a CLIC appointment at the time of referral, removing the time pressure and potential technical barriers associated with photography and image attachment. Each centre follows the same standardized image capture and hardware operating procedure, ensuring that high-quality, in-focus digital images are consistently acquired. The CLIC appointments take an average of 15 min, during which a suitably trained healthcare professional obtains written patient consent and, using a National Health Service-approved mobile phone with a dermatoscope attachment, takes paired macroscopic and dermoscopic views of each lesion. Relevant metadata, in line with the recently agreed DICOM standards for dermatology, are recorded for individual lesions, enhancing the utility of each photograph. Paired images and metadata are regularly archived to a secure medical image management system and are linked with the referral, allowing dermatologists to perform enhanced clinical triage and communicate one of the following outcomes directly to the referring GP: routine dermatology appointment, urgent dermatology appointment, direct to biopsy or benign lesion–reassurance and discharge. This process aims to streamline the primary care referral pathway and promote immediate benefits to patient care by reducing unnecessary travel for face-to-face outpatient appointments. The establishment of CLICs in Scotland supports referral optimization by providing an efficient, convenient option for GPs and patients to obtain high-quality clinical photography. This model allows for flexible integration into local services: hospital-based with medical photographers, intermediate secondary care-led centres or community-based primary care hubs. Suspected skin cancer referrals can be efficiently triaged by dermatologists when paired with macroscopic and dermoscopic images and relevant patient metadata compliant with DICOM standards. The same images and metadata, once anonymized, can be securely transferred to a nationwide database for deep learning AI algorithm development. Validated AI programs, with the aim of being deployed at the primary care level, inform opportunities for further enhancement of the referral pathway.
BT10 Skin lesion triage teledermatology service: a review of secondary care 2-week wait upgrades
Authors: Harnett Clare , Mitchell Bethany , Azurdia Richard , Gallard Stephanie , McGovern Paul
Published: June 2023

A teledermatology service for skin lesions was commenced in January 2021 initially as a pilot scheme with six general practices and one dermatology department in a metropolitan area; to date, 70% of the city practices have since been on-boarded. Many 2-week wait (2WW) referrals are made not just for suspected skin cancer, but also for cases where there is diagnostic uncertainty and secondary care opinion/reassurance sought. The aim of the service was to embed a fully integrated information technology solution to facilitate single skin lesion triage in an attempt to help to address the 2WW capacity issues in secondary care. The referring general practitioners (GPs) were provided with a mobile phone adaptor attachment and dermatoscope to obtain images of the index lesion in question. A proforma that includes a concise history of the lesion and clinical impression is completed. The GPs were encouraged to use this triage service but could also refer directly to the 2WW service if concerned. The consultant then provided advice and guidance with a menu of triage outcomes, including upgrade to a 2WW appointment. We reviewed the referrals received via this skin lesion pathway and numbers of cases converted to a 2WW appointment from 12 April to 1 December 2022 as a snapshot of the service. We aimed to determine factors from the referral that prompted the conversion. There were 1201 skin lesion referrals, and 299 cases were converted to 2WW (24.9% of the cohort). In 93 of 299 referrals, the GP’s impression was possible squamous cell carcinoma or melanoma. In 137 of 299 cases, the GP had not provided a clinical impression. In 70 of 299 referrals, the GP’s clinical impression correlated with the dermatology’s impression based on the dermatoscopic images. In 44 cases, the clinician’s impression based on the image was of a benign lesion; however, we noted that a more cautious approach was adopted by some clinicians who triaged to 2WW if there was any diagnostic uncertainty. After face-to-face review, 159 of 299 were listed for biopsy or excision. Some factors identified that limited diagnostic accuracy included poor image quality and some referrals contained multiple lesions, causing confusion. This skin lesion triage service appears to support the idea that photographic triage could reduce the burden of 2WW face-to-face referrals. Areas for improvement identified include ensuring that the referrer provides a concise history and clinical impression, the use of gel for dermatoscopic images and feedback when images are not of adequate quality. In the future, it may be necessary to consider photographic hubs to standardize referral photographic quality.
BT12 A comparison of outcomes and cost-effectiveness in a teledermatology vs. a standard face-to-face 2-week wait UK model
Authors: Ahmed Fiza , Barlow Richard , Mehrtens Sarah , Atkar Ravinder , Gilaberte Montserrat , Ekeowa-Anderson Arucha , Maguire Andrew , Hasan Zeeshaan , Mohandas Padma
Published: June 2023

Teledermatology (TD) assessment of lesions referred on the 2-week wait (2WW) pathway reduces the need for in-person review, and thus facilitates increased clinical capacity. Although studies have demonstrated that TD can be cost-effective compared with a standard face-to-face (F2F) model, there is a lack of literature on the cost-effectiveness of TD with medical photography in the UK 2WW skin cancer pathway (Snoswell C, Finnane A, Janda M et al. Cost-effectiveness of store-and-forward teledermatology. JAMA Dermatol 2016; 152:702). In this study, we undertook a retrospective analysis of a store-and-forward TD 2WW pathway supported by medical photography at a UK centre (October–November 2022). As a comparator, we looked at the outcomes of a 2WW F2F clinic that took place 1 year earlier. Primary outcomes included comparing costs associated with both TD and F2F clinics, and outcomes after initial TD vs. F2F review (discharges, surgeries and subsequent F2F reviews). Inclusion criteria for TD were age 18–60 years, < 3 lesions referred and lesions being on culturally nonsensitive body sites. Cost estimates were included for physicians, nurses, healthcare assistants, administration staff and medical photographers. The tariff per 2WW skin cancer referral to the trust is £159.27. In total, 292 patient images were reviewed virtually in this study. Thirty of 68 patients in the F2F group met the same age criteria as those in the TD group (18–60 years), and thus these patients were used as comparators. Each 4-h TD session comprised an assessment of 25 patients vs. 12 patients per F2F session. Discharge rates from the first clinic appointment were higher for F2F clinics than for TD clinics (76.7% vs. 58.6%). Referrals for surgery were similar between the two groups (16.7% for F2F and 17.8% for TD). However, we found there were substantially more follow-ups requested after TD assessment vs. patients reviewed in F2F clinics (23.2% vs. 6.7%). The nonattendance rate for TD was 36 of 328 patients (11.0%) vs. five of 73 (6.8%) for F2F. Per-patient cost of the TD pathway was estimated to be £16.16 vs. £25.68 for a F2F 2WW appointment. Total revenue to the trust per clinical session was estimated to be £3981.75 (TD) vs. £1911.24 (F2F). This represented additional revenue of approximately £1975 for TD. Twenty-nine of 33 TD patients who completed feedback questionnaires reported overall satisfaction with the TD pathway. In this study, outcome rates between TD and F2F groups were similar in terms of planned surgeries. Planned subsequent F2F review rates were higher for TD, and discharge rates were higher for F2F. The revenue to the trust was greater for TD than F2F.
BT16 A service evaluation of dermatology Clinical Assessments, Services, Education and Support which aims to reduce referrals from primary to secondary care through peer review and education
Authors: Shah Rishi , Story Helen , Hepden Andrea , Ramsay Helen , Cockayne Sarah
Published: June 2023

Clinical Assessments, Services, Education and Support (CASES) is a collaboration between primary and secondary care to aid management of routine referrals via the National Health Service e-Referral Service (eRS) by providing clinical support and education to primary care through peer review, advice and guidance from local general practitioners (GPs) since 2016. The service covers 10 specialities. The CASES is optional, and primary care can choose to bypass the service, referring directly to secondary care. Three GP peer reviewers work under the supervision of dermatology consultants. They review elective referrals from primary healthcare professionals (GPs, advanced clinical practitioners and physician associates) via the eRS. Referrals are either sent back to the referrer with advice and educational resources or sent on to secondary care, often with interim advice. Monthly mentoring meetings enable the assessors to discuss difficult cases. Data were recorded for dermatology referrals from January 2022 to December 2022. Within the 12-month period, 3940 referrals were processed via CASES (mean 328 referrals a month). Of the referrals received, 90.0% (n = 3545) were routinely referred on to secondary care and 1.4% (n = 55) required a 2-week wait. However, 6.9% (n = 273) were returned to the referrer with advice and guidance. Further information was requested for 1.1% (n = 44) of the referrals that had been returned to the referrer. Twenty-three (0.6%) had been referred to the wrong specialty. Lesions (n = 1835; 46.6%) made up the bulk of the referrals, alongside rashes referred for diagnosis (n = 573; 14.5%). Chronic disease management (acne, eczema, psoriasis, contact dermatitis, etc.) made up 36.1%. Overall, the results suggest that 6.9% (n = 273) of referrals were managed in primary care. Almost half of the referrals were related to lesions. We have not yet been able to establish the proportion of cases where referrals were returned with advice and guidance and were then later referred to secondary care for the same issue, which is currently a limitation. Secondary care dermatology is overwhelmed with the current workload and waiting times. Peer review services like CASES, using a digital platform like the eRS, have the potential to be extremely beneficial to help manage the workload. However, the sharing of information between primary and secondary care needs to be improved in our service, and we would aim to make images mandatory to enable triage, although our beleaguered primary care colleagues currently feel that this is not possible.
BT18 Evaluation of a teledermatology service for lesion monitoring
Authors: Bali Radhika , Chung Jenny , Macedo Chrystalla , Thomas Lucy , Fearfield Louise
Published: June 2023

Teledermatology (TD) is an established diagnostic and triage tool for the initial assessment of skin lesions and is increasingly being used for monitoring. A previous study conducted at our trust found that 5% of our 2-week wait (2WW) referrals required follow-up for lesion monitoring. We therefore established a TD follow-up pathway to accommodate these patients and increase capacity for face-to-face (F2F) appointments. We retrospectively reviewed the outcomes of all TD follow-up patients seen from 1 April 2022 to 22 December 2022. The TD follow-up is usually requested 4 months after an initial assessment. We evaluated the proportion of benign lesions and those requiring further follow-up or surgery. In total, 3796 patients were assessed via TD, with 319 (8.4%) comprising TD follow-up. Altogether, 292 (91.5%) patients were initially reviewed via TD 2WW referral and 27 (8.5%) were referred from the clinic. Forty-eight (15.0%) did not attend (DNA) their follow-up and were discharged. Of the remaining 271 patients, seven (2.6%) who failed to attend their TD follow-up were rebooked, 179 (66%) were discharged after one TD follow-up assessment, 16 (5.9%) were booked for further TD follow-up, 19 (7.0%) were booked for routine F2F follow-up and five (1.8%) were booked for an urgent 2WW F2F appointment. Patients were also referred directly for excision, with 21 (7.7%) referred routinely and 24 (8.8%) referred urgently. From the 24 lesions excised urgently, five (21%) were dysplastic naevi, one (4%) was a moderately differentiated squamous cell carcinoma, 11 (46%) were benign (naevi, seborrhoeic keratoses or dermatofibroma) and for seven (29%), histology was unavailable (DNA appointment, sought private treatment or excision pending) at the time of data collection. No lesions were confirmed histologically as melanoma. Of the five dysplastic lesions, dermoscopic changes noted at follow-up included new atypical amorphous streaks, new and darker globules, loss of pigment and erythema. Our data suggest that TD for lesion monitoring may offer a suitable and time-efficient approach to follow-up, helping to alleviate pressure on services. Three to six months of follow-up has previously been considered an appropriate time period for short-term lesion monitoring; however, the optimal duration remains debatable. The low numbers of malignant lesions detected suggest an encouraging safety profile. However, with 66% of patients being discharged after TD follow-up, we plan to pilot a collaborative team approach to initial decision-making through mega processing clinics with the aim of improving specificity and ‘getting it right first time’ for patients. Longer-term data and cost-effectiveness analyses are required to further evaluate the sustained safety and efficacy of this service.
BT19 Teledermatology preserves the number needed to biopsy for diagnosis of skin cancer
Authors: Kirwin Thomas , Kentley Jonathan
Published: June 2023

In order to ensure a high sensitivity and prevent a missed skin cancer diagnosis, specificity is sacrificed. The number needed to biopsy (NNB) describes the number of benign lesions excised in order to diagnose one skin cancer. Published NNBs are highly variable, but a 2020 meta-analysis reported the overall NNB for melanoma to be 9.6 (Petty AJ, Ackerson B, Garza R et al. Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting. J Am Acad Dermatol 2020; 82:1158–65). The overall NNB is reported to be 3 for any skin cancer and 1.6 for nonmelanoma skin cancer (Matsumoto M, Secrest A, Anderson A et al. Estimating the cost of skin cancer detection by dermatology providers in a large health care system. J Am Acad Dermatol 2018; 78:701–9). The incidence of skin cancer is rising significantly in the UK, placing increased pressures on dermatology departments. A growing body of evidence suggests that the diagnostic accuracy of teledermatology is similar to that of face-to-face (F2F) care and many trusts now employ teledermatology for triage of 2-week wait (2WW) referrals. Our trust uses a teledermatology model where all patients referred via the 2WW pathway complete a digital form with details of the lesion. Both clinical and dermoscopic images are taken by a trained medical photographer and reviewed by a consultant dermatologist. Lesions felt to be suspicious for malignancy are triaged directly for biopsy. We aimed to evaluate the effectiveness of our teledermatology service by calculating the NNB, as well as the number of appointments where a biopsy was not performed following F2F assessment. Over a 2-month period, 251 lesions in 221 patients were triaged for biopsy via teledermatology, and 212 were biopsied following a F2F assessment. Of these, 54 (25.5%) were histologically diagnosed as skin cancer [11 melanoma, nine squamous cell carcinoma (SCC) and 33 basal cell carcinoma (BCC)]. When comparing the teledermatology diagnosis with the histological diagnosis, the overall NNB for skin cancer was 3.9. The NNB varied depending on the type of lesion suspected (7 for melanoma, 7.1 for SCC and 1.6 for BCC). When examining our NNB, it seems the accuracy of our teledermatology service is in keeping with data published from other centres. Furthermore, only a small proportion of lesions (10%) were not biopsied following a F2F assessment, demonstrating that teledermatology probably has a similar accuracy to F2F assessment. Although this is a small study from one centre, it further demonstrates that teledermatology is an efficient use of resources with no clear reduction in diagnostic accuracy.
Mitral valve repair with papillary muscle repositioning for functional mitral regurgitation (Type IIIb) with metal allergies: a case report
Authors: Mitsuishi Atsuyuki , Miura Yujiro , Kubo Toru
Published: June 2023

Background

Prosthetic heart valves, rings, and clips commonly used in heart surgery may contain metals, such as nickel and cobalt, that can cause severe hypersensitivity reactions in allergic patients. These reactions can cause paravalvular leakage and valve dysfunction. Similarly, stainless steel sternal wires can cause contact dermatitis. We should select rings, valves, and wires that do not contain any metals known to cause allergies in patients undergoing cardiac surgery.

Case summary

We report the case of a 79-year-old man with severe functional mitral regurgitation (Type IIIb) and a history of nickel and cobalt allergies. We safely performed mitral valve repair with papillary muscle repositioning with nickel- and cobalt-free rings in this patient. He was discharged from the hospital on the 26th postoperative day without dialysis intervention. Two years after surgery, mitral and tricuspid regurgitation had not worsened.

Discussion

According to the 2020 American Heart Association guidelines, surgery for severe functional mitral valve insufficiency (Type IIIb) is considered class IIb. Meanwhile, transcatheter edge-to-edge repair is class IIa. Long-term regurgitation is difficult to control with valve replacement and annuloplasty alone; recurrence has been observed. Therefore, additional techniques were considered. Papillary muscle repositioning has been reported and shown good results. The method used in the present case made intervening in the subvalvular tissue easy and demonstrated technical feasibility, safety, and effectiveness.
Forty years after mediastinal radiotherapy for Hodgkin lymphoma: how late is late cardiotoxicity? A case report
Authors: Ha Francis J , Mclellan Alex , Newcomb Andrew , Creati Louise
Published: June 2023

Radiation-associated cardiovascular disease is well-described yet under-recognized. Mediastinal radiation is known to affect any component of the heart. We present a case of valvular, coronary, and conduction abnormalities up to decades after initial radiotherapy.
Social capital is associated with cooperation and indirect norm enforcement in the field: behavioural evidence from Switzerland
Authors: Berger Joël
Published: June 2023

Social capital, comprising networks, generalized trust, and cooperation norms, is often considered a key factor in promoting prosperity and cooperation. Informal norm enforcement also drives cooperation. While early theories of social capital and norm enforcement propose that networks encourage sanctions, strong reciprocity theory argues that sanctioning non-cooperation is a universal preference. In the lab, people uphold cooperation through sanctions without networks, but this occurs only in regions characterized by high trust levels and strong cooperation norms outside the laboratory. Are trust, cooperation, and enforcement linked in the field, and if so, what are the generative mechanisms? In two neighbourhoods of Bern, one high in social capital and one low, we linked indicators of social capital and expected norm compliance from resident surveys (N = 466) with cooperation, measured with the lost-letter technique (N = 240), and norm enforcement, measured with reactions to transgressions of the antilittering norm (N = 123). Cooperation and indirect enforcement were more prevalent in the high social capital neighbourhood. Direct enforcement was rare in both neighbourhoods. The less optimistic expectations of cooperation and norm compliance prevalent in the low social capital neighbourhood can potentially explain the lower levels of cooperation and norm enforcement.
Do grandparents really matter? The effect of regular grandparental childcare on the second-birth transition
Authors: Rutigliano Roberta
Published: June 2023

In the last five decades, almost all European countries have experienced a decline in actual fertility, but not in desired fertility. The incompatibility of motherhood and paid work has been identified as one of the main drivers of women’s unrealized fertility desires. Regular grandparental childcare might reduce mothers’ work–family conflicts, increasing their chances of having a second birth. An extensive literature has estimated the role of grandparenting in adult children’s fertility. However, less attention has been devoted to the direct role of regular grandparental childcare, which is among the main resources in women’s reconciliation strategies. This article contributes to this debate by estimating the causal effect of regular grandparental childcare on women’s chances of having a second child. Using data from the first five waves of the Millennium Cohort Study, I implement an instrumental variable approach. I observe a strong and positive effect of regular grandparental childcare on women’s likelihood of having a second birth. This effect remains strong and positive net of women’s partnership status and income and educational levels. These results highlight the importance of the affordability and the availability of childcare for the decision to have a second child and the need for more supportive childcare policies.
Triglyceride-rich lipoprotein remnants, low-density lipoproteins, and risk of coronary heart disease: a UK Biobank study
Authors: Björnson Elias , Adiels Martin , Taskinen Marja-Riitta , Burgess Stephen , Rawshani Aidin , Borén Jan , Packard Chris J
Published: June 2023

Aims

The strength of the relationship of triglyceride-rich lipoproteins (TRL) with risk of coronary heart disease (CHD) compared with low-density lipoprotein (LDL) is yet to be resolved.

Methods and results

Single-nucleotide polymorphisms (SNPs) associated with TRL/remnant cholesterol (TRL/remnant-C) and LDL cholesterol (LDL-C) were identified in the UK Biobank population. In a multivariable Mendelian randomization analysis, TRL/remnant-C was strongly and independently associated with CHD in a model adjusted for apolipoprotein B (apoB). Likewise, in a multivariable model, TRL/remnant-C and LDL-C also exhibited independent associations with CHD with odds ratios per 1 mmol/L higher cholesterol of 2.59 [95% confidence interval (CI): 1.99–3.36] and 1.37 [95% CI: 1.27–1.48], respectively. To examine the per-particle atherogenicity of TRL/remnants and LDL, SNPs were categorized into two clusters with differing effects on TRL/remnant-C and LDL-C. Cluster 1 contained SNPs in genes related to receptor-mediated lipoprotein removal that affected LDL-C more than TRL/remnant-C, whereas cluster 2 contained SNPs in genes related to lipolysis that had a much greater effect on TRL/remnant-C. The CHD odds ratio per standard deviation (Sd) higher apoB for cluster 2 (with the higher TRL/remnant to LDL ratio) was 1.76 (95% CI: 1.58–1.96), which was significantly greater than the CHD odds ratio per Sd higher apoB in cluster 1 [1.33 (95% CI: 1.26–1.40)]. A concordant result was obtained by using polygenic scores for each cluster to relate apoB to CHD risk.

Conclusion

Distinct SNP clusters appear to impact differentially on remnant particles and LDL. Our findings are consistent with TRL/remnants having a substantially greater atherogenicity per particle than LDL.
Stroke in patients with heart failure and reduced or preserved ejection fraction
Authors: Yang Mingming , Kondo Toru , Butt Jawad H , Abraham William T , Anand Inder S , Desai Akshay S , Køber Lars , Packer Milton , Pfeffer Marc A , Rouleau Jean L , Sabatine Marc S , Solomon Scott D , Swedberg Karl , Zile Michael R , Jhund Pardeep S , McMurray John J V
Published: June 2023

Aims

Stroke is an important problem in patients with heart failure (HF), but the intersection between the two conditions is poorly studied across the range of ejection fraction. The prevalence of history of stroke and related outcomes were investigated in patients with HF.

Methods and results

Individual patient meta-analysis of seven clinical trials enrolling patients with HF with reduced (HFrEF) and preserved ejection fraction (HFpEF). Of the 20 159 patients with HFrEF, 1683 (8.3%) had a history of stroke, and of the 13 252 patients with HFpEF, 1287 (9.7%) had a history of stroke. Regardless of ejection fraction, patients with a history of stroke had more vascular comorbidity and worse HF. Among those with HFrEF, the incidence of the composite of cardiovascular death, HF hospitalization, stroke, or myocardial infarction was 18.23 (16.81–19.77) per 100 person-years in those with prior stroke vs. 13.12 (12.77–13.48) in those without [hazard ratio 1.37 (1.26–1.49), P < 0.001]. The corresponding rates in patients with HFpEF were 14.16 (12.96–15.48) and 9.37 (9.06–9.70) [hazard ratio 1.49 (1.36–1.64), P < 0.001]. Each component of the composite was more frequent in patients with stroke history, and the risk of future stroke was doubled in patients with prior stroke. Among patients with prior stroke, 30% with concomitant atrial fibrillation were not anticoagulated, and 29% with arterial disease were not taking statins; 17% with HFrEF and 38% with HFpEF had uncontrolled systolic blood pressure (≥140 mmHg).

Conclusion

Heart failure patients with a history of stroke are at high risk of subsequent cardiovascular events, and targeting underutilization of guideline-recommended treatments might be a way to improve outcomes in this high-risk population.
Increased knowledge levels of patients with diabetes in resource-limited communities after receiving peer-led education
Authors: Kobayashi Nobuyuki , Tanimura Chika , Aoto Haruka , Nagata Abir , Otani Shinji , Tokushima Yasuko , Fukada Mika , Morita Tetsuji , Inoue Kazuoki , Kageyama Seiji
Published: June 2023

Diabetes self-management education through peer support has been beneficial, especially in regions with limited medical resources. Studying the effects of education offered by trained peers of patients will facilitate tailoring the peer-led education programs to the regions’ specific needs. Here, we evaluated changes in diabetes-related indicators in Filipino patients who received a peer-led education. We used data on 23 patients (age, 67.83 ± 6.69 years; 82.6% female) who participated in all five surveys performed every 6 months from March 2017 to March 2019. After the second survey until the end of this study, the participants were educated in diabetes self-management by their 13 peers who previously had received the training in diabetes self-management. Participants’ knowledge of diabetes and the related ‘cause, risk factors, nature of diabetes and complications’ subindicator were greater on all surveys after starting the peer-led education compared with those on the second survey (i.e. before starting the education); these values did not differ between the first two surveys. Because increasing patients’ knowledge can enhance their ability to self-manage their disease and thus improve their quality of life, strategies to expand patients’ knowledge about diabetes should be included when organizing peer-led education in regions with limited medical resources.
Stratified genome-wide association analysis of type 2 diabetes reveals subgroups with genetic and environmental heterogeneity
Authors: Christiansen Colette E , Arathimos Ryan , Pain Oliver , Molokhia Mariam , Bell Jordana T , Lewis Cathryn M
Published: June 2023

Type 2 diabetes (T2D) is a heterogeneous illness caused by genetic and environmental factors. Previous genome-wide association studies (GWAS) have identified many genetic variants associated with T2D and found evidence of differing genetic profiles by age-at-onset. This study seeks to explore further the genetic and environmental drivers of T2D by analyzing subgroups on the basis of age-at-onset of diabetes and body mass index (BMI). In the UK Biobank, 36 494 T2D cases were stratified into three subgroups, and GWAS was performed for all T2D cases and for each subgroup relative to 421 021 controls. Altogether, 18 single nucleotide polymorphisms were significantly associated with T2D genome-wide in one or more subgroups and also showed evidence of heterogeneity between the subgroups (Cochrane’s Q P < 0.01), with two SNPs remaining significant after multiple testing (in CDKN2B and CYTIP). Combined risk scores, on the basis of genetic profile, BMI and age, resulted in excellent diabetes prediction [area under the ROC curve (AUC) = 0.92]. A modest improvement in prediction (AUC = 0.93) was seen when the contribution of genetic and environmental factors was evaluated separately for each subgroup. Increasing sample sizes of genetic studies enables us to stratify disease cases into subgroups, which have sufficient power to highlight areas of genetic heterogeneity. Despite some evidence that optimizing combined risk scores by subgroup improves prediction, larger sample sizes are likely needed for prediction when using a stratification approach.
Cefixime–tellurite-deoxycholate tryptic soy broth (CTD-TSB), a selective enrichment medium, for enhancing isolation ofEscherichia albertiifrom wild raccoon fecal samples
Authors: Xu Bingting , Hatanaka Noritoshi , Awasthi Sharda Prasad , Tekehira Keiji , Hinenoya Atsushi , Yamasaki Shinji
Published: June 2023

Aim

The aim of this study was to develop a selective enrichment broth for efficient isolation of Escherichia albertii.

Methods and Results

A total of 412 raccoon rectal swabs suspended in PBS (phosphate-buffered saline) were tested by a real-time PCR to quantify the number of E. albertii followed by its isolation. The number of E. albertii in the PBS suspension strongly affected the isolation rate (1.2%–89%), which notably dropped (≤33%) when the number was <4 log10 CFU ml−1. However, enrichment of PBS suspension containing raccoon feces in tryptic soy broth containing cefixime, tellurite, and deoxycholate (CTD-TSB), the selective medium developed in this study, remarkably improved the isolation efficiency (up to 48%) of E. albertii.

Conclusions

CTD-TSB is a useful enrichment culture medium for E. albertii and contributes to increase its isolation rate.
Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory
Authors: Boyd Andrew D , Gonzalez-Guarda Rosa , Lawrence Katharine , Patil Crystal L , Ezenwa Miriam O , O’Brien Emily C , Paek Hyung , Braciszewski Jordan M , Adeyemi Oluwaseun , Cuthel Allison M , Darby Juanita E , Zigler Christina K , Ho P Michael , Faurot Keturah R , Staman Karen L , Leigh Jonathan W , Dailey Dana L , Cheville Andrea , Del Fiol Guilherme , Knisely Mitchell R , Grudzen Corita R , Marsolo Keith , Richesson Rachel L , Schlaeger Judith M
Published: June 2023

Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges—incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology—that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.