bluuebunny/crossref_metadata_2025 huggingface dataset:
PA25 Persistent and widespread infantile transient smooth muscle contraction of the skin: an atypical presentation of a rare condition.
Authors: Keeling Elizabeth , Devereux Clare , Browne Fiona
Published: June 2023

Infantile transient smooth muscle contraction of the skin is a rare entity. Eleven cases have been described in the literature to date. Herein, we describe an unusual presentation, persistent and widespread in nature. A 2-year-old girl presented with asymptomatic bilateral transient textural change of the skin overlying the thighs. Textural changes were noted from birth, occurring a number of times each day. Episodes resolved spontaneously, sometimes within minutes, on occasion lasting up to 1 h. The child remained systemically well during episodes. Textural change progressed to involve the skin overlying the abdomen. Friction and temperature change did not provoke episodes. No other triggers were elicited. Background history included metatarsus adductus, which was under routine follow-up with orthopaedics. Full skin examination between episodes revealed no cutaneous abnormality. The areas affected were normal to palpate. Photographs and videos of episodes revealed marked textural change of the skin overlying both thighs and abdomen, with a striking stippled appearance. Laboratory investigations, including tryptase, lactate dehydrogenase, immunoglobulins and complement, were unremarkable. A case series first described nine cases of infantile transient smooth muscle contraction in 2013 (Torrelo A, Moreno S, Castro C et al. Infantile transient smooth muscle contraction of the skin. J Am Acad Dermatol 2013; 69:498–500). Textural skin changes occurred most frequently on the lower limbs. In eight of these cases, episodes resolved within 1 min. Episodes occurred both spontaneously and secondary to light friction from clothing, cool air and bathing. The majority of cases were noted from birth or in the first days of life. Skin biopsies taken from three of these patients revealed no abnormality. Episodes resolved by 2 years of age in all cases. It has been suggested that this transient phenomenon may be secondary to autonomic nervous system immaturity, primitive reflex phenomena or transient hypersensitivity of the smooth muscle. A more recent case has since been described in the literature (Theodosiou G, Belfrage E, Berggård K, Cristiansen J. Infantile transient smooth muscle contraction of the skin: a case report and literature review. Eur J Dermatol 2021; 31:260–1). We describe a persistent case of infantile transient smooth muscle contraction of the skin, in a child aged > 2 years, with prolonged episodes, progressing from lower limbs to truncal involvement. Recognition of this rare condition is important, to allow appropriate reassurance regarding its benign and self-limiting nature.
PA28 Case series of concomitant use of propranolol and prednisolone in the treatment of ulcerated infantile haemangiomas and an updated literature review
Authors: Kuan Amanda , Koh Mark
Published: June 2023

Infantile haemangiomas (IHs) are the most common benign tumours of infancy. Ten per cent of patients suffer complications, including ulceration, bleeding and functional impairment, and systemic treatment is required to reduce permanent disfigurement. Prednisolone was once the most commonly used and most efficacious treatment modality for complicated IHs, but propranolol has since overtaken its role as the first-line therapy in the last decade. In our practice, we have seen that propranolol monotherapy may not be sufficient in cases of IH with complex ulceration, and oral corticosteroids may serve as an effective adjunct in managing this group of patients. We present a case series of all patients diagnosed with ulcerated IH at KK Women’s and Children’s Hospital over the last 10 years. Fifteen patients were found to have ulcerated IHs. Eight patients were treated with both oral propranolol and oral prednisolone, and four patients were treated with oral propranolol alone. Patients were initiated on propranolol 1–2 mg kg−1 daily, and this dosage was titrated over an average of 9.6 months. Patients prescribed prednisolone had a tapering dosage starting from 0.5–2 mg kg−1 daily for 8–36 days. Average time to complete healing of ulcerated IHs in patients treated with both prednisolone and propranolol was 27.1 days, while patients treated with propranolol alone took 34 days. One patient had recurrence of ulceration after 2 months and had a second, 9-day course of prednisolone. None of the patients had complications from propranolol or prednisolone. Ulceration—the most common complication of IH—tends to heal poorly and is associated with pain, bleeding, infection and scarring. Early and efficacious treatment is needed to prevent functional impairment and permanent disfigurement. Several cases of ulcerated IH have been observed to be recalcitrant to propranolol monotherapy. In these patients, prednisolone used as an adjunct to propranolol has resulted in accelerated healing of these ulcerations. There are no guidelines on the dose and duration of prednisolone use, although a tapering dose starting at 1 mg kg−1 daily is usually given until complete healing of ulceration.
PA34 A case of disseminated herpes zoster in an immunocompetent child
Authors: Jacob Mareen Ann , Kelly Susan
Published: June 2023

Herpes zoster (HZ) caused by the reactivation of varicella-zoster virus (VZV) affects mainly the adult population. The incidence is low in children (0.45 cases per 1000 individuals annually), especially in the immunocompetent. It is said to be disseminated when there are > 20 lesions outside the primary and adjacent affected dermatome. We present this case to highlight a rare complication of cutaneous dissemination in a previously healthy child with HZ, following in utero exposure to varicella at 28 weeks’ gestation. A 15-year-old boy presented with painful blisters in the T2 dermatome of 1 week’s duration, which later spread to trunk, extremities and face. This was associated with fever and neuralgia. There was no previous history of varicella and no recent contact history. He had no significant past medical history and was not on any medications. Antenatal history revealed that his mother had varicella at 28 weeks’ gestation and was treated with aciclovir. He was febrile on admission (39°C). There were coalesced vesiculopustules and crusted lesions with marked perilesional erythema in the T2 dermatome. In addition, disseminated vesicular lesions were seen on the trunk, extremities and face. Remaining systemic examination was unremarkable. C-reactive protein was elevated. Complete blood count and renal function tests were normal. Liver function tests, namely alanine transaminase and γ-­glutamyl transferase were elevated. Blood culture showed no growth. Varicella-zoster IgG was positive. Viral swab (polymerase chain reaction) from the skin lesions was positive for varicella-zoster DNA. Infectious serology for HIV, hepatitis B and hepatitis C was negative. Antinuclear antibody and antineutrophil cytoplasmic antibodies were negative. A clinical diagnosis of HZ with cutaneous dissemination was made, and he was treated with intravenous aciclovir. Intravenous antibiotics were added for suspected secondary bacterial infection. Disseminated zoster is less common in children and mainly occurs in patients with underlying immunodeficiency like HIV, immunosuppressive drug use or malignancy. In immunocompetent children, this can happen when primary infection (varicella) has occurred in utero or the first year of life due to the low response in specific varicella-zoster virus immunity. Complications like cutaneous dissemination due to viraemia are rare in healthy children, but can affect 2–10% of immunocompromised patients. It occurs 3–4 days after the onset of dermatomal lesions. It is important to look for other complications, especially in the immunocompromised, as viraemia can affect the brain, kidneys, lung and liver. Sequelae like postherpetic neuralgia is rare, but it is important to follow-up these children to look for its development.
PS02 Illicit drug use in psoriasis and psoriatic arthritis and its relationship with suicidality in a tertiary population
Authors: Lada Georgia , Chinoy Hector , Talbot Peter S , Warren Richard B , Kleyn C Elise
Published: June 2023

Limited evidence suggests an increased lifetime prevalence of illicit drug use in psoriasis. To our knowledge, there are no data for psoriatic arthritis (PsA) in this regard. Given the pronounced psychiatric morbidity in psoriasis and PsA, including evidence of increased suicidality outcomes, we aimed to investigate illicit drug use prevalence and its relationship with disease characteristics and psychopathology in psoriasis. We surveyed 216 adults attending a specialist psoriasis service, 83 of whom had comorbid PsA. Participants completed paper questionnaires about the type, amount and frequency of lifetime and current illicit drug use (including cannabis, opioids, cocaine/stimulants, hallucinogens and volatile solvents). Participants also completed validated psychometric tools; suicidality was measured with the Sheehan Suicidality Tracking Scale. The prevalence of lifetime (21.7%) and current (6.0%) illicit drug use in PsA did not differ from the respective rates in psoriasis only (27.1% and 8.3%; P > 0.1), but patients with PsA showed lower regular use rates (2.7% in PsA vs. 12.9% in psoriasis only; P = 0.03). Dermatology Life Quality Index and Psoriasis Area and Severity Index scores were numerically higher among illicit drug users than nonusers, but the differences were not statistically significant. In our sample, lifetime illicit drug use was associated with increased lifetime suicidal planning and behaviour but not suicidal ideation. The association of drug use with suicidal planning remained after adjusting for age, sex, psychiatric comorbidity and alcohol consumption scores (odds ratio 2.44, 95% confidence interval 1.04–5.76). Patients reporting current drug use were more likely to have been previously diagnosed with anxiety but were not disproportionately affected by depression and alexithymia. The prevalence of lifetime illicit drug use in our study is consistent with findings from a recent North American psoriasis cohort. Although it is not clear why regular drug use is less prevalent in patients with PsA, increased medical attention may play a role. The higher prevalence of suicidal planning/behaviours, but not ideation, among patients with psoriasis with illicit drug use is an important and concerning finding. This aligns with some previous research suggesting that illicit drug use is associated with suicidality progression toward action, possibly due to impulse-control deficits. Early detection and management of drug use may help prevent suicidal behaviours in psoriasis. Study limitations include the cross-sectional design and social desirability bias-related under-reporting. Prospective cohorts are needed to further investigate the role of illicit drug use in patients’ psychiatric morbidity and quality of life, and address its sequelae within dermatology settings.
PS05 A qualitative assessment of the impact of hidradenitis suppurativa on sexual function
Authors: Pearce Julian , Ferguson Leila , Maybury Catriona , Loibner Natalie , Lamb Ruth
Published: June 2023

Hidradenitis suppurativa (HS) is associated with significant physical and psychosocial morbidity. There are limited data in the literature on the impact of the condition on patients’ psychological, physical and emotional sexual functioning and wellbeing. A patient survey was collaboratively designed by dermatologists and a clinical psychologist to assess sexual function in HS. This was adapted from existing published scales assessing components of sexual functioning, as there is no validated tool for use in HS. Nineteen patients (10 men and nine women) with HS were surveyed. They had a mean age of 41 years and a mean Hurley stage of 2.2. Twenty-six per cent (n = 5) were current smokers. The mean body mass index of participants was 28 kg m−2. Seventy-nine per cent (n = 15) were in a current sexual relationship. Seventy-four per cent (n = 14) felt that HS affected their sexual relationships negatively and 50% (n = 8/16) documented that HS had prevented them starting a new sexual relationship. Eighty-four per cent (n = 16) reported that their HS caused them to avoid sexual intimacy. Sixty-three per cent (n = 12) suffered a degree of dyspareunia and 63% (n = 12) described that odour from HS lesions impacted negatively on sexual activity. Confidence with regard to emotional closeness with partners during sex was variable, with 31% (n = 5) reporting low confidence; 58% (n = 11) had low confidence when engaging in sexual activity. Fifty per cent (n = 9/18) felt sad when considering the impact of HS on their sexual life and 88% (n = 14/16) felt ashamed and stressed when considering being naked or intimate. Ninety-four per cent (n = 17/18) felt a degree of sexual unattractiveness due to HS, with 44% (n = 8/18) rating it as ‘extremely’ or ‘very much’. Eighty-nine per cent (n = 16/18) reported that HS had negatively impacted on the sexual quality of their lives, with 33% (n = 6) rating it as ‘extremely’ or ‘very much’. Sexual function in HS is an important, often overlooked component of quality of life. Sexual dysfunction is of particular concern in HS due to the location and nature of lesions, which are often close to or affect erogenous zones (Varney P, Guo W, Brown M et al. A systematic review and meta-analysis of sexual dysfunction in patients with hidradenitis suppurativa. Int J Dermatol 2022; 85:AB23). This study demonstrates that HS has a significant impact on patients’ psychosexual, physical and emotional sexual functioning and wellbeing. The Permission, Limited Information, Specific Suggestions, Intensive Therapy model is a useful, structured framework for clinicians to incorporate the discussion and management of sexual dysfunction into consultations, and clinicians should work with local psychological, sexual and biomedical services to address any identified morbidity.
PS12 A new meaning to ‘picking your nose’: the use of N-acetylcysteine to treat trigeminal trophic syndrome
Authors: Vaughan Emily , Abid Maaz , Nambi Rabi , Hawari Rand
Published: June 2023

Trigeminal trophic syndrome (TTS) is a rare condition in which patients induce unilateral facial ulceration by persistent physical manipulation. Peripheral or central damage to the trigeminal nerve causes anaesthesia, paraesthesia, formication or pruritus. Compulsive skin picking leads to ulceration of the ala nasi, cheek, scalp or mouth in the distribution of the trigeminal nerve. Patients with TTS are often subjected to extensive investigations and can be misdiagnosed as having a psychocutaneous disorder, such as dermatitis artefacta, skin-picking disorder or delusional parasitosis. We describe a 90-year-old woman who developed TTS following rhizotomy and radiofrequency treatment for trigeminal neuralgia. Underlying infectious, malignant and vasculitic causes for her ala nasi and cheek ulceration were ruled out through six incisional biopsies and two punch biopsies over 8 years. Previous treatment of TTS has included patient education and physical barriers (e.g. face masks and occlusive dressings). Treatment to date has been challenging, with trials of medications to address paraesthesia, including carbamazepine, gabapentin and amitriptyline. This patient re-presented to dermatology in 2022 with significantly worsened ulceration to her cheek and severe loss of nasal cartilage. In September 2022, the patient was started on N-acetylcysteine (NAC) 600 mg twice daily, and within 3 months, there was a considerable improvement. This drug is a mucolytic that has historically been used as an antidote for paracetamol overdose. It has antioxidant properties by replenishing glutathione and maintaining redox balance within cells. It also modulates neurotransmitters and can increase glutamate and alter dopamine levels. In addition, it has anti-inflammatory action by inhibiting interleukins (ILs), including IL-6 (Adil M, Amin SS. N-acetylcysteine in dermatology. Indian J Dermatol Venereol Leprol 2018; 84:652). In recent years, NAC has been reported to be successful in small case series and case reports among patients with trichotillomania, skin-picking disorders, onychotillomania, toxic epidermal necrolysis, alopecia, contact dermatitis, atopic dermatitis and wound healing (Grant JE, Chamberlain SR, Redden SA, Leppink EW. N-Acetylcysteine in the treatment of excoriation disorder. JAMA Psychiatry 2016; 73:490). It is an inexpensive drug that appears to be well tolerated and effective. To our knowledge, this is the first case report of the use of NAC in TTS. In summary, this was a case of TTS in a 90-year-old woman who successfully responded to NAC. The drug has antioxidant, anti-inflammatory and neurotransmitter modulatory effects. Reliable randomized controlled studies are needed to confirm the efficacy and optimum dose of NAC. Increased awareness of this rare syndrome and potential treatment options will ensure prompt diagnosis and prevention of permanent disfiguration.
BT01 Taking pressure off the skin cancer service: impact of primary care dermoscopy pilot, medical photographer-led clinics and non-2-week-wait skin lesion advice and guidance pathway
Authors: Darwish Iman , Sandhu Daisy , Batta Kapila , Champagne Caroline
Published: June 2023

Since the COVID-19 pandemic, we have struggled with similar pressures and capacity issues as most dermatology departments across the country. Our number of 2-week-wait (2WW) and general referrals have increased by 26%. To manage this, we have gradually introduced strategies based around a triaging system for 2WW referrals received with photographic images from the general practitioner (GP) via the National Health Service e-Referral Service (e-RS). We triage patients either to a face-to-face 2WW clinic, a spot clinic run by supervised junior members of the team or a photography/dermoscopy clinic. If we receive dermoscopic images with the GP referral, where appropriate, we can discharge or downgrade the patient to a routine clinic. Strategy 1: in September 2021, we set up a 1-year primary care 2WW dermoscopy pilot. Dermatoscopes were delivered to interested GP practices (appropriate technical training was provided), and the GPs attended skin lesion teaching sessions every 2 months. Thirteen per cent of all our 2WW referrals came through this dedicated pilot 2WW e-RS pathway. We discharged or downgraded 26% of those that were referred with both macroscopic and dermoscopic images. All GP practices (not just the pilot practices) in our region now have dermatoscopes. Strategy 2: in July 2022, we introduced secondary care photography/dermoscopy clinics run by both dermatology nurses and medical photographers using the Pathpoint/eDERMA platform. We triage patients from 2WW e-RS referrals with macroscopic images suggestive of benign lesions to these clinics. We can discharge or downgrade directly from the platform, which immediately sends patients’ information about their diagnosis and management plan via text message. Around 15% of 2WW referrals are booked to eDERMA clinics and around 60% are discharged. Strategy 3: in October 2022, we developed a non-2WW advice and guidance (A&G) e-RS skin lesion pathway for lesions of diagnostic uncertainty and basal cell carcinomas. Dermatoscopic images are not an essential requirement as this is not a 2WW pathway. Referrals are triaged within 72 h, providing rapid advice to GPs. Initial data show that since introducing this service, 2WW referral numbers decreased by 32%. Of the A&G referrals, 28% were discharged with advice and 17% were upgraded to 2WW. Within 3 months of starting this pathway, our department’s 2WW and Faster Diagnostic Standard 28-day cancer targets were no longer breaching. The combination of GP-based photography and dermoscopy, careful triage to a 2WW photography clinic in secondary care and a non-2WW lesion A&G pathway has significantly improved our 2WW service.
BT11 Bringing clinical photography closer to home: reporting on a prototype Community and Locality Imaging Centre model
Authors: Yu Jacqueline , Chin Gillian X M , Bryden Alyson , Coon Andrew , Muthiah Shareen , Morton Colin , Fleming Colin
Published: June 2023

Teledermatology services are widely used and operate using different models. We work with a long-established teledermatology service across a mixed rural and urban population, where primary care attaches images of variable quality to secondary care referrals. We have previously reported that introduction of a high-quality image to select patients in this system can improve diagnostic accuracy. We now report on the establishment of a prototype Community and Locality Imaging Centre (CLIC) designed to capture high-quality photographs, including standardized macro, localizing and dermoscopy views to reduce travel for selected patients. We assessed the potential impact of this model over a 2-week period in one locality of our catchment area in spring 2022 through data review. In total, 203 referrals were screened by a single consultant over the 2 weeks of interest: 122 (60.1%) lesions and 81 (39.9%) rashes. Of all lesions referred, 51 (41.8%) were vetted to CLIC for the capture of additional, higher-quality images. Eighty-six per cent of patients referred to the CLIC attended their appointment. Of those who attended, 70% attended within 1–2 weeks, and just over 91% of patients attended within 4 weeks. Ninety-five per cent of patients who attended lived within a 10-mile radius. Of those who attended the CLIC, 36% were returned to primary care with advice or reassurance and did not require face-to-face appointments. The remaining patients were booked for appointments, with some given advice on treatment that could be initiated immediately while awaiting appointment. Our existing system allowed 29% of patients to be managed remotely. The introduction of a prototype CLIC permitted an extra 8% of referrals to be managed without attending dermatology, bringing this to a total of 37%. The prototype CLIC combined with the primary care image-capture teledermatology model allowed more patients to be managed remotely, and also permitted patients to bypass initial consultation and be appointed directly to services such as surgery, phototherapy and patch testing. The 91% attendance rate for the CLIC within 4 weeks suggests that patients found the model accessible. Meanwhile, shorter travel distances could potentially reduce overall patient carbon emission. The CLIC model can benefit patients who return to primary care, as they only need to attend for clinical photography instead of waiting for an in-person appointment. The introduction of a CLIC on an already efficient teledermatology model will enhance the patient journey and support efficient decision-making. The CLIC model is being developed through the use of a mobile app by trained nurses, with the intention to produce standardized, high-quality data suitable for real-world AI use.
BT14 Diamonds in the rough: patient-captured images can be used to triage out benign lesions
Authors: Muna Abdul Gafoor Shafiah , Adityani Btari , Nelson Toby
Published: June 2023

Dermatology is struggling with 2-week-wait (2WW) cancer referrals, resulting in a lack of capacity to review other dermatoses. National data indicate that only 6% of the 500 000 referrals are confirmed skin malignancies (www.england.nhs.uk/wp-content/uploads/2022/04/B0829-suspected-skin-cancer-two-week-wait-pathway-optimisation-guidance.pdf), and our local data suggest that 40% of referrals are, in fact, benign, with 24% being seborrhoeic keratoses. Could there be a way to triage these lesions safely? Novel consumer-level smartphone attachments could be the way forward. Patient-led teledermatology has proven to be a convenient, environmentally friendly way of assessing cutaneous lesions. Dermoscopic modalities such as the Molescape™ and Dyplens™ show promise in facilitating the triage of skin lesions, but have we really established the efficacy of these devices first-hand with our local patient cohorts? Studies suggest that the resolution and clarity of these images are comparable to clinical dermatoscopes. To challenge this theory, we obtained patient-led dermoscopic images of lesions that were referred under the 2WW pathway. We then allocated a blinded dermatology consultant to analyse these images (n = 50) for diagnoses and proposed management plan, based on the patient-captured image and brief history. We compared the proposed diagnoses with histological and clinical outcomes for those 50 patients. We found an accuracy of 78% vs. in-person assessment, but, most importantly, all benign lesions, including seborrhoeic keratoses, were excluded safely. All malignancies were triaged as suspicious with the use of these simple devices, with basal cell carcinomas (n = 3) being diagnosed with 100% accuracy. Could these smartphone attachments be the answer to improved national triaging pathways? We may have found a solution. However, will this affect patient expectation, experience and satisfaction? Surprisingly, our local survey revealed that 80% of our 2WW patients would prefer these devices as opposed to attending primary care or photograph clinics. We appreciate that patient-led dermoscopy may not have the accuracy needed to diagnose complex cutaneous lesions, and these will always warrant prompt clinical review. However, these pioneering devices may be the solution to filtering out simple benign lesions, preventing unnecessary hospital footfall and reducing carbon footprint. In keeping with the contemporaneous goals set by the National Health Service COVID-19 recovery plan, these innovative devices should be considered as part of our existing triage pathways, to help optimize skin cancer triage and treatment and to better patient care.
BT21 Usability evaluation and reporting for mobile health apps targeting patients with skin diseases: a systematic review
Authors: Kounidas Georgios , Cleer Iona , Harriss Elinor , Harrison Rachel , Matin Rubeta
Published: June 2023

Usability is an important method for evaluating emerging technologies, including mobile health apps, from a user perspective. However, many apps have been made available to the public with insufficient effort devoted to their design, development and evaluation. We conducted a systematic review to assess usability evaluation and reporting for mobile health apps targeting patients with skin diseases. The primary outcome was to assess the usability of patient/public-facing skin disease-specific smartphone apps. The secondary outcome was to assess the usability testing methods employed. The protocol was registered with PROSPERO (CRD42022347184). A search strategy combined terms for usability evaluation, user experience, skin disease and mobile health apps (search date 2012–27 May 2022). Six databases (Embase, MEDLINE, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews and Scopus) were searched providing 15 234 results. Nine studies were eligible for inclusion in the final analysis. A narrative synthesis of usability evaluation methods used was reported. All studies included an equal uptake between men and women. Two studies of interest included sun protection (n = 3) and skin cancer (n = 3), and one study identified cutaneous leishmaniasis, spina bifida, chronic pruritus, acne, psoriasis, rosacea laser treatments, actinic damage, monitoring benign moles, alopecia and inflammatory rash. All studies assessed app usability and/or feasibility, with eight of nine studies concluding that their app was useful and easy to use. Most studies were qualitative, employing usability questionnaires or semi-structured interviews. Common emerging themes included easy to use/easy to navigate, easy to understand, security/privacy, method of self-monitoring, data sharing with a healthcare provider, customizability, costs and ability to track progress. The most common modules of the apps included taking/storing skin photographs, reminders to monitor skin, education modules and e-diaries/rating of symptoms. Usability encompassed various concepts, including feasibility, usefulness and satisfaction. In conclusion, smartphone apps used in the context of health-related skin disorders have a high degree of usability and are being developed across a wide variety of disease processes and indications. The paucity of reported literature compared with the current explosion of app development and deployment highlights the importance of careful user-centred design and rigorous evaluation of these tools before they are released for widespread uptake. Future studies should aim to evaluate all usability factors rather than focusing on single components of usability as this would optimize greater long-term uptake of these apps.
BT22 The concordance between dermatology doctors in their approach to teledermatology referrals
Authors: Almasi-Nasrabadi Mina , English John , Ayyalaraju Radha S
Published: June 2023

Telemedicine is an innovative, rapidly evolving method of care delivery in the National Health Service. The main long-term benefit of teledermatology triage is to ensure that patients receive timely care in the most appropriate setting, and to increase capacity in secondary care for patients who need face-to-face referrals. However, the diagnosis made and the advice given may vary depending on the experience and knowledge of the person triaging. The aim of this study was to evaluate how the interpretation of the information/images by different clinicians can affect the outcome of a teledermatology referral. The data collected in this project are expected to provide knowledge about the concordance between dermatology doctors in their approach to teledermatology referrals and to evaluate the impact on quality of care. The teledermatology service referrals to our dermatology department are made through the national electronic Referral Service, with the option to attach images or to refer patients to an image-taking clinic based at the hospital. Dermatology consultants will then review referrals virtually, relaying advice back to the referrer. We provided a mixture of 10 teledermatology referrals who had attended the image-taking clinic to dermatology consultants and dermatology trainees. The dermatology doctors were asked to complete an outcome template for each referral based on the information/images provided. The study was completed by nine consultants and four trainees. Only three consultants (33%) and no trainees had previous experience of the teledermatology service. The respondents evaluated the clinical information provided in the referrals as good (41%), satisfactory (47%) and poor (12%). The clinicians evaluated the quality of images taken following the referral as good (68%), satisfactory (28%) and poor (4%). Overall, 90% of the consultants and 72% of the trainees agreed with the final diagnosis/outcome of the teledermatology referral. The benign skin lesions had the least consistency between the clinicians in terms of the diagnosis and type of the follow-up arranged. The follow-ups arranged after a referral included routine referral to clinic (consultants 30%, trainees 32%), urgent referral to clinic (consultants 25%, trainees 40%), referral to clinic if not improved (consultants 21%, trainees 17%) and discharge (consultants 23%, trainees 10%). In conclusion, there was satisfactory concordance between clinicians in responding to the majority of the teledermatology referrals. Trainees have shown to agree with the final diagnosis in the majority of cases; however, they still need more training in this area, particularly on how to gain confidence in arranging an appropriate follow-up plan after the advice given.
BT25 A survey of users of a regional dermatology advice and guidance service
Authors: Campbell Fiona , Thomson Kathryn , Love Caroline
Published: June 2023

Electronic advice and guidance (A&G) was implemented in our trust in April 2016. Referrals to this service steadily increased with weekly requests up to 313 (average 261) in 2022. We noticed that, increasingly, requests were being sent from allied health professionals or junior medical staff often for quite rudimentary dermatology. A survey was constructed to understand who is using our service, their level of dermatology training, whether there is discussion prior to sending A&G and to examine user satisfaction. A survey link comprising 16 questions was attached to A&G replies within a 12-week period from October 2022. In total, 144 responses were received. Most responders were regular users of the service, with 20% sending over six requests a month. Of those responding, 94 were fully trained general practitioners (GPs), with the others a mix of junior doctors, nurses and allied health professionals. Only 27.8% of referrers had discussed the case within primary care prior to sending the request; this included one-third of non-GPs. Levels of formal dermatology training among requestors are low, with 10.4% stating they have no formal dermatology training and 35.4% having training only within primary care. Eighty-five per cent stated they would like more dermatology training. Our department has developed online management guidelines for use in primary care. While 75.7% of those responding were aware of these guidelines, only 30.3% looked at these prior to sending the A&G request. Most requesters found the A&G process very easy, and 99.3% felt they received a satisfactory A&G response. Only 28.4% of requests were converted to a referral. Additional comments from the responders were universally positive with the service repeatedly described as ‘excellent’. We have created an easy-to-use, valued and quick service, but this creates extra work within secondary care if cases are not discussed locally before requesting specialist input. Many may not have been referred to secondary care prior to electronic A&G being established. We will discuss the issues this presents and ways we can address this to ensure we are providing the optimal A&G service for those who really need it.
The organization of R&D work and knowledge search in intrafirm networks
Authors: Gomez-Solorzano Manuel , Soda Giuseppe , Furlotti Marco
Published: June 2023

This study investigates the effects of the organization of industrial Research & Development on industrial researchers’ knowledge acquisition behavior. Specifically, we test a model about how the fit of individuals with their research tasks affects whether industrial researchers acquire knowledge from outside their assigned projects. Empirical analyses from the R&D laboratory of a global pharmaceutical company show that person-task-fit has a non-linear effect on the knowledge content exchanged through interpersonal interactions. Implications for the management and organization of R&D activities are discussed.
Counterclaims in Investment Arbitration: Towards an Integrated Approach
Authors: Brenninkmeijer Mees , Gélinas Fabien
Published: June 2023

It is widely accepted that counterclaims may not be used as a means to exceed the limits of a tribunal’s jurisdiction, while they must at the same time be closely connected to the other party’s claim. However, in the particular context of investment arbitration, these two propositions create a tension that has led to a problematic and unfair construction of the investor-State dispute settlement mechanism. This article explores the foundations for a better, more integrated approach. It argues that jurisdiction over counterclaims should be seen as incidental to the one already established over the original claim, allowing tribunals to hear a wider range of counterclaims. This is inherent to the exercise of a tribunal’s adjudicative function, and rests on a foundation not only of implied consent, but also on one of principle. The approach presented here has the potential to protect counterclaims as a matter of procedural fairness and to address some of the reasons for the backlash against international investment arbitration law.
Human Rights Violations, Moral Emotions, and Moral Disengagement: How States use Moral Disengagement to Justify their Human Rights Abuses
Authors: Luongo Ben
Published: June 2023

States often use strategic messaging in order to defend their human rights violations. Such messaging often relies on promoting exclusionary ideologies or referencing national security doctrines in order to justify a breach of human rights. Less understood, however, are the specific mechanisms that makes such justifications so effective, especially when they aim to excuse unthinkable human rights atrocities. This is important to understand in order to prevent states from relying on these strategies and to hold them accountable when they violate human rights. To address this, the article demonstrates the role that emotion plays in the politics of human rights. Specifically, the article argues that states employ emotionally manipulative/deceptive strategies in attempts to either defend or obscure their human rights abuses. It builds on recent research in both the political and psychological sciences that evidence the role that emotion plays in issues of morality, rights, and justice. Research in this area refers to ‘moral emotions’ which are implicated in informing and communicating moral judgements, as well as motivating moral behaviour. This article argues that states effectively work to manipulate, or ‘disengage’, those emotional processes involved in moral judgements in attempts to reconstrue their human rights abuses as morally acceptable. In doing so, it advances our understanding as to how human rights violations persist, while also contributing to the literature on human rights theory and the role that emotion plays in the politics of human rights.
Endometriosis of the Appendix: When Appendicitis Is Less Than Straightforward
Authors: Hale Justin , Scott Benjamin , Suydam Camille , Brockmeyer Joel
Published: June 2023

We present a case report of a 49-year-old female with a history of ulcerative colitis who originally presented to the general surgery clinic after an incidental finding on computed tomography was concerning for a dilated, fluid-filled appendix. She ultimately underwent a laparoscopic appendectomy. The pathology returned consistent with early acute appendicitis, with endometrial tissue along the outer wall of the appendix. We then performed a literature review regarding appendiceal masses and the occurrence of endometriomas and/or endometriosis of the appendix. A PubMed search was performed using the key words of appendix and appendicitis and endometrioma. Specific articles were examined mentioning the occurrence of endometriomas of the appendix and isolated endometriosis of the appendix. Between 2% and 6% of cases of appendicitis present due to an appendiceal mass, usually an inflammatory phlegmon. A variety of other causes, including primary malignancy, secondary malignancy, and combinations of pathologies, may lead to the eventual removal of the appendix. Specifically, endometriosis of the appendix is reported in less than 1% of females on post-appendectomy pathologic analysis. Although specific symptoms may guide a provider, there are few distinguishing symptoms that would point a provider toward a different etiology, to include malignancy, for appendicitis. Further information is needed to determine when a patient has an increased risk for an underlying pathology when presenting with appendicitis. This information will help drive continued treatment and lead to improved screening for appendiceal masses.
Pulmonary oxygen toxicity in occupational diving
Authors: de Jong Feiko J M , Wingelaar Thijs T , van Hulst Rob A
Published: June 2023

One of the hazards of occupational diving is pulmonary oxygen toxicity, which can lead to reduced lung diffusion capacity and fibrosis. The current gold standard to determine the ‘safe limits’ for oxygen was developed more than 50 years ago and lacks the accuracy required for occupational specialists. These restrictions may be overcome by new diagnostic methods like exhaled breath analysis, which would allow occupational specialists to accurately monitor pulmonary health in the individual diver, and thus reduce long-term health effects of professional diving.
High-grade pleomorphic sarcoma associated with an orthopedic implant: a rare case report
Authors: Benabbouha Abdellatif , Benyass Youssef , Sallahi Hicham , Margad Omar
Published: June 2023

The use of prosthetic implants and metallic materials is widespread in modern orthopedic surgery. Generally, these materials are non-toxic and inert. Nevertheless, a few cases of malignancy associated with certain implants have been documented in the literature. It has been reported that some components of these implants have carcinogenic properties. In most cases, these tumors are high-grade sarcomas that occur in the bone or soft tissue adjacent to the implant site. Here we present the case of a 53-year-old patient who underwent intramedullary nailing of the tibia and developed a pleomorphic sarcoma at the implant site 18 years later.
Development of a single-ended magnetic alloy loaded cavity in the Japan Proton Accelerator Research Complex rapid cycling synchrotron
Authors: Yamamoto Masanobu , Nomura Masahiro , Okita Hidefumi , Shimada Taihei , Tamura Fumihiko , Hara Keigo , Hasegawa Katsushi , Ohmori Chihiro , Sugiyama Yasuyuki , Yoshii Masahito
Published: June 2023

The Japan Proton Accelerator Research Complex (J-PARC) Rapid Cycling Synchrotron (RCS) employs magnetic alloy (MA) loaded cavities. We realize multi-harmonic rf driving and beam-loading compensation owing to the broadband characteristics of the MA. The currently installed cavity is the conventional type, which is designed to be driven by tube amplifiers in a push–pull operation. The push–pull operation has some advantages, i.e., suppressing a higher harmonic distortion without the beam acceleration and shortening the cavity length. However, a disadvantage arises at the high intensity beam acceleration where the multi-harmonic rf driving causes a severe imbalance of the anode voltage swing and restricts the tube operation. Although we have achieved an acceleration for the design beam power of 1 MW, the imbalance becomes an issue in increasing the beam power further. We have developed a single-ended MA cavity to avoid such difficulty. The cavity has no tube imbalance intrinsically and it is found that the power consumption to drive the cavity can be reduced compared with the conventional one.
Experimentation in Endogenous Organizations
Authors: Gieczewski Germán , Kosterina Svetlana
Published: June 2023

We study policy experimentation in organizations with endogenous membership. An organization decides when to stop a policy experiment based on its results. As information arrives, agents update their beliefs, and enter or leave the organization based on their expected flow payoffs. Unsuccessful experiments make all agents more pessimistic, but also drive out conservative members. We identify sufficient conditions under which the latter effect dominates, leading to excessive experimentation. In fact, the organization may experiment forever in the face of mounting negative evidence. Ex post heterogeneous payoffs exacerbate the problem, as optimists can join forces with guaranteed winners. Control by shareholders who own all future payoffs, however, can have a corrective effect. Our results contrast with models of collective experimentation with fixed membership, in which under-experimentation is the typical outcome.
Late autumn warming can both delay and advance spring budburst through contrasting effects on bud dormancy depth in Fagus sylvatica L.
Authors: Garrigues Romain , Dox Inge , Flores Omar , Marchand Lorène J , Malyshev Andrey V , Beemster Gerrit , AbdElgawad Hamada , Janssens Ivan , Asard Han , Campioli Matteo
Published: June 2023

The current state of knowledge on bud dormancy is limited. However, expanding such knowledge is crucial in order to properly model forest responses and feedback to future climate. Recent studies have shown that warming can decrease chilling accumulation and increase dormancy depth, thereby inducing delayed budburst in European beech (Fagus sylvatica L). Whether fall warming can advance spring phenology is unclear. To investigate the effect of warming on endodormancy of deciduous trees, we tested the impact of mild elevated temperature (+2.5–3.5 °C; temperature, on average, kept at 10 °C) in mid and late autumn on the bud dormancy depth and spring phenology of beech. We studied saplings by inducing periods of warming in greenhouses over a 2-year period. Even though warming reduced chilling accumulation in both years, we observed that the response of dormancy depth and spring budburst were year-specific. We found that warming during endodormancy peak could decrease the bud dormancy depth and therefore advance spring budburst. This effect appears to be modulated by factors such as the date of senescence onset and forcing intensity during endodormancy. Results from this study suggest that not only chilling but also forcing controls bud development during endodormancy and that extra forcing in autumn can offset reduced chilling.
TWF1 induces autophagy and accelerates malignant phenotype in lung adenocarcinoma via inhibiting the cAMP signaling pathway
Authors: Wang Yu , Zuo Ran , Huo Gengwei , Han Zhiqiang , He Yuchao , Luo Yi , Chen Liwei , Li Guangtao , Cui Jinfang , Zhu Fuyi , Yue Ping , Yuan Dongqi , Sun Yi , Li Zhaoyue , Chen Peng , Guo Hua
Published: June 2023

Many studies have shown that the actin cytoskeleton plays an essential role in the initiation and progression of cancer. As an actin‐binding protein, Twinfilin1 (TWF1) plays an important role in regulating cytoskeleton‐related functions. However, little is known about the expression and function of TWF1 in human tumors. The present study aimed to investigate the functional roles and the underlying molecular mechanisms of TWF1 in human lung adenocarcinoma (LUAD). By using bioinformatics databases and tumor tissues, TWF1 expression was found to be higher in LUAD tissues than in adjacent tissues and poor survival was predicted in patients with LUAD. In vitro and in vivo assays indicated that downregulation of TWF1 expression suppressed LUAD cells invasion and migration. Further studies revealed that TWF1 interacted with p62 and was involved in the regulation of autophagy. The molecular mechanisms underlying TWF1 were investigated by RNA‐seq analysis and a series of functional experiments. The results showed that downregulation of TWF1 suppressed LUAD progression through the cAMP signaling pathway. Therefore, overexpression of TWF1 in LUAD promoted migration, invasion, and autophagy through the cAMP signaling pathway.
Giant cell arteritis and innovative treatments
Authors: Costanzo Giulia , Ledda Andrea Giovanni , Sambugaro Giada
Published: June 2023

Purpose of review

Giant cell arteritis (GCA) is an idiopathic and persistent condition characterized by granulomatous vasculitis of the medium and large vessels with overlapping phenotypes, including conventional cranial arteritis and extra-cranial GCA, also known as large-vessel GCA. Vascular problems linked with large vessel involvement may partly be caused by delayed diagnosis, emphasizing the necessity of early detection and the fast beginning of appropriate therapy. Glucocorticoids are the cornerstone of treatment for GCA, but using them for an extended period has numerous, often severe, side effects.

Recent findings

clinical practice and novel discoveries on the pathogenic pathways suggest that steroid-free biologic treatments may be efficient and safe for GCA patients.

since now, only Tocilizumab is approved for GCA treatment, but several drugs are currently used, and ongoing trials could give both researchers and patients novel therapeutic strategies for induction, maintenance, and prevention of relapse of GCA. The aims of this work is to synthesize evidence from current studies present in scientific literature about innovative treatment of Giant cell artheritis