bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract:
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.