bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract
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

Abstract
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

Abstract
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, &lt; 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

Abstract
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

Abstract
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

Abstract
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

Abstract

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

Abstract
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

Abstract
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

Abstract
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.