Inter-rater variability in patch test readings and final interpretation using store-forward teledermatology.

BACKGROUND: Data regarding teledermatology for patch testing are limited. OBJECTIVES: Compare patch test readings and final interpretation by two in-person dermatologists (IPDs) with eight teledermatologists (TDs). METHODS: Patch tested patients had photographs taken of 70 screening series of allergens at 48 hours and second readings. Eight TDs reviewed photos and graded reactions (negative, irritant, doubtful, +, ++, +++) at 48 hours and second readings; in addition, they coded a final interpretation (allergic, indeterminant, irritant, negative) for each reaction. TDs rated overall image quality and confidence level for each patient and patch test reaction, respectively. Percentage of TD-IPD agreement based on clinical significance (success, indeterminate, and failure) was calculated. Primary outcome was agreement at the second reading. RESULTS: Data were available for 99, 101, and 66 participants at 48 hours, second reading, and final interpretation, respectively. Pooled failure (+/++/+++ vs negative) at second reading was 13.6% (range 7.9%-20.4%). Pooled failure at 48 hours and final interpretation was 5.4% (range 2.9%-6.8%) and 24.6% (range 10.2%-36.8%), respectively. Confidence in readings was statistically correlated with quality of images and disagreement. CONCLUSION: For patch testing, teledermatology has significant limitations including clinically significant pooled failure percentages of 13.6% for second readings and 24.6% for final interpretation.

What Is the Best Way for Patients to Take Photographs of Medical Images (Radiographs, CT, and MRI) Using a Smartphone?

BACKGROUND: Teleradiology has become one of the most important approaches to virtual clinical diagnosis; its importance has only grown during the coronavirus 2019 pandemic. In developing countries, asking patients to take photographs of their images using a smartphone can facilitate the process and help keep its costs down. However, the images taken by patients with smartphones often are of poor quality, and there is no regulation or standard instruction about how to use smartphones to take photographs of medical examination images effectively. These problems limit the use of smartphones in remote diagnosis and treatment. QUESTIONS/PURPOSES: To formulate a set of guidelines for the most appropriate and effective use of smartphones to capture images (radiographs, CT images, and MR images), and to determine whether these guidelines are more effectively adopted by patients of differing ages and genders. METHODS: In this prospective study, a set of step-by-step instructions was created with the goal of helping patients take better smartphone photographs of orthopaedic diagnostic images for transfer to telemedicine services. Following the advice of surgeons, experts in smartphone technology, imaging experts, and suggestions from patients, the instructions were modified based on clinical experience and finalized with the goals of simplicity, clarity, and convenience. Potentially eligible patients were older than 18 years, had no cognitive impairment, and used smart phones. Based on that, 256 participants (patients or their relatives and friends) who visited the orthopaedic department of our hospital from June to October 2020 potentially qualified for this study. A total of 11% (29) declined to participate, leaving 89% (227) for analysis here. Their mean age was 36 ± 11 years, 50% were women (113 of 227), and the patient himself/herself represented in 34% (78 of 227) of participants while relatives or friends of patients made up 66% (149 of 227) of the group. In this study, the diagnoses included spinal stenosis (47% [107 of 227]), disc herniation without spinal stenosis (31% [71 of 227]), vertebral fractures (14% [32 of 227]), and other (7% [17 of 227]). Each study participant first took photographs of their original medical images based on their own knowledge of how to use the smartphone camera function; each participant then took pictures of their original images again after receiving our instructional guidance. Three senior spine surgeons (YZ, TQL, TCM) in our hospital analyzed, in a blinded manner, the instructed and uninstructed imaging files based on image clarity (the content of the image is complete, the text information in the image is clearly visible, there is neither reflection nor shadow in the image) and image position (it is not tilted, curled, inverted, or reversed). If either of these conditions was not satisfied, the picture quality was deemed unacceptable; two of three judges' votes determined the outcome. Interobserver reliability with kappa values for the three judges were 0.89 (YZ versus TQL), 0.92 (YZ versus TCM), and 0.90 (TQL versus TCM). RESULTS: In this study, the overall proportion of smartphone medical images deemed satisfactory increased from 40% (91 of 227) for uninstructed participants to 86% (196 of 227) for instructed participants (risk ratio 2.15 [95% CI 1.82 to 2.55]; p<0.001). The proportion of acceptable-quality images in different age groups improved after instruction, except for in patients aged 51 years or older (3 of 17 uninstructed participants versus 8 of 17 instructed participants; RR 2.67 [95% CI 0.85 to 8.37]; p = 0.07). The proportion of acceptable-quality images in both genders improved after instruction, but there was no difference between the genders. CONCLUSION: We believe our guidelines for patients who wish to take smartphone photographs of their medical images will decrease image transmission cost and facilitate orthopaedic telemedicine consultations. However, it appears that patients older than 50 years are more likely to have difficulty with this approach, and if so, they may benefit from more hands-on assistance from clinic staff or younger relatives or friends. The degree to which our findings are culture-specific should be verified by other studies in other settings, but on the face of it, there is little reason to believe our findings would not generalize to a reasonable degree. Other studies in more heterogeneous populations should also evaluate factors related to levels of educational attainment and wealth differences, but in the meantime, our findings can give clinical teams an idea of which patients may need a little extra assistance. LEVEL OF EVIDENCE: Level II, therapeutic study.

Standardizing serial photography for assessing and monitoring vitiligo: A core set of international recommendations for essential clinical and technical specifications.

BACKGROUND: Clinical photography is an important component of the initial assessment and follow-up of patients with vitiligo in clinical practice and research settings. Standardization of this photographic process is essential to achieve useful, high-quality, and comparable photographs over time. OBJECTIVE: The aim is to develop an international consensus for a core set of recommendations for standardized vitiligo clinical photography. METHODS: Based an international meeting of vitiligo experts, a standard operating procedure was developed for vitiligo photography in daily practice and research settings. This protocol was subsequently reviewed by 20 vitiligo experts until agreement was reached. RESULTS: The resulting protocol includes a set of 10 and 15 photographs for clinical practice and research purposes, respectively. The photographic series are based on anatomic units included in the Vitiligo Extent Score. Furthermore, graphic representations of standardized positioning and suggestions for guidelines to standardize the process (background color, lighting, position marking, scales, materials, instruments) for both color and ultraviolet photographs are described. CONCLUSIONS: This consensus-based protocol for vitiligo photography will harmonize imaging for both clinical practice, translational research, and clinical trials. It can improve outcome assessment, foster multicenter collaboration, and promote better communication with patients regarding outcomes of treatment.

Photo-Based Range-of-Motion Measurement: Reliability and Concurrent Validity in Children With Cerebral Palsy.

PURPOSE: To investigate intrarater and interrater reliability, agreement, and concurrent validity of a smartphone photography-based application compared with a universal goniometer in children with cerebral palsy. METHODS: Range of motion of hip abduction, popliteal angle, and ankle dorsiflexion was measured with a universal goniometer and a photography-based application in children with cerebral palsy, Gross Motor Function Classification System levels I to V.A 2-way random-effects intraclass correlation coefficients and Bland-Altman plots, standard error of measurement, and smallest detectable change were used for analyses. RESULTS: The application had good to excellent reliability and concurrent validity compared with a universal goniometer, while the large measurement error of both methods suggests that changes of 10° to 23° are needed to be certain that changes over time are not results of measurement error. CONCLUSIONS: A photography-based goniometer can be a reliable and valid tool when measuring range of motion in children with cerebral palsy.

Stillbirth memento photography.

Research into stillbirth memento photography shows the practice to be welcomed by the bereaved. The visual attributes and content of stillbirth memento photographs are yet to be rigorously analysed however, representing a significant gap in current understanding. This study seeks to address this. 51 professionally produced stillbirth memento photographs have been sampled, anonymised and analysed. Using a content analysis methodology, imagery was characterised by aesthetic and semantic properties. The results were then cross-referenced against existing stillbirth scholarship, data from an interview study with people who had experienced pregnancy loss, and against image theories. The content analysis identified four distinctive image tropes in the sample: images of mother, father and baby, with the baby being held and the parents touching; macro photography of the baby; portrait photographs of babies lying alone with little or no physical trauma evident; and images of a parent, usually the mother, cradling the baby. The analysis also identified specific attributes, present across the sample, that appeared significant and distinctive of stillbirth memento photography. These were: (1) stylistic attributes, (2) acknowledgement and validation, (3) identity construction, (4) ambiguity and (5) embodiment.

Use of an alternative method to evaluate erythema severity in a clinical trial: difference in vehicle response with evaluation of baseline and postdose photographs for effect of oxymetazoline cream 1·0% for persistent erythema of rosacea in a phase IV study.

BACKGROUND: Once-daily topical oxymetazoline cream 1·0% significantly reduced persistent facial erythema of rosacea in trials requiring live, static patient assessments. OBJECTIVES: To evaluate critically the methodology of clinical trials that require live, static patient assessments by determining whether assessment of erythema is different when reference to the baseline photograph is allowed. METHODS: In two identically designed, randomized, phase III trials, adults with persistent facial erythema of rosacea applied oxymetazoline or vehicle once daily. This phase IV study evaluated standardized digital facial photographs from the phase III trials to record ≥ 1-grade Clinician Erythema Assessment (CEA) improvement at 1, 3, 6, 9 and 12 h postdose. RESULTS: Among 835 patients (oxymetazoline n = 415, vehicle n = 420), significantly greater proportions of patients treated with oxymetazoline vs. vehicle achieved ≥ 1-grade CEA improvement. For the comparison between phase IV study results and the original phase III analysis, when reference to baseline photographs was allowed while evaluating post-treatment photographs, the results for oxymetazoline were similar to results of the phase III trials (up to 85.7%), but a significantly lower proportion of vehicle recipients achieved ≥ 1-grade CEA improvement (up to 29.7% [phase 4] vs. 52.3% [phase 3]; P<0.001). In the phase IV study, up to 80·2% of patients treated with oxymetazoline achieved at least moderate erythema improvement vs. up to 22·9% of patients treated with vehicle. The association between patients' satisfaction with facial skin redness and percentage of erythema improvement was statistically significant. CONCLUSIONS: Assessment of study photographs, with comparison to baseline, confirmed significant erythema reduction with oxymetazoline on the first day of application. Compared with the phase III trial results, significantly fewer vehicle recipients attained ≥ 1-grade CEA improvement, suggesting a mitigated vehicle effect. This methodology may improve the accuracy of clinical trials evaluating erythema severity.

Wake Forest Alcohol Imagery Set: Development and Validation of a Large Standardized Alcohol Imagery Dataset.

BACKGROUND: The study of alcohol use frequency utilizes alcohol-related cue imagery. Although a number of alcohol-image databases currently exist, they have several limitations: Many are not publicly available, some use stock images or clip art rather than real photographs, several eliminate any photographs displaying brand information, and predominantly they contain relatively few images. The aim of this project was to develop a large, open-access database of alcohol-related cue images, containing photographs with and without brand information, taken in real-world environments, with images in a variety of orientations and dimensions. METHODS: The study collected 1,650 images voluntarily from the larger community, to capture photographs with a wide range of content, environments, and relation to alcohol. All images were then rated on scales of valence, arousal, and relation to alcohol by 1,008 Amazon Mechanical Turk workers, using classical emotion validation methods based on the International Affective Picture System (IAPS). Survey respondents were screened with the Alcohol Use Disorders Identification Test (AUDIT), and Cronbach's alpha scores were calculated to determine the interrater reliability of scores across the whole sample, and within low-risk, moderate-risk, and high-risk drinkers for each rating domain. Univariate ANOVAs were run to determine differences in ratings across drinking groups. RESULTS: All Cronbach's alpha scores indicated high interrater reliability within the whole sample, and across drinking severity groups. Tukey's HSD post hoc results indicated greater arousal and affect in response to image viewing in moderate- and high-risk drinkers, and higher relation-to-alcohol ratings in low-risk drinkers. All images had categorization tags assigned by members of the study team. CONCLUSIONS: The established imagery set includes 1,650 alcohol-related images, rated on scales of valence, arousal, and relation to alcohol, and categorized by type of alcohol depicted. The imagery database will be available for open-access download and use through Google Photos.

Black and white box: Take good gross pathology photographs.

Macroscopic study of surgical samples sent to the histopathology lab provides the first diagnostic approach. Obtaining quality photographs of these pieces facilitates proper case documentation for publication, sharing, teaching and research.This device has been originally designed for enucleated eyes but it could be used for a wide diversity of human or animal samples including thyroids, pituitary glands, prostates… It can be coupled to any smartphone camera.The Black and White Box is an affordable and easy option for taking gross pathology photographs of high quality. In this work we provide full instructions on how to make it.

Standardized Photographic Documentation of Hidradenitis Suppurativa/Acne Inversa.

BACKGROUND: Despite existing guidelines and methods for standardized clinical photography in dermatology and plastic surgery, human skin exhibits exquisite site-specific morphologies and functions, and each body region can exhibit an individual pathologic phenotype. The aim of this work was to develop a standardized, representative and reproducible documentation of the multilocular hidradenitis suppurativa/acne inversa (HS) lesions, a disease mostly occurring in skin folds. METHOD: Optimal body positions for medical photography of candidate areas for HS involvement were evaluated. Pictures of volunteers were taken, and indicative scientific graphics were designed. RESULTS: Due to the variability of HS lesions and the fact of their localization in skin folds, a standardized, reproducible photographic documentation of HS candidate skin areas (50 cm from the skin surface) is proposed. The photographic series includes: (1) right armpit, (2) left armpit, (3) right groin, (4) left groin, (5) genital area, (6) anal area and anal fold, (7) right buttock, (8) left buttock, (9) chest area, (10) mons pubis, (11) right submammary area (females), (12) left submammary area (females). The protocol is accompanied with indicative scientific graphics for photography-proper positioning of the relevant body parts for documentation of potentially flat skin areas. In addition, former proposals for technical standardization of photography in dermatology, regarding instrumentation, environmental lighting and background colour, have to be respected. CONCLUSION: Standardized photography of candidate skin areas for HS involvement will allow longitudinal intraindividual and interindividual evaluation of the disease course as well as prospective and retrospective comparative studies.

Validation of a digitally displayed photographic food portion-size estimation aid among women in urban and rural Malawi.

OBJECTIVE: To validate digitally displayed photographic portion-size estimation aids (PSEA) against a weighed meal record and compare findings with an atlas of printed photographic PSEA and actual prepared-food PSEA in a low-income country. DESIGN: Participants served themselves water and five prepared foods, which were weighed separately before the meal and again after the meal to measure any leftovers. Participants returned the following day and completed a meal recall. They estimated the quantities of foods consumed three times using the different PSEA in a randomized order. SETTING: Two urban and two rural communities in southern Malawi. PARTICIPANTS: Women (n 300) aged 18-45 years, equally divided by urban/rural residence and years of education (≤4 years and ≥5 years). RESULTS: Responses for digital and printed PSEA were highly correlated (>91 % agreement for all foods, Cohen's κw = 0·78-0·93). Overall, at the individual level, digital and actual-food PSEA had a similar level of agreement with the weighed meal record. At the group level, the proportion of participants who estimated within 20 % of the weighed grams of food consumed ranged by type of food from 30 to 45 % for digital PSEA and 40-56 % for actual-food PSEA. Digital PSEA consistently underestimated grams and nutrients across foods, whereas actual-food PSEA provided a mix of under- and overestimates that balanced each other to produce accurate mean energy and nutrient intake estimates. Results did not differ by urban and rural location or participant education level. CONCLUSIONS: Digital PSEA require further testing in low-income settings to improve accuracy of estimations.

Agreement study between color and IR retinal images based on retinal vasculature morphological parameters.

BACKGROUND: Color fundus photography have been extensively used to explore the link between retinal morphology changes associated with various disease i.e. Diabetic Retinopathy, Glaucoma. The development of multimodal imaging system that integrates Infrared Scanning Laser Ophthalmoscope (IR-SLO) and Optical Coherence Tomography (OCT) could help in studying these diseases at an early stage. The aim of this study was to test the agreement between the retinal vasculature parameters from the Infrared images obtained from optical coherence tomography and color fundus imaging. METHODS: The IR and Color retinal images were obtained from 16 volunteer participants and seven retinal vessel parameters, i.e. Fractal Dimension (FD), Average Angle (ABA), Total Angle Count (TAC), Tortuosity (ST), Vessel/Background ratio (VBR), Central Retinal Arteriolar Equivalent (CRAE) and Central Retinal Venular Equivalent (CRVE) were extracted from these retinal images using Retinal Image Vasculature Assessment software (RIVAS) and Integrative Vessel Analysis (IVAN). RESULTS: The Bland Altman plot was used to investigate the agreement between the two modalities. The paired sample t-test was used to assess the presence of fixed bias and the slope of Least Square Regression (LSR) line for the presence of proportional bias. The paired sample t-test showed that there was no statistically significant difference between Color and IR based on retinal vessel features (all p values > 0.05). LSR also revealed no statistically significant difference in the retinal vessel features between Color and IR. CONCLUSION: This study has revealed that there is a fair agreement between Color and IR images based on retinal vessel features. This research has shown that it is possible to use IR images of the retina to measure the retinal vasculature parameters which has the advantage of being flash-less, can be used even if there is opacity due to cataract, and can be performed along with OCT on the same device.

UV light set-ups for vitiligo photography, a comparative study on image quality and ease of use.

BACKGROUND: Ultraviolet (UV) light is an essential tool to assess the extent, spreading and staging of vitiligo. Different UV light set-ups are used for vitiligo photography, including the following: (i) hand-held Wood's lamps; (ii) soft boxes with UV lamps; (iii) UV flash attached to the camera; and (iv) high output UV flash. OBJECTIVE: Our objective was to compare UV light set-ups for vitiligo photography regarding image quality and ease of use. METHODS: Patients with vitiligo lesions with unclear borders were included. Two images were made with all four UV set-ups per patient, for a large and a small area. Image quality was scored separately by three blinded vitiligo experts on five criteria: overall quality, clearness of borders, contrast and sharpness and for larger areas the shadows. The two professional medical photographers were asked to score the ease of use for each set-up. RESULTS: A total of 88 photos were assessed from 11 patients. For larger areas, the frequency of a 'good' or 'very good' overall quality rating was 12.1% (Wood's), 6.1% (soft boxes), 15.2% (camera flash) and 78.8% (high output flash). For smaller areas, the score 'good' or 'very good' was given to 54.5%, 3%, 66.6% and 84.8% in the same order. For the shadow criteria, each set-up scored below 40% on a 'good' or 'very good' score. The high output flash was scored as most easy to use by the photographers. CONCLUSION: When comparing four different UV light set-ups for vitiligo photography, we concluded that the UV set-ups strongly influenced the quality scores of the obtained images. The high output flash scored best for both small and large areas and for ease of use. For small areas, Wood's lamp and camera flash were acceptable. All set-ups scored badly for shadows, and more research is needed to find the optimal exposure to avoid shadows.

Multicolour imaging for the detection of polypoidal choroidal vasculopathy and age-related macular degeneration.

IMPORTANCE: Multicolour is a new imaging technology and its sensitivity for detecting polypoidal choroidal vasculopathy (PCV) and age-related macular degeneration (AMD) has not been well described. BACKGROUND: To evaluate the accuracy of multicolour imaging compared to colour fundus photography (CFP) in differentiating AMD and PCV from normal eyes, and in detecting PCV. DESIGN: Prospective cohort study at a tertiary referral centre. PARTICIPANTS: Fifty consecutive patients with PCV or AMD. METHODS: Standardized multimodal imaging, including CFP, multicolour imaging, and fluorescein and indocyanine green angiography, were graded by a Central Reading Center using standardized grading protocols. MAIN OUTCOMES AND MEASURES: Sensitivity, specificity, positive and negative predictive values (PPV and NPV). RESULTS: Of 100 eyes, 44 had PCV, 33 had AMD, and 23 were normal. Multicolour imaging had higher specificity (73.9% vs 52.2%) and NPV (94% vs 85.7%) compared to CFP for detecting all types of AMD. For the detection of PCV, multicolour had higher sensitivity (86.4% vs 59.1%) and NPV (89.3% vs 74.3%). Polypoidal lesions were detected in 39 of 44 eyes (88.6%) using multicolour imaging, while the branching vascular network (BVN) was detected in 16 of 44 eyes (36.4%). Using BVN as a parameter, infrared imaging specificity and PPV for detecting PCV were 96.6% and 88.9%, respectively. CONCLUSIONS AND RELEVANCE: Multicolour imaging is superior to standard CFP in differentiating AMD and PCV from normal eyes, and in detecting features of PCV. Specific features seen on multicolour imaging can alert ophthalmologists to the likely presence of these diseases so that additional definitive investigations can be performed.

Diabetic Retinopathy Assessment Variability Among Eye Care Providers in an Urban Teleophthalmology Program.

BACKGROUND: Teleophthalmology is an evidence-based method for diabetic eye screening. It is unclear whether the type of eye care provider performing teleophthalmology interpretation produces significant variability. INTRODUCTION: We assessed grading variability between an optometrist, general ophthalmologist, and retinal specialist using images from an urban, diabetic retinopathy teleophthalmology program. METHODS: Three readers evaluated digital retinal images in 100 cases (178 eyes from 90 patients with type 2 diabetes). Fisher's exact test, percent agreement, and the observed proportion of positive (Ppos) or negative agreement (Pneg) were used to assess variability. RESULTS: Among cases deemed gradable by all three readers (n = 65), there was substantial agreement on absence of any retinopathy (88% ± 4.6%, Pneg = 0.91-0.95), presence of moderate nonproliferative or worse retinopathy (87% ± 3.9%, Ppos = 0.67-1.00), and presence of macular edema (99% ± 0.9%, Ppos = 0.67-1.00). There was limited agreement regarding presence of referable nondiabetic eye pathology (61% ± 11%, Ppos = 0.21-0.59) and early, nonroutine referral for a follow-up clinical eye exam (66% ± 8.1%, Ppos = 0.19-0.54). Among all cases (n = 100), there was acceptable agreement regarding which had gradable images (77% ± 5.0%, Ppos = 0.50-0.90). DISCUSSION: Inclusion of multiple types of eye care providers as teleophthalmology readers is unlikely to produce significant variability in the assessment of diabetic retinopathy among high-quality images. Greater variability was found regarding image gradability, nondiabetic eye pathology, and recommended clinical referral times. CONCLUSIONS: Our results suggest that more extensive training and uniform referral standards are needed to improve consensus on image gradability, referable nondiabetic eye pathology, and recommended clinical referral times.