Efficient triaging of advice and guidance referrals using teledermatology via the UK National Health Service e-Referral service platform: reporting positive outcomes from the COVID era.

BACKGROUND: Substantial increases in the implementation and use of dermatology advice and guidance (A&G) services has been a legacy of the COVID pandemic. OBJECTIVES: To evaluate the impact that a 45-month period of A&G use had on the health service outcomes in a university teaching hospital dermatology department. METHODS: A&G data for June in 2019, 2020, 2021 and 2022 were retrospectively analysed. Areas analysed included: total number of A&G requests; number of requests converted to referrals; percentage of discharges at first attendance; and referral-to-treatment (RTT) performance (defined as percentage of referrals seen by 18 weeks). RESULTS: A&G requests increased over the study period, from 45 requests in June 2019 to 1384 in June 2021. Increased request numbers were because of the COVID-19 pandemic, and then a subsequent change to the referral pathway. In January 2021, A&G became the obligatory referral route for all routine referrals to our department. The percentage of A&G requests converted to referral were 22.4%, 46.4%, 43.4% and 52.2% in June 2019, 2020, 2021 and 2022, respectively. Between 2019 and 2022 our discharges at first attendance decreased from 36.7% to 29.0%. RTT performance remained consistently above the national average; local RTT performances were 95.2% (2543/2671), 59.8% (782/1308), 90.1% (1697/1884) and 87.9% (1660/1888), in June 2019, 2020, 2021 and 2022, respectively, which compared favourably against RTT figures for England (90.2%, 56.5%, 78.2% and 65.1%). CONCLUSIONS: We highlight to other NHS dermatology departments the positive impact A&G triaging can have on outcomes, as observed for our service, reducing our discharges at first attendance and maintaining an RTT performance above the national average.

Addressing Social Determinants of Health to Reduce Disparities Among Individuals with Cancer: Insights for Rehabilitation Professionals.

PURPOSE OF REVIEW: This report aims to provide a framework for cancer rehabilitation professionals to assess social determinants of health in individuals with cancer and discuss strategies that can be implemented in practice to overcome barriers to care. RECENT FINDINGS: There has been an increased focus in improving patient conditions that can affect access to cancer rehabilitation. Along with government and world health organization initiatives, healthcare professionals and institutions continue to work towards decreasing disparities. Several disparities exist in healthcare and education access and quality, patients' social and community context, neighborhood and built environments, and economic stability. The authors emphasized the challenges that patients who require cancer rehabilitation face that healthcare providers, institutions, and governments can mitigate with outlined strategies. Education and collaboration are essential to make true progress in decreasing disparities in the populations most in need.

Chat GPT vs Clinician: challenging the diagnostic capabilities of A.I. in dermatology.

BACKGROUND: Chat Generative Pre-trained Transformer (Chat GPT) is an online language-based platform, designed to answer questions in a human-like way, using deep learning technology. OBJECTIVE: To examine the diagnostic capabilities of Chat GPT using real world, anonymised, medical dermatology cases. METHODS: Clinical information from 90 consecutive patients referred to a single dermatology emergency clinic between June to December 2022 were examined. Thirty-six patients were included. Anonymised clinical information was transcribed and input into Chat GPT 4.0 followed by the question "what is the most likely diagnosis?". The suggested diagnosis made by Chat GPT was then compared to the diagnosis made in dermatology. RESULTS: After inputting a clinical history and examination by a dermatologist, Chat GPT made a correct primary diagnosis 56% of the time (20/36). Using the clinical history and cutaneous signs from non-specialists, it was able to make a correct diagnosis 38% of the time (14/36). This was similar to the diagnostic rate of non-specialists 36% (13/36), although much lower than dermatologists (83%, 30/36). There was no differential offered by referring sources 27% of the time (10/36), unlike chat GPT which provided a differential diagnosis 100% of the time. Qualitative analysis showed Chat GPT offered responses with caution, often justifying reasoning. CONCLUSION: This study illustrates that whilst Chat GPT has a diagnostic capability, in its current form it does not significantly improve diagnostic yield in primary or secondary care.

Cutaneous sarcoma: a review and practical approach to management.

Sarcomas arising in the skin are rare but potentially fatal. These tumours originate from mesenchymal cells and can be divided between those that arise in soft tissue and those arising from bone. General guidelines exist for the management of soft-tissue sarcomas; however, there are no specific guidelines for cutaneous sarcomas. Current literature was reviewed for management of seven cutaneous sarcomas including atypical fibroxanthoma, pleomorphic dermal sarcoma, dermal and subcutaneous leiomyosarcoma, dermatofibroma sarcoma protuberans, Kaposi sarcoma, cutaneous angiosarcoma and malignant peripheral nerve sheath tumour. All suspected sarcomas should be discussed in a sarcoma multidisciplinary team meeting. This article is not a clinical guideline but should serve as a practical summary of how these tumours present, how they are recognized histologically, and how best to manage and follow-up patients. The aim is to support clinicians and facilitate the best and most evidence-based standard of care available.

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study.

CONTEXT: Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention. METHODS: In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2). RESULTS: Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order). CONCLUSION: Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

Effects of joint loading on the development of capital femoral epiphysis morphology.

INTRODUCTION: The deleterious influence of increased mechanical forces on capital femoral epiphysis development is well established; however, the growth of the physis in the absence of such forces remains unclear. The hips of non-ambulatory cerebral palsy (CP) patients provide a weight-restricted (partial weightbearing) model which can elucidate the influence of decreased mechanical forces on the development of physis morphology, including features related to development of slipped capital femoral epiphysis (SCFE). Here we used 3D image analysis to compare the physis morphology of children with non-ambulatory CP, as a model for abnormal hip loading, with age-matched native hips. MATERIALS AND METHODS: CT images of 98 non-ambulatory CP hips (8-15 years) and 80 age-matched native control hips were used to measure height, width, and length of the tubercle, depth, width, and length of the metaphyseal fossa, and cupping height across different epiphyseal regions. The impact of age on morphology was assessed using Pearson correlations. Mixed linear model was used to compare the quantified morphological features between partial weightbearing hips and full weightbearing controls. RESULTS: In partial weightbearing hips, tubercle height and length along with fossa depth and length significantly decreased with age, while peripheral cupping height increased with age (r > 0.2, P < 0.04). Compared to normally loaded (full weightbearing) hips and across all age groups, partially weightbearing hips' epiphyseal tubercle height and length were smaller (P < .05), metaphyseal fossa depth was larger (P < .01), and posterior, inferior, and anterior peripheral cupping heights were smaller (P < .01). CONCLUSIONS: Smaller epiphyseal tubercle and peripheral cupping with greater metaphyseal fossa size in partial weightbearing hips suggests that the growing capital femoral epiphysis requires mechanical stimulus to adequately develop epiphyseal stabilizers. Deposit low prevalence and relevance of SCFE in CP, these findings highlight both the role of normal joint loading in proper physis development and how chronic abnormal loading may contribute to various pathomorphological changes of the proximal femur (i.e., capital femoral epiphysis).

A Brief Review of Inpatient Palliative Rehabilitation.

Cancer patients face many challenges that can have a significant impact on their quality of life (QOL). When patients experience multiple functional impairments due to disease or treatment, their QOL and the efficient use of healthcare resources can be compromised. This is particularly true for patients who are nearing the end of their lives, as the physical and emotional burden of cancer can have a profound effect on both the individual and their caregivers. One approach to improving QOL in these patients is through palliative rehabilitation. Despite being an underutilized and understudied resource, palliative rehabilitation has shown promise in helping patients with advanced cancer retain their dignity and sense of control. By maximizing functional independence and reducing symptom burdens, palliative rehabilitation can provide a vital source of support for patients and their caregivers during this challenging time. Inpatient rehabilitation is one way that palliative rehabilitation can be applied in a healthcare setting. While further research is needed to fully understand the benefits of this approach, it is clear that palliative rehabilitation has the potential to play a key role in helping patients and their caregivers navigate the challenges of cancer treatment and end-of-life care. This approach is specific to the USA context but can be applied in other settings where cancer patients require such care.

Clinical Implications of Hematologic and Hemostatic Abnormalities in Children With COVID-19.

Leukopenia, thrombocytopenia, elevated D-dimer, and prolonged prothrombin time are considered poor prognostic factors in adults with acute Coronavirus Disease 2019. The prognostic significance of these abnormalities among pediatric patients remains underreported in the literature. This retrospective cohort study evaluates the prognostic implications of hematologic and hemostatic derangements in patients younger than 22-years-of-age who were admitted to a tertiary-care referral institution for management of acute Coronavirus Disease 2019 infection. Leukopenia and thrombocytopenia were identified as independent prognostic factors of disease severity. Although the majority of children, with available results, had elevated D-dimer or prolonged prothrombin time upon initial presentation, these markers were not found to be associated with the development of severe clinical complications.

A qualitative assessment of patient satisfaction with remote dermatology consultations utilized during the UK's first wave of the COVID-19 pandemic in a single secondary care dermatology department.

During the first wave of the SARS-CoV-2 coronavirus (COVID-19) pandemic, many dermatology departments in the UK delivered remote consultations in order to minimize viral transmission. To assess patient perception of remote consultations delivered in a single dermatology department during this time, we retrospectively contacted patients via an electronic questionnaire and the responses are summarized. We anticipate that increased use of remote consultations will be a legacy of the pandemic, although healthcare professionals will have a responsibility for ensuring appropriate patient suitability.

A suspicious skin nodule with dilated chest veins: the importance of a full skin examination.

This letter outlines the case of a new-onset skin nodule, which led to the diagnosis of both a primary bronchial carcinoma and a cutaneous metastatic squamous cell carcinoma deposit. This case highlights the importance of a full skin examination to pick up important clinical signs as, although these can be subtle, they can have a significant effect on further management.

Evaluation of a serum-based antigen test for tuberculosis in HIV-exposed infants: a diagnostic accuracy study.

BACKGROUND: Non-sputum methods are urgently needed to improve tuberculosis diagnosis and treatment monitoring in children. This study evaluated the ability of a serum assay quantifying a species-specific peptide of the Mycobacterium tuberculosis CFP-10 virulence factor via nanotechnology and matrix-assisted laser desorption ionization time-of-flight mass spectrometry to diagnose tuberculosis in HIV-infected and HIV-uninfected infants. METHODS: Serum CFP-10 peptide signal was blinded evaluated in cryopreserved sera of 519 BCG-immunized, HIV-exposed infants (284 HIV-infected, 235 HIV-uninfected) from a multi-center randomized placebo-controlled isoniazid prophylaxis trial conducted in southern Africa between 2004 and 2008, who were followed up to 192 weeks for Mtb infection and TB. Children were classified as confirmed, unconfirmed, or unlikely tuberculosis cases using 2015 NIH diagnostic criteria for pediatric TB. RESULTS: In HIV-infected infants, CFP-10 signal had 100% sensitivity for confirmed TB (5/5, 95% CI, 47.8-100) and 83.7% sensitivity for unconfirmed TB (36/43, 95% CI 69.3-93.2), with 93.1% specificity (203/218, 95% CI 88.9-96.1). In HIV-uninfected infants, CFP-10 signal detected the single confirmed TB case and 75.0% of unconfirmed TB cases (15/20; 95% CI 50.9-91.3), with 96.2% specificity (177/184, 95% CI, 92.3-98.5). Serum CFP-10 achieved 77% diagnostic sensitivity for confirmed and unconfirmed TB (13/17, 95% CI, 50-93%) at ≤ 24 weeks pre-diagnosis, and both CFP-10-positivity and concentration declined following anti-TB therapy initiation. CONCLUSIONS: Serum CFP-10 signal exhibited high diagnostic sensitivity and specificity for tuberculosis in HIV-infected and HIV-uninfected infants and potential utility for early TB detection and monitoring of anti-TB treatment responses.

Indirect interactions among co-infecting parasites and a microbial mutualist impact disease progression.

Interactions among parasites and other microbes within hosts can impact disease progression, yet study of such interactions has been mostly limited to pairwise combinations of microbes. Given the diversity of microbes within hosts, indirect interactions among more than two microbial species may also impact disease. To test this hypothesis, we performed inoculation experiments that investigated interactions among two fungal parasites, Rhizoctonia solani and Colletotrichum cereale, and a systemic fungal endophyte, Epichloë coenophiala, within the grass, tall fescue (Lolium arundinaceum). Both direct and indirect interactions impacted disease progression. While the endophyte did not directly influence R. solani disease progression or C. cereale symptom development, the endophyte modified the interaction between the two parasites. The magnitude of the facilitative effect of C. cereale on the growth of R. solani tended to be greater when the endophyte was present. Moreover, this interaction modification strongly affected leaf mortality. For plants lacking the endophyte, parasite co-inoculation did not increase leaf mortality compared to single-parasite inoculations. By contrast, for endophyte-infected plants, parasite co-inoculation increased leaf mortality compared to inoculation with R. solani or C. cereale alone by 1.9 or 4.9 times, respectively. Together, these results show that disease progression can be strongly impacted by indirect interactions among microbial symbionts.

Parasites, niche modification and the host microbiome: A field survey of multiple parasites.

Parasites can affect and be affected by the host's microbiome, with consequences for host susceptibility, parasite transmission, and host and parasite fitness. Yet, two aspects of the relationship between parasite infection and host microbiota remain little understood: the nature of the relationship under field conditions, and how the relationship varies among parasites. To overcome these limitations, we performed a field survey of the within-leaf fungal community in a tall fescue population. We investigated how diversity and composition of the fungal microbiome associate with natural infection by fungal parasites with different feeding strategies. A parasite's feeding strategy affects both parasite requirements of the host environment and parasite impacts on the host environment. We hypothesized that parasites that more strongly modify niches available within a host will be associated with greater changes in microbiome diversity and composition. Parasites with a feeding strategy that creates necrotic tissue to extract resources (necrotrophs) may not only have different niche requirements, but also act as particularly strong niche modifiers. Barcoded amplicon sequencing of the fungal ITS region revealed that leaf segments symptomatic of necrotrophs had lower fungal diversity and distinct composition compared to segments that were asymptomatic or symptomatic of other parasites. There were no clear differences in fungal diversity or composition between leaf segments that were asymptomatic and segments symptomatic of other parasite feeding strategies. Our results motivate future experimental work to test how the relationship between the microbiome and parasite infection is impacted by parasite feeding strategy and highlight the potential importance of parasite traits.

Responsive self-assembly of tectoRNAs with loop-receptor interactions from the tetrahydrofolate (THF) riboswitch.

Naturally occurring RNAs are known to exhibit a high degree of modularity, whereby specific structural modules (or motifs) can be mixed and matched to create new molecular architectures. The modular nature of RNA also affords researchers the ability to characterize individual structural elements in controlled synthetic contexts in order to gain new and critical insights into their particular structural features and overall performance. Here, we characterized the binding affinity of a unique loop-receptor interaction found in the tetrahydrofolate (THF) riboswitch using rationally designed self-assembling tectoRNAs. Our work suggests that the THF loop-receptor interaction has been fine-tuned for its particular role as a riboswitch component. We also demonstrate that the thermodynamic stability of this interaction can be modulated by the presence of folinic acid, which induces a local structural change at the level of the loop-receptor. This corroborates the existence of a THF binding site within this tertiary module and paves the way for its potential use as a THF responsive module for RNA nanotechnology and synthetic biology.

Eutrophication, biodiversity loss, and species invasions modify the relationship between host and parasite richness during host community assembly.

Host and parasite richness are generally positively correlated, but the stability of this relationship in response to global change remains poorly understood. Rapidly changing biotic and abiotic conditions can alter host community assembly, which in turn, can alter parasite transmission. Consequently, if the relationship between host and parasite richness is sensitive to parasite transmission, then changes in host composition under various global change scenarios could strengthen or weaken the relationship between host and parasite richness. To test the hypothesis that host community assembly can alter the relationship between host and parasite richness in response to global change, we experimentally crossed host diversity (biodiversity loss) and resource supply to hosts (eutrophication), then allowed communities to assemble. As previously shown, initial host diversity and resource supply determined the trajectory of host community assembly, altering post-assembly host species richness, richness-independent host phylogenetic diversity, and colonization by exotic host species. Overall, host richness predicted parasite richness, and as predicted, this effect was moderated by exotic abundance-communities dominated by exotic species exhibited a stronger positive relationship between post-assembly host and parasite richness. Ultimately, these results suggest that, by modulating parasite transmission, community assembly can modify the relationship between host and parasite richness. These results thus provide a novel mechanism to explain how global environmental change can generate contingencies in a fundamental ecological relationship-the positive relationship between host and parasite richness.

Herbivores and nutrients control grassland plant diversity via light limitation.

Human alterations to nutrient cycles and herbivore communities are affecting global biodiversity dramatically. Ecological theory predicts these changes should be strongly counteractive: nutrient addition drives plant species loss through intensified competition for light, whereas herbivores prevent competitive exclusion by increasing ground-level light, particularly in productive systems. Here we use experimental data spanning a globally relevant range of conditions to test the hypothesis that herbaceous plant species losses caused by eutrophication may be offset by increased light availability due to herbivory. This experiment, replicated in 40 grasslands on 6 continents, demonstrates that nutrients and herbivores can serve as counteracting forces to control local plant diversity through light limitation, independent of site productivity, soil nitrogen, herbivore type and climate. Nutrient addition consistently reduced local diversity through light limitation, and herbivory rescued diversity at sites where it alleviated light limitation. Thus, species loss from anthropogenic eutrophication can be ameliorated in grasslands where herbivory increases ground-level light.

Viral hepatitis B and C in HIV-exposed South African infants.

BACKGROUND: Whilst much attention is given to eliminating HIV mother-to-child transmission (MTCT), little has been done to ensure the same for hepatitis B virus (HBV) transmission. The introduction of HBV immunization at six weeks of age has reduced HBV horizontal transmission in South Africa. However, in order to eliminate HBV MTCT, further interventions are needed. The risk of hepatitis C virus (HCV) MTCT in HIV-infected (HIV+) African women is not yet well described. This study aimed to determine the rate of HBV and HCV vertical transmission in HIV-exposed infants in South Africa. METHODS: Serum samples from infants enrolled in an isoniazid prevention study (P1041) were screened for HBV and HCV serology markers; screening was performed on samples collected at approximately 60 weeks of age of the infants. HBV DNA was quantified in HBsAg positive samples and HBV strains characterized through gene sequencing. All HCV antibody samples with inconclusive results underwent molecular testing. RESULTS: Three of 821 infants were positive for both HBsAg and HBV DNA. All HBV strains belonged to HBV sub-genotype A1. The rtM204I mutation associated with lamivudine resistance was identified in one infant, a second infant harboured the double A1762T/G1764A BCP mutation. Phylogenetic analysis showed clustering between mother and infant viral genomic sequences. Twenty-one of 821 HIV-exposed infants tested had inconclusive HCV antibody results, none were HCV PCR positive. CONCLUSIONS: This study suggests that HBV vertical transmission is likely to be occurring in HIV-exposed infants in South Africa.. A more robust strategy of HBV prevention, including birth dose vaccination, is required to eradicate HBV MTCT. HCV infection was not detected.

Past is prologue: host community assembly and the risk of infectious disease over time.

Infectious disease risk is often influenced by host diversity, but the causes are unresolved. Changes in diversity are associated with changes in community structure, particularly during community assembly; therefore, by incorporating change over time, host community assembly may provide a framework to resolve causation. In turn, community assembly can be driven by many processes, including resource enrichment. To test the hypothesis that community assembly causally links host diversity to future disease, we experimentally manipulated host diversity and resource supply to hosts, then allowed communities to assemble for 2 years (surveyed 2012-2014). Initially, host diversity increased disease. Subsequently, host diversity did not directly alter disease. However, host diversity determined the trajectory of host community assembly, altering colonisation by exotic host species and richness-independent host phylogenetic diversity, which together reversed the initial increase in disease. Ultimately, incorporating the temporal dimension of community assembly revealed novel mechanisms linking host diversity to future disease.

A growth-defense trade-off is general across native and exotic grasses.

High-resource environments typically favor quick-growing, poorly defended plants, while resource-poor environments typically favor slow-growing, well-defended plants. The prevailing hypothesis explaining this pattern states that, as resource availability increases, well-defended, slow-growing species are replaced by poorly defended, fast-growing species. A second hypothesis states that greater resource availability increases allocation to growth at the expense of defense, within species. Regardless of mechanism, if exotic species are released from enemies relative to natives, shifts in allocation to growth and defense both within and among species could differ by geographic provenance. To test whether resource availability alters growth or defense, within and among species, and whether any such effects differ between natives and exotics, we manipulated soil nutrient supply and access of aboveground insect herbivores and fungal pathogens under field conditions to individuals of six native and six exotic grass species that co-occurred in a North Carolina old field. The prevailing hypothesis' prediction-that species-level enemy impact increases with species' nutrient responsiveness-was confirmed. Moreover, this relationship did not differ between native and exotic species. The second hypothesis' prediction-that individual-level enemy impact increases with nutrient supply, after accounting for species-level variation in performance-was not supported. Together, these results support the idea, across native and exotic species, that plant species turnover is the primary mechanism underlying effects of nutrient enrichment on allocation to growth and defense in plant communities.

Graptolite community responses to global climate change and the Late Ordovician mass extinction.

Mass extinctions disrupt ecological communities. Although climate changes produce stress in ecological communities, few paleobiological studies have systematically addressed the impact of global climate changes on the fine details of community structure with a view to understanding how changes in community structure presage, or even cause, biodiversity decline during mass extinctions. Based on a novel Bayesian approach to biotope assessment, we present a study of changes in species abundance distribution patterns of macroplanktonic graptolite faunas (∼447-444 Ma) leading into the Late Ordovician mass extinction. Communities at two contrasting sites exhibit significant decreases in complexity and evenness as a consequence of the preferential decline in abundance of dysaerobic zone specialist species. The observed changes in community complexity and evenness commenced well before the dramatic population depletions that mark the tipping point of the extinction event. Initially, community changes tracked changes in the oceanic water masses, but these relations broke down during the onset of mass extinction. Environmental isotope and biomarker data suggest that sea surface temperature and nutrient cycling in the paleotropical oceans changed sharply during the latest Katian time, with consequent changes in the extent of the oxygen minimum zone and phytoplankton community composition. Although many impacted species persisted in ephemeral populations, increased extinction risk selectively depleted the diversity of paleotropical graptolite species during the latest Katian and early Hirnantian. The effects of long-term climate change on habitats can thus degrade populations in ways that cascade through communities, with effects that culminate in mass extinction.