Smartphone teledermoscopy referrals: a novel process for improved triage of skin cancer patients.

In this open, controlled, multicentre and prospective observational study, smartphone teledermoscopy referrals were sent from 20 primary healthcare centres to 2 dermatology departments for triage of skin lesions of concern using a smartphone application and a compatible digital dermoscope. The outcome for 816 patients referred via smartphone teledermoscopy was compared with 746 patients referred via the traditional paper-based system. When surgical treatment was required, the waiting time was significantly shorter using teledermoscopy for patients with melanoma, melanoma in situ, squamous cell carcinoma, squamous cell carcinoma in situ and basal cell carcinoma. Triage decisions were also more reliable with teledermoscopy and over 40% of the teledermoscopy patients could potentially have avoided face-to-face visits. Only 4 teledermoscopy referrals (0.4%) had to be excluded due to poor image quality. Smartphone teledermoscopy referrals allow for faster and more efficient management of patients with skin cancer as compared to traditional paper referrals.

[Specialist referral with photography for faster diagnosis of skin tumor. Management can be better planned--and saves resources]. / Specialistremiss med fotografi ger snabbare diagnos av hudtumör - Omhändertagandet kan planeras bättre - och resurser sparas.

Adding a photograph of suspected skin cancer to the standard referral can shorten the time to the initial evaluation by a specialist department. The management of the patient can also be better planned and resources can be saved.

Mobile teledermoscopy-there's an app for that!

BACKGROUND: The introduction of the smartphone with high-quality, built-in digital cameras and easy-to-install software may make it more convenient to perform teledermatology. In this study we looked at the feasibility of using a smartphone (iPhone 4(®)) with an installed application especially developed for teledermatology (iDoc24(®)) and a dermoscope (FotoFinder Handyscope(®)) that is customized to attach to the smartphone to be able to carry out mobile teledermoscopy. OBJECTIVES: To study the diagnostic accuracy of this mobile teledermoscopy solution, to determine the interobserver concordance between teledermoscopists (TDs) and a dermatologist meeting the patient face-to-face (FTF), and to assess the adequacy of the TDs' management decisions and to evaluate the image quality obtained. PATIENTS/METHODS: During a 16-week period, patients with one or more suspicious skin lesions deemed to need a biopsy or excision were included. The smartphone app was used to send a clinical image, a dermoscopy image and relevant clinical information to a secure Internet platform (Tele-Dermis(®)). Two TDs assessed the incoming cases, providing a specific primary diagnosis and a management decision. They also graded the image quality. The histopathological diagnosis was used as the gold standard. RESULTS: Sixty-nine lesions were included. The FTF dermatologist's diagnostic accuracy was 66.7%, which was statistically higher than TD 1 (50.7%, P=0.04) but similar to TD 2 (60.9%, P=0.52). The interobserver concordances between the FTF dermatologist and the two TDs and between the respective TDs showed moderate to substantial agreement. The TDs provided adequate management decisions for 68 (98.6%) and 69 (100%) lesions, respectively. The image quality was rated as excellent or sufficient in 94% and 84% of the cases by the respective TDs. CONCLUSION: This novel mobile teledermoscopy solution may be useful as a triage tool for patients referred to dermatologists for suspicious skin lesions.

Dermoscopic evaluation of nodular melanoma.

IMPORTANCE: Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical. OBJECTIVE: To determine the dermoscopy features of NM. DESIGN: Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes. SETTING: Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES: Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma. RESULTS: Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM. CONCLUSIONS AND RELEVANCE: When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

Poor correlation between spectrophotometric intracutaneous analysis and histopathology in melanoma and nonmelanoma lesions.

Spectrophotometric intracutaneous analysis (SIAscopy) is an imaging technique developed for diagnostics of pigmented skin lesions. By image analysis, the displayed images indicate the potential distribution and position of melanin, blood, and collagen within the lesion. A topographic comparison was performed between SIAscopic findings and histopathology. In total, 60 patients with suspicious pigmented skin lesions were included. The lesions were SIAscopically imaged and documented before excision and histopathological preparation. Topographical comparisons between SIAscopy findings and histopathology were made. A sensitivity and specificity of 24% and 84%, respectively, were obtained for invasive melanomas. The positive and negative predicted values were 58% and 54%, respectively. The features indicating dermal melanin, blood displacement and collagen holes did only show "no" to "slight" agreement with histopathology, i.e., κ ≤ 0.21. It was concluded that (i) SIAscopy-based diagnosis has low diagnostic accuracy for melanoma, (ii) single SIAscopic features do not provide reliable diagnostic information relating to the lesions internal structure on histopathology examination and (iii) SIAscopy cannot be used as a guide for localizing the maximum tumor thickness when performing the histopathological examination. The importance of validating new optical tools for tumor diagnostics with histopathological findings was demonstrated.

Pressure ulcer prevalence, use of preventive measures, and mortality risk in an acute care population: a quality improvement project.

The primary aim of this quality improvement project was to determine pressure prevalence, risk of mortality, and use of preventive measures in a group of hospitalized patients. Two hundred fifty-eight patients recruited from Skaraborg Hospital in Sweden were assessed. A 1-day point prevalence study was carried out using a protocol advocated by the European PU Advisory Panel. Patients' age, gender, severity of PU (grades I-IV), anatomical location of PU, and use of preventive measures were recorded. The Swedish language version of the Modified Norton Scale was used for PU risk assessment. Data were collected by nurses trained according to the Web-based training: PU classification, "ePuclas2." After 21 months, a retrospective audit of the electronic records for patients identified with pressure ulcers was completed. The point prevalence of pressure ulcers was 23%. The total number of ulcers was 85, most were grade 1 (n = 39). The most common locations were the sacrum (n = 15) and the heel (n = 10). Three percent of patients (n = 9) had been assessed during their current hospital stay using a risk assessment tool. There was a statistically significant relationship between pressure ulcer occurrence and a low total score on the Modified Norton Scale. The patients' ages correlated significantly to the presence of a pressure ulcer. Patients with a pressure ulcer had a 3.6-fold increased risk of dying within 21 months, as compared with those without a pressure ulcer. Based on results from this quality improvement project, we recommend routine pressure ulcer risk assessment for all patients managed in a hospital setting such as ours. We further recommend that particular attention should be given to older and frail patients who are at higher risk for pressure ulcer occurrence and mortality.

Dermoscopic evaluation of amelanotic and hypomelanotic melanoma.

OBJECTIVE: To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma. DESIGN: A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions. SETTING: Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES: Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy. RESULTS: The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

Pigmented basal cell carcinoma--comparing the diagnostic methods of SIAscopy and dermoscopy.

Pigmented basal cell carcinomas can be difficult to distinguish clinically from melanoma. Dermoscopy has proven to be useful in the differential diagnosis of the two tumour types. SIAscopy (Spectrophotometric intracutaneous analysis) is a fairly new technique of imaging pigmented skin lesions that has been presented previously as a useful tool in diagnosing melanoma. The aim of this study was to evaluate whether SIAscopy can be useful in diagnosing pigmented basal cell carcinomas. Twenty-one pigmented basal cell carcinomas were analysed, comparing dermoscopic and SIAscopic findings. The results, in this limited setting, show that SIAscopy has no advantages over dermoscopy when diagnosing pigmented basal cell carcinomas. On the contrary, pigmented basal cell carcinomas show, in SIAscopy, similar features to those previously reported for melanoma.