Machine-learning algorithm to predict multidisciplinary team treatment recommendations in the management of basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) is the most common human cancer. Facial BCCs most commonly occur on the nose and the management of these lesions is particularly complex, given the functional and complex implications of treatment. Multidisciplinary team (MDT) meetings are routinely held to integrate expertise from dermatologists, surgeons, oncologists, radiologists, pathologists and allied health professionals. The aim of this research was to develop a supervised machine-learning algorithm to predict MDT recommendations for nasal BCC to potentially reduce MDT caseload, provide automatic decision support and permit data audit in a health service context. METHODS: The study population included all consecutive patients who were discussed at skin cancer-specialised MDT (SSMDT) with a diagnosis of nasal BCC between January 1, 2015 and December 31, 2015. We conducted analyses for gender, age, anatomical location, histological subtype, tumour size, tumour recurrence, anticoagulation, pacemaker, immunosuppressants and therapeutic modalities (Mohs surgery, conventional excision or radiotherapy). We used S-statistic computing language to develop a supervised machine-learning algorithm. RESULTS: We found that 37.5% of patients could be reliably predicted to be triaged to Mohs micrographic surgery (MMS), based on tumour location and age. Similarly, the choice of conventional treatment (surgical excision or radiotherapy) by the MDT could be reliably predicted based on the patient's age, tumour phenotype and lesion size. Accordingly, the algorithm reliably predicted the MDT decision outcome of 45.1% of nasal BCCs. CONCLUSIONS: Our study suggests that the machine-learning approach is a potentially useful tool for predicting MDT decisions for MMS vs conventional surgery or radiotherapy for a significant group of patients. We suggest that utilising this algorithm gives the MDT more time to consider more complex patients, where multiple factors, including recurrence, financial costs and cosmetic outcome, contribute to the final decision, but cannot be reliably predicted to determine that outcome. This approach has the potential to reduce the burden and improve the efficiency of the specialist skin MDT and, in turn, improve patient care, reduce waiting times and reduce the financial burden. Such an algorithm would need to be updated regularly to take into account any changes in patient referral patterns, treatment options or local clinical expertise. CLINICAL TRIAL REGISTRATION: lPLAS_20-21_A08.

Immediate nipple reconstruction in combination with implant reconstruction using dermal sling.

The inferior de-epithelialized dermal flap with implant is increasingly used for immediate breast reconstruction. We have adapted the technique to provide concurrent immediate nipple reconstruction by recruiting the triangle of skin above the excised nipple as a modified C-V flap. The safety and efficacy of this technique has been assessed in 15 patients, of which eight were bilateral and seven were unilateral cases. We suggest that this is a safe, reliable, and original technique for immediate nipple reconstruction in patients undergoing immediate breast reconstruction with an inferior dermal sling and implant.

The Mersey Burns App: evolving a model of validation.

INTRODUCTION: 'Mersey Burns App' is a smartphone/tablet application that aids in the assessment of total burn surface area (TBSA) and calculation of fluid resuscitation protocols in burns. This paper presents two studies assessing the speed and accuracy of calculations using Mersey Burns (App) in comparison with a Lund and Browder chart (paper) when a burn is assessed by medical students and clinicians. METHODS: The first study compared the speed and accuracy of TBSA and resuscitation calculation for a photograph of a burn with App and paper using burns and plastics and emergency medicine trainees and consultants. Developing on some of the feedback and results of that study, a second study was then carried out using burns-naive medical students assessing a fully simulated burn with both modalities. Preference and ease of use of each modality were assessed anonymously. RESULTS: The clinician study showed a lower variance in TBSA and fluid calculations using the App (p<0.05). The student study showed no difference in mean TBSA estimations (p=0.7). Mean time to completion of calculations was faster and calculations were more likely to be correct with the App (p<0.001). Students favoured the App in the following categories: preference in emergency setting, confidence in output, accuracy, speed, ease of calculation, overall use and shading (p<0.0001). CONCLUSIONS: Mersey Burns App can facilitate quicker and more accurate calculations than Lund and Browder charts. Students also preferred the App. This suggests a useful role for the App in the care of patients with burns by inexperienced staff.

Anomalous cerebral venous sinus drainage.

The case discussed is a 58 year old female that presented with sudden onset of headache, a Glasgow Coma Score of 15 and no neurological deficit. Computed tomography (CT) scan of the brain did not show any evidence of haemorrhage. CT angiography revealed a left sided cerebellar ateriovenous malformation with the Digital Subtraction Angiography (DSA) also showing anomalous posterior fossa venous sinus anatomy. In this case the occipital sinus provided the only drainage pathway for both the superior sagittal sinus (SSS) and the straight sinus. Of clinical significance is during the routine method of access to midline posterior fossa surgery the occipital sinus is ligated and divided. This would have resulted in massive venous infarction. Highlighting the importance of reviewing the venous anatomy on radiological images prior to neurosurgical procedures.

Cosmetic tourism: public opinion and analysis of information and content available on the Internet.

BACKGROUND: The medical tourism market is a rapidly growing sector fueled by increasing health care costs, longer domestic waiting times, economic recession, and cheaper air travel. OBJECTIVES: The authors investigate public opinion on undergoing cosmetic surgery abroad and then explore the information patients are likely to encounter on the Internet when searching for such services. METHODS: A poll of 197 members of the general public was conducted in the United Kingdom. An Internet search including the terms plastic surgery abroad was conducted, and the first 100 relevant sites were reviewed. RESULTS: Of the 197 respondents, 47% had considered having some form of cosmetic surgery. Most (97%) would consider going abroad for their procedure. The Internet was a source of information for 70%. The review of the first 100 sites under "plastic surgery abroad" revealed that most centers were located in Eastern Europe (26%), South America (14%), and the Far East (11%). Exploring the information provided on the Web sites, we found 37% contained no information regarding procedures. Only 10% of sites contained any information about potential complications. Even less frequently mentioned (4%) were details of aftercare or follow-up procedures. CONCLUSIONS: The authors found that the overwhelming majority of respondents considering plastic surgery would also consider seeking cosmetic surgical treatment abroad. The Internet sites that appear most prominently in an online search contained a distinct lack of information for potential patients, particularly with regard to complications and aftercare. There is, therefore, a need for improved public awareness and education about the considerations inherent in medical tourism. The introduction of more stringent regulations for international centers providing such services should also be considered to help safeguard patients.

Epidemiology of U.K. Military Burns 2008-2013.

After sustaining burn injuries overseas, U.K. Armed Forces personnel are evacuated to the Royal Centre for Defence Medicine. The objective was to review the etiology of U.K. Military burns managed at the center between 2008 and 2013. Analysis will aid provision planning and assist in the prevention of burn injuries for future tours. The International Burn Injury Database database of all U.K. Armed Forces burn injured patients evacuated to the Queen Elizabeth University Hospital Birmingham between 2008 and 2013 were reviewed retrospectively. Analysis included patient demographics, injury mechanism, burn severity, management, and mortality. There were 65 military personnel with burn injuries requiring repatriation to the United Kingdom. Percentage of 78.5 were sustained in Afghanistan. The mean age was 25 (18-46) years. Percentage of 70.8 were considered noncombat burn injuries. Of the noncombat burns, the mechanism of injury most commonly involved burning waste and misuse of fuels and scalds. The mean TBSA for all patients was 6% (0.05-51%). Areas most commonly affected included arms, legs, and face. The length of hospital stay for combat vs noncombat burn injury patients was 10 vs 7 days. There were no fatalities. In conclusion, substantially fewer military personnel sustained combat burns between 2008 and 2013 than in preceding study period (19 vs 79). The number of accidental noncombat burns remained constant. The decrease in combat burns may reflect a relative decrease in military intensity and effective protective equipment and safety measures. Further education may allow for an additional decrease in preventable burn injuries.