Teledermatology in Norway using a mobile phone app

Basic principles of artificial intelligence in dermatology explained using melanoma

The use of artificial intelligence (AI) continues to establish itself in the most diverse areas of medicine at an increasingly fast pace. Nevertheless, many healthcare professionals lack the basic technical understanding of how this technology works, which severely limits its application in clinical settings and research. Thus, we would like to discuss the functioning and classification of AI using melanoma as an example in this review to build an understanding of the technology behind AI. For this purpose, elaborate illustrations are used that quickly reveal the technology involved. Previous reviews tend to focus on the potential applications of AI, thereby missing the opportunity to develop a deeper understanding of the subject matter that is so important for clinical application. Malignant melanoma has become a significant burden for healthcare systems. If discovered early, a better prognosis can be expected, which is why skin cancer screening has become increasingly popular and is supported by health insurance. The number of experts remains finite, reducing their availability and leading to longer waiting times. Therefore, innovative ideas need to be implemented to provide the necessary care. Thus, machine learning offers the ability to recognize melanomas from images at a level comparable to experienced dermatologists under optimized conditions.

Grundprinzipien der künstlichen Intelligenz in der Dermatologie erklärt am Beispiel des Melanoms

Der Einsatz von künstlicher Intelligenz (KI) setzt sich in den verschiedensten Bereichen der Medizin immer schneller durch. Dennoch fehlt vielen medizinischen Kollegen das technische Grundverständnis für die Funktionsweise dieser Technologie, was ihre Anwendung in Klinik und Forschung stark einschränkt. Daher möchten wir in dieser Übersichtsarbeit die Funktionsweise und Klassifizierung der KI am Beispiel des Melanoms erörtern, um ein Verständnis für die Technologie hinter der KI zu schaffen. Dazu werden ausführliche Illustrationen verwendet, die die Technologie schnell erklären. Bisherige Übersichten konzentrieren sich eher auf die potenziellen Anwendungen der KI und verpassen die Gelegenheit, ein tieferes Verständnis für die Materie herauszuarbeiten, das für die klinische Anwendung so wichtig ist. Das maligne Melanom ist zu einer erheblichen Belastung für die Gesundheitssysteme geworden. Bei frühzeitiger Entdeckung ist eine bessere Prognose zu erwarten, weshalb das Hautkrebs‐Screening immer populärer und von den Krankenkassen unterstützt wird. Die Zahl der Fachärzte ist jedoch begrenzt, was ihre Verfügbarkeit einschränkt und zu längeren Wartezeiten führt. Daher müssen innovative Ideen umgesetzt werden, um die notwendige Versorgung zu gewährleisten. Das maschinelle Lernen bietet die Möglichkeit, Melanome auf Bildern zu erkennen, und zwar auf einem Niveau, das mit dem von erfahrenen Dermatologen – unter optimierten Bedingungen – vergleichbar ist.

Advancing Dermatological Care: A Comprehensive Narrative Review of Tele-Dermatology and mHealth for Bridging Gaps and Expanding Opportunities beyond the COVID-19 Pandemic

Mobile health (mHealth) has recently had significant advances in tele-dermatology (TD) thanks to the developments following the COVID-19 pandemic. This topic is very important, as telemedicine and mHealth, when applied to dermatology, could improve both the quality of healthcare for citizens and the workflow in the health domain. The proposed study was centered on the last three years. We conducted an overview on the opportunities, the perspectives, and the problems involved in TD integration with mHealth. The methodology of the narrative review was based on: (I) a search of PubMed and Scopus and (II) an eligibility assessment, using properly proposed parameters. The outcome of the study showed that during the COVID-19 pandemic, TD integration with mHealth advanced rapidly. This integration enabled the monitoring of dermatological problems and facilitated remote specialist visits, reducing face-to-face interactions. AI and mobile apps have empowered citizens to take an active role in their healthcare. This differs from other imaging sectors where information exchange is limited to professionals. The opportunities for TD in mHealth include improving service quality, streamlining healthcare processes, reducing costs, and providing more accessible care. It can be applied to various conditions, such as (but not limited to) acne, vitiligo, psoriasis, and skin cancers. Integration with AI and augmented reality (AR), as well as the use of wearable sensors, are anticipated as future developments. However, integrating TD with mHealth also brings about problems and challenges related to regulations, ethics, cybersecurity, data privacy, and device management. Scholars and policymakers need to address these issues while involving citizens in the process.

Mobile nutrition and health management platform for perioperative recovery: an interdisciplinary research achievement using WeChat Applet

Background

In recent years, the number of people using mobile applications to promote health and welfare has exponentially increased. However, there are fewer applications in the field of ERAS. How to promote the rapid rehabilitation of patients with malignant tumor surgery during perioperative period and the mastery of its long-term nutritional state is a problem to be solved.

Objective

The purpose of this study is to design and develop a mobile application, and use Internet technology to better manage nutritional health to achieve rapid recovery of patients with malignant tumor surgery.

Methods

This study is divided into three stages: (1) Design: use participating design to make the MHEALTH APP adapt to the clinical practice of nutritional health management; (2) Development: the WeChat Applet of Nutrition and Health Assessment (WANHA) developed using the Internet technology development, and web management programs. (3) Procedure test: patients and medical staff evaluate WANHA's quality (UMARS), availability (SUS), and satisfaction, and conduct semi-structured interviews.

Results

In this study, 192 patients with malignant tumor surgery, 20 medical staff used WANHA. Patients with nutritional risks are supported by supporting treatment. The results show that patients who have not been treated during the perioperative period, the incidence of postoperative complications (22.4%) and the average hospitalization time after surgery decreased significantly. The incidence of nutritional risks is nearly more than the preoperative level. 45 patients and 20 medical staff participated in the survey of WANHA's SUS, UMARS, and satisfaction. In the interview, most patients and medical personnel believe that the procedure can improve the current medical services and nutritional health knowledge levels, promote the communication of medical staff and patients, and strengthen the nutritional health management of patients with malignant tumors under the concept of ERAS.

Conclusion

WeChat Applet of Nutrition and Health Assessment is a MHEALTH APP that enhances the nutrition and health management of patients with perioperative period. It can play a huge role in improving medical services, increasing patient satisfaction, and ERAS.

Effectiveness and cost-effectiveness of a telemedicine programme for preventing unplanned hospitalisations of older adults living in nursing homes: the GERONTACCESS cluster randomized clinical trial

OBJECTIVE

The GERONTACCESS trial evaluated the utility and cost-effectiveness of a gerontological telemedicine (TLM) programme for preventing unplanned hospitalisation of residents living in nursing homes (NHs) in regions lacking medical facilities and/or qualified medical providers ("medical deserts").

DESIGN

GERONTACCESS was a 12-month, multicentre, prospective cluster-randomised trial conducted in NHs. The intervention group underwent TLM assessments every 3 months. The control group received the usual care. In both groups, comprehensive on-site assessments were conducted at baseline and the final visit. Care requirements were documented throughout the study.

SETTING AND PARTICIPANTS

NH residents aged ≥ 60 years with multiple chronic diseases.

METHODS

The study outcomes were the proportion of patients who experienced avoidable and unplanned hospitalisation, and the incremental cost savings per quality-adjusted life years from baseline to the 12-month follow-up.

RESULTS

Of the 426 randomised participants (mean ± standard deviation age, 87.2 ± 7.6 years; 311 [73.0%] women), 23.4% in the intervention group and 32.5% in the control group experienced unplanned hospitalisation (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.43 to 0.97; p = 0.034). Each avoided hospitalisation in the intervention group saved $US 3,846.

CONCLUSIONS AND IMPLICATIONS

The results of GERONTACCESS revealed that our gerontological, preventative TLM program significantly reduced unplanned hospitalisations. This innovative intervention limited disease progression and promoted a healthy lifestyle among NH residents.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02816177, registered June 28, 2016.

Experience of using a smartphone WeChat applet for dental anxiety assessment and preoperative evaluation: A nationwide multicenter study

Introduction

Dental anxiety is a multivariate phenomenon that regularly occurs during a dental procedure. Although it may lead to patients' safety concerns and adverse events in routine treatment, it is often ignored. The purpose of this research is to develop a novel WeChat Applet for dental anxiety (WADA) with the following features and aims: (1) to help patients with dental anxiety management; (2) provide patient with a physical status self-evaluation; and(3) provide a platform for online assessment and tele-consultancy by dentists. We aimed to test and verify whether such an applet could play a beneficial role before and after a dental procedure and facilitate management of high-risk patients during the COVID-19 pandemic.

Materials and methods

During the 12-month survey period (August 2020 to July 2021), a total of 180 patients aged 3–74 years from eight different cities (n = 180 at the end of treatment, n = 25 for the System Usability Scale (SUS) and follow-up interview) and 20 medical staff from eight different cities (n =20 for follow-up interview) were evaluated by WADA. At the end of the survey period, the results of the interviews were analyzed thematically.

Results

WADA assessment results from 180 patients and follow-up interview results from 45 participants were analyzed. In this study with a male to female ratio of 2:3, 75% were found to be suffering from dental anxiety, 86% were found with postoperative complications, and 11 cases were found to have contraindications to surgery. The total SUS score for WADA is 72.25 above the mean score, proving that WADA is a relevant and useful tool before and after dental treatment. Based on the results of the interviews, the following themes were identified: patient satisfaction; dentists' effectiveness; multi-center data integration; and increase its frequency of usage.

Conclusions

The WADA was developed for dental procedures and is effective for reducing treatment risks, improving patients' satisfaction and dentists' convenience, especially in terms of facilitating management of high-risk patient during the COVID-19 pandemic.

Teledermoscopy in the Diagnosis of Melanocytic and Non-Melanocytic Skin Lesions: NurugoTM Derma Smartphone Microscope as a Possible New Tool in Daily Clinical Practice

Background: Due to the COVID-19 pandemic, teledermoscopy has been increasingly used in the remote diagnosis of skin cancers. In a study conducted in 2020, we demonstrated a potential role of an inexpensive device (Nurugo^TM Derma) as a first triage to select the skin lesions that require a face-to-face consultation with dermatologists. Herein, we report the results of a novel study that aimed to better investigate the performance of Nurugo^TM. Objectives: (i) verify whether the Nurugo^TM can be a communication tool between the general practitioner (GP) and dermatologist in the first assessment of skin lesions, (ii) analyze the degree of diagnostic–therapeutic agreement between dermatologists, (iii) estimate the number of potentially serious diagnostic errors. Methods: One hundred and forty-four images of skin lesions were collected at the Dermatology Outpatient Clinic in Novara using a conventional dermatoscope (instrument F), the Nurugo^TM (instrument N), and the latter with the interposition of a laboratory slide (instrument V). The images were evaluated in-blind by four dermatologists, and each was asked to make a diagnosis and to specify a possible treatment. Results: Our data show that F gave higher agreement values for all dermatologists, concerning the real clinical diagnosis. Nevertheless, a medium/moderate agreement value was obtained also for N and V instruments and that can be considered encouraging and indicate that all examined tools can potentially be used for the first screening of skin lesions. The total amount of misclassified lesions was limited (especially with the V tool), with up to nine malignant lesions wrongly classified as benign. Conclusions: Nurugo^TM, with adequate training, can be used to build a specific support network between GP and dermatologist or between dermatologists. Furthermore, its use could be extended to the diagnosis and follow-up of other skin diseases, especially for frail patients in emergencies, such as the current pandemic context.

Usefulness of Smartphones in Dermatology: A US-Based Review

(1) Background: As smartphones have become more widely used, they have become an appealing tool for health-related functions. For dermatology alone, hundreds of applications (apps) are available to download for both patients and providers. (2) Methods: The Google Play Store and Apple App Store were searched from the United States using dermatology-related terms. Apps were categorized based on description, and the number of reviews, download cost, target audience, and use of AI were recorded. The top apps from each category by number of reviews were reported. Additionally, literature on the benefits and limitations of using smartphones for dermatology were reviewed. (3) Results: A total of 632 apps were included in the study: 395 (62.5%) were marketed towards patients, 203 (32.1%) towards providers, and 34 (5.4%) towards both; 265 (41.9%) were available only on the Google Play Store, 146 (23.1%) only on the Apple App Store, and 221 (35.0%) were available on both; and 595 (94.1%) were free to download and 37 (5.9%) had a cost to download, ranging from USD 0.99 to USD 349.99 (median USD 37.49). A total of 99 apps (15.7%) reported the use of artificial intelligence. (4) Conclusions: Although there are many benefits of using smartphones for dermatology, lack of regulation and high-quality evidence supporting the efficacy and accuracy of apps hinders their potential.

Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study

BACKGROUND

There is a high demand for managing skin disease, and dermatologists are in short supply.

OBJECTIVES

To better understand how rashes and other specific skin conditions are co-managed by primary care providers (PCPs) and dermatologists, we estimated the frequency with which PCPs sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days.

DESIGN AND SETTING

The retrospective longitudinal study included 106,459 patients with a skin condition diagnosed by 3,830 PCPs, from January 2017 to March 2017.

METHODS

Comprehensive electronic medical record data with generalized linear mixed modeling accounted for patient factors including diagnosis and clustering by medical center and PCP.

RESULTS

PCPs escalated 9% of patients to dermatology through consultation or referral, while 5% required a follow-up dermatology office visit within 90 days. Patients with bullous, hair, or pigment conditions or psoriasis were most likely to be escalated. Clustering of escalation and follow-up visits was minimal in relation to medical center (intraclass correlation, 0.04 for both outcomes) or PCP (escalation, intraclass correlation, 0.16; follow-up visits, 0.09).

DISCUSSION

Improving primary care education in skin disease and, for certain skin conditions, standardizing approaches to workup, treatment, and escalation may further streamline care and reduce pressure on the dermatologist workforce.

CONCLUSION

PCPs managed 91% of rashes without consultation or referral to dermatology, and the frequency of patients scheduled for dermatology office visits after primary care was similar from one PCP to another.

Smartphones’ Skin Colour Reproduction Analysis for Neonatal Jaundice Detection

Abstract In recent years, smartphone-based colour imaging systems are being increasingly used for Neonatal jaundice detection applications. These systems are based on the estimation of bilirubin concentration levels that correlates with newborns’ skin colour images corresponding to total serum bilirubin (TSB) and transcutaneous bilirubinometry (TcB) measurements. However, the colour reproduction capacity of smartphone cameras are known to be influenced by various factors including the technological and acquisition process variabilities. To make an accurate bilirubin estimation, irrespective of the type of smartphone and illumination conditions used to capture the newborns’ skin images, an inclusive and complete model, or data set, which can represent all the possible real world acquisitions scenarios needs to be utilized. Due to various challenges in generating such a model or a data set, some solutions tend towards the application of reduced data set (designed for reference conditions and devices only) and colour correction systems (for the transformation of other smartphone skin images to the reference space). Such approaches will make the bilirubin estimation methods highly dependent on the accuracy of their employed colour correction systems, and the capability of reducing device-to-device colour reproduction variability. However, the state-of-the-art methods with similar methodologies were only evaluated and validated on a single smartphone camera. The vulnerability of the systems in making an incorrect jaundice diagnosis can only be shown with a thorough investigation of the colour reproduction variability for extended number of smartphones and illumination conditions. Accordingly, this work presents and discuss the results of such broad investigation, including the evaluation of seven smartphone cameras, ten light sources, and three different colour correction approaches. The overall results show statistically significant colour differences among devices, even after colour correction applications, and that further analysis on clinically significance of such differences is required for skin colour based jaundice diagnosis.

International Teledermatology Review

Purpose of Review

The use of teledermatology has been evolving slowly for the delivery of health care to remote and underserved populations. Improving technology and the recent COVID-19 pandemic have hastened its use internationally.

Recent Findings

Some barriers to the use of teledermatology have fallen considerably in the last year.

Summary

Teledermatology use has increased significantly in recent years in both government-sponsored and private health care systems and individual practices. There are no recognized international practice guidelines and variable use within countries. Many barriers remain to increasing the use of teledermatology.

The Role in Teledermoscopy of an Inexpensive and Easy-to-Use Smartphone Device for the Classification of Three Types of Skin Lesions Using Convolutional Neural Networks

Background. The use of teledermatology has spread over the last years, especially during the recent SARS-Cov-2 pandemic. Teledermoscopy, an extension of teledermatology, consists of consulting dermoscopic images, also transmitted through smartphones, to remotely diagnose skin tumors or other dermatological diseases. The purpose of this work was to verify the diagnostic validity of images acquired with an inexpensive smartphone microscope (Nurugo^TM), employing convolutional neural networks (CNN) to classify malignant melanoma (MM), melanocytic nevus (MN), and seborrheic keratosis (SK). Methods. The CNN, trained with 600 dermatoscopic images from the ISIC (International Skin Imaging Collaboration) archive, was tested on three test sets: ISIC images, images acquired with the Nurugo^TM, and images acquired with a conventional dermatoscope. Results. The results obtained, although with some limitations due to the smartphone device and small data set, were encouraging, showing comparable results to the clinical dermatoscope and up to 80% accuracy (out of 10 images, two were misclassified) using the Nurugo^TM demonstrating how an amateur device can be used with reasonable levels of diagnostic accuracy. Conclusion. Considering the low cost and the ease of use, the Nurugo^TM device could be a useful tool for general practitioners (GPs) to perform the first triage of skin lesions, aiding the selection of lesions that require a face-to-face consultation with dermatologists.

Mobile Health Strategies to Tackle Skin Neglected Tropical Diseases With Recommendations From Innovative Experiences: Systematic Review

Background

Neglected tropical diseases (NTDs) represent a diverse group of 20 communicable diseases that occur in tropical and subtropical areas in 149 countries, affecting over 1 billion people and costing developing economies billions of dollars every year. Within these diseases, those that present lesions on the skin surface are classified as skin NTDs (sNTDs). Mobile health interventions are currently being used worldwide to manage skin diseases and can be a good strategy in the epidemiological and clinical management of sNTDs.

Objective

We aimed to analyze existing evidence about mobile health interventions to control and manage sNTDs in low- and middle-income countries (LMICs) and make recommendations for what should be considered in future interventions.

Methods

A systematic review was conducted of the MEDLINE, Embase, and Scopus databases over 10 years up to April 30, 2020. All types of clinical studies were considered. Data were synthesized into evidence tables. Apps were selected through a comprehensive systematic search in the Google Play Store and Apple App Store conducted between March 20 and April 15, 2020.

Results

From 133 potentially relevant publications, 13 studies met our criteria (9.8%). These analyzed eight different interventions (three SMS text messaging interventions and five app interventions). Six of the 13 (46%) studies were community-based cross-sectional studies intended to epidemiologically map a specific disease, mainly lymphatic filariasis, but also cutaneous leishmaniasis, leprosy, and NTDs, as well as sNTDs in general. Most of the studies were considered to have a high (5/13, 39%) or moderate (4/13, 31%) risk of bias. Fifteen apps were identified in the Google Play Store, of which three were also in the Apple App Store. Most of the apps (11/15, 73%) were targeted at health care professionals, with only four targeted at patients. The apps focused on scabies (3/15, 20%), lymphatic filariasis (3/15, 20%), cutaneous leishmaniasis (1/15, 7%), leprosy (1/15, 7%), yaws and Buruli ulcer (1/15, 7%), tropical diseases including more than one sNTDs (3/15, 20%), and NTDs including sNTDs (2/15, 13%). Only 1 (7%) app focused on the clinical management of sNTDs.

Conclusions

All mobile health interventions that were identified face technological, legal, final user, and organizational issues. There was a remarkable heterogeneity among studies, and the majority had methodological limitations that leave considerable room for improvement. Based on existing evidence, eight recommendations have been made for future interventions.

Accuracy of an Affordable Smartphone-Based Teledermoscopy System for Color Measurements in Canine Skin

Quality smartphone cameras and affordable dermatoscopes have enabled teledermoscopy to become a popular medical and veterinary tool for analyzing skin lesions such as melanoma and erythema. However, smartphones acquire images in an unknown RGB color space, which prevents a standardized colorimetric skin analysis. In this work, we supplemented a typical veterinary teledermoscopy system with a conventional color calibration procedure, and we studied two mid-priced smartphones in evaluating native and erythematous canine skin color. In a laboratory setting with the ColorChecker, the teledermoscopy system reached CIELAB-based color differences ΔE of 1.8-6.6 (CIE76) and 1.1-4.5 (CIE94). Intra- and inter-smartphone variability resulted in the color differences (CIE76) of 0.1, and 2.0-3.9, depending on the selected color range. Preliminary clinical measurements showed that canine skin is less red and yellow (lower a* and b* for ΔE of 10.7) than standard Caucasian human skin. Estimating the severity of skin erythema with an erythema index led to errors between 0.5-3%. After constructing a color calibration model for each smartphone, we expedited clinical measurements without losing colorimetric accuracy by introducing a simple image normalization on a white standard. To conclude, the calibrated teledermoscopy system is fast and accurate enough for various colorimetric applications in veterinary dermatology.