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Holm KBE, Nielsen LJ, Lock-Andersen J, Behrendt N, Svensson MS, Themstrup L, Jemec GBE. Optical coherence tomography for presurgical delineation of basal cell carcinomas on the face-A comparison with histopathology. J Cutan Pathol 2023; 50:441-449. [PMID: 36794511 DOI: 10.1111/cup.14412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND To minimize the risk of incomplete excision of basal cell carcinomas (BCC) the macroscopic tumor margins should be adequately defined. Optical coherence tomography (OCT) is a non-invasive imaging tool that can provide structural and vascular information about skin cancer lesions. The study objective was to compare the presurgical delineation of facial BCC by clinical examination, histopathology, and OCT imaging in tumors undergoing full excision. METHODS Ten patients with BCC lesions on the face were examined clinically, with OCT and histopathology at 3-mm intervals, from the clinical lesion border and beyond the resection line. The OCT scans were evaluated blinded and a delineation estimate of each BCC lesion was made. The results were compared to the clinical and histopathologic results. RESULTS OCT evaluations and histopathology were in agreement in 86.6% of the collected data points. In three cases the OCT scans estimated a reduction of the tumor size compared to the clinical tumor border set by the surgeon. CONCLUSION The results of this study support the notion that OCT can have a role in the clinical daily practice by aiding clinicians in delineating BCC lesions before surgery.
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Affiliation(s)
- K B E Holm
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - L J Nielsen
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | - J Lock-Andersen
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | - N Behrendt
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - M S Svensson
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - L Themstrup
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
| | - G B E Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Health Sciences Faculty, University of Copenhagen, Copenhagen, Denmark
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Litaiem N, Hayder F, Benlagha I, Karray M, Dziri C, Zeglaoui F. The Use of Dermoscopy in the Delineation of Basal Cell Carcinoma for Mohs Micrographic Surgery: a Systematic Review With Meta-Analysis. Dermatol Pract Concept 2022; 12:e2022176. [PMID: 36534540 PMCID: PMC9681184 DOI: 10.5826/dpc.1204a176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/30/2023] Open
Abstract
INTRODUCTION Several studies investigated the use of dermoscopy in the delineation of basal cell carcinoma (BCC) for Mohs micrographic surgery (MMS) with conflicting results. OBJECTIVES The purpose of this systematic review with meta-analysis was to evaluate the effectiveness of the use of dermoscopy-guided MMS in the treatment of BCC. METHODS We included all comparative studies. Cases of BCC treated using dermoscopy-guided MMS (or slow MMS) were compared to those treated with curettage-guided MMS or "standard" MMS. RESULTS A total of 6 studies including 508 BCCs were reviewed. There was no statistically significant difference in the proportion of total margin clearance on the first MMS stage between BCCs removed using dermoscopy-guided MMS and those that had curettage or visual inspection. However, lateral margin involvement was significantly lower in BCCs that had dermoscopy-guided MMS. CONCLUSIONS Dermoscopy allows visualization of structures up to 1mm into the dermis. Therefore, it is rational to use it for lateral margin evaluation. Currently, there are two comparative studies showing the efficacy of dermoscopy for lateral margin evaluation during MMS. Future studies are required to develop an evidence-based recommendation regarding the utility of dermoscopy in MMS.
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Affiliation(s)
- Noureddine Litaiem
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Faten Hayder
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Imene Benlagha
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Manel Karray
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Chadli Dziri
- University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
- Director of Honoris Medical Simulation Center, Tunisia
| | - Faten Zeglaoui
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
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3
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Automatic Segmentation of Laser-Induced Injury OCT Images Based on a Deep Neural Network Model. Int J Mol Sci 2022; 23:ijms231911079. [PMID: 36232378 PMCID: PMC9570418 DOI: 10.3390/ijms231911079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/13/2022] [Accepted: 09/18/2022] [Indexed: 11/16/2022] Open
Abstract
Optical coherence tomography (OCT) has considerable application potential in noninvasive diagnosis and disease monitoring. Skin diseases, such as basal cell carcinoma (BCC), are destructive; hence, quantitative segmentation of the skin is very important for early diagnosis and treatment. Deep neural networks have been widely used in the boundary recognition and segmentation of diseased areas in medical images. Research on OCT skin segmentation and laser-induced skin damage segmentation based on deep neural networks is still in its infancy. Here, a segmentation and quantitative analysis pipeline of laser skin injury and skin stratification based on a deep neural network model is proposed. Based on the stratification of mouse skins, a laser injury model of mouse skins induced by lasers was constructed, and the multilayer structure and injury areas were accurately segmented by using a deep neural network method. First, the intact area of mouse skin and the damaged areas of different laser radiation doses are collected by the OCT system, and then the labels are manually labeled by experienced histologists. A variety of deep neural network models are used to realize the segmentation of skin layers and damaged areas on the skin dataset. In particular, the U-Net model based on a dual attention mechanism is used to realize the segmentation of the laser-damage structure, and the results are compared and analyzed. The segmentation results showed that the Dice coefficient of the mouse dermis layer and injury area reached more than 0.90, and the Dice coefficient of the fat layer and muscle layer reached more than 0.80. In the evaluation results, the average surface distance (ASSD) and Hausdorff distance (HD) indicated that the segmentation results are excellent, with a high overlap rate with the manually labeled area and a short edge distance. The results of this study have important application value for the quantitative analysis of laser-induced skin injury and the exploration of laser biological effects and have potential application value for the early noninvasive detection of diseases and the monitoring of postoperative recovery in the future.
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Wan B, Ganier C, Du-Harpur X, Harun N, Watt FM, Patalay R, Lynch MD. Applications and future directions for optical coherence tomography in dermatology. Br J Dermatol 2020; 184:1014-1022. [PMID: 32974943 DOI: 10.1111/bjd.19553] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 12/24/2022]
Abstract
Optical coherence tomography (OCT) is a noninvasive optical imaging method that can generate high-resolution en face and cross-sectional images of the skin in vivo to a maximum depth of 2 mm. While OCT holds considerable potential for noninvasive diagnosis and disease monitoring, it is poorly understood by many dermatologists. Here we aim to equip the practising dermatologist with an understanding of the principles of skin OCT and the potential clinical indications. We begin with an introduction to the technology and discuss the different modalities of OCT including angiographic (dynamic) OCT, which can image cutaneous blood vessels at high resolution. Next we review clinical applications. OCT has been most extensively investigated in the diagnosis of keratinocyte carcinomas, particularly basal cell carcinoma. To date, OCT has not proven sufficiently accurate for the robust diagnosis of malignant melanoma; however, the evaluation of abnormal vasculature with angiographic OCT is an area of active investigation. OCT, and in particular angiographic OCT, also shows promise in monitoring the response to therapy of inflammatory dermatoses, such as psoriasis and connective tissues disease. We additionally discuss a potential role for artificial intelligence in improving the accuracy of interpretation of OCT imaging data.
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Affiliation(s)
- B Wan
- Centre for Stem Cells and Regenerative Medicine, King's College London, Guy's Hospital, Great Maze Pond, London, UK
| | - C Ganier
- Centre for Stem Cells and Regenerative Medicine, King's College London, Guy's Hospital, Great Maze Pond, London, UK
| | - X Du-Harpur
- Centre for Stem Cells and Regenerative Medicine, King's College London, Guy's Hospital, Great Maze Pond, London, UK.,The Francis Crick Institute, 1 Midland Road, London, UK
| | - N Harun
- Centre for Stem Cells and Regenerative Medicine, King's College London, Guy's Hospital, Great Maze Pond, London, UK
| | - F M Watt
- Centre for Stem Cells and Regenerative Medicine, King's College London, Guy's Hospital, Great Maze Pond, London, UK
| | - R Patalay
- St John's Institute of Dermatology, King's College London, London, UK
| | - M D Lynch
- Centre for Stem Cells and Regenerative Medicine, King's College London, Guy's Hospital, Great Maze Pond, London, UK.,St John's Institute of Dermatology, King's College London, London, UK
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5
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Reddy N, Nguyen B. The utility of optical coherence tomography for diagnosis of basal cell carcinoma: a quantitative review. Br J Dermatol 2018; 180:475-483. [DOI: 10.1111/bjd.17201] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 12/14/2022]
Affiliation(s)
- N. Reddy
- Department of Dermatology Tufts Medical Center/Tufts University School of Medicine 800 Washington St, #114 Boston MA 02111 U.S.A
| | - B.T. Nguyen
- Department of Dermatology Tufts Medical Center/Tufts University School of Medicine 800 Washington St, #114 Boston MA 02111 U.S.A
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van Manen L, Dijkstra J, Boccara C, Benoit E, Vahrmeijer AL, Gora MJ, Mieog JSD. The clinical usefulness of optical coherence tomography during cancer interventions. J Cancer Res Clin Oncol 2018; 144:1967-1990. [PMID: 29926160 PMCID: PMC6153603 DOI: 10.1007/s00432-018-2690-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/16/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Tumor detection and visualization plays a key role in the clinical workflow of a patient with suspected cancer, both in the diagnosis and treatment. Several optical imaging techniques have been evaluated for guidance during oncological interventions. Optical coherence tomography (OCT) is a technique which has been widely evaluated during the past decades. This review aims to determine the clinical usefulness of OCT during cancer interventions focussing on qualitative features, quantitative features and the diagnostic value of OCT. METHODS A systematic literature search was performed for articles published before May 2018 using OCT in the field of surgical oncology. Based on these articles, an overview of the clinical usefulness of OCT was provided per tumor type. RESULTS A total of 785 articles were revealed by our search, of which a total of 136 original articles were available for analysis, which formed the basis of this review. OCT is currently utilised for both preoperative diagnosis and intraoperative detection of skin, oral, lung, breast, hepatobiliary, gastrointestinal, urological, and gynaecological malignancies. It showed promising results in tumor detection on a microscopic level, especially using higher resolution imaging techniques, such as high-definition OCT and full-field OCT. CONCLUSION In the near future, OCT could be used as an additional tool during bronchoscopic or endoscopic interventions and could also be implemented in margin assessment during (laparoscopic) cancer surgery if a laparoscopic or handheld OCT device will be further developed to make routine clinical use possible.
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Affiliation(s)
- Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Jouke Dijkstra
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Michalina J Gora
- ICube Laboratory, CNRS, Strasbourg University, Strasbourg, France
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
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Abstract
Skin cancer is the most commonly diagnosed cancer in the USA. Mohs micrographic surgery is a microscopically controlled surgical technique that excises lateral and deep surgical margins while also sparing function and achieving a good cosmetic outcome. Given the increasing incidence in skin cancer worldwide and its associated treatment costs, techniques are being developed to improve the time and cost efficacy of this procedure. The use of noninvasive imaging, both in vivo and ex vivo, has the potential to increase efficiency of diagnosis and surgical management of skin cancers. These devices are useful in delineating lateral and deep tumor margins prior to surgery in vivo as well as to detect residual tumor ex vivo virtually in real time.
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Affiliation(s)
- Amanda Levine
- Department of Dermatology, Mount Sinai Medical Center, New York, NY, 10029, USA
- Department of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY, 11203, USA
- Department of Dermatology, New York Harbor Healthcare System, Brooklyn, NY, 11209, USA
| | - Daniel Siegel
- Department of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY, 11203, USA
- Department of Dermatology, New York Harbor Healthcare System, Brooklyn, NY, 11209, USA
| | - Orit Markowitz
- Department of Dermatology, Mount Sinai Medical Center, New York, NY, 10029, USA
- Department of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY, 11203, USA
- Department of Dermatology, New York Harbor Healthcare System, Brooklyn, NY, 11209, USA
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9
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Kwon S, Yoon Y, Kim B, Jang WH, Oh B, Chung KY, Kim KH. Dermoscopy guided dark-field multi-functional optical coherence tomography. BIOMEDICAL OPTICS EXPRESS 2017; 8:1372-1381. [PMID: 28663834 PMCID: PMC5480549 DOI: 10.1364/boe.8.001372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 05/21/2023]
Abstract
Dermoscopy is a skin surface microscopic technique allowing specular reflection free observation of the skin, and has been used to examine pigmented skin lesions. However, dermoscopy has limitations in providing depth information due to lack of 3D resolution. In order to overcome the limitations, we developed dermoscopy guided multi-functional optical coherence tomography (MF-OCT) providing both high-contrast superficial information and depth-resolved structural, birefringent, and vascular information of the skin simultaneously. Dermoscopy and MF-OCT were combined by using a dichroic mirror, and dark-field configuration was adapted for MF-OCT to reduce specular reflection. After characterization, dermoscopy guided MF-OCT was applied to several human skin lesions such as the scar, port-wine stain (PWS) as well as the normal skin for demonstration. Various features of the scar and PWS were elucidated by both dermoscopy and MF-OCT. Dermoscopy guided MF-OCT may be useful for evaluation and treatment monitoring of skin lesions in clinical applications.
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Affiliation(s)
- Soonjae Kwon
- Department of Mechanical Engineering, Pohang University of Science and Technology, San 31, Hyoja-dong, Nam-gu, Pohang, Gyeongbuk 790-784, South Korea
- These authors contributed equally to this work
| | - Yeoreum Yoon
- Department of Mechanical Engineering, Pohang University of Science and Technology, San 31, Hyoja-dong, Nam-gu, Pohang, Gyeongbuk 790-784, South Korea
- These authors contributed equally to this work
| | - Bumju Kim
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, San 31, Hyoja-dong, Nam-gu, Pohang, Gyeongbuk 790-784, South Korea
| | - Won Hyuk Jang
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, San 31, Hyoja-dong, Nam-gu, Pohang, Gyeongbuk 790-784, South Korea
| | - Byungho Oh
- Department of Dermatology, Keimyung University, College of Medicine, 56, Dalseong-ro, Jung-gu, Daegu, 41931, South Korea
| | - Kee Yang Chung
- Departments of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, 03722, South Korea
| | - Ki Hean Kim
- Department of Mechanical Engineering, Pohang University of Science and Technology, San 31, Hyoja-dong, Nam-gu, Pohang, Gyeongbuk 790-784, South Korea
- Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, San 31, Hyoja-dong, Nam-gu, Pohang, Gyeongbuk 790-784, South Korea
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10
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Zhang W, Wang X, Zhang J, Shen G. Application of preoperative registration and automatic tracking technique for image-guided maxillofacial surgery. Comput Assist Surg (Abingdon) 2016; 21:137-142. [PMID: 27973961 DOI: 10.1080/24699322.2016.1187767] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Wenbin Zhang
- Department of Oral and Cranio-maxillofacial Science, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Huang Pu District, Shanghai, China
| | - Xudong Wang
- Department of Oral and Cranio-maxillofacial Science, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Huang Pu District, Shanghai, China
| | - Jianfei Zhang
- Department of Oral and Cranio-maxillofacial Science, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Huang Pu District, Shanghai, China
| | - Guofang Shen
- Department of Oral and Cranio-maxillofacial Science, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Huang Pu District, Shanghai, China
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11
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Cheng HM, Guitera P. Systematic review of optical coherence tomography usage in the diagnosis and management of basal cell carcinoma. Br J Dermatol 2015. [PMID: 26211438 DOI: 10.1111/bjd.14042] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Optical coherence tomography (OCT) is a noninvasive imaging tool used in vivo in real time for diagnosis, treatment delineation and monitoring of basal cell carcinoma (BCC). Features of BCC on OCT have been widely described and reviewed. However, the diagnostic accuracy of OCT in these various applications is unclear. We systematically reviewed the literature to assess the accuracy of OCT in diagnosis and management of BCC using the Embase and Medline databases. In total 179 unique references were identified in the initial search, of which 22 studies with 556 histologically proven BCCs were eligible. Assessment of the quality of eligible studies was undertaken using the STROBE criteria. Data extraction and quality assessment were performed independently by the two authors. This systematic review provides an overview of the clinical applications of OCT in the diagnosis and management of BCC. OCT has been suggested to be useful in the diagnosis, treatment planning and treatment monitoring of BCC. As the technology improves and its utility increases, further studies with good methodological quality will be needed to implement OCT into daily practice.
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Affiliation(s)
- H M Cheng
- Melanoma Institute Australia, 40 Rocklands Rd, North Sydney, NSW, 2060, Australia
| | - P Guitera
- Department of Dermatology, University of Sydney, Sydney New South Wales, Australia
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Dinnes J, Wong KY, Gulati A, Chuchu N, Leonardi-Bee J, Bayliss SE, Takwoingi Y, Davenport C, Matin RN, Bath-Hextall FJ, Jain A, Lear JT, Motley R, Deeks JJ, Williams HC, Godfrey K, O'Sullivan C. Tests to assist in the diagnosis of keratinocyte skin cancers in adults: a generic protocol. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011901] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Jac Dinnes
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Kai Yuen Wong
- Salisbury NHS Foundation Trust; Department of Plastic and Reconstructive Surgery; Salisbury UK
| | - Abha Gulati
- Barts Health NHS Trust; Department of Dermatology; Whitechapel London UK E11BB
| | - Naomi Chuchu
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Jo Leonardi-Bee
- The University of Nottingham; Division of Epidemiology and Public Health; Clinical Sciences Building Nottingham City Hospital NHS Trust Campus, Hucknall Road Nottingham UK NG5 1PB
| | - Susan E Bayliss
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Yemisi Takwoingi
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Clare Davenport
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Rubeta N Matin
- Churchill Hospital; Department of Dermatology; Old Road Headington Oxford UK OX3 7LJ
| | - Fiona J Bath-Hextall
- The University of Nottingham; School of Health Sciences; Room D83, Medical school Queens medical centre Nottingham UK NG7 2UH
| | - Abhilash Jain
- University of Oxford; NDORMS; 2 Chesham Close Oxford UK NW7 4AF
| | - John T Lear
- Manchester Royal Infirmary; Dermatology; Oxford Road Manchester UK M13 9WL
| | - Richard Motley
- University Hospital of Wales; Welsh Institute of Dermatology; Heath Park Cardiff UK CF14 4XW
| | - Jonathan J Deeks
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Hywel C Williams
- The University of Nottingham; Centre of Evidence Based Dermatology; Queen's Medical Centre Derby Road Nottingham UK NG7 2UH
| | - Kathie Godfrey
- The University of Nottingham; c/o Cochrane Skin Group; Nottingham UK
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