Evaluating remote skin cancer multidisciplinary team meetings in the United Kingdom post-COVID-19

INTRODUCTION

Prior to the COVID-19 pandemic, there was concern that virtual or remote multidisciplinary teams (MDT) meetings represented a niche concept that was unlikely to replace traditional face-to-face meetings in the management of cancer. However, the sudden shift to virtual meetings during COVID-19 has been one of the most dramatic changes since the inception of the MDT. This study aims to investigate the effectiveness of virtual skin MDTs since the move to virtual meetings.

METHODS

A cross-sectional survey was sent to all Specialist Skin Cancer MDTs (SSMDTs) and the British Association of Plastic, Reconstructive, and Aesthetic Surgeons Skin Oncology Special Interest and Advisory Group.

RESULTS

There were 68 responses (55.3% response rate) from 36 SSMDTs in the UK. Respondents felt communication, chairing, and decision-making were similar in virtual and in-person MDTs, but the team working was worse in virtual meetings. Recruitment, data security, and patient confidentiality were maintained in virtual MDTs. Most preferred a hybrid format for future MDTs, with the option to attend virtually. Recommendations for improvement included better connectivity, IT support, training, and staff integration.

CONCLUSION

The virtual MDT is here to stay. We highlight the strengths and weaknesses of remote virtual skin MDTs. It is key that we look at ways to retain team working to ensure that the collegiate nature of MDT working, and therefore treatment options for patients, are not lost in this transformation in MDT delivery.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Latinx Patients' Perceptions of Culturally Sensitive Health Care and their Association with Patient Satisfaction, Patient-Provider Communication, and Therapeutic Alliance

Latinx in the USA experience disparities in morbidity and mortality when compared to their non-Hispanic White counterparts. Patient-centered culturally sensitive health care (PC-CSHC) has been deemed a best practice approach to alleviate and eliminate these disparities. However, literature on how Latinx patients perceive their care and what indicators of PC-CSHC may be most related to treatment outcomes is limited. This study collected data from 81 adult Latinx participants who had been admitted to an inpatient care unit to understand the following: (a) their perception of their providers' PC-CSHC in three different areas: Competence/Confidence, Sensitivity/Interpersonal, and Respect/Communication; (b) whether there are differences between English- and Spanish-speaking Latinx patients in their perception of their providers' PC-CSHC; and (c) whether these PC-CSHC indicators were associated to patient satisfaction, patient-provider communication, and therapeutic alliance. Participants were mostly male, older than 55 years of age, and working or lower class, with English as their primary language. Results showed that patients rated their providers' Competence (M = 3.57, SD = .46) higher than both Sensitivity, t(68) = .04, p = .04, (M = 3.49, SD =.54), and Respect, t(53) = 2.765, p = .008, (M = 3.38, SD = .57). English-speaking Latinx were overall less satisfied with their providers than Spanish-speaking Latinx, in particular in their communication. Finally, higher provider cultural sensitivity appears to be a predictor of patient satisfaction, patient-provider communication, and working alliance. Implications for refining provider trainings to treat this vulnerable and understudied (i.e., Latinx) population are discussed.

The association of smoking and socioeconomic status on cutaneous melanoma: a population-based, data-linkage, case-control study

BACKGROUND

Previous studies have identified an inverse association between melanoma and smoking; however, data from population-based studies are scarce.

OBJECTIVES

To determine the association between smoking and socioeconomic (SES) on the risk of development of melanoma. Furthermore, we sought to determine the implications of smoking and SES on survival.

METHODS

We conducted a population-based case-control study. Cases were identified from the Welsh Cancer Intelligence and Surveillance Unit (WCISU) during 2000-2015 and controls from the general population. Smoking and SES were obtained from data linkage with other national databases. The association of smoking status and SES on the incidence of melanoma were assessed using binary logistic regression. Multivariate survival analysis was performed on a melanoma cohort using a Cox proportional hazard model using survival as the outcome.

RESULTS

During 2000-2015, 9636 patients developed melanoma. Smoking data were obtained for 7124 (73·9%) of these patients. There were 26 408 controls identified from the general population. Smoking was inversely associated with melanoma incidence [odds ratio (OR) 0·70, 95% confidence interval (CI) 0·65-0·76]. Smoking was associated with an increased overall mortality [hazard ratio (HR) 1·30, 95% CI 1·09-1·55], but not associated with melanoma-specific mortality. Patients with higher SES had an increased association with melanoma incidence (OR 1·58, 95% CI 1·44-1·73). Higher SES was associated with an increased chance of both overall (HR 0·67, 95% CI 0·56-0·81) and disease-specific survival (HR 0·69, 95% CI 0·53-0·90).

CONCLUSIONS

Our study has demonstrated that smoking appeared to be associated with reduced incidence of melanoma. Although smoking increases overall mortality, no association was observed with melanoma-specific mortality. Further work is required to determine if there is a biological mechanism underlying this relationship or an alternative explanation, such as survival bias. What's already known about this topic? Previous studies have been contradictory with both negative and positive associations between smoking and the incidence of melanoma reported. Previous studies have either been limited by publication bias because of selective reporting or underpowered. What does this study add? Our large study identified an inverse association between smoking status and melanoma incidence. Although smoking status was negatively associated with overall disease survival, no significant association was noted in melanoma-specific survival. Socioeconomic status remains closely associated with melanoma. Although higher socioeconomic populations are more likely to develop the disease, patients with lower socioeconomic status continue to have a worse prognosis.

An investigation to ascertain whether or not time pressure influences the accuracy of final year student radiographers in abnormality detection when interpreting conventional appendicular trauma radiographs: A pilot study

INTRODUCTION

There is an increasing demand on diagnostic imaging departments, a shortage of radiologists, and a backlog of images requiring a report across several trusts in the UK. A negative impact on performance can result in significant outcomes for the patient. The aim of this study is to ascertain whether decisions made under time pressure will affect the accuracy of the interpretation of conventional radiographs.

METHODS

Final year undergraduate diagnostic radiography students were recruited [n = 21] and separated into three groups of seven at random, assigning time limits per image for a set of normal and abnormal conventional appendicular radiographs; 15 s (high pressure), 30 s (moderate pressure) and unlimited time (low pressure). Each image was assessed, and answers were recorded as normal or abnormal with an approximate location of the pathology.

RESULTS

The ANOVA test revealed no statistical significance amongst results. The mean accuracy was highest in the 15 s group (82.86%) and lowest in the unlimited time group (74.52%). The results also demonstrated a decrease in accuracy with increased image review times within the unlimited time group; with the quickest participant achieving 88.33% and the slowest, 56.67%.

CONCLUSION

The results demonstrated no statistical significance. However, it is recommended to conduct a similar study using sufficient reporting practitioners to enable direct parallels to be drawn with statistical significance.

IMPLICATIONS FOR PRACTICE

The results signify an importance for imaging departments to manage the number of staff and their workload. Subsequently, this aims to ensure reporting practitioners work at their optimum stress level for efficient work performance.

Management of regional metastatic disease in cutaneous malignancy of the head and neck. 3. Merkel cell carcinoma

This is the third of three articles that give an overview of the current evidence for management of the neck and parotid in patients with cutaneous cancers of the head and neck. In this paper we discuss Merkel cell carcinoma (MCC) and review the latest evidence for management of the regional nodes.

Skin tissue engineering using 3D bioprinting: An evolving research field

BACKGROUND

Commercially available tissue engineered skin remains elusive despite extensive research because the multi-stratified anisotropic structure is difficult to replicate in vitro using traditional tissue engineering techniques. Bioprinting, involving computer-controlled deposition of cells and scaffolds into spatially controlled patterns, is able to control not only the macro but also micro and nanoarchitecture and could offer the potential to more faithfully replicate native skin.

METHODS

We conducted a literature review using PubMed, EMBASE and Web of Science for studies on skin 3D bioprinting between 2009 and 2016, evaluating the bioprinting technique, cell source, scaffold type and in vitro and in vivo outcomes.

RESULTS

We outline the evolution of biological skin replacements, principles of bioprinting and how they apply to the skin tissue engineering field, potential clinical applications as well the current limitations and future avenues for research. Of the studies analysed, the most common types of bioinks consisted of keratinocytes and fibroblasts combined with collagen, although stem cells are gaining increasing recognition. Laser assisted deposition was the most common printing modality, although ink-jet and pneumatic extrusion have also been tested. Bioprinted skin promoted accelerated wound healing, was able to mimic stratified epidermis but not the thick, elastic, vascular dermis.

CONCLUSIONS

Although 3D bioprinting shows promise in engineering skin, evidenced by large collective investments from the cosmetic industry, the research is still in its infancy. The resolution, vascularity, optimal cell and scaffold combinations and cost of bioprinted skin are hurdles that need to be overcome before the clinical applicability can be realised. Small scale 3D skin tissue models for cosmetics, drug and toxicity testing as well as tumour modelling are likely to be translated first before we see this technology used in reconstructive surgery patients.

Multifocal capillary malformations in an older, asymptomatic child with a novel RASA1 mutation

Multifocal capillary malformation (CM) is the cardinal feature of patients with RASA1 mutations. These CMs are ‘red flags’, signalling the possible association with an arteriovenous malformation (AVM) or an arteriovenous fistula (AVF). We report an 8‐year‐old boy who presented with > 20 CMs, who was found to have a novel mutation in the RASA1 gene. Radiological screening of children with RASA1 mutations is not standardized, and we elected to carry out baseline magnetic resonance imaging of the brain and spine in our case, which gave normal results. We discuss the recent literature and our approach in the management of such a case.

Volumetric modulated arc therapy: a review of current literature and clinical use in practice

Volumetric modulated arc therapy (VMAT) is a novel radiation technique, which can achieve highly conformal dose distributions with improved target volume coverage and sparing of normal tissues compared with conventional radiotherapy techniques. VMAT also has the potential to offer additional advantages, such as reduced treatment delivery time compared with conventional static field intensity modulated radiotherapy (IMRT). The clinical worldwide use of VMAT is increasing significantly. Currently the majority of published data on VMAT are limited to planning and feasibility studies, although there is emerging clinical outcome data in several tumour sites. This article aims to discuss the current use of VMAT techniques in practice and review the available data from planning and clinical outcome studies in various tumour sites including prostate, pelvis (lower gastrointestinal, gynaecological), head and neck, thoracic, central nervous system, breast and other tumour sites.

Undergraduate occupational medicine tuition in UK schools of medicine

AIMS

To assess any recent change in the quantity of teaching of occupational medicine (OM) in UK undergraduate medical curricula, and to compare these results with those obtained in previous years.

METHODS

A questionnaire survey designed to capture information on the teaching of OM to undergraduates in all medical schools listed in the UK Universities and Colleges Admissions Service prospectus for 2008-09.

RESULTS

Twenty-one of 32 (66%) UK medical schools returned a completed questionnaire. A comparison of results from this survey, with previous surveys, of teaching of OM to undergraduates in the UK showed that fewer schools now provide lectures, project work or ward-based tuition in this subject, than previously. In contrast to previous surveys, workplace visits were not undertaken by any institution. Only three (15%) of the schools setting an examination question related to OM also had a syllabus or explicit learning outcomes. More schools reported incorporating OM teaching within the teaching of other subjects.

CONCLUSIONS

Despite the increasing recognition of the impact and value of work on health and the growing evidence base to support work as a means of enhancing health, medical schools fall far short of a comprehensive programme of teaching in this important subject area. This may result in doctors being poorly prepared to recognize and diagnose occupational diseases adequately, and poorly equipped to support their patients in, for example, return to work, rehabilitation or providing advice on fitness to work.

Observation of Large-Scale Structures in Unsaturated Materials

We report here the use of nuclear magnetic resonance imaging in the observation of liquid-phase fraction distributions in a partially-wetted sample of glass beads. By combiningboth large- and small-scale imaging techniques, we can study the transition from local-averaged saturations to large-scale averaged saturations. The image data allows us to assess the utility of the large-scale measurements We comment on the reliability and generality of the measurements for our specific system.

When to respond? And how much?

Rats were trained on mixed-fixed-interval (FI) schedules, with component FIs of 30 and 60s. The probability of reinforcement according to FI 30s varied between conditions, across values of 0.1, 0.3, 0.5, 0.7 and 0.9. When response rate in the 60s intervals was measured, separate response peaks, one close to 30s, the other at 60s, could be identified when the probability of reinforcement at 30s was 0.3 or greater. Nonlinear regression found that the location of the earlier peak was always close to 30s, that the coefficient of variation of the response functions at 30 and 60s were unaffected by reinforcement probability, but that the 30s component appeared to be timed slightly more precisely than the 60s one. Response rate at around 30s increased with increasing probability of reinforcement according to FI 30s, but responding at 60s was unaffected by reinforcement probability. The data are discussed with respect to a number of contemporary models of animal timing (scalar expectancy theory, the Behavioural Theory of Timing and the Learning to Time model), and a recent account of response output on FI-like schedules.

Multiple-interval timing in rats: Performance on two-valued mixed fixed-interval schedules

Three experiments studied timing in rats on 2-valued mixed-fixed-interval schedules, with equally probable components, Fixed-Interval S and Fixed-Interval L (FI S and FI L, respectively). When the L:S ratio was greater than 4, 2 distinct response peaks appeared close to FI S and FI L, and data could be well fitted by the sum of 2 Gaussian curves. When the L:S ratio was less than 4, only 1 response peak was usually visible, but nonlinear regression often identified separate sources of behavioral control, by FI S and FI L, although control by FI L dominated. Data were used to test ideas derived from scalar expectancy theory, the behavioral theory of timing, and learning to time.

Cellular growth in biofilms

In this paper we develop a macroscopic evolutionary equation for the growth of the cellular phase starting from a microscopic description of mass transport and a simple structured model for product formation. The methods of continuum mechanics and volume averaging are used to develop the macroscopic representation by carefully considering the fluxes of chemical species that pertain to cell growth. The concept of structured models is extended to include the transport of reacting chemical species at the microscopic scale. The resulting macroscopic growth model is similar in form to previously published models for the transport of a single substrate and electron donor and for the production of cellular mass and exopolymer. The method of volume averaging indicates under what conditions the developed growth model is valid and provides an explicit connection between the relevant microscopic model parameters and their corresponding macroscopic counterparts.

Hu23F2G, an antibody recognizing the leukocyte CD11/CD18 integrin, reduces injury in a rabbit model of transient focal cerebral ischemia

Neutrophils are known to mediate injury in acute ischemic stroke especially during reperfusion. Migration of neutrophils into regions of ischemic injury involves binding to the endothelial cell's intercellular adhesion molecule (ICAM-1) through the leukocyte integrin, CD11/CD18. We studied the potential for neuroprotection with a humanized antibody that binds to and blocks the functions of the CD11/CD18 integrin in a rabbit model of transient focal ischemia. Fifteen New Zealand White rabbits underwent transorbital occlusion of the left middle cerebral, anterior cerebral, and internal carotid arteries using aneurysm clips for 2 h, followed by 6 h of reperfusion. Treatment with a maximally saturating dose (4 mg/kg) of a humanized CD11/CD18 monoclonal antibody (Hu23F2G, ICOS Corp., Bothell, WA) (n = 8) or placebo (n = 7) was administered 20 min after occlusion and given as a single intravenous bolus. Hemispheric ischemic neuronal damage (IND) as seen on hematoxylin- and eosin-stained sections was significantly reduced in Hu23F2G-treated animals by 57% (Hu23F2G: 15 +/- 6.9%; placebo: 35 +/- 5%; mean +/- SEM, P < 0.05, t-test). Immunohistochemical staining with neutrophil elastase confirmed the presence of neutrophils within regions of IND in control brains. Treatment with Hu23F2G resulted in marked reduction of neutrophil infiltration. (No. of neutrophils/IND area: Hu23F2G 36.1 +/- 36.7 cm-2, placebo 460.6 +/- 101.8 cm-2, P = 0.001. ) Antagonism of neutrophil migration at the level of the CD11/CD18 integrin reduces ischemic injury in experimental stroke.

Electrocochleographic signal analysis: condensation and rarefaction click stimulation contributes to diagnosis in Menière's disorder

Thirty patients with Menière's disorder, 11 patients with cochlear hearing loss of other aetiologies and 10 normally-hearing subjects, were investigated using transtympanic electrocochleography (TT ECochG). Alternating polarity clicks, condensation and rarefaction clicks and long tone-bursts of 1 kHz were used for stimulation. The latencies of the AP responses to click stimulation were evaluated. It was found that the latency differences between the condensation and rarefaction click-evoked responses were significantly larger in patients with Menière's disorder as compared to normal subjects and to patients with other cochlear hearing losses. It was found that the sensitivity of TT ECochG, obtained by using measurements of SP-AP ratios and the SP amplitude at 1 kHz burst stimulation, increased from 83 per cent to 87 per cent by addition of the con-rar shift measurement. The specificity of TT ECochG obtained by this combination of variables was 100 per cent in our material. The results of the study indicate that the latency shift found in responses evoked by clicks of opposite polarities in TT ECochG, can be a useful parameter in the detection of suspected endolymphatic hydrops.

A polycistronic transcript in transformed cells encodes the dihydrofolate reductase of herpesvirus saimiri

Herpesvirus saimiri, an oncogenic gamma herpesvirus of primates, is the only eukaryotic virus that carries the entire metabolic gene set for a complex biochemical synthesis. Every element of the thymidine synthesis gene cascade is present in the virus, and their function is probably related to the uniquely high A + T content of the genome. Although one member of the gene set, dihydrofolate reductase (DHFR), is mapped in a region required for oncogenesis, very little is known of the expression and function of this gene in transformed cells. We report the expression of the DHFR sequence on a novel, unique tricistronic transcript in virally transformed tumor cells. The DHFR sequence is the first open reading frame on a 5.3 kb minor transcript. Alpha-amanitine sensitivity indicates that it is an RNA polymerase II transcript, and since it is also polyadenylated it appears to be a functional, relatively unstable (half-life 3 hr) mRNA. Initiation of transcription uniquely overlaps with the HSUR3 small RNA gene. Expression of the small transcript appears to be alpha-amanitine resistant, implicating polymerase III transcription. Together with the remarkably low-level expression of HSUR3 in tumor cells, the data may indicate transcription interference between two different RNA polymerases, with unusual overlapping regulation and initiation.

Audit of pre-employment assessments by occupational health departments in the National Health Service

Pre-employment health assessment of applicants to the National Health Service (NHS) is one of the functions of occupational health departments in the NHS. This paper describes the results of a process and outcome audit of this activity, concentrating on the current practice of occupational health departments. The audit was carried out by 40 NHS occupational health units who provided information on a standard questionnaire on all pre-employment assessments undertaken over a three-month period. This produced 9139 questionnaire returns. The analysis showed that the most common method of assessment was the use of a self-administered questionnaire alone (49.4%). A self-administered questionnaire followed by a nurse interview as standard practice was the next most common method (34.1%), but referral to a physician was uncommon. The outcome of the assessments for 98% of all applicants was 'fit for work'. A total of 120 individuals (1.3%) were assessed as 'fit to work, but with some restriction' and 65 individuals (0.7%) were considered 'unfit'. The most common reasons for rejection were abnormal body mass index (40%), skin conditions (21.5%) and psychiatric conditions (10.8%). The most common reasons for restriction were musculoskeletal conditions (27.5%), skin conditions (15%) and abnormal body mass index and psychiatric conditions (both 10.8%). The audit identified wide variation between occupational health departments in the NHS in the practice of restriction and rejection. A decision on the value of pre-employment assessment in the NHS mus take into consideration the ability of the process to achieve its aim, the time and manpower involved in the process, and the probability of low restriction and rejection rates.(ABSTRACT TRUNCATED AT 250 WORDS)

The art and science of home infant apnea monitoring in the 1990s

The use of home apnea monitoring (HAM) continues as an accepted or recommended intervention for infants with certain signs and symptoms or medical diagnoses. Results of HAM in terms of case outcomes versus cost-effectiveness and efficacy remain matters of controversy in relation to the limited number of studies that show conflicting results. There are no studies that document the effectiveness of apnea monitoring. When an apnea monitor is prescribed, nursing can provide quality care through education and emotional support of families using HAM.

Protecting nurses' mental health

Following the recommendations of the Allitt Inquiry (1), the role of managers in ensuring staff's mental health needs are catered for and that others are protected from any risk posed by a nurse's mental health status has been highlighted. This article reviews the evidence for mental ill health within the NHS and looks at ways of ensuring recommendations are implemented.

PEA: working towards standards of good practice in the NHS

At the beginning of the year Stuart Whitaker described a pilot study for the national audit of pre-employment assessment in the NHS. Having completed the project he now presents its findings with a call for the introduction of standards of good practice.