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1.  Industrializing skin cancer care: better and cheaper? 
PMCID: PMC3480856  PMID: 23104939
2.  The Importance of a Full Clinical Examination: Assessment of Index Lesions Referred to a Skin Cancer Clinic Without a Total Body Skin Examination Would Miss One in Three Melanomas 
Acta dermato-venereologica  2013;93(6):10.2340/00015555-1625.
Traditional clinical teaching emphasises the importance of a full clinical examination. In the clinical assessment of lesions that may be skin cancer, full examination allows detection of incidental lesions, as well as helping in the characterisation of the index lesion. Despite this, a total body skin examination is not always performed. Based on two prospective studies of over 1,800 sequential patients in two UK centres we show that over one third of melanomas detected in secondary care are found as incidental lesions, in patients referred for assessment of other potential skin cancers. The majority of these melanomas occurred in patients whose index lesion turned out to be benign. Alternative models of care – for instance some models of teledermatology in which a total body skin examination is not performed by a competent practitioner – cannot be considered equivalent to a traditional consultation and, if adopted uncritically, without system change, will likely lead to melanomas being missed.
PMCID: PMC3808818  PMID: 23695107
melanoma; skin cancer; screening; teledermatology; total body skin examination
3.  Melanoma: What Are the Gaps in Our Knowledge? 
PLoS Medicine  2008;5(6):e122.
Jonathan Rees outlines a number of puzzling gaps that remain in our knowledge of the etiology of non-acral melanomas.
PMCID: PMC2408613  PMID: 18532876
5.  A Questionnaire Elicitation of Surgeons’ Belief about Learning within a Surgical Trial 
PLoS ONE  2012;7(11):e49178.
Surgeons gain expertise as they repeatedly conduct a procedure. Such learning is widely acknowledged to pose a challenge to evaluating new surgical procedures. Most surgical trials report little if any information on learning. We elicited surgeons’ belief regarding learning within the context of a randomised trial which assessed two surgical procedures.
Materials and Methods
Surgeons participating in the UKUFF trial were sent a postal questionnaire requesting details on current practice, prior experience and their belief regarding acquiring proficiency and the learning curve of operation time for two surgical procedures (open and arthroscopic rotator cuff repair).
In total 52 (58%) participating surgeons returned a completed questionnaire. The median (IQR) number of procedures required to acquire proficiency were 17 (10,23) and 35 (23,50) for the open and arthroscopic repairs respectively. The distribution of surgeons’ belief regarding the initial point had median (IQR) of 109 (69,128) and 145 (97,171) minutes for open and arthroscopic repair respectively. Corresponding values for the plateau point were 60 (46, 82) and 79 (58, 110).
We have shown that information on the current practice, prior experience and beliefs on the learning process of a surgical procedure can be elicited using a short questionnaire. The approach could aid the interpretation of trial results in terms of generalisability and be used a priori in the design of a trial.
PMCID: PMC3493499  PMID: 23145113
6.  Dermatology undergraduate skin cancer training: a disconnect between recommendations, clinical exposure and competence 
BMC Medical Education  2012;12:27.
Skin cancers are the most common malignancies in Caucasian populations. Non-specialists are responsible for the initial assessment of skin lesions and are required to act as the gatekeepers to dermatological cancer services in many healthcare systems. The majority of such physicians receive very limited formal undergraduate or postgraduate dermatology training. The British Association of Dermatologists (BAD) has produced guidelines that list the lesions that students should be able to diagnose on graduation and the majority of UK medical schools’ operate curricula in keeping with these. There is, however, virtually no evidence as to whether these competencies are being achieved. We set out to determine students’ competence at skin lesion diagnosis and to quantify their clinical exposure to examples of such lesions during their dermatology attachment.
Three linked studies were undertaken. In the first, students’ competence was tested by randomized slideshows of images containing the 16 lesions recommended in the UK guidelines. Students’ accuracy was tested at the beginning (Day 1) and end (Day 10) of their clinical placement, with a random sample of students retested 12 months later. Secondly, students’ exposure to these lesions was recorded during their attachments. Finally a survey of the additional dermatological resources used by the students was undertaken.
Study 1: Students’ diagnostic accuracy increased from 11% on Day 1 to 33% on Day 10 (effect size +2.72). After 12 months half of this effect had disappeared and the students accuracy had dropped to 24%. Study 2: Students’ exposure to the recommended lesions was poor with 82% not even witnessing a single example of each of the 3 major skin cancers. Despite these measurements, only a minority of students reported that they were not confident at diagnosing skin tumours. Study 3: The majority of students use additional resources to supplement their learning.
In the light of what we know about learning in dermatology, our data would suggest, that the current (traditional) undergraduate attachment is inadequate to meet the UK recommendations for graduate competence. As well as critically examining the basis for these recommendations, we need more empirical data on student performance and exposure, in order to improve teaching and learning.
PMCID: PMC3391986  PMID: 22569037
7.  Novice Identification of Melanoma: Not Quite as Straightforward as the ABCDs 
Acta dermato-venereologica  2011;91(2):125-130.
The “ABCD” mnemonic to assist non-experts’ diagnosis of melanoma is widely promoted; however, there are good reasons to be sceptical about public education strategies based on analytical, rule-based approaches – such as ABCD (i.e. Asymmetry, Border Irregularity, Colour Uniformity and Diameter). Evidence suggests that accurate diagnosis of skin lesions is achieved predominately through non-analytical pattern recognition (via training examples) and not by rule-based algorithms. If the ABCD are to function as a useful public education tool they must be used reliably by untrained novices, with low inter-observer and intra-diagnosis variation, but with maximal inter-diagnosis differences. The three subjective properties (the ABCs of the ABCD) were investigated experimentally: 33 laypersons scored 40 randomly selected lesions (10 lesions × 4 diagnoses: benign naevi, dysplastic naevi, melanomas, seborrhoeic keratoses) for the three properties on visual analogue scales. The results (n=3,960) suggest that novices cannot use the ABCs reliably to discern benign from malignant lesions.
PMCID: PMC3325479  PMID: 21311845
ABCD; non-analytical reasoning; pattern recognition; skin cancer; melanoma; dermatology diagnosis
8.  Are Subjective Accounts of Itch to be Relied on? The Lack of Relation Between Visual Analogue Itch Scores and Actigraphic Measures of Scratch 
Acta dermato-venereologica  2011;91(1):18-23.
There is a widespread belief that subjective accounts of disease are key components of measures of disease severity and quality of life. In the present study we have set out to test this hypothesis using visual analogue scales (VAS) for itch, as a subjective measure, and actigraphy as an objective measure. One-hundred and seventeen itchy children and adults (and 25 controls) were studied for clusters of nights (total number 1,654) and actigraphy scores and VAS itch taken daily. Fifty-six percent of the night-to-night variation in actigraphy scores occurred between different individuals, while 44% was intra-subject. Neither age nor sex (children’s or adults’) predicted actigraphy scores, and the only significant predictor of actigraphy score was disease type (p = 0.001, r2 = 0.51). In a multivariate model VAS itch score was not a significant determinant of actigraphy scores for either children or adults (p = 0.26). In order to see if there was a relation between VAS itch and actigraphy within the same patients (rather than between patients), 20 eczema patients wore the actigraph and scored VAS itch nightly for 42 nights. Little relationship was found between the actigraphy score and the VAS itch. Empirical autocorrelation analysis of VAS itch and actigraphy score reveal a clear autocorrelation for subjective VAS scores that was not found for the objective actigraphy score. Our data suggest a dissociation between scratch and perceived or recalled itch. One explanation is that VAS itch scores suffer from considerable anchoring, and context bias, and that their use in measures of disease severity is problematic.
PMCID: PMC3160471  PMID: 21103852
actigraphy; pruritus; visual analogue scale; bias
9.  Utility of Non-rule-based Visual Matching as a Strategy to Allow Novices to Achieve Skin Lesion Diagnosis 
Acta dermato-venereologica  2011;91(3):279-283.
Non-analytical reasoning is thought to play a key role in dermatology diagnosis. Considering its potential importance, surprisingly little work has been done to research whether similar identification processes can be supported in non-experts. We describe here a prototype diagnostic support software, which we have used to examine the ability of medical students (at the beginning and end of a dermatology attachment) and lay volunteers, to diagnose 12 images of common skin lesions. Overall, the non-experts using the software had a diagnostic accuracy of 98% (923/936) compared with 33% for the control group (215/648) (Wilcoxon p < 0.0001). We have demonstrated, within the constraints of a simplified clinical model, that novices’ diagnostic scores are significantly increased by the use of a structured image database coupled with matching of index and referent images. The novices achieve this high degree of accuracy without any use of explicit definitions of likeness or rule-based strategies.
PMCID: PMC3160473  PMID: 21461552
non-analytical reasoning; skin cancer; electronic clinical decision support software; melanoma; dermatology diagnosis
10.  Genetic determinants of hair and eye colours in the Scottish and Danish populations 
BMC Genetics  2009;10:88.
Eye and hair colour is highly variable in the European population, and is largely genetically determined. Both linkage and association studies have previously been used to identify candidate genes underlying this variation. Many of the genes found were previously known as underlying mutant mouse phenotypes or human genetic disease, but others, previously unsuspected as pigmentation genes, have also been discovered.
We assayed the hair of a population of individuals of Scottish origin using tristimulus colorimetry, in order to produce a quantitative measure of hair colour. Cluster analysis of this data defined two groups, with overlapping borders, which corresponded to visually assessed dark versus red/light hair colour. The Danish population was assigned into categorical hair colour groups. Both cohorts were also assessed for eye colour. DNA from the Scottish group was genotyped at SNPs in 33 candidate genes, using 384 SNPs identified by HapMap as representatives of each gene. Associations found between SNPs and colorimetric hair data and eye colour categories were replicated in a cohort of the Danish population. The Danish population was also genotyped with SNPs in 4 previously described pigmentation genes. We found replicable associations of hair colour with the KITLG and OCA2 genes. MC1R variation correlated, as expected, with the red dimension of colorimetric hair colour in Scots. The Danish analysis excluded those with red hair, and no associations were found with MC1R in this group, emphasising that MC1R regulates the colour rather than the intensity of pigmentation. A previously unreported association with the HPS3 gene was seen in the Scottish population. However, although this replicated in the smaller cohort of the Danish population, no association was seen when the whole study population was analysed.
We have found novel associations with SNPs in known pigmentation genes and colorimetrically assessed hair colour in a Scottish and a Danish population.
PMCID: PMC2810292  PMID: 20042077
11.  Post-traumatic flexion contractures of the elbow: Operative treatment via the limited lateral approach 
Varying surgical techniques, patient groups and results have been described regards the surgical treatment of post traumatic flexion contracture of the elbow. We present our experience using the limited lateral approach on patients with carefully defined contracture types.
Surgical release of post-traumatic flexion contracture of the elbow was performed in 23 patients via a limited lateral approach. All patients had an established flexion contracture with significant functional deficit. Contracture types were classified as either extrinsic if the contracture was not associated with damage to the joint surface or as intrinsic if it was.
Overall, the mean pre-operative deformity was 55 degrees (95%CI 48 – 61) which was corrected at the time of surgery to 17 degrees (95%CI 12 – 22). At short-term follow-up (7.5 months) the mean residual deformity was 25 degrees (95%CI 19 – 30) and at medium-term follow-up (43 months) it was 32 degrees (95%CI 25 – 39). This deformity correction was significant (p < 0.01). One patient suffered a post-operative complication with transient dysaesthesia in the distribution of the ulnar nerve, which had resolved at six weeks. Sixteen patients had an extrinsic contracture and seven an intrinsic. Although all patients were satisfied with the results of their surgery, patients with an extrinsic contracture had significantly (p = 0.02) better results than those with an intrinsic contracture. (28 degrees compared to 48 degrees at medium term follow up).
Surgical release of post-traumatic flexion contracture of the elbow via a limited lateral approach is a safe technique, which reliably improves extension especially for extrinsic contractures. In this series all patients with an extrinsic contracture regained a functional range of movement and were satisfied with their surgery.
PMCID: PMC2546394  PMID: 18783605

Results 1-11 (11)