Impact of Liposomal Bupivacaine on Enhanced Recovery After Surgery Protocol for Lung Resection.

BACKGROUND: There is limited data showing the benefit of liposomal bupivacaine as part of an Enhanced Recovery After Surgery (ERAS) protocol in reducing opioid use in minimally invasive lobectomies. METHODS: A retrospective observational study compared three cohorts of patients undergoing lobectomies between January 2015 and December 2021. The control group neither received liposomal bupivacaine intraoperatively nor underwent an ERAS protocol. The liposomal bupivacaine cohort only received a nerve block, whereas the ERAS cohort received a nerve block intraoperatively and underwent an ERAS protocol. Primary outcome was post-operative opioid consumption. RESULTS: There were 433 patients in this study (n=87 for controls, n=138 for liposomal bupivacaine alone, and n=208 for ERAS/liposomal bupivacaine). There was a statistically significant difference in the amount of opioids used between the control (43 OME) and liposomal bupivacaine alone cohort (30.5 OME) (p<.001); between control vs. ERAS/liposomal bupivacaine cohort (17 OME) (p<.001); and between liposomal bupivacaine alone and ERAS/liposomal bupivacaine cohorts (p<.001). Hospital stay was not statistically different between the two groups of interest (3 days); however, hospital stay differed from the control (4 days). 30-day readmission was not significantly different between the 3 groups (p=.43). CONCLUSIONS: Liposomal bupivacaine alone as part of a larger ERAS protocol significantly reduced opioid use and hospitalization duration; however, the reduction in opioid use was much greater with incorporation of liposomal bupivacaine into an ERAS protocol rather than in isolation. Prospective studies are needed to determine reproducibility and applicability of liposomal bupivacaine for opioid use reduction in other US hospital systems.

Lateral Compartment Syndrome From Inversion Injury.

A 17-year-old male presented for the evaluation of right calf pain after an inversion ankle sprain sustained while playing soccer 24 hours prior. On exam, he exhibited swelling and tenderness to palpation over his right calf, mild first web space numbness, and compartment pressures <30 mmHg. Magnetic resonance imaging was significant for findings of lateral compartment syndrome (CS). Upon admission, his exam worsened, prompting an anterior and lateral compartment fasciotomy. Intraoperative findings were significant for lateral CS, with findings of avulsed, nonviable muscle with associated hematoma. Postoperatively the patient had mild foot drop, which improved with physical therapy. Lateral CS rarely develops from an inversion ankle sprain. This presentation of CS is unique due to its mechanism, delayed clinical presentation, and limited signs of CS. Providers should maintain a high index of suspicion for CS in patients with this injury complex and continued pain beyond 24 hours without signs of ligamentous injury.

Feasibility and Safety of a Combined Metabolic Strategy in Glioblastoma Multiforme: A Prospective Case Series.

Background: Glioblastoma multiforme (GBM) may be susceptible to metabolic strategies such as fasting and ketogenic diets, which lower blood glucose and elevate ketones. Combining these two strategies may be an ideal approach for sustaining a potentially therapeutic glucose ketone index (GKI). In this prospective case series, we observed whether a combined metabolic strategy was feasible, safe, and capable of sustaining a GKI <6 in patients with GBM. Methods: We provided recommendations and guidelines to 10 GBM patients at various stages of tumour progression and treatment that enabled them to complete a 5-7-day fast every 1-2 months combined with a modified ketogenic diet during the intervening weeks. Patients monitored their blood glucose and ketone levels and body weight. Adverse effects were assessed. Results: Patients completed a mean of 161 ± 74 days of the combined metabolic strategy, with 34 ± 18 (21%) days of prolonged fasting (mean fast duration: 6.0 ± 1.4 days) and 127 ± 59 (79%) days on the ketogenic diet. The mean GKI for all 10 patients was 3.22 (1.28 during the fasts, 5.10 during the ketogenic diet). Body weight decreased by 8.4 ± 6.9 kg (11.2% decrease in baseline weight). The most common adverse effects attributed to the fasts and ketogenic diet were fatigue, irritability, and feeling lightheaded. The metabolic strategy did not interfere with standard oncological treatments. Conclusion: This is the first study to observe the feasibility and safety of repeated, prolonged fasting combined with a modified ketogenic diet in patients with GBM. Using minimal support, patients maintained the combined metabolic strategy for 5-6 months while sustaining a potentially therapeutic mean GKI of 3.22. Weight loss was considerable. Adverse effects attributed to the metabolic strategy were mild, and it did not interfere with standard oncological treatments. Study Registration: This study is registered on the Australia New Zealand Clinical Trials Registry, number ACTRN12620001310954. The study was registered on 4 December 2020.

Portal vein thrombosis after second Pfizer/BioNTech coronavirus disease 2019 vaccine.

We have reviewed a case of portomesenteric venous thrombosis that occurred shortly after the administration of the second Pfizer/BioNTech coronavirus disease 2019 (COVID-19) vaccine and discussed the literature surrounding the subject. Our report was generated after reviewing the patient's medical records and clinical images with his written informed consent. The literature review was conducted using PubMed and Google Scholar. Portomesenteric venous thrombosis after the Pfizer/BioNTech COVID-19 vaccine has previously been reported, although infrequently. We did not find enough information, given the paucity of the reported data, to assert a causative relationship between the Pfizer/BioNTech COVID-19 vaccine and the occurrence of portomesenteric thrombosis.

Comparison of Donor Corneal Endothelial Cell Density Determined by Eye Banks and by a Central Image Analysis Reading Center Using the Same Image Analysis Method.

PURPOSE: The purpose of this study was to evaluate agreement between eye banks (EBs) and an image analysis reading center on endothelial cell density (ECD) determinations using the same image analysis method. METHODS: The Cornea Image Analysis Reading Center (CIARC) determined ECD with a single experienced analyst on EB-obtained central endothelial images from donors intended for keratoplasty from 2 eye banks, Eversight and Lions VisionGift, using the Konan center analysis method. The EBs performed ECD determination on their respective sets of images using the same analysis method with experienced eye bank technicians. RESULTS: The mean age of the 200 donors was 54 years (range 30-75 years). Seventy (35%) of the 200 patients were women, and 57 (29%) were diabetic. The mean ECD was 10 cells/mm2 greater by the EBs than by CIARC (P = 0.39), with 95% limits of agreement of [-304 to 323 cells/mm2]. The mean difference was not substantially changed when the difference between EBs and CIARC ECD was adjusted for sex, donor age, donor diabetes, CV, HEX, number of cells analyzed, and EBs as a random effect (estimated mean difference of 20 cells/mm2 after adjustment in a linear mixed model; P = 0.73). The EB-determined preoperative ECD was within 10% of the CIARC-determined ECD for 178 (89%) image sets, with 15 (8%) higher by >10% and 7 (3%) lower by >10%. CONCLUSIONS: Well-trained eye bank technicians achieve comparable results for ECD determination with an experienced image analyst from an image analysis reading center when the same image analysis method is used.

Comparison of Donor Cornea Endothelial Cell Density Determined by Eye Banks and by a Central Reading Center in the Cornea Preservation Time Study.

PURPOSE: To evaluate agreement between eye banks (EBs) and a reading center on endothelial cell density (ECD) determinations in the Cornea Preservation Time Study. METHODS: The Cornea Image Analysis Reading Center (CIARC) performed variable frame image analysis on EB-obtained-preoperative central endothelial images (after lamellar dissection for Descemet stripping automated endothelial keratoplasty by the EBs or before shipping, if surgeon prepared) to determine ECD. The EBs performed their usual method of ECD determination. The CIARC and EBs also provided ECD determinations from screening central endothelial images taken by the EBs during donor evaluation. Two independent masked CIARC readers determined ECD with measurements averaged. RESULTS: The mean preoperative ECD was 15 cells/mm greater by the EBs than by CIARC (N = 1286, P < 0.001) with 95% limits of agreement of (-644, 675 cells/mm). The limits of agreement in preoperative ECD were wider in the After-Lamellar-Dissection Group (-687, 683 cells/mm) than in the Before Shipping Group [(-505, 633 cells/mm); P = 0.03]. The EBs-determined preoperative ECD was within 10% of the CIARC-determined ECD for 886 (69%) image sets, with 236 (18%) higher by >10% and 164 (13%) lower by >10%. Excellent agreement appeared between the EBs and CIARC when 100-300 cells could be analyzed in contrast to <100 cells (SD = 308 cells/mm vs. SD = 603 cells/mm; P < 0.001). CONCLUSIONS: The mean ECD by the EBs and CIARC were similar, but there was considerable variability between determinations for individual corneas. Agreement improved between the 2 measurements when more than 100 cells were able to be analyzed.

A prospective study of weekly intensity modulated radiation therapy plan adaptation for head and neck cancer: improved target coverage and organ at risk sparing.

This prospective study of weekly CT scanning and plan adaption during H&N IMRT reports on the frequency of plan adaptations based on dosimetric differences between original and re-optimised IMRT plans. The volumetric and geometric change occurring in target volumes and salivary glands is also described. Ten H&N cancer patients underwent weekly planning CT imaging and re-optimisation of the IMRT plan if PTV or OAR coverage was unacceptable. Comparisons of PTV and parotid gland dosimetry between the original and adaptive plans were made. Parotid and submandibular gland volume changes and shift were calculated. Eight of ten patients required one or more plan adaptations, with 41% of adaptations occurring by fraction ten. Salivary glands reduced in volume, with a medial shift of the lateral border of the parotid gland and a superior shift of the submandibular gland. Change in PTV coverage did not correlate with weight loss or nutritional score. Inadequate PTV coverage, requiring plan adaptation, occurs early in the course of IMRT. A weekly Adaptive RT (ART) protocol results in significant improvement of PTV coverage. Implementation of a clinical ART protocol should include imaging and dose calculation within the first ten fractions.

Improving comprehensive care for patients with diabetes.

Patients with diabetes require access to systematic and ongoing care delivered by a team of healthcare providers. Despite national attention and well-accepted best practices, diabetic care, blood pressure and haemoglobin A1c (A1c) levels for patients with diabetes in our primary care setting were highly variable and below the Healthcare Effectiveness Data and Information Set (HEDIS) 75th percentile benchmark. From January 2015 to January 2016, 22% of patients with diabetes in our primary care setting had both blood pressure and A1c levels controlled and 23% had their annual diabetic care bundle completed, which includes A1c and blood pressure measurements, foot examination and nephropathy attention. Lack of standardised care algorithms, electronic health record documentation and education was identified. Lean Six Sigma methodologies were used to re-engineer the care that patients with diabetes receive. Key improvement initiatives focused on standardisation of accepted care practices through electronic templates, education and re-evaluation of patients to make 90-day, rapid cycle changes. Interventions were piloted in one primary care clinic then expanded to eight additional clinics. At the pilot site, the per cent of patients who completed the diabetic care bundle increased from 33% to 71% and the per cent of patients with diabetes with both A1c and blood pressure controlled increased from 31% to 43% (two-proportion test, p<0.01) postintervention. On rollout to eight additional clinics, the per cent of patients who completed the diabetic care bundle increased from 23% to 67% and the per cent of patients with diabetes with both their A1c and their blood pressure controlled increased from 22% to 41% (two-proportion test, p<0.01). After the interventions, nephropathy attention, A1c and blood pressure metrics exceeded HEDIS 75th percentile. Standardisation of accepted care practices for patients with diabetes improved compliance with diabetic care bundle completion and patient outcomes in the primary care setting.

Chronic Granulomatous Disease: Epidemiology, Pathophysiology, and Genetic Basis of Disease.

Chronic Granulomatous Disease is one of the classic primary immunodeficiencies of childhood. While the incidence and severity of bacterial and fungal infections have been greatly reduced in this patient population, much remains to be learned about the pathophysiology of the disease, particularly for autoinflammatory manifestations. In this review, we examine the epidemiology, pathophysiology, and genetic basis for CGD.

Correlations between contouring similarity metrics and simulated treatment outcome for prostate radiotherapy.

Many similarity metrics exist for inter-observer contouring variation studies, however no correlation between metric choice and prostate cancer radiotherapy dosimetry has been explored. These correlations were investigated in this study. Two separate trials were undertaken, the first a thirty-five patient cohort with three observers, the second a five patient dataset with ten observers. Clinical and planning target volumes (CTV and PTV), rectum, and bladder were independently contoured by all observers in each trial. Structures were contoured on T2-weighted MRI and transferred onto CT following rigid registration for treatment planning in the first trial. Structures were contoured directly on CT in the second trial. STAPLE and majority voting volumes were generated as reference gold standard volumes for each structure for the two trials respectively. VMAT treatment plans (78 Gy to PTV) were simulated for observer and gold standard volumes, and dosimetry assessed using multiple radiobiological metrics. Correlations between contouring similarity metrics and dosimetry were calculated using Spearman's rank correlation coefficient. No correlations were observed between contouring similarity metrics and dosimetry for CTV within either trial. Volume similarity correlated most strongly with radiobiological metrics for PTV in both trials, including TCPPoisson (ρ = 0.57, 0.65), TCPLogit (ρ = 0.39, 0.62), and EUD (ρ = 0.43, 0.61) for each respective trial. Rectum and bladder metric correlations displayed no consistency for the two trials. PTV volume similarity was found to significantly correlate with rectum normal tissue complication probability (ρ = 0.33, 0.48). Minimal to no correlations with dosimetry were observed for overlap or boundary contouring metrics. Future inter-observer contouring variation studies for prostate cancer should incorporate volume similarity to provide additional insights into dosimetry during analysis.

Sodium Orthovanadate Inhibits Proliferation and Triggers Apoptosis in Oral Squamous Cell Carcinoma in vitro.

Sodium orthovanadate (SOV) is a general inhibitor of tyrosine phosphatases, a large family of enzymes that catalyze the removal of phosphate groups from tyrosine residues. SOV is commonly used in the laboratory to preserve the protein tyrosyl phosphorylation state of proteins under study. It has shown promising antineoplastic activity in some human cancer cell lines; this effect has not been fully investigated in head and neck squamous cell carcinoma. In this study, the effect of SOV on cell growth, proliferation, viability, and apoptosis was assessed in Cal27 cells, an oral squamous cell carcinoma (OSCC) cell line. SOV exhibited dose-dependent inhibition of cell growth and decrease in cell viability and colony formation. The IC50 values for treatment lasting 72 h and 7 days were 25 and 10 µM, respectively. The cytotoxic effect of the drug was associated with poly(ADP-ribose)polymerase cleavage detected by immunoblot. Flow cytometry of Cal27 cells stained with annexin V-FITC and propidium iodide showed a dose-dependent increase in apoptosis that reached approximately 40% at 25 µM SOV. These findings demonstrate that SOV has in vitro antiproliferative and proapoptotic effect on OSCC cells.

Science Outside the Lab: Helping Graduate Students in Science and Engineering Understand the Complexities of Science Policy.

Helping scientists and engineers challenge received assumptions about how science, engineering, and society relate is a critical cornerstone for macroethics education. Scientific and engineering research are frequently framed as first steps of a value-free linear model that inexorably leads to societal benefit. Social studies of science and assessments of scientific and engineering research speak to the need for a more critical approach to the noble intentions underlying these assumptions. "Science Outside the Lab" is a program designed to help early-career scientists and engineers understand the complexities of science and engineering policy. Assessment of the program entailed a pre-, post-, and 1 year follow up survey to gauge student perspectives on relationships between science and society, as well as a pre-post concept map exercise to elicit student conceptualizations of science policy. Students leave Science Outside the Lab with greater humility about the role of scientific expertise in science and engineering policy; greater skepticism toward linear notions of scientific advances benefiting society; a deeper, more nuanced understanding of the actors involved in shaping science policy; and a continued appreciation of the contributions of science and engineering to society. The study presents an efficacious program that helps scientists and engineers make inroads into macroethical debates, reframe the ways in which they think about values of science and engineering in society, and more thoughtfully engage with critical mediators of science and society relationships: policy makers and policy processes.

Altered tactile processing in children with autism spectrum disorder.

Although tactile reactivity issues are commonly reported in children with autism spectrum disorder (ASD), the underlying mechanisms are poorly understood. Less feed-forward inhibition has been proposed as a potential mechanism for some symptoms of ASD. We tested static and dynamic tactile thresholds as a behavioral proxy of feed-forward inhibition in 42 children (21 children with ASD and 21 typically developing [TD] children). Subthreshold conditioning typically raises the dynamic detection threshold, thus comparison of the dynamic to the static threshold generates a metric that predicts gamma-aminobutyric acid (GABA) mediated feed-forward inhibition. Children with ASD had marginally higher static thresholds and a significantly lower ratio between thresholds as compared with TD children. The lower ratio, only seen in children with ASD, might be indicative of less inhibition. Static thresholds were correlated with autism spectrum quotient scores, indicating the higher the tactile threshold, the more ASD traits. The amount of feed-forward inhibition (ratio between dynamic/static) was negatively correlated with autism diagnostic observation schedule repetitive behavior scores, meaning the less inhibition the more ASD symptoms. In summary, children with ASD showed altered tactile processing compared with TD children; thus measuring static and dynamic thresholds could be a potential biomarker for ASD and might be useful for prediction of treatment response with therapeutics, including those that target the GABAergic system. Autism Res 2016, 9: 616-620. © 2015 International Society for Autism Research, Wiley Periodicals, Inc.

Delegating to the automobile: experimenting with automotive restraints in the 1970s.

This article explores the attempts in the United States in the 1970s to implement a new paradigm for automobile safety-crashworthiness, the idea that automobile passengers should be protected in the event of a crash. A large number of strategies were proposed, including air bags, seatbelt modifications, mandatory belt-use laws, and ignition interlocks. Many of these did not initially come to fruition, but they did give the automobile safety community a chance to experiment with different ways of distributing responsibilities between automobile occupants, automobile manufacturers, and, to a lesser extent, government agencies. These experiments helped pave the way for the successful implementation of a number of new strategies in the 1980s, 1990s, and 2000s.

A randomized phase II study comparing capecitabine alone with capecitabine and oral cyclophosphamide in patients with advanced breast cancer-cyclox II.

BACKGROUND: Capecitabine and cyclophosphamide are active in patients with advanced breast cancer, have non-overlapping toxic effects and synergy pre-clinically. We explored the efficacy and toxic effect of an all-oral combination of capecitabine with cyclophosphamide versus capecitabine alone in a multicentre, randomized, phase II study. PATIENTS AND METHODS: Patients with locally advanced or metastatic breast cancer were randomized to treatment with capecitabine given continuously (666 mg/m(2) b.i.d. days 1-28) alone (C) or with oral cyclophosphamide (100 mg/m(2) days 1-14 of a 28-day cycle) (CCy) for up to six cycles. RESULTS: Eighty-two patients were randomized. There was no complete response. The proportions with partial response were 36% on C and 44% on CCy, a difference of 7.9% [95% confidence interval (CI) -13.4 to 29.1]. Significant toxic effect was uncommon: grade ≥3 diarrhoea in 4 (10%) versus 1 (3%) patients; grade ≥3 fatigue in 2 (5%) versus 5 patients (13%) and grade ≥2 hand-foot syndrome in 7 (17%) versus 11 (28%) patients receiving C versus CCy, respectively. Median progression-free survival was 3.1 months on C and 6.9 months on CCy, not significantly different statistically. There was no difference in overall survival. CONCLUSION: The difference in tumour response suggests a reasonable chance that CCy is superior to C alone.

Persistent neck disease after chemoradiation for head and neck squamous cell carcinoma.

OBJECTIVE: This study aimed to identify the incidence of residual viable neck disease in patients with mucosal squamous cell carcinoma of the upper aero-digestive tract, following primary chemoradiation at a tertiary centre. STUDY DESIGN: Retrospective review. METHODS: Retrospective chart review of patients treated with primary chemoradiation for squamous cell carcinoma of the aero-digestive tract between August 2001 and August 2008. Neck status pre- and post-treatment was the primary focus. RESULTS: Forty-two patients with node-positive disease prior to chemoradiation were included. Thirty-seven (88.1 per cent) achieved complete response to treatment: no patient in this group underwent neck dissection, five died due to recurrence at the primary site or distant metastasis, and none suffered neck recurrence. Five (11.9 per cent) patients achieved partial response to chemoradiation and underwent neck dissection; viable tumour was found in one patient. CONCLUSION: Our data support conservative management of the neck in patients with complete response to chemoradiation, and consolidation neck dissection in patients with partial response.

Interobserver variability in clinical target volume delineation in tangential breast irradiation: a comparison between radiation oncologists and radiation therapists.

AIMS: The delineation of target volumes has been radiation oncologist led. If radiation therapists were to undertake this task, work processes may be more efficient and the skills set of radiation therapy staff broadened. This study was undertaken to quantify interobserver variability of breast target volumes between radiation oncologists and radiation therapists. MATERIALS AND METHODS: The planning computed tomography datasets of 30 patients undergoing tangential breast radiotherapy were utilised. Four radiation oncologists and four radiation therapists independently contoured the clinical target volume (CTV) of the breast on planning computed tomography using a written protocol. The mean CTV volumes and the mean distance between centres of volume (COV) were determined for both groups to determine intergroup variation. Each of the radiation oncologists' readings in turn has been used as the gold standard and compared with that of the radiation therapists. The concordance index for each patient's CTV was determined relative to the gold standard for each group. A paired t-test was used for statistical comparison between the groups. An intraclass correlation coefficient was calculated to measure the agreement between the radiation oncologist and radiation therapist groups. RESULTS: The mean concordance index was 0.81 for radiation oncologists and 0.84 for radiation therapists. The intraclass correlation coefficient for the mean volume was 0.995 (95% confidence interval 0.981-0.998) between radiation oncologist- and radiation therapist-contoured volumes. The intraclass correlation for the mean difference between radiation oncologists' and radiation therapists' COV was 0.999 (95% confidence interval 0.999-1.000). CONCLUSIONS: Interobserver variability between radiation oncologists and radiation therapists was found to be low. Radiation therapists could potentially assume the role of CTV voluming for breast radiotherapy provided a standardised contouring protocol is in place.

Interobserver variability of teledermoscopy: an international study.

BACKGROUND: Teledermoscopy is a rapidly developing field of dermatology with studies demonstrating excellent agreement with face-to-face diagnosis. However, we are unaware of studies evaluating interobserver variability in diagnosis between dermatologists from different continents. This evaluation is important to determine the robustness of teledermoscopy and allow comparisons to be made between different studies. OBJECTIVES: To assess the interobserver diagnostic variability between five independent experienced dermatologists (A-E) in New Zealand, Australia and the U.S.A. METHODS: Images from 979 lesions from 206 patients were distributed to five dermatologists. The lesions were viewed and diagnoses recorded using MoleMap Diagnose (MoleMap, Auckland, New Zealand) software. The diagnoses were analysed for interobserver variability. RESULTS: There was excellent agreement between four of five dermatologists (A-D) for lesions that were agreed upon as melanoma (κ = 0·81-0·97) and benign naevus (κ = 0·77-0·82).The fifth dermatologist (E) made a more frequent diagnosis of atypical naevus and melanoma than the others. For nonmelanocytic lesions, there was moderate to very good agreement for seborrhoeic keratosis (κ = 0·64-0·80) and basal cell carcinoma (κ = 0·55-0·67), but poor agreement for invasive squamous cell carcinoma (SCC) (κ = 0·05-0·15). Agreement for actinic keratosis (κ = 0·32-0·67) and SCC in situ (κ = 0·15-0·32) was only moderate. When atypical and benign naevi were grouped together and actinic keratosis and SCC in situ grouped together, there was better agreement among all dermatologists. There was good ability to distinguish malignant from benign lesions (κ = 0·57-0·93). CONCLUSIONS: There was good agreement among dermatologists A-D but dermatologist E varied from the group with more frequent diagnosis of melanoma and atypical naevus. This difference could be due to different definition of terms with lack of consensus guidelines in definition of atypical naevus, lack of familiarity with the specific patient population and/or diagnostic drift.

Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial).

BACKGROUND: Teledermatology is a rapidly growing field with studies showing high diagnostic accuracy when compared with face-to-face diagnosis. Teledermoscopy involves the use of epiluminescence microscopy to increase diagnostic accuracy. The utility of teledermoscopy as a triage tool has not been established. OBJECTIVES: To assess teledermoscopy as a triage tool for a hospital skin lesion clinic. METHODS: Patients referred to a dermatology skin lesion clinic were recruited. Digital and dermoscopic photographs were taken of skin lesions of concern and the patients were then seen independently face-to-face by two out of three dermatologists. The digital images were evaluated 4 weeks later, as a teledermoscopy consultation, by two of these dermatologists. The diagnosis and management from both types of consultation were compared. RESULTS: Two hundred patients with a total of 491 lesions were seen. There was excellent agreement between teledermoscopy and face-to-face diagnosis with only 12.3% of lesions having disparate diagnoses of clinical significance. Twelve of 491 (2.4%) lesions appeared to have been under-reported by teledermoscopy when compared with face-to-face diagnosis. However, when histopathology became available, only one malignant lesion had been missed (a basal cell carcinoma diagnosed as solar keratosis) by teledermoscopy. Teledermoscopy approximated 100% sensitivity and 90% specificity for detecting melanoma and nonmelanoma skin cancers. Importantly, 74% of all lesions were determined to be manageable by the general practitioner without needing to be seen face-to-face by a dermatologist. CONCLUSIONS: This use of teledermoscopy as a triage tool offers the potential to shorten waiting lists and thus improve healthcare access and delivery.