Artificial Intelligence and Skin Melanoma.

Melanoma is the deadliest skin cancer, presenting typically with changing pigmented areas and usually treated with surgical removal. As benign cutaneous pigmented lesions are very common in all populations, it can be challenging to identify which areas should be cut out or left untreated. Delayed treatment in melanoma increases the risk of death, but it is not possible to remove all lesions. Dermatoscopy uses polarised light and can be used to help distinguish melanomas from benign lesions. Dermatoscopy images with a confirmed diagnosis can be utilized to develop artificial intelligence as a medical device (AIaMD) tool. This contribution discusses the utilization of artificial intelligence (AI) in melanoma management and describes an AIaMD tool that has been used in current UK clinical practice on over 80,000 patients. This is a springboard for discussing the scope, risks, and mitigations for future AI use by all clinicians involved in managing people with melanoma.

Validation of a modified-composite autonomic symptom score (COMPASS-31) as an outcome measure for persistent autonomic symptoms post-concussion: an observational pilot study.

OBJECTIVE: Persistent symptoms post-mild traumatic brain injury (mTBI) includes autonomic dysregulation (AD). The composite autonomic symptoms score, (COMPASS-31), was developed to quantify AD symptom severity in the last year, which limits clinical utility. The primary aim was to determine validity of a modified-COMPASS-31 measuring symptoms in the last month compared to the original, secondarily to compare both original and modified versions to the Neurobehavioral Symptom Inventory (NSI), and tertiarily to detect change post-treatment of the modified-COMPASS-31 compared to NSI and headache intensity (HI). PARTICIPANTS: Thirty-three military personnel with persistent headache post-mTBI. MAIN OUTCOME MEASURES: Total and domain scores for COMPASS-31 (original vs. modified) NSI and HI at baseline. Change in modified-COMPASS-31. NSI, and HI. RESULTS: Baseline COMPASS-31 versions were comparable and highly correlated (r = 0.72, p < 0.001), they were moderately correlated at best to the NSI (r < 0.6), which may suggest differences in measurement metrics. The mean change in modified-COMPASS-31 scores (15.4/100, effect size 0.8) was mild to moderately correlated to the change in HI (r = 0.39) score, but not to NSI (r = 0.28). CONCLUSION: The modified-COMPASS-31 appears to be valid, can measure change of AD symptom severity, and is recommended as an outcome measure.

Accuracy of an artificial intelligence as a medical device as part of a UK-based skin cancer teledermatology service.

Introduction: An artificial intelligence as a medical device (AIaMD), built on convolutional neural networks, has demonstrated high sensitivity for melanoma. To be of clinical value, it needs to safely reduce referral rates. The primary objective of this study was to demonstrate that the AIaMD had a higher rate of correctly classifying lesions that did not need to be referred for biopsy or urgent face-to-face dermatologist review, compared to teledermatology standard of care (SoC), while achieving the same sensitivity to detect malignancy. Secondary endpoints included the sensitivity, specificity, positive and negative predictive values, and number needed to biopsy to identify one case of melanoma or squamous cell carcinoma (SCC) by both the AIaMD and SoC. Methods: This prospective, single-centre, single-arm, masked, non-inferiority, adaptive, group sequential design trial recruited patients referred to a teledermatology cancer pathway (clinicaltrials.gov NCT04123678). Additional dermoscopic images of each suspicious lesion were taken using a smartphone with a dermoscopic lens attachment. The images were assessed independently by a consultant dermatologist and the AIaMD. The outputs were compared with the final histological or clinical diagnosis. Results: A total of 700 patients with 867 lesions were recruited, of which 622 participants with 789 lesions were included in the per-protocol (PP) population. In total, 63.3% of PP participants were female; 89.0% identified as white, and the median age was 51 (range 18-95); and all Fitzpatrick skin types were represented including 25/622 (4.0%) type IV-VI skin. A total of 67 malignant lesions were identified, including 8 diagnosed as melanoma. The AIaMD sensitivity was set at 91 and 92.5%, to match the literature-defined clinician sensitivity (91.46%) as closely as possible. In both settings, the AIaMD identified had a significantly higher rate of identifying lesions that did not need a biopsy or urgent referral compared to SoC (p-value = 0.001) with comparable sensitivity for skin cancer. Discussion: The AIaMD identified significantly more lesions that did not need to be referred for biopsy or urgent face-to-face dermatologist review, compared to teledermatologists. This has the potential to reduce the burden of unnecessary referrals when used as part of a teledermatology service.

Is proprioception affected in those with persistent intra-articular temporomandibular disorders? A cross-sectional study exploring joint position sense and force sense of the jaw.

BACKGROUND: Proprioception is an important component of normal jaw function, although to date it is unknown if and how proprioception is affected in those with intra-articular temporomandibular disorders (IA-TMDs). This challenges effective management of this subgroup. OBJECTIVES: Determine whether differences in local joint position sense and force sense exist between individuals with IA-TMD and those without a jaw problem. DESIGN: Cross-sectional study. METHOD: Sixty age and sex matched participants were recruited (n = 30 IA-TMD, n = 30 healthy controls). Temporomandibular joint position sense was tested to one target (50% of maximal mouth opening) using a ruler. Temporomandibular force sense was tested to two targets (50% and 70% of maximal molar pain-free bite force) using a bite sensor. Constant, absolute and variable errors were calculated for each outcome and compared between groups using p-values and 95% confidence intervals for effect size (d). RESULTS: Significantly greater degrees of constant, absolute and variable error were seen for force sense testing at the 50% target (p < 0.05). No statistically significant difference was observed between groups for joint position sense, or for constant or variable force sense error at the 70% target (p > 0.05). Despite this, all joint position sense and force sense measures demonstrated possible clinical significance (upper limits 95% CI d ≥ 0.5). CONCLUSIONS: Force sense, particularly at lower levels, appears impaired in those with IA-TMD. Joint position sense and force sense at higher levels appear less affected, although may still be important to consider in the management of IA-TMD in some patients.

Development of a diagnostic support tool for predicting cervical arterial dissection in primary care.

OBJECTIVES: Cervical arterial dissection (CAD) is an important cause of stroke in young people which may be missed because early features may mimic migraine or a musculoskeletal presentation. The study aimed to develop a diagnostic support tool for early identification of CAD. DESIGN: Retrospective observational study. SETTING: Tertiary hospital. PARTICIPANTS: Radiologically confirmed CAD cases (n = 37), non-CAD stroke cases (n = 20), and healthy controls (n = 100). MAIN OUTCOME MEASURES: The presence of CAD is confirmed with imaging. Predictive variables included risk factors and clinical characteristics of CAD. Variables with a p-value <0.2 included in a multivariable model. Predictive utility of the model is assessed by calculating area underthe ROC curve (AUC). RESULTS: The model including four variables: age 40-55 years (vs < 40), trauma, recent onset headache, and > 2 neurological features, demonstrated excellent discrimination: AUC of 0.953 (95% CI: 0.916, 0.987). A predictive scoring system (total score/7) identified an optimal threshold of ≥ 3 points, with a sensitivity of 87% and specificity of 79%. CONCLUSIONS: The study identified a diagnostic support tool with four variables to predict increased risk of CAD. Validation in a clinical sample is needed to confirm variables and refine descriptors to enable clinicians to efficiently apply the tool.Optimum cutoff scores of ≥ 3/7 points will help identify those in whom CAD should be considered and further investigation instigated. The potential impact of the tool is to improve early recognition of CAD in those with acute headache or neck pain, thereby facilitating more timely medical intervention, preventing inappropriate treatment, and improving patient outcomes.Wordcount: 3195.

Patient perspectives of artificial intelligence as a medical device in a skin cancer pathway.

The use of artificial intelligence as a medical device (AIaMD) in healthcare systems is increasing rapidly. In dermatology, this has been accelerated in response to increasing skin cancer referral rates, workforce shortages and backlog generated by the COVID-19 pandemic. Evidence regarding patient perspectives of AIaMD is currently lacking in the literature. Patient acceptability is fundamental if this novel technology is to be effectively integrated into care pathways and patients must be confident that it is implemented safely, legally, and ethically. A prospective, single-center, single-arm, masked, non-inferiority, adaptive, group sequential design trial, recruited patients referred to a teledermatology cancer pathway. AIaMD assessment of dermoscopic images were compared with clinical or histological diagnosis, to assess performance (NCT04123678). Participants completed an online questionnaire to evaluate their views regarding use of AIaMD in the skin cancer pathway. Two hundred and sixty eight responses were received between February 2020 and August 2021. The majority of respondents were female (57.5%), ranged in age between 18 and 93 years old, Fitzpatrick type I-II skin (81.3%) and all 6 skin types were represented. Overall, there was a positive sentiment regarding potential use of AIaMD in skin cancer pathways. The majority of respondents felt confident in computers being used to help doctors diagnose and formulate management plans (median = 70; interquartile range (IQR) = 50-95) and as a support tool for general practitioners when assessing skin lesions (median = 85; IQR = 65-100). Respondents were comfortable having their photographs taken with a mobile phone device (median = 95; IQR = 70-100), which is similar to other studies assessing patient acceptability of teledermatology services. To the best of our knowledge, this is the first comprehensive study evaluating patient perspectives of AIaMD in skin cancer pathways in the UK. Patient involvement is essential for the development and implementation of new technologies. Continued end-user feedback will allow refinement of services to ensure patient acceptability. This study demonstrates patient acceptability of the use of AIaMD in both primary and secondary care settings.

Real-world post-deployment performance of a novel machine learning-based digital health technology for skin lesion assessment and suggestions for post-market surveillance.

Introduction: Deep Ensemble for Recognition of Malignancy (DERM) is an artificial intelligence as a medical device (AIaMD) tool for skin lesion assessment. Methods: We report prospective real-world performance from its deployment within skin cancer pathways at two National Health Service hospitals (UK) between July 2021 and October 2022. Results: A total of 14,500 cases were seen, including patients 18-100 years old with Fitzpatrick skin types I-VI represented. Based on 8,571 lesions assessed by DERM with confirmed outcomes, versions A and B demonstrated very high sensitivity for detecting melanoma (95.0-100.0%) or malignancy (96.0-100.0%). Benign lesion specificity was 40.7-49.4% (DERM-vA) and 70.1-73.4% (DERM-vB). DERM identified 15.0-31.0% of cases as eligible for discharge. Discussion: We show DERM performance in-line with sensitivity targets and pre-marketing authorisation research, and it reduced the caseload for hospital specialists in two pathways. Based on our experience we offer suggestions on key elements of post-market surveillance for AIaMDs.

Individual perceptions on the relationship between migraine and neck pain.

BACKGROUND: Despite neck pain being a common complaint for people with migraine, little is known about how individuals perceive the relationship between their migraine and neck pain. Exploring their beliefs and perceptions could provide valuable understanding to improve overall management and reduce the burden of migraine and neck pain. OBJECTIVES: To investigate individual perspectives on how migraine and neck pain relate. METHODS: A retrospective qualitative study was performed. Seventy participants (mean age 39.2, 60 female) were recruited via community and social media advertisements, and interviewed by an experienced physiotherapist using a semi-structured interview framework. An Inductive thematic analysis was used to analyse the responses. RESULTS: Five themes were identified from the interviews: (i) the timing of neck pain and migraine, (ii) causality beliefs, (iii) burden of neck pain and migraine, (iv) experiences with treatment and (v) mismatched perspectives. Diverse views emerged, revealing links between the first two themes of timing and causality, showing increased burden in those suffering from both neck pain and migraine, and providing insights into apparently ineffective or even aggravating treatments. CONCLUSIONS: Valuable insights for clinicians emerged. Due to the complex relationship, clinicians should discuss the aetiology of neck pain in migraine with patients. For some individuals, neck treatment may not produce long-term relief and may even aggravate migraine, but the value of short-term relief in a chronic condition must be considered individually. Clinicians are ideally placed to have discussions with patients individually to tailor individual decisions about management.

Subgrouping individuals with migraine associated neck pain for targeted management.

INTRODUCTION: Neck pain is one of the most common and burdensome symptoms associated with migraine. Many individuals with migraine and neck pain seek neck treatment, but evidence for such treatment is limited. Most studies have treated this population as a homogenous group, providing uniform cervical interventions that have yet to show clinically important effects. However, different neurophysiological and musculoskeletal mechanisms can underlie neck pain in migraine. Targeting treatment to specific underlying mechanisms may therefore be the key to improving treatment outcomes. Our research characterised neck pain mechanisms and identified subgroups based on cervical musculoskeletal function and cervical hypersensitivity. This suggests that specific management aimed towards addressing mechanisms relevant to each subgroup might be beneficial. PURPOSE: This paper explains our research approach and findings to date. Potential management strategies for the identified subgroups and future research directions are discussed. IMPLICATIONS: Clinicians should perform skilled physical examination with the aim of identifying if patterns of cervical musculoskeletal dysfunction and or hypersensitivity are present in the individual patient. There is currently no research into treatments differentiated for subgroups to address specific underlying mechanisms. It is possible that neck treatments addressing musculoskeletal impairments may be most beneficial for those subgroups where neck pain is primarily due to musculoskeletal dysfunction. Future research should define treatment aims and select specific subgroups for targeted management to determine which treatments are most effective for each subgroup. TRIAL REGISTRATION: Not applicable.

Do intra-articular temporomandibular disorders show an association between physical bite function, self-perceived bite limitation and kinesiophobia? A case-control study.

BACKGROUND: Little is known about the impact of intra-articular temporomandibular disorders (TMDs) on bite function, or how bite impairments in this subgroup relate to self-perceived bite limitation or kinesiophobia. This presents a challenge to practitioners involved in delivering care. OBJECTIVES: To determine what bite impairments are associated with intra-articular TMDs, and explore how these impairments relate to self-perceived bite limitations and kinesiophobia. DESIGN: Observational, case-control study. METHOD: Sixty participants (n = 30 intra-articular TMDs, n = 30 healthy controls) were recruited via convenience sampling. Bite function was explored using pain-free bite force and bite endurance/steadiness (submaximal bite hold) measures. Self-perceived bite function and kinesiophobia were evaluated via the Patient specific functional scale (PSFS) and the Tampa Scale for kinesiophobia of Temporomandibular disorders (TSK-TMD) respectively. Between-group data were compared and associations between physical bite impairments, self-perceived bite limitation and kinesiophobia were explored in the intra-articular TMD group. RESULTS: Pain-free bite force was significantly impaired in the intra-articular TMD group (-108N, p < 0.01, d = 0.9), and this impairment demonstrated moderate association with degree of kinesiophobia (p < 0.01, r = -0.4). No significant between-group difference was observed for bite endurance or force steadiness (p > 0.05). No association was observed between pain-free bite force and self-perceived bite limitation, or self-perceived bite limitation and kinesiophobia (p > 0.05). CONCLUSIONS: Impaired pain-free bite force appears to be an important feature of intra-articular TMDs which should be considered within management. Kinesiophobia may be important to consider when assessing bite function in this subgroup. Future research is needed to guide optimal interventions and inform subsequent management guidelines.

Cervical and axioscapular muscle stiffness measured with shear wave elastography: A comparison between different levels of work-related neck disability.

Assessing muscle mechanical properties in terms of stiffness may provide important insights into mechanisms underlying work-related neck pain. This study compared stiffness of cervical and axioscapular muscles between 92 participants (sonographers) with no (n = 31), mild (n = 43) or moderate/severe (n = 18) neck disability. It was hypothesized that participants with more severe neck pain and disability would present with altered distribution of stiffness in cervical and axioscapular muscles than those with no disability. Using shear wave elastography, the shear modulus (kPa) of five cervical and six axioscapular muscles or muscle segments were measured in a relaxed seated upright or side-lying position. Muscle activity was measured simultaneously using surface electromyography during the elastography measurements and scapular depression was measured using a measurement tape and inclinometer before the elastography measurements to evaluate their potential confounding influences on shear modulus. Increased shear modulus was found in deeper than superficial cervical muscles and more cranial than caudal axioscapular muscles. However, no differences in shear modulus of the cervical or axioscapular muscles were found between sonographers with varying levels of disability. This study suggests no alterations in stiffness of cervical and axioscapular muscles were associated with work-related neck pain and disability.

Improving the recognition of cervical arterial dissection in clinical practice: investigation of a five criteria diagnostic support tool.

BACKGROUND: Cervical arterial dissection (CeAD) is a serious condition that can mimic a musculoskeletal condition. A diagnostic tool using five key criteria could help prompt early medical referral, but these criteria may occur in healthy people or benign neck pain/headache. OBJECTIVE: To determine the frequency of CeAD criteria in healthy individuals and those with neck pain/headache, and identify refinements needed to improve specificity. METHODS: An interview and neurological screen to identify the presence of the five criteria was conducted. Definitions were refined and the frequency of the modified criteria in each individual was determined. The criteria were re-administered using data from 37 CeAD cases of the derivation cohort, to examine how the modifications impact sensitivity of the tool. RESULTS: One hundred healthy and 20 participants with neck pain/headache were interviewed. Most participants had ≤ 2 criteria, mainly age or trauma, 3% had 3 criteria, but had migraine or resolving symptoms. None had >3. Modifications to definitions were needed to improve potential specificity of the tool (96.7%). Changes did not impact sensitivity of the tool (81%). Further refinements may be required. CONCLUSIONS: Strictly defined CeAD criteria may assist in identifying when to refer, when to wait and monitor, or when management can proceed. Trialing the tool in those with migraine and in emergency departments to calculate risk scores is recommended.

Possible autonomic or cranial nerve symptoms triggered during sustained neck rotation in persistent headache post-concussion: a retrospective observational cross-sectional study.

OBJECTIVES: To examine and categorize symptoms occurring within 60 s of vertebrobasilar-insufficiency (VBI) testing (left- and right-neck rotation) in individuals with persistent post-traumatic headache. BACKGROUND: As part of routine clinical cervical screening in our patients, we found extended VBI testing often triggered additional symptoms. Therefore, we aimed to document the prevalence and precise symptoms occurring during each movement direction of this test and determine any demographic or baseline signs or symptoms associated with a positive test. METHODS: A retrospective medical record review on military personnel receiving treatment for persistent post-traumatic headache was performed. Participants were grouped according to presence of non-headache related symptoms triggered during the tests. Frequency, onset, and symptom characteristics reported were categorized as potentially vascular and/or possible autonomic or cranial nerve in nature. RESULTS: At least one symptom was reported by 81.3% of 123 patients. Of these, 54% reported symptoms in one and 46% in both directions of rotation, yielding 146 abnormal tests. Most reported symptoms were tear disruption (41%), altered ocular-motor-control (25%), and blepharospasm (16%). Enlisted individuals and those with altered baseline facial sensation were more likely to have a positive test. CONCLUSIONS: The majority reported symptoms not typical of VBI within 60 seconds of sustained neck rotation. Further study is needed to better understand the mechanisms and clinical relevance.

Reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization may help identify cervicogenic headaches: a case-control study.

BACKGROUND: The relative value of clinical tests toward identifying cervicogenic headache (CGH) remains under investigated. Whilst certain physical examination findings have been associated with CGH, consensus on which findings provide the strongest association remains elusive. OBJECTIVES: To determine which cervical musculoskeletal assessment procedures used in CGH are positively associated with CGH. DESIGN: Single blind observational study. METHODS: Four selected musculoskeletal assessment procedures of the cervical spine, craniocervical flexion test, cervical flexion-rotation test, cervical retraction range of motion and reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization, were applied to 20 headache and 20 controls. Inclusion criteria for the headache group met the International Headache Society criteria for CGH except positive diagnostic blocks. RESULTS: Upper cervical spine sustained joint mobilization testing associated with reproduction and resolution of familiar head pain was strongly associated with CGH (Odds Ratio = 36, p < 0.01). This was 78% sensitive and 90% specific in identifying CGH. Other physical tests were not statistically associated with CGH. CONCLUSIONS: Reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization is effective in differentiating those with CGH from control participants. Other cervical measures did not clearly identify CGH in this study.

Sub-occipital muscle pressure pain thresholds correlate to direction of symptomatic active comfortable sustained neck rotation testing in post-concussive headache: a retrospective observational cross-sectional study.

OBJECTIVES: To compare sub-occipital muscle pressure sub pain thresholds (PPTs) in individuals with persistent-post-traumatic-headache (PPTH) in relation to the presence or not of cranial nerve and/or autonomic symptoms reported during sustained neck rotation (SNR). BACKGROUND: Previously 81% of military service members with PPTH demonstrated symptoms with SNR up to 60 seconds. Of these, 54% reported symptoms in one (Uni-Symp) and 46% in both directions of rotation (Bi-Symp). Sub-occipital PPTs, in relation to SNR direction, were of interest. METHODS: Retrospective review of records of 77 individuals, with PPTH with both SNR and PPTs. Average suboccipital and scalene PPTs were compared between Asymptomatic (n = 13), upon SNR testing, or Symptomatic (Uni-Symp, n = 32, Bi-Symp, n = 32), groups. RESULTS: The Bi-Symp group had significantly reduced sub-occipital PPTs relative to the Asymptomatic group on both sides [p < 0.009] with no side-to-side differences in either group. The Uni-Symp group had significantly lower sub-occipital PPTs on the symptomatic SNR test direction compared to the asymptomatic side [t(31) = 3.37, p = 0.002]. There were no differences within or between groups in the scalene PPTs(p's > 0.08). CONCLUSIONS: An upper cervical mechanical trigger of symptoms during SNR tests in some individuals with PPTH is possible. The direction of symptomatic SNR tests may indicate direction of guarded hypermobile dysfunction and direct treatment.

Reducing risks for infant mortality in the Midlands, UK: a qualitative study identifying areas for improvement in the delivery of key public health messages in the perinatal period.

BACKGROUND: The Midlands has amongst the highest rates of neonatal and infant mortality in the UK. A public health parent education and empowerment programme, aimed at reducing key risks associated with this mortality was established and evaluated in the region. This was undertaken in an attempt to identify areas for optimal delivery of the public health messages around reducing risks for neonatal and infant mortality. METHOD: Qualitatively assessment, using the software package Dedoose®, was undertaken. This involved analysis of reflections by the programme trainers, after the delivery of their training sessions to parents, families and carers, between 01 January and 31 December 2021. These were intended to capture insights from the trainers on parent, family, carer and staff perspectives, perceptions/misperceptions around reducing risks for infant mortality. Potential areas for improvement in delivery of the programme were identified from this analysis. RESULTS: A total of 323 programmes, comprising 524 parents, family members and carers were offered the programme. Analysis of 167 reflections around these interactions and those of staff (n = 29) are reported. The programme was positively received across parents, families, carers and staff. Four overall themes were identified: (a) reach and inclusion, (b) knowledge, (c) practical and emotional support and (d) challenges for delivery of the programme. Recommendations for improved delivery of the programme were identified, based on qualitative analysis. CONCLUSION: This novel approach to empowerment and education around neonatal public health messaging is a valuable tool for parents, families, carers and staff in the Midlands. Key practical recommendations for enhancing delivery of these critical public health messages were identified from this qualitative research. These are likely to be of value in other parts of the UK and globally.

National Survey of United Kingdom Paediatric Allergy Services.

BACKGROUND: Comprehensive national assessments of paediatric allergy services are rarely undertaken, and have never been undertaken in the United Kingdom. A 2006 survey estimated national capacity at 30,000 adult or paediatric new allergy appointments per year and identified 58 hospital clinics offering a paediatric allergy service. OBJECTIVE: The UK Paediatric Allergy Services Survey was the first comprehensive assessment of UK paediatric allergy service provision. METHODS: All 450 UK hospitals responded to a survey. Paediatric allergy services are provided in 154 lead hospitals with 75 further linked hospitals. All 154 lead paediatric allergy services completed a detailed questionnaire between February 2019 and May 2020. RESULTS: The 154 paediatric allergy services self-define as secondary (126/154, 82%) or tertiary (28/154, 18%) level services. The annual capacity is 85,600 new and 111,400 follow-up appointments. Fifty-eight percent (85/146) of services offer ≤10 new appointments per week (no data provided from 8 services-2 no response, 6 unknown) and 50% (70/139) of the services undertaking challenges undertake ≤2 food or drug challenges per week (no data from 3 challenge services). Intramuscular adrenaline is rarely used during challenges-median annual frequency 0 in secondary services and 2 in tertiary services. Allergen-specific immunotherapy is offered in 39% (60/154) of services, with 71% (41/58) of these centres treating ≤10 patients per annum (no data from 2 immunotherapy services). The 12 largest services see 31% of all new paediatric allergy appointments, undertake 51% of new immunotherapy patient provision and 33% of food or drug challenges. Seventy percent (97/126) of secondary and all tertiary services are part of a regional paediatric allergy network. Only nine services offer immunotherapy for any food (3 for peanut), 10 drug desensitization and 18 insect venom immunotherapy. CONCLUSIONS: There has been a fourfold increase in paediatric allergy clinics and an approximately sevenfold increase in new patient appointment numbers in the United Kingdom over the past 15 years. Most services are small, with significant regional variation in availability of specific services such as allergen immunotherapy. Our findings emphasize the need for national standards, local networks and simulation training to ensure consistent and safe service provision.

Time Course and Risk Profile of Work-Related Neck Disability: A Longitudinal Latent Class Growth Analysis.

OBJECTIVE: Given the economic burden of work-related neck pain and disability, it is important to understand its time course and associated risk factors to direct better management strategies. This study aimed to identify the 1-year trajectories of work-related neck disability in a high-risk occupation group such as sonography and to investigate which baseline biopsychosocial factors are associated with the identified trajectories. METHODS: A longitudinal study was conducted among 92 sonographers with neck disability assessed at 3 time points-baseline, 6 months, and 12 months-using the Neck Disability Index. Baseline biopsychosocial measures included individual characteristics (demographics and physical activity levels), work-related physical and psychosocial factors (eg, ergonomic risk, workplace social support, job satisfaction), general psychological features (depression, anxiety, pain catastrophizing, and fear-avoidance beliefs), and quantitative sensory testing of somatosensory function (cold and pressure pain thresholds at neck and tibialis anterior, and temporal summation). RESULTS: Two distinct trajectories of neck disability were identified, including a "low-resolving disability" trajectory showing slow improvement toward no disability (64.8%) and a "moderate-fluctuating disability" trajectory characterized by persistent moderate disability with a small fluctuation across time (35.2%). The trajectory of moderate-fluctuating disability was associated with more severe symptoms, lower vigorous physical activity, higher ergonomic risk, remote cold hyperalgesia, widespread mechanical hyperalgesia, heightened pain facilitation, and several psychosocial factors such as anxiety, depression, lower job satisfaction, and lower workplace social support at baseline. CONCLUSION: Over one-third of sonographers were at risk of developing a moderate-fluctuating disability trajectory. This unfavorable trajectory was associated with low physical activity level, poor ergonomics, psychosocial distress, and central sensitization at baseline. IMPACT: This study has important implications for the management of neck disability in workers. Addressing modifiable factors including low vigorous physical activity, poor ergonomics, anxiety, depression, and lack of workplace social support may improve the trajectory of work-related neck disability.