Skin cancer, the most common human malignancy, is primarily diagnosed visually, beginning with an initial clinical screening and followed potentially by dermoscopic analysis, a biopsy and histopathological examination. Automated classification of skin lesions using images is a challenging task owing to the fine-grained variability in the appearance of skin lesions. Deep convolutional neural networks (CNNs) show potential for general and highly variable tasks across many fine-grained object categories. Here we demonstrate classification of skin lesions using a single CNN, trained end-to-end from images directly, using only pixels and disease labels as inputs. We train a CNN using a dataset of 129,450 clinical images-two orders of magnitude larger than previous datasets-consisting of 2,032 different diseases. We test its performance against 21 board-certified dermatologists on biopsy-proven clinical images with two critical binary classification use cases: keratinocyte carcinomas versus benign seborrheic keratoses; and malignant melanomas versus benign nevi. The first case represents the identification of the most common cancers, the second represents the identification of the deadliest skin cancer. The CNN achieves performance on par with all tested experts across both tasks, demonstrating an artificial intelligence capable of classifying skin cancer with a level of competence comparable to dermatologists. Outfitted with deep neural networks, mobile devices can potentially extend the reach of dermatologists outside of the clinic. It is projected that 6.3 billion smartphone subscriptions will exist by the year 2021 (ref. 13) and can therefore potentially provide low-cost universal access to vital diagnostic care.

Dermatologist-level classification of skin cancer with deep neural networks

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. A total of 1,596,670 new cancer cases and 571,950 deaths from cancer are projected to occur in the United States in 2011. Overall cancer incidence rates were stable in men in the most recent time period after decreasing by 1.9% per year from 2001 to 2005; in women, incidence rates have been declining by 0.6% annually since 1998. Overall cancer death rates decreased in all racial/ethnic groups in both men and women from 1998 through 2007, with the exception of American Indian/Alaska Native women, in whom rates were stable. African American and Hispanic men showed the largest annual decreases in cancer death rates during this time period (2.6% and 2.5%, respectively). Lung cancer death rates showed a significant decline in women after continuously increasing since the 1930s. The reduction in the overall cancer death rates since 1990 in men and 1991 in women translates to the avoidance of about 898,000 deaths from cancer. However, this progress has not benefitted all segments of the population equally; cancer death rates for individuals with the least education are more than twice those of the most educated. The elimination of educational and racial disparities could potentially have avoided about 37% (60,370) of the premature cancer deaths among individuals aged 25 to 64 years in 2007 alone. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population with an emphasis on those groups in the lowest socioeconomic bracket. CA Cancer J Clin 2011. © 2011 American Cancer Society.

https://onlinelibrary.wiley.com/doi/pdf/10.3322/caac.20121

Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths.

NUDGE: IMPROVING DECISIONS ABOUT HEALTH, WEALTH, AND HAPPINESS by Richard H. Thaler and Cass R. Sunstein Penguin Books, 2009, 312 pp, ISBN 978-0-14-311526-7This book is best described formally as a general explanation of and advocacy for libertarian paternalism, a term coined by the authors in earlier publications. Informally, it is about how leaders, systems, organizations, and governments can nudge people to do the things the nudgers want and need done for the betterment of the nudgees, or of society. It is paternalism in the sense that "it is legitimate for choice architects to try to influence people's behavior in order to make their lives longer, healthier, and better", (p. 5) It is libertarian in that "people should be free to do what they like - and to opt out of undesirable arrangements if they want to do so", (p. 5) The built-in possibility of opting out or making a different choice preserves freedom of choice even though people's behavior has been influenced by the nature of the presentation of the information or by the structure of the decisionmaking system. I had never heard of libertarian paternalism before reading this book, and I now find it fascinating.Written for a general audience, this book contains mostly social and behavioral science theory and models, but there is considerable discussion of structure and process that has roots in mathematical and quantitative modeling. One of the main applications of this social system is economic choice in investing, selecting and purchasing products and services, systems of taxes, banking (mortgages, borrowing, savings), and retirement systems. Other quantitative social choice systems discussed include environmental effects, health care plans, gambling, and organ donations. Softer issues that are also subject to a nudge-based approach are marriage, education, eating, drinking, smoking, influence, spread of information, and politics. There is something in this book for everyone.The basis for this libertarian paternalism concept is in the social theory called "science of choice", the study of the design and implementation of influence systems on various kinds of people. The terms Econs and Humans, are used to refer to people with either considerable or little rational decision-making talent, respectively. The various libertarian paternalism concepts and systems presented are tested and compared in light of these two types of people. Two foundational issues that this book has in common with another book, Network of Echoes: Imitation, Innovation and Invisible Leaders, that was also reviewed for this issue of the Journal are that 1 ) there are two modes of thinking (or components of the brain) - an automatic (intuitive) process and a reflective (rational) process and 2) the need for conformity and the desire for imitation are powerful forces in human behavior. …

Nudge: Improving Decisions about Health, Wealth, and Happiness

BackgroundIn a phase 1 trial, axicabtagene ciloleucel (axi-cel), an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy, showed efficacy in patients with refractory large B-cell lymphoma after the failure of conventional therapy. MethodsIn this multicenter, phase 2 trial, we enrolled 111 patients with diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, or transformed follicular lymphoma who had refractory disease despite undergoing recommended prior therapy. Patients received a target dose of 2×106 anti-CD19 CAR T cells per kilogram of body weight after receiving a conditioning regimen of low-dose cyclophosphamide and fludarabine. The primary end point was the rate of objective response (calculated as the combined rates of complete response and partial response). Secondary end points included overall survival, safety, and biomarker assessments. ResultsAmong the 111 patients who were enrolled, axi-cel was successfully manufactured for 110 (99%) and administered to 101 (91%)....

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Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma

Title: Benzoyl Peroxide Gel Stains Synthetic Fabrics less than Cotton

Bilateral chondrodermatitis nodularis chronica helicis on the antihelix in an elderly woman

Atopic dermatitis is responsive to midpotency topical corticosteroids, which are the mainstay of treatment, yet many patients have disease that is "resistant" to triamcinolone prescribed for outpatient use. Such resistance is often due to poor adherence, but patients and caregivers may remain adamant that the steroid was ineffective and assure the physician that it was applied as recommended. We describe the case of a young girl with a 2-year history of atopic dermatitis resistant to triamcinolone whose condition rapidly improved with continued use of triamcinolone. Our case raises the ethical dilemma of whether physicians should base treatment plans on what patients report or what evidence on adherence suggests.

Rapid, successful treatment of atopic dermatitis recalcitrant to topical corticosteroids.

While biologics are highly effective, most psoriasis patients do not achieve complete skin clearance with their biologic monotherapy. How to achieve complete skin clearance in psoriasis patients who fail their biologic is not well characterized. To describe treatment approaches in psoriasis patients who fail to achieve complete clearance from their biologic, we modeled and assessed the efficacy, cost, and safety of three treatment approaches– adding a topical agent with their biologic, escalating the biologic dose, and switching to a different biologic. Efficacy of each approach was obtained from literature identifying complete clearance defined as 100% improvement in Psoriasis Area and Severity Index and/or Physician’s Global Assessment score of clear. Cost of each treatment approach was calculated using medication wholesale acquisition cost obtained from Medi-Span Price Rx. Safety was assessed by adverse event (AE) rates. Complete clearance in patients not cleared on their initial biologic was achieved when adding calcipotriene/betamethasone dipropionate (Cal/BD) foam (28%), switching to guselkumab (20%), and switching to infliximab (15.8%). Adding Cal/BD foam to the initial biologic ($3,780 per additional patient cleared) was a less costly approach compared to the lowest cost dose escalation (guselkumab; $73,370 per additional patient cleared) or switching the initial failed biologic to the lowest cost alternative biologic (infliximab; $88,250 per additional patient cleared). There were no treatment-related or serious AEs when adding Cal/BD foam. Adding a topical agent may be an efficacious, low cost, and safe approach to achieve complete clearing in psoriasis patients who previously failed to clear on their biologic. J Drugs Dermatol. 2020;19(2)188-194. doi:10.36849/JDD.2020.3989

Management of Residual Psoriasis in Patients on Biologic Treatment

Severe, uncontrolled atopic dermatitis (AD) persisting from childhood to adulthood can have enduring quality of life (QoL) impacts on daily functioning, academics, career, family and social life, and mental health. In addition, AD has an impact on direct and indirect healthcare resource utilization. Several studies have attempted to quantify the quality of life and direct/indirect economic burden of AD. However, these estimates may not capture the more intangible disease-related burden and associated economic burden. This was a qualitative case report that aimed to investigate the full lifetime impact of severe, uncontrolled AD on all aspects of a single patient's life. This case report emphasizes the enormous cumulative lifetime impact of severe, uncontrolled AD and where the qualitative indirect impact may not be fully captured. After obtaining consent, a patient, diagnosed with severe AD since birth, was asked close- and open-ended questions about AD history, direct and indirect healthcare resource utilization, and impact of AD on work, home, family, social life, daily functioning, and mental health over the course of her lifetime. Our patient attributed her severe, uncontrolled AD since birth to causing poor sleep quality, depression, anxiety, and difficulty with social connections and to her choosing an alternative, less physically demanding career. Early effects on sleep and school performance, along with impact on social connections, likely contribute to weaker career opportunities and further social isolation with age.

/pdf/lifelong-impact-of-severe-atopic-dermatitis-on-quality-of-1u81y9g2lg.pdf

Steven R. Feldman

Papers

Title: Benzoyl Peroxide Gel Stains Synthetic Fabrics less than Cotton

Bilateral chondrodermatitis nodularis chronica helicis on the antihelix in an elderly woman

Rapid, successful treatment of atopic dermatitis recalcitrant to topical corticosteroids.

Management of Residual Psoriasis in Patients on Biologic Treatment

Lifelong Impact of Severe Atopic Dermatitis on Quality of Life: A Case Report.