Information science

Manual of simulation in healthcare, 2nd edition

Benjamin B Symon

To the Editor:While highlighting the benefits of endovascular clot retrieval (ECR), Hwang and Gawarikar1 identified Victoria as establishing the first statewide 24/7 ECR service in Australia. We agree with the authors’ caution against focusing on a singular therapy for a few patients at the cost of delivering basic, high quality stroke care to all. As they note in the article, offering ECR requires capacity to appropriately assess patients with advanced imaging and to treat or transfer patients if ECR is indicated.1 We want to provide some background to the ECR service and the role of telemedicine for delivering evidence-based stroke care across regional Victoria, including ECR access. In Victoria, stroke telemedicine has been an important linchpin for overcoming clinical practice variation. The Victorian Stroke Telemedicine (VST) program (www.vst.org.au), operational since 2011, is a statewide service providing 16 regional hospitals with remote access to stroke specialists 24/7.2 The first VST patient eligible for ECR was identified in May 2015, with 78 identified to date. The Victorian Government statewide ECR protocol3 was released in May 2016, with VST being pivotal in identifying and transferring suitable patients from regional areas. Working with regional colleagues through telemedicine has led to numerous benefits,4 including capacity building and incorporating the latest evidence into local stroke protocols. So far, 1600 patients have received a VST consultation, the thrombolysis rate for ischaemic stroke under 4.5 hours is 38% (nationally, 24%),5 some hospitals have provided thrombolysis therapy for the first time, more patients are receiving thrombolysis in under 60 minutes and haemorrhagic complications rates are comparable with those of metropolitan hospitals. Moreover, VST delivers a broader neurological service: 38% of VST consultations receive a “not stroke” diagnosis. We agree that attention to guideline adherence (ie, stroke unit access, care plans and preventive medication) is required.1 Telemedicine may improve access to both basic and specialised care, and in our experience, it provides important infrastructure to incorporate new evidence rapidly. If systems of care could be improved to support rapid uptake of evidence, then geographical boundaries may be overcome: a national acute stroke telemedicine service may be one solution. Commensurate with the need to ensure value, we are undertaking a comprehensive cost effectiveness analysis to support optimal stroke care policy and practice decisions.

Kathleen L Bagot · Dominique A Cadilhac · Chris Bladin

In reply

Yun Tae Hwang · Yash Gawarikar

To the Editor:High technology solutions to the difficult task of selecting and monitoring moles (pigmented skin naevi) may be useful to keep accurate records of people’s skin. Adopting military surveillance and warfare technology,1 there are computer algorithms that search for changes in moles’ appearance over time. Deep convolutional neural networks analysis can group them into benign or malignant lesions with high accuracy.2 In a study by Esteva and colleagues,2 the convolutional neural networks algorithm differentiated between benign, malignant or non-neoplastic lesions with about 72% accuracy compared with about 66% accuracy by two dermatologists; for melanocytic lesions, the algorithm had a better sensitivity and specificity performance compared with the average of 21 dermatologists, although these findings still need to be replicated in independent datasets. Despite recent advances, there are still questions about how Australians can benefit from this technology and how it is best integrated into clinical practice. Cancer agencies worldwide do not recommend screening for melanoma, but instead ask people to make skin self-examinations a habit and present to a doctor with moles of concern — although informal screening is widespread in Australia. Apps that provide easy access to personalised risk estimation may alert people to engage in such exams more frequently. Moreover, apps that guide people through the skin self-examination process may also be useful, as most people find this task complex.3 Once people notice a spot or mole, they may seek a clinical skin examination. Evidence that clinical skin exams are beneficial comes from the Queensland melanoma case control study4 and other similar studies that show that they lead to the detection of thinner melanomas. There are many apps that allow people to take and send photos of moles, but these are highly variable in sophistication and costs. Whether such technology is best placed in front of (for filtering out clearly benign lesions) or after a clinician’s diagnosis (for additional validation) is also matter of debate. Apps should not distract from the patient–doctor relationship, as the final decision about excision requires face-to-face consultations. While technology solutions are promising, validation studies have mostly been small, have lacked a control group or have not been replicated in clinical practice. Independent big research initiatives, such as the International Skin Imaging Collaboration Challenge on Skin Lesion Analysis towards Melanoma Detection,5 are underway to take the momentum further. This healthy competition may be just what is needed to take the last steps to eradicate melanoma.

Monika Janda · H Peter Soyer