Assessing Open-world Foundation Models for Zero-shot Skin Segmentation in Clinical Dermatological Photographs.

Physicians are increasingly using smartphones to take clinical photographs. This study evaluates a smartphone application for clinical photography that prioritizes and facilitates patient security. Ethics approval was obtained to trial a smartphone clinical photography application, PicSafe Medi. Calgary plastic surgeons and residents used the application to obtain informed consent and photograph patients. Surveys gauging the application's usability, consent process, and photograph storage/sharing were then sent to surgeons and patients. Over a 6-month trial period, 15 plastic surgeons and residents used the application to photograph 86 patients. Over half of the patients (57%) completed the survey. The majority of patients (96%) were satisfied with the application's consent process, and all felt their photographs were secure. The majority (93%) of surgeons/residents completed the survey. The application was felt to overcome issues with current photography practices: inadequate consent and storage of photographs (100%), risk to patient confidentiality (92%), and unsecure photograph sharing (93%). Barriers to regular use of the application included need for cellphone service/Internet (54%), sanitary concerns due to the need for patients to sign directly on the phone (46%), inability to obtain proactive/retroactive consent (85%), and difficulty viewing photographs (80%). The majority of surgeons (85%) believe a smartphone application would be suitable for clinical patient photography, but due to its limitations, only 23% would use the trialed application. A smartphone clinical photography application addresses the patient confidentiality risks of current photography methods; however, limitations of the trialed application prevent its broad implementation.

The use of medical illustrations for clinical documentation dates back several hundred years, as evidenced by artists’ engravings of pathologic skin conditions in fourteenth-century Europe.1 Clinical photography has since emerged as an important instrument for communication regarding a patient’s medical condition, particularly in the smartphone era. Compared to verbal or written descriptions, photographs convey superior clinical detail and understanding. In addition, clinical photography effectively mediates timely medical care and has been applied successfully in numerous specialties.2 Three categories typically define uses of medical images: clinical documentation, publication, and education. In plastic surgery, medical photography is used as an adjunct to clinical examination, for example, by facilitating visual demonstration of notable physical features by the surgeon to the patient in the preoperative and postoperative settings. In addition, it is used to substantiate research findings and also to teach trainees and surgeons about clinical management and surgical techniques. Occasionally, clinical photographs are also used for nonmedical purposes such as advertising and marketing.3 Despite the myriad benefits of clinical photography, several ethical issues must be considered (Table 1).1,4,5 These include informed consent regarding benefits, risks, and intended uses of patient photographs; privacy/confidentiality; appropriate distribution/storage; standardization of photographic procedure to facilitate consistent outcomes and equitable care; and use in social media. As a result, authors have proposed standards to facilitate appropriate and ethical implementation of clinical photography (Table 2).2,4 Table 1. - Ethical Considerations in Clinical Photography Principle Ethical Concern Description/Example Beneficence Photographs obtained to facilitate intended benefits Patients should benefit from photography (e.g., tracking response to intervention) or a secondary benefit (e.g., research) must be identified Nonmaleficence Patients not harmed by medical photography Patients should not be harmed by use of photographs (e.g., reduced confidentiality with inappropriate use) Patient autonomy Informed consent Patients educated on risks/benefits of medical photography and aware of intended uses (e.g., clinical care, research, marketing) Privacy Ensuring confidentiality and appropriate storage/dissemination Social media Inability to revoke consent once published by means of social media/Internet Justice Equitable use of medical photography Standardization of photographic procedure with consistent technology, lighting, distances, views, angles, camera settings Table 2. - Suggested Practices for Appropriate Clinical Photography • Informed consent should be sought before obtaining photographs; patients should be given the opportunity to consent to each use of their images • Consent may be withdrawn at any time • Patients should be made to feel comfortable by the photographer and medical team • Patient autonomy and dignity must be respected at all times • Complete anonymity should be attempted; if impossible, minimal identifiable exposure is recommended • Images must be stored in an environment that is safe, protected, and regulated • Photographic data should be deidentified and should be discarded securely when no longer needed • Photographic procedure should be standardized • Patients should be made explicitly aware of whether primary intended use is marketing, advertising, or social media; additional consent should be obtained • Provide appropriate photographs most similar to expected results and offer standardized photographic examples of complications Despite previous analyses of ethical concerns and promotion of good practices in clinical photography, there remains an important ethical consideration yet to be discussed. A common use of clinical photography by plastic surgeons is display of preoperative and postoperative photographs (online or in person) of prior patients for education and marketing to prospective patients. Generally, surgeons provide examples of successful cases, but do not offer unfavorable examples. We believe this is misleading and that both positive and suboptimal results ought to be provided to interested patients. We contend that this practice is ethically superior and may also improve patient care. First, providing both favorable and unfavorable case examples would facilitate a more comprehensive discussion of potential outcomes and risks, thereby augmenting the informed consent process. Although possible approaches to this practice (e.g., photographs of suboptimal results versus common complications; standardized photographic examples versus surgeon’s personal outcomes) require further investigation to identify best practice, a potential strategy would consist of showing appropriate photographs most similar to expected results for an individual patient and to offer standardized photographic examples of complications. This improved communication is also likely to advance the patient-physician relationship. In addition, surgeons may benefit, as patients would be less likely to suggest that preoperative discussions of potential complications were inadequate. Certainly, valid concerns exist with offering unfavorable case examples, including the theoretical risk of losing prospective patients. In addition, patients suffering poor outcomes may be less willing to consent to use of their photographs. Nevertheless, we believe that if photographs of successful outcomes are shown, ethical practice also compels provision of examples of unfavorable outcomes to interested patients, which will ultimately serve to improve patient care. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work.

Aim: The purpose of this study was to assess the knowledge, attitude, and practices of dental practitioners registered in Indian Dental Association (IDA) Vadodara, Gujarat regarding clinical photography. Materials and Methods: A cross-sectional survey of 193 dental practitioners registered in IDA Vadodara, Gujarat regarding clinical photography was conducted. The participant's information sheet was given to all participants, and a written informed consent was also taken from the participants. The questionnaire consisted of 16 questions which were divided into 3 sections that gave information regarding the knowledge, attitude, and practices regarding clinical photography. The descriptive statistical analysis was used for the study. Results: A total of 172 respondents completed the questionnaire forms. Under knowledge section, 64% dentists knew that digital single lens reflex (DSLR) was the best camera for taking clinical photographs. Under attitude section, (93% of practitioners were ready to invest 50,000). Very few practitioners (5%) had attended more than 5 Continuous Dental Education (CDE) programs on digital dental practice. Under practice section, 53% of practitioners used a mobile phone only for taking clinical photography although they had knowledge that DSLR was the best tool for taking photographs. Conclusion: Dental practitioner's had good knowledge, fair attitude, and comparatively poor practice. Thus, more hands-on courses, workshops, and trainings for clinical photography should be encouraged for dental practitioners.

The origins and early development of photography in Scotland have been much discussed.1 The involvement of medically trained men in its early years is also well docunlented.2 However, surprisingly little is known about early Scottish clinical photography. In fact only Alison Gernsheim has specifically written about Victorian clinical photography.3 The more general field of medical photography is better served. Contributions include general surveys, studies of developments in particular countries, and an important monograph by Fox and Lawrence about how medical men used photography to enhance their professional prospects.4 Gilman's work identifies a cultural tradition of representing the insane, and the history of clinical psychiatric photography is a significant part of this broader enterprise. Gilman links together historical figures such as Hugh Diamond, John Conolly, W. A. F. Browne, his son James Crichton-Browne and Charles Darwin, all of whom either produced, used or circulated clinical photographs of the insane.5

Although clinical photography serves an important role in the education of clinicians, there is still a disparity of darker skin tones in the photographs used for medical education. This disparity results in a skill deficit for clinicians because the differences in skin pigmentation change the appearance of visible diseases so that it is essential for students and trainees to have examples of clinical photographs on varying skin tones. To effectively address the problem, we need to understand the complex sociotechnical processes involved in clinical photography, which is more than simply the act of taking a photograph. Therefore, we conducted semi-structured interviews on clinical photography with 10 clinicians, 1 medical photographer, and 1 clinical administrator at a tertiary academic medical centre. The interviews revealed 5 deductive themes based on the questions and 19 inductive codes within those themes on how clinical photography is conducted. Analysis of the themes through a lens of critical theory showed how simple awareness of the disparity has not led to interventions for the poor representation of varying skin tones in photographs for medical education and also suggests initial next steps.

Objective: The aim of this paper is to document the practice of photography among clinicians whose daily work depends and is influenced so much by medical photography. Materials and Methods: Questionnaires documenting the bio data, place of practice, and experience of cleft caregivers with clinical photography were distributed. Knowledge of rules guiding clinical photography and adherence to them were also asked. Types of camera used were documented and knowledge of the value of clinical photographs were also inquired. Results: Plastic surgeons constitute the highest proportion of 27 (38.6%), followed by Oral and Maxillofacial surgeons with 14 (20.0%). Twenty one (30.0%) of the respondents always, 21 (30.0%) often, 12 (17.1%) frequently, while 9 respondents sometimes took photographs of their patients. Suggested uses of clinical photographs included training, 52 (74.3%), education, 51 (72.9%), medicolegal, 44 (62.9%) and advertisement, 44 (62.9%) among others. Twenty two (31.4%) did not know that there were standard guidelines for taking clinical photographs. Twenty three (32.9%) of them did not seek the consent of the patients before taking clinical photographs. Conclusion: While the practice of clinical photography is high among African cleft caregivers, there is a need for further education on the issues of standard rules and obtaining consent from patients.

Clinical photography is a fundamental component of visually oriented medical fields. The ubiquity of digital technology has brought the capacity to capture clinical photographs to the palm of a practitioner's hand. It is important for general practitioners (GPs) who take clinical photographs of skin lesions to be aware of the associated legal and ethical obligations. The aim of this article is to explore and explain current professional and legal considerations related to the use of clinical photography in general practice. Ensuring compliance with professional and legal standards when using clinical photography in general practice requires a firm grasp of the obligations associated with image capture, use, sharing, storage and security. GPs should ensure that before employing clinical photography, they have adequate consent-obtaining practices, regular habits of uploading images to the patient record, and sufficient device security. This will help to ensure that patient images are protected from being compromised.

Background and Aim:Clinical photographs have become an important entity in contemporary dental education in Saudi Arabia. The study assessed the knowledge and skills related to clinical photography among final-year undergraduate dental students in different dental schools in the Western province of Saudi Arabia.Materials and Methods:A face-to-face interview was conducted using a pretested and validated questionnaire after obtaining relevant consent from the college administration and the students. Trained and calibrated data collectors interviewed the dental students between November 2019 and February 2020.Results:The knowledge related to clinical photography was “good” only in 17.2% of the participants, and most of the students demonstrated “poor” knowledge (58.9%). Digital single lens-reflex (DSLR) camera was used by only 43.9% of the students for taking clinical photographs. The practice of taking informed consent from patients for taking and using clinical photographs was reported in 77.6% of the dental students.Conclusion:The knowledge related to dental clinical photography was not satisfactory, and students need to improve the understanding of the proper functioning of digital cameras and also the medicolegal issues related to clinical photography.

Human skin segmentation has several applications in computer vision beyond its main purpose of distinguishing between skin and nonskin regions. Despite the large number of methods available in the literature, accurate skin segmentation is still a challenging task. Many methods rely only on color information, which does not completely discriminate the image regions due to variations in lighting conditions and ambiguity between skin and background color. This chapter extends upon a self-contained method for skin segmentation that outlines regions from which the overall skin color can be estimated and such that the color model is adjusted to a particular image. This process is based on thresholds that were empirically defined in a first approach. The proposed method has three main contributions over the previous one. First, genetic algorithm (GA) is applied to search for better thresholds that will be used to extract appropriate seeds from the general probability and texture maps. Next, the GA is also applied to define thresholds for edge detectors aiming to improve edge connections. Finally, a fuzzy method for fusion is included where its parameters are optimized by GA during a learning phase. The improvements added to the skin segmentation method are evaluated on a set of hand gesture images. A statistical analysis is conducted over the computational results achieved by each evaluated method, indicating a superior performance of our novel skin segmentation method.

PurposeSince skin is highly accessible, clinical photography is a useful tool to visually substantiate the real-world effectiveness outcomes of biologic-treated adults with moderate-to-severe psoriasis (PsO). We report the effectiveness and patient-reported outcomes at Week 12 between anti-interleukin (IL)-17A biologics and other biologics as well as ixekizumab and guselkumab in patients with available clinical photography at baseline and Week 12.Patients and MethodsThe Psoriasis Study of Health Outcomes (PSoHO) is an international, non-interventional, cohort study investigating the effectiveness of biologics in adults with moderate-to-severe psoriasis at Week 12. Outcomes included the proportion of patients who achieved 90% improvement in Psoriasis Area and Severity Index (PASI90) and/or static Physician Global Assessment (sPGA) 0/1 (primary endpoint), PASI100, PASI90, Dermatology Life Quality Index (DLQI), and Itch Numeric Rating Scale (NRS) (secondary endpoints) at Week 12. Data are reported descriptively.ResultsThis analysis included 59 biologic-treated (23 anti-IL-17A; 36 other biologics) patients with available clinical photographs from the overall PSoHO study (n=1981). At baseline, the mean (standard deviation [SD]) age was 45.7 (11.1) years, 71.2% were male, 52.5% were bio-experienced and the median (interquartile range) duration of disease was 10.5 (12.4) years. Mean (SD) PASI was 16.9 (9.3) and sPGA was 3.5 (0.8). At Week 12, 65.2%/47.2% of the anti-IL-17A/other biologics cohort achieved the primary outcome. Response rates for PASI90/100 were numerically higher with anti-IL-17A than with other biologics. Patients receiving anti-IL-17A had numerically better outcomes for DLQI 0/1 and Itch NRS than those receiving other biologics at Week 12. Clinical photographs confirmed skin improvements in ixekizumab- and guselkumab-treated patients.ConclusionThis subgroup analysis showed that anti-IL-17A biologics are effective at rapidly improving signs and symptoms of PsO and improving quality of life. Additionally, serial photography provided visual evidence of biologic treatment response over time.

Clinical Problem Clinical photography is an essential component and integral part of healthcare. These photographs are utilized in clinical documentation, record keeping, medical and surgical procedures, teaching, publication and research. Most often, a close proximity with the patient is unavoidable during clinical photography. With the current COVID-19 scenario, where world health organization (WHO) advocates maintaining social distancing (at least 1 m), it is difficult to take a clinical photograph (especially close-up picture of a lesion). The chance of transmission to and from the device has to be kept in mind and there is always a chance of getting self-infected through aerosol transmission.[1] Solution To avoid close proximity to the patients, a selfie stick can be put to use along with a smart phone. Taking all the universal precautions advised by world health organization (WHO), the smart phone could be mounted on the selfie stick. The stick is then extended to ascertain at least 1-m distance between the patient and the clinician [Figure 1]. The piece of selfie stick holding the phone is hinged and can be adjusted as desired. Depending on the selfie stick, the phone can be connected either with a cable or a Bluetooth. Holding it by both hands can minimize the shaking/tremor of the selfie stick. As the selfie stick and smart phone can become fomites for transmission of virus, after the photography, they should be cleaned with 60–90% isopropyl alcohol for at least 1 minute.[2] The length of selfie stick gives an idea about social distancing (>1 m) at all time during photography.Figure 1: Clinical photography of a patient with a selfie stick and smart phone, maintaining at least 1 m distance between patient and clinicianThough many smart phones with high-resolution cameras can capture good quality images from a distance, this technique gives an opportunity to take close up picture of lesions. In addition, it will be useful for those clinicians who don't have expensive, high-resolution camera smart phones. Stabilization of the selfie stick while clicking pictures will require some practice, because shaking/tremor of the selfie stick is possible even with both hands. The selfie-stick mounted smartphone can also be used by the patients to self-click pictures of difficult to access areas and use them for teledermatology consultations.[3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement The patient in this manuscript have given written informed consent to publication of their case details.

Objective:The aim of this paper is to document the practice of photography among clinicians whose daily work depends and is influenced so much by medical photography.Materials and Methods:Questionnaires documenting the bio data, place of practice, and experience of cleft caregivers with clinical photography were distributed. Knowledge of rules guiding clinical photography and adherence to them were also asked. Types of camera used were documented and knowledge of the value of clinical photographs were also inquired.Results:Plastic surgeons constitute the highest proportion of 27 (38.6%), followed by Oral and Maxillofacial surgeons with 14 (20.0%). Twenty one (30.0%) of the respondents always, 21 (30.0%) often, 12 (17.1%) frequently, while 9 respondents sometimes took photographs of their patients. Suggested uses of clinical photographs included training, 52 (74.3%), education, 51 (72.9%), medicolegal, 44 (62.9%) and advertisement, 44 (62.9%) among others. Twenty two (31.4%) did not know that there were standard guidelines for taking clinical photographs. Twenty three (32.9%) of them did not seek the consent of the patients before taking clinical photographs.Conclusion:While the practice of clinical photography is high among African cleft caregivers, there is a need for further education on the issues of standard rules and obtaining consent from patients.

In the mid-nineteenth century, photographers used mirrors to document different views of a patient in the same image. The first clinical photographs were taken by portrait photographers. As conventions for clinical photography were not yet established, early clinical photographs resemble contemporary portraits. The use of mirrors in clinical photography probably originated from the portrait studios, as several renowned photographers employed mirrors in their studio portraits. Clinical photographs taken for the US Army Medical Museum between 1862 and 1882 show different ways of employing this mirror technique.

Fundamentals of Esthetic Implant Dentistry.

DEAR EDITOR Photography is an essential part of plastic surgery given the visual nature of our specialty. Its uses are innumerable; it enables us to document form and function, helps us plan an operation, assists us in teaching, serves a medico-legal purpose and may even assist with research.1 This is by no means an exhaustive list. Yet, despite its indispensability to the proper practice of plastic surgery very few surgeons receive any sort of formal teaching or training in clinical photography. In this manuscript the author attempts to provide some of the theoretical essentials of clinical photography required to take adequate clinical images for the patient’s record. The aim of clinical photography is to present the patient most accurately as opposed to portrait photography where the aim is to iron out inconsistencies in the physical form.2,3 The key principle underlying good clinical photography is consistency i.e. taking every picture of the patient under the exact same conditions. This may sound relatively simple but is in fact quite difficult to achieve in practice. The principal factors to consider are (i) Lighting which is the first and most important aspect. Lighting conditions under which the photographs are taken must remain exactly the same as variations in lighting may very easily alter the appearance of pre and post-operative photographs;2,3 (ii) Pose that refers to the position of the patient when the photograph is taken and the “perspective” or “angle” from which the camera “looks” at the patient. This must be kept as consistent as possible and is one of the more difficult competencies to achieve in photography;2,3 (iii) Patient exposure that adequate patient exposure over the anatomical location of interest is essential. Hair should be tied back, distracting jewellery removed and the patient clothed appropriately. Ideally the same cloths should be worn if possible for pre and post-operative photographs;2,3 (iv) Background that refers to the peripheral space around the patient. It should be free of distracting influences and preferably be of a uniform plain colour (such as light blue or green);2,3 and (v) Magnification that all images should be of the same consistent magnification or size. The introduction of digital cameras with the “zoom” function has made this a much easier process.2,3 Apart from the above discussed principles, one should also have an awareness of basic photographic concepts such as lens aperture, shutter speed and exposure although this is now much less important with contemporary point and shoot digital cameras. Digital cameras tend to automatically adjust for these settings and Letter to Editor