***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE Primary care physicians ( PCPs ) constitute an appropriate target for new interventions and educational campaigns design ed to increase skin cancer screening and prevention . The aim of this r and omized study was to determine whether the adjunct of dermoscopy to the st and ard clinical examination improves the accuracy of PCPs to triage lesions suggestive of skin cancer . PATIENTS AND METHODS PCPs in Barcelona , Spain , and Naples , Italy , were given a 1-day training course in skin cancer detection and dermoscopic evaluation , and were r and omly assigned to the dermoscopy evaluation arm or naked-eye evaluation arm . During a 16-month period , 73 physicians evaluated 2,522 patients with skin lesions who attended their clinics and scored individual lesions as benign or suggestive of skin cancer . All patients were re-evaluated by expert dermatologists at clinics for pigmented lesions . Referral accuracy of both PCP groups was calculated by their scores , which were compared to those tabulated for dermatologists . RESULTS Referral sensitivity , specificity , and positive and negative predictive values were 54.1 % , 71.3 % , 11.3 % , and 95.8 % , respectively , in the naked-eye arm , and 79.2 % , 71.8 % , 16.1 % , and 98.1 % , respectively , in the dermoscopy arm . Significant differences were found in terms of sensitivity and negative predictive value ( P = .002 and P = .004 , respectively ) . Histopathologic examination of equivocal lesions revealed 23 malignant skin tumors missed by PCPs performing naked-eye observation and only six by PCPs using dermoscopy ( P = .002 ) . CONCLUSION The use of dermoscopy improves the ability of PCPs to triage lesions suggestive of skin cancer without increasing the number of unnecessary expert consultations Background Few patients with lower bowel symptoms who consult their general practitioner need a specialist opinion . However data from referred patients suggest that those who are referred would benefit from detailed assessment before referral . Methods A cluster r and omised factorial trial . 44 general practice s in North Trent , UK . Practice s were offered either an electronic interactive referral pro forma , an educational outreach visit by a local colorectal surgeon , both or neither . The main outcome measure was the proportion of cases with severe diverticular disease , cancer or precancerous lesions and inflammatory bowel disease in those referred by each group . A secondary outcome was a referral letter quality score . Semi-structured interviews were conducted to identify key themes relating to the use of the software Results From 150 invitations , 44 practice s were recruited with a total list size of 265,707 . There were 716 consecutive referrals recorded over a six-month period , for which a diagnosis was available for 514 . In the combined software arms 14 % ( 37/261 ) had significant pathology , compared with 19 % ( 49/253 ) in the non-software arms , relative risk 0.73 ( 95 % CI : 0.46 to 1.15 ) . In the combined educational outreach arms 15 % ( 38/258 ) had significant pathology compared with 19 % ( 48/256 ) in the non-educational arms , relative risk 0.79 ( 95 % CI : 0.50 to 1.24 ) . Pro forma practice s documented better assessment of patients at referral . Conclusion There was a lack of evidence that either intervention increased the proportion of patients with organic pathology among those referred . The interactive software did improve the amount of information relayed in referral letters although we were unable to confirm if this made a significant difference to patients or their health care providers . The potential value of either intervention may have been diminished by their limited uptake within the context of a cluster r and omised clinical trial . A number of lessons were learned in this trial of novel innovations OBJECTIVE To investigate whether the observational skills of doctors and nurses can be improved by arts-based observational skills training . METHODS We carried out a cluster design , controlled trial involving 42 general practitioners and 26 primary care nurses in 12 primary care practice s in London . Six practice s were allocated to the intervention arm and 6 to the control arm . The intervention group received 90 minutes of arts-based observational skills training . The control group received practical training in the management of psoriasis . Before and after this , control and intervention participants were asked to describe 3 dermatological photographs . Descriptions were scored blindly against a predetermined marking key . Participants completed a question naire about the intervention , and about their own confidence in diagnosing and referring suspicious pigmented skin lesions . RESULTS Post-intervention scores were significantly higher in the intervention group compared with the control group ( P < 0.001 ) . The majority of participants judged the intervention relevant , enjoyable and valuable . A majority lacked confidence in their dermatological knowledge and skills . DISCUSSION This study provides statistically significant evidence that arts-based observational skills training can improve the observational skills of doctors and nurses . It is important not to overstate the clinical significance of these findings , and to recognise that observational skills are just one of many complex and subtle factors affecting the quality of the clinical process . Further research is needed to assess the existence , nature and clinical significance of longer-term benefits , and to identify differences between professional groups Objectives To evaluate the effects of a brief educational program on beliefs , knowledge , and behaviors related to skin cancer control among internal medicine housestaff and attending physicians . Design R and omized controlled trial . Setting Urban academic general medicine practice . Participants Internal medicine housestaff and attending physicians with continuity clinics at the practice site . InterventionTwo 1-hour educational seminars on skin cancer control conducted jointly by a general internist and a dermatologist . Measurements and main results Self-reported attitudes and beliefs about skin cancer control , ability to identify and make treatment decisions on 18 skin lesions , and knowledge of skin cancer risk factors were measured by a question naire before and after the teaching intervention . Exit surveys of patients at moderate to high risk of skin cancer were conducted 1 month before and 1 month after the intervention to measure physician skin cancer control practice s reported by patients . Eighty-two physicians completed baseline question naires and were enrolled in the study , 46 in the intervention group and 36 in the control group . Twenty-five physicians attended both sessions , 11 attended one , and 10 attended neither . Postintervention , the percentage of physicians feeling adequately trained increased from 35 % to 47 % in the control group ( p=.34 ) and from 37 % to 57 % in the intervention group ( p=.06 ) . Intervention physicians had an absolute mean improvement in their risk factor identification score of 6.7 % , while control physicians ' mean score was unchanged ( p=.06 ) . Intervention and control physicians had similar increases in their postintervention lesion identification and managment scores . Postintervention , the mean proportion of patients per physician stating they were advised to watch their moles increased more among intervention physicians than control physicians ( absolute difference of 19 % vs −8%,p=.04 ) . Other changes in behavior were not significant . Conclusions Although we observed a few modest intervention effects , overall this brief skin cancer education intervention did not significantly affect primary care physicians ’ skin cancer control attitudes , beliefs , knowledge , or behaviors . A more intensive intervention with greater participation may be necessary to show a stronger impact on attitudes and knowledge about skin cancer control among primary care physicians OBJECTIVE To determine whether a distance-learning programme on LUTS provided to the general practitioner affected patient self-management . METHODS A r and omised trial was performed to examine the effects of the distance-learning programme ( an educational package for the GP and a patient information leaflet ) compared with written guidelines on LUTS mailed to the GP . In 63 general practice s ( 32 intervention and 31 control ) across the Netherl and s all patients older than 50 years presenting LUTS for the first time were invited to participate . Main outcome measures were patient evaluation of quality of care received and perceptions of enablement . RESULTS A total of 151 patients was included . The intervention increased patient enablement regarding maintenance of independence ( OR = 3.14 ) and coping with illness ( OR = 2.21 ) . Overall enablement scores were not changed . Patients in the intervention group had more positive evaluations of general practice care received ( OR = 2.28 to 3.95 ) . An explorative analysis suggested that the effects of the intervention were mediated in particular by h and ing out of patient information leaflets . CONCLUSIONS A distance-learning programme on LUTS for general practitioners had positive effects on patient self-management . H and ing out leaflets appeared to be a crucial mediating factor Background : Iron deficiency anaemia ( IDA ) remains the most common cause of anaemia and is frequently secondary to occult gastrointestinal blood loss requiring further investigation . The study was design ed to prospect ively assess the adequacy of investigation of IDA and to establish whether a simple computerised prompt would increase the completeness of investigation of patients presenting to their general practitioners . Patients and methods : All men aged > 20 and women aged > 50 newly found to have a probable IDA ( n=431 ) in primary care were r and omised according to general practice ( n=89 ) to one of two computer generated prompts , by the haematology laboratories in two large district general hospitals . Data were collected 12 months after the index date . The primary outcome measure was the adequacy of investigation of the cause of anaemia . Multiple logistic regression was used to analyse each binary outcome . Results : Two hundred and three ( 47 % ) of 431 patients presenting to their general practitioner with an IDA were adequately managed and 140/357 ( 39 % ) of patients who were otherwise fit for investigation had no tests at all . Twenty one ( 17 % ) of 125 patients who did have adequate investigation at the time of presentation were found to have colorectal cancer . Only 30 % of patients had a confirmed diagnosis within 12 months . The prompt did not affect the level of investigation ( odds ratio 0.88 , 95 % confidence interval ( CI ) 0.60 to 1.29 , p=0.52 ) . The initial prescribing of  oral iron was improved ( odds ratio 2.19 , 95 % CI 1.27 to 3.77 , p=0.005 ) , but not the documented prescribing of a full therapeutic course or the use of follow up blood counts . Conclusions : The investigation and management of IDA presenting in general practice remains inadequate and is not improved by a simple management prompt Background Skin surface microscopy ( oil epiluminescence microscopy , dermoscopy , dermatoscopy ) has been shown to increase the diagnostic accuracy of melanoma . However , all studies to date have been in an expert setting The purpose of this study was to determine whether a targeted intervention could improve  primary care practitioners ' concordance with guidelines regarding management of  women with breast symptoms . One hundred and twelve practitioners from r and omly selected areas around Australia prospect ively audited their investigations for each woman with a new breast symptom over two 12-week periods , before and five months after the release of national guidelines . Between the two audits , doctors received feedback on practice in relation to peers and attended one seminar in their local areas led by specialists from the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons . For five recommendations , there were statistically significant improvements at the second audit in line with st and ard Investigation of a New Breast Symptom ( INBS ) guidelines . All these were for investigations of breast lumps . At first audit , there were seven recommendations where practitioners were already managing more than 80 % of women in accordance with the INBS , and where there were no statistically significant increases in concordance at second audit . Another six recommendations had lower concordance with the recommendations prior to the release of the guidelines and did not significantly improve at second audit . These tended to be for less-common presentations and where clinical findings were not consistent with other test results . We concluded that a targeted intervention improved physician concordance with current best advice for investigating women who present with new breast symptoms in a primary care setting . Further educational programs are needed to improve investigations for rarer symptoms , and to enhance physicians ' confidence in the results of their clinical examinations OBJECTIVE To determine the efficacy of an Internet-based  skin cancer triage intervention for physicians . METHODS Physicians were r and omly assigned to an intervention group or a control group . The 14 outcome measures included diagnosis and evaluation planning for malignant melanoma , basal cell carcinoma , and squamous cell carcinoma . RESULTS Forty-six physicians ( 27 of 39 in the intervention group ) completed the program . The intervention group scored significantly higher than did the control group in nine of 14 outcome measures ; this improvement was maintained for five of the nine outcomes . CONCLUSION The Internet intervention improved physicians ' skin cancer diagnosis and evaluation planning test performances Background : Family physicians have an important clinical role in assessment and management of  suspicious skin lesions .  As a result of a previous needs assessment study , an educational intervention based on audit and feedback with opportunity for reflection on practice was introduced to 46 family physicians r and omly allocated to either an intervention ( 23 ) or control group ( 23 ) . As an educational tool , audit allows doctors to systematic ally review their practice and establish the quality of care they provide . When combined with feedback and comparison of clinical performance with peers or st and ards , it has been shown to increase learning and change behavior . Methods : Data based on their own patients , on the correlation between clinical and histologic diagnosis , and excisions of skin lesions were collated and reported to the intervention group . Results : Despite r and omization of the doctors , the patient population of doctors in the intervention and control groups were significantly different in key characteristics , including the types of skin lesions treated . The intervention group of doctors showed improved performance in providing clinical information on pathology requests and 
    Output:
    
Most studies reported a positive effect on their specified outcomes , although no study measured a direct effect on reducing delay .
CONCLUSION There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer .
Limited evidence suggests that complex interventions , including audit and feedback and specific skills training , have the potential to do so