Patient perception and satisfaction with a smartphone-based teledermatology service initiated during the COVID-19 pandemic at a tertiary care hospital in North India

Background: Telemedicine is being increasingly used to provide healthcare to patients, particularly during the COVID-19 pandemic. Aims: The study aimed to study patient perception and satisfaction with a smartphone-based hybrid teledermatology service initiated during the COVID-19 pandemic. Methods: This was a cross-sectional telephonic survey including patients ?18 years of age who had received a teledermatology consultation. After noting the demographic, clinical and teleconsultation details, patients were administered the Telemedicine Satisfaction Questionnaire and an additional 6-item questionnaire. Patients were also asked to give qualitative feedback and suggestions for improvement using a semi-structured interview guide. Results: We interviewed 201 subjects. The most common diagnoses were pemphigus (27, 13.4%), superficial fungal infections (24, 11.8%), psoriasis (22, 10.9%) and dermatitis (21, 10.4%). The overall mean Telemedicine Satisfaction Questionnaire score was 4.20± 0.71. One hundred seventy-one (85.1%) patients responded that they would use teledermatology services again, while 168 (83.6%) reported satisfaction with the quality of services. A majority of the patients were largely satisfied with the various components involved, though some concerns were raised about the care perceived as not at par with physical consultations, difficulty in procuring medicines, lack of confidence in photographic diagnoses and the lack of a personal touch. Patients with urticaria (P=0.020), those who were advised a change in treatment (P=0.029) and those with improvement in their skin disease (P=0.026) were more likely to be satisfied. Limitations: Our study was conducted during the COVID-19 pandemic when patient acceptability was likely to be higher. Only follow-up patients were included in the study. Conclusion: Patient satisfaction levels were generally high with teledermatology. Addressing lacunae that negatively impact patient perception and satisfaction will help in greater acceptance of teledermatology services.

Chlamydia trachomatis serovar G infection in a bisexual male with urethritis.

We report a case of Chlamydia trachomatis serovar G urogenital tract infection in a 33-year-old human immunodefi ciency virus-1 (HIV-1) seropositive Indian bisexual male. This case highlights the emergence of a new serovar in India. The patient was tested positive for C. trachomatis by both cryptic plasmid and ompA gene polymerase chain reaction (PCR). On further characterization using polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP) and ompA gene sequencing, the strain was found to be C. trachomatis serovar G. His spouse was also found to be infected with C. trachomatis serovar G. Phylogenetic analysis was performed on the clinical isolates obtained from both partners and were found to be identical to the isolates available in GenBank. The sexual network could not be traced further. Detection of a new genotype suggests importation of a new strain into the population probably by sexual contact with a person from a geographical area where the strain is common. Identifying circulating genotypes in the community can assist in developing strategies for improved sexually transmitted disease control.

Prevalence of metabolic syndrome and cardiovascular changes in patients with chronic plaque psoriasis and their correlation with disease severity: A hospital-based cross-sectional study.

Background: Previous epidemiological studies suggest an association between psoriasis and metabolic syndrome and risk of subclinical atherosclerosis. However, there is a paucity of data in the Indian population on these associations. Objectives: To evaluate the prevalence of metabolic syndrome and subclinical atherosclerosis in patients with chronic plaque psoriasis compared to healthy controls and to correlate the prevalence of metabolic syndrome with severity of psoriasis. Methods: A hospital-based cross-sectional study was performed on 140 patients with chronic plaque psoriasis and 140 controls. Psoriasis was categorized as mild, moderate and severe based on psoriasis area and severity index (<10, 10–14 and ≥15, respectively) and as disease of short (<1 year), intermediate (1–3 years) and long duration (>3 years). In all patients and controls, body mass index was calculated, blood pressure and waist circumference were measured and fasting blood sugar and lipid profi le were estimated. Metabolic syndrome was diagnosed by the presence of 3 or more of the modifi ed National Cholesterol Education Program’s Adult Treatment Panel III criteria. A subset of 30 psoriatic patients and 30 healthy controls were selected by the systematic sampling method for cardiac evaluation including electrocardiography, echocardiography and carotid intima-media thickness measurement. Results: The prevalence of metabolic syndrome was signifi cantly more in psoriatic patients than in controls (39.3% vs. 17.1%, odds ratio = 3.13). Psoriatic patients also had a signifi cantly higher prevalence of hypertension, abdominal obesity and diabetes. There was a signifi cant trend to increase in prevalence of metabolic syndrome, hypertension and type 2 diabetes with increased severity and longer duration of the psoriasis. Patients with psoriasis had signifi cantly higher carotid intima-media thickness (mean 0.61 mm ± 0.01 mm vs. 0.37 mm ± 0.01 mm) than controls. Limitation: This was a hospital-based cross-sectional study with a relatively small sample size. A prospective study with a larger sample would have validated the results further. Conclusion: There is a signifi cantly higher prevalence of metabolic syndrome in psoriasis patients as compared to controls; the prevalence of metabolic syndrome and its components increases with severity and duration of psoriasis. There is a higher prevalence of subclinical atherosclerosis in patients with psoriasis thus increasing the risk of cardiovascular disease. We suggest that patients with moderate to severe psoriasis be screened routinely for metabolic syndrome and cardiovascular disease and encouraged to correct modifi able cardiovascular risk factors.

Clinical effifi cacy of rituximab in the treatment of pemphigus: A retrospective study.

Background: Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. Objective: The primary objective was to assess the effi cacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. Methods: We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modifi ed in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3–4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. Results: Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the fi rst dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. Limitations: A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. Conclusion: Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.

Genital Mycoplasma and Chlamydia trachomatis infections in patients with genital tract infections attending a tertiary care hospital of North India.

Limited data are available on the prevalence of genital mycoplasmas and Chlamydia trachomatis (CT) among Indian patients with genital tract infections. The objectives of the study were to determine the prevalence of Ureaplasma urealyticum (UU), Mycoplasma hominis (MH), Mycoplasma genitalium (MG), and CT in patients with genital tract infections. The antimicrobial susceptibilities of UU and MH were also assessed. Endocervical swabs/urethral swabs and first void urine samples of patients (n = 164) were collected. UU and MH were detected by culture and multiplex polymerase chain reaction (PCR). MG and CT were identified by PCR. Ureaplasma isolates were further biotyped and serotyped. Antimicrobial susceptibility was done by microbroth dilution method. UU, MH, MG, and CT were detected in 15.2%, 5.4%, 1.2%, and 6% patients, respectively. Ureaplasma parvum serovar 3/14 was the most prevalent. All isolates of UU and MH were uniformly susceptible to doxycycline and josamycin. Routine screening for these pathogens and antimicrobial susceptibility testing is warranted to prevent sequel of infections and formulate treatment guidelines.

Co-infections with Ureaplasma parvum, Mycoplasma hominis and Chlamydia trachomatis in a human immunodeficiency virus positive woman with vaginal discharge.

A 30-year-old human immunodeficiency virus (HIV)-1 infected woman presented with vaginal discharge and associated vulval irritation. The vaginal swabs tested positive for Ureaplasma parvum and Mycoplasma hominis by both culture and polymerase chain reaction (PCR). The specimen also tested positive for Chlamydia trachomatis deoxyribonucleic acid (DNA) by cryptic plasmid and omp1 gene PCR assays. The patient was successfully treated with azithromycin based on the antibiotic susceptibility testing results of U. parvum and M. hominis by microbroth dilution. Since sexually transmitted infections enhance the transmission of HIV, HIV-positive patients should be screened routinely for these pathogens.

Ureaplasma serovars & their antimicrobial susceptibility in patients of infertility & genital tract infections.

Background & objectives: Ureaplasmas have been implicated in a variety of clinical conditions. However, only certain serovars of ureaplasmas are disease associated. Only a few classes of antimicrobial agents are available for the treatment of mycoplasmal infections in humans. Increase of resistance of genital mycoplasmas to antimicrobials has been reported worldwide. The aim of the present study was to determine the occurrence of Ureaplasma serovars in patients with infertility and genital tract infections with polymerase chain reaction (PCR)–based serotyping. The antimicrobial susceptibilities of Ureaplasma spp. and Mycoplasma hominis were also assessed to determine the most suitable treatment strategy. Methods: Sexually active adults (n=147) with symptoms of genital tract infections and 115 infertile women were enrolled. Endocervical swabs from women and urethral swabs from men were subjected to culture and multiplex PCR for detection of genital mycoplasmas. Serotyping of Ureaplasma was done by PCR and antimicrobial susceptibility to doxycycline, azithromycin, josamycin and ofloxacin was done by microbroth dilution method. Results: Ureaplasma was detected in 25.8 per cent patients with genital tract infections and 20.8 per cent in infertile women. Serovar 3/14 was the most frequent isolate followed by serovar 1 and serovar 6. The majority of Ureaplasma isolates were susceptible to doxycycline (91%) and josamycin (86%) followed by ofloxacin (77%) and azithromycin (71%). All the isolates of M. hominis were uniformly susceptible to doxycycline, josamycin and ofloxacin. Interpretation & conclusions: The predominance of Ureaplasma serovar 3/14 suggests their possible pathogenic role in genital tract infections and infertility. For empirical treatment, doxycycline could be the drug of choice for genital mycoplasmas.

Facial melanoses: Indian perspective.

Facial melanoses (FM) are a common presentation in Indian patients, causing cosmetic disfigurement with considerable psychological impact. Some of the well defined causes of FM include melasma, Riehl's melanosis, Lichen planus pigmentosus, erythema dyschromicum perstans (EDP), erythrosis, and poikiloderma of Civatte. But there is considerable overlap in features amongst the clinical entities. Etiology in most of the causes is unknown, but some factors such as UV radiation in melasma, exposure to chemicals in EDP, exposure to allergens in Riehl's melanosis are implicated. Diagnosis is generally based on clinical features. The treatment of FM includes removal of aggravating factors, vigorous photoprotection, and some form of active pigment reduction either with topical agents or physical modes of treatment. Topical agents include hydroquinone (HQ), which is the most commonly used agent, often in combination with retinoic acid, corticosteroids, azelaic acid, kojic acid, and glycolic acid. Chemical peels are important modalities of physical therapy, other forms include lasers and dermabrasion.

Liposomal delivery of Mycobacterium leprae antigen(s) with murabutide and Trat peptide inhibits Fas-mediated apoptosis of peripheral blood mononuclear cells derived from leprosy patients.

Protective immunity against intracellular pathogen Mycobacterium leprae is dependent on the activation of T cells. Repeated stimulation of T cells by M. leprae antigens MLCwA (M. leprae total cell wall antigen) and ManLAM (mannose capped lipoarabinomannan) may lead to apoptosis in leprosy patients. In the present study, inhibition of the Fas-induced apoptosis of peripheral blood mononuclear cells of leprosy patients was investigated using above M. leprae antigen(s), in combination with immunomodulators murabutide (MB) and a Trat peptide in particulate form (liposome). Incubation of the cells with particulate mode of antigen presentation led to both decreased percentage of propidium iodide (PI) positive cells and T cells expressing Fas-FasL, as well as decreased caspase-8/-3 activities in the lepromatous patients, thereby inhibiting apoptosis, while converse was true with stimulation with soluble antigen. Concurrently, there was an upregulation of antiapoptotic protein Bcl-X(L) in the lepromatous patients, thereby inhibiting apoptosis. Thus, the liposomal formulation of antigen promoted proliferation of anergized T cell by inhibiting apoptosis through decreased expression of death receptors and caspase activities and increased expression of anti-apoptotic protein Bcl-X(L) in these patients.

Cutaneous horn and thermal keratosis in erythema AB igne.

A 46-year-old Kashmiri lady developed erythema ab igne on both legs. She subsequently developed multiple keratoses and a cutaneous horn in the involved skin. An uncommon association of these three clinical conditions is being presented.