Unilateral multiple facial angiofibromas as a solitary manifestation of tuberous sclerosis

We describe the case of a 12-year-old boy who presented via teledermatology with a 5-6-year history of multiple lesions on the right side of his face. They were unchanged since their initial appearance at 6 years of age but were slowly increasing in number across his right cheek and extending onto the chin. Although the lesions were asymptomatic, growing older had made him feel increasingly self-conscious. He was otherwise fit and well, and attended mainstream school, with no past medical history or family history of note. Perinatal and birth history were also uneventful. On examination, he had multiple, 1-2-mm, erythematous papules confined to the right cheek and right chin. Dermoscopy showed an unusual pattern of vessels with nonspecific globules in between. The rest of the skin, hair and nails were entirely normal in appearance. There were no systemic symptoms and a detailed general and systemic examination, as well as radiological imaging, did not reveal any abnormality. An excisional biopsy was taken of one of the lesions, with histological examination demonstrating focal superficial telangiectasia with associated bland round-tospindle cell proliferation, appearances most in keeping with an angiofibroma. This correlated well clinically, apart from unilateral facial angiofibromas being the solitary finding in our patient. Facial angiofibromas - also called adenoma sebaceum - are well described as part of the cutaneous manifestations of tuberous sclerosis (TSC). Classically, these appear as a facial rash in the form of small pink or red spots across the cheeks and nose in a butterfly distribution, at between 3 and 10 years of age, increasing in size and number until adolescence. TSC is an autosomal dominant disorder with defective mammalian target of rapamycin (mTOR) signalling, characterized by hamartomas in many organs, particularly the skin, central nervous system, renal and cardiovascular systems. The clinical presentation is variable, with other well known and frequently reported cutaneous findings such as shagreen patches, ash-leaf macules and periungual fibromas. Unilateral multiple facial angiofibromas in the absence of other cutaneous or systemic manifestations of TSC - as in our patient - are rare, with only 13 reported cases. These may form part of the clinical spectrum of TSC as a probable consequence of cutaneous mosaicism in which a postzygotic genetic mutation has occurred. Our patient was referred for genetic testing, but this has been delayed as a result of the COVID-19 pandemic. Topical sirolimus 1% - an mTOR inhibitor - has been used with good effect for facial angiofibromas, and our patient also responded well to this.

Teledermatology reporting experiential teaching model for dermatology registrars: a qualitative study

Teledermatology was introduced into the UK dermatology training curriculum in August 2021. National surveys of dermatology trainees in the UK undertaken in 2019 and 2020 demonstrated a vital learning gap in teledermatology (Lowe A, Pararajasingam A, Goodwin R. A UK-wide survey looking at teaching and trainee confidence in teledermatology: a vital gap in a COVID-19-induced era of rapid digital transformation? Clin Exp Dermatol 2020;45: 876-9). Feedback received elucidated that registrars were desirous of observing dermatology consultants during teledermatology reporting, particularly undertaking this themselves under direct supervision. To bridge the gap, we set up a regional virtual teledermatology reporting teaching programme for registrars in our deanery, applying Kolb's experiential learning model and using our local asynchronous teledermatology service. Our aim was for trainees to participate directly in teledermatology reporting for skin lesions under consultant supervision, developing confidence in triaging patients, providing appropriate advice to general practitioners (GPs), and for discharging benign lesions. Teaching was delivered through eight interactive sessions with a focus on skin lesions, over a 12-month period from August 2020 to August 2021, by a senior consultant dermatologist with an interest in teledermatology and skin cancer. Eight dermatology registrars from four different hospital trusts participated, using MS Teams as the virtual platform. Registrars logged in and selected a new referral awaiting review. Screen sharing enabled registrars and the supervising consultant to view the accompanying clinical history and images and engage in a brief discussion. Trainees decided to either accept or reject, directing accepted referrals into urgent suspected cancer, urgent or routine. Where appropriate, advice regarding treatment that GPs could prescribe in the community was given. Qualitative feedback was collected pre- and postprogramme, using e-mailed questionnaires. A 5-point Likert scale was used to assess confidence levels in the following domains: assessing and diagnosing;triaging;discharging skin lesions;giving advice regarding benign skin lesions;and overall confidence in teledermatology. Responses ranged from 1 (strongly agree) to 5 (strongly disagree). The response rate was 100% (n = 8). Trainee confidence was compared using a nonparametric Mann-Whitney U-test. A significant improvement post-teaching was demonstrated in all domains. Most (87%) rated the programme as being extremely relevant to their training. Our study is limited by a relatively small sample size of residents. Nevertheless, results demonstrate that this model is effective in increasing trainee confidence in using teledermatology for the reporting of skin lesion referrals in actual practice, thus equipping registrars with the skills needed to keep pace with changing service demands in an increasingly digital ecosystem.

Science, Medicine, and Cytology: A Pilot Program of the ASC Diversity Equity and Inclusion (DEI) Committee

Introduction: The percentage of pathology trainees who are underrepresented minorities is low. The DEI committee established a Science, Medicine, and Cytology summer pilot program to improve exposure to cytopathology focusing on DEI. Material(s) and Method(s): An online course was developed during the Covid-19 pandemic targeting underrepresented minorities at the high school and college level, and consisted of several didactic sessions, presenting the most common procedures involving cytologists, including fine-needle aspiration, rapid onsite evaluation, and smearing techniques. Interviews of cytopathologists were also included. Participants were surveyed for their demographic information and for an evaluation of the course. Result(s): 23 participants completed the survey (Table 1). The highest level of education was high school 16 (70%), college 6 (26%), and other 1 (4%). Self-identified demographics included 2 (9%) Hispanic, 9 (36%) Asian/Asian American, 2 (8%) Black / Black American, 6 (24%) White/Caucasian, 2 (8%) African, 1 (4%) Muslim American and 1 (4%) Sudanese. Household highest level of education was high school 2 (9%), some college 1 (4%), completed college 9 (39%), completed graduate program 9 (39%), 2 (9%) preferred not to answer. 14 (61%) participants have a family member in healthcare. The program met expectations for 20 (87%). The program format was effective and appropriate for their level of education for 23 (100%). The content helpful for 22 (96%). 13 (57%) considered healthcare as a potential career. 5 (22%) considered cytology as a career (Table 2). Conclusion(s): Evaluations were excellent, generating awareness of medicine and cytopathology. Individuals with families in healthcare were overrepresented, as there were barriers in reaching underrepresented minorities. The population that signed up was influenced by our ability offer the course online. Expansion to a wider audience would increase the number of attendees. (Table Presented).

Science, Medicine, and Cytology: A Pilot Program of the ASC Diversity Equity and Inclusion (DEI) Committee

Introduction: The percentage of pathology trainees who are underrepresented minorities is low. The DEI committee established a "Science, Medicine, and Cytology" summer pilot program to improve exposure to cytopathology focusing on DEI. Material(s) and Method(s): An online course was developed during the Covid-19 pandemic targeting underrepresented minorities at the high school and college level, and consisted of several didactic sessions, presenting the most common procedures involving cytologists, including fine-needle aspiration, rapid onsite evaluation, and smearing techniques. Interviews of cytopathologists were also included. Participants were surveyed for their demographic information and for an evaluation of the course. Result(s): 23 participants completed the survey (Table 1). The highest level of education was high school 16 (70%), college 6 (26%), and other 1 (4%). Self-identified demographics included 2 (9%) Hispanic, 9 (36%) Asian/Asian American, 2 (8%) Black /Black American, 6 (24%) White/Caucasian, 2 (8%) African, 1 (4%) Muslim American and 1 (4%) Sudanese. Household highest level of education was high school 2 (9%), some college 1 (4%), completed college 9 (39%), completed graduate program 9 (39%), 2 (9%) preferred not to answer. 14 (61%) participants have a family member in healthcare. The program met expectations for 20 (87%). The program format was effective and appropriate for their level of education for 23 (100%). The content helpful for 22 (96%). 13 (57%) considered healthcare as a potential career. 5 (22%) considered cytology as a career (Table 2). Conclusion(s): Evaluations were excellent, generating awareness of medicine and cytopathology. Individuals with families in healthcare were overrepresented, as there were barriers in reaching underrepresented minorities. The population that signed up was influenced by our ability offer the course online. Expansion to a wider audience would increase the number of attendees. [Formula presented] [Formula presented] [Formula presented] Copyright © 2022

COVID-19 on the Navajo Nation: Experiences of Dine Families of Children with Asthma

BACKGROUND: Approximately 173,000 persons live on the Navajo Nation (NN) and 14.7% live in multi-generational households. One-third of the Nation's residents are children and 44% live in poverty. The median household income is $27,389 with 1/3 having incomes < $15,000/year. The first confirmed case of COVID-19 on the NN was identified March 17, 2020. The Navajo government took swift action to combat COVID-19 by declaring a public health state of emergency which established the Navajo Department of Health Command Operations Center, closed the government offices except for essential employees, ceased inperson classroom instruction for all schools located within the borders of the NN and issued travel restriction for governmental employees. Even with strong public health efforts, Navajo Nation saw the highest per capita infection rate in the US during May of 2020 with 2450/100,000 versus New York 2119/100,000. METHODS: The Community Asthma Program is an NHLBI funded program working to improve health outcomes for children with asthma on the NN. We sought to determine the impact of COVID- 19 on the families of children with asthma who were participating in our study. RESULTS: Sixty-six of 193 families (34%) were interviewed about their pandemic experience. The average age of the child with asthma was 13.5 (SD=3.9) and 33% were female. On average, 5.2 people lived in each house (SD=2.1). Results of the interviews are shown in the table. Our data indicate that most Diné children with asthma in our study did not contract COVID-19. However, the pandemic had a significant impact on them and their families. Many family members contracted COVID-19, some children lost family members, and half of interviewed parents reported a decline in their child's mental health. Responses suggest that Navajo families may have been less able to work remotely than the US population at large, perhaps increasing stress for families. Despite the trauma from COVID-19, families adopted strategies to cope with the pandemic. Most diligently followed health guidelines including washing hands, wearing masks, and social distancing. One in four families sought the help of a traditional healer. Many accessed medical care through telehealth and most were able to obtain asthma medications when needed. More recently, as the pandemic subsides, parents indicate that their outlook and mental health have significantly improved. CONCLUSION. Despite significant challenges, our research indicated resilience among Navajo families and we heard stories of positive community structures and relationships that are particular to the Diné culture. (Figure Presented).

Advanced Preparation Makes Research in Emergencies and Isolation Care Possible: The Case of Novel Coronavirus Disease (COVID-19)

The optimal time to initiate research on emergencies is before they occur. However, timely initiation of high quality research may launch during an emergency under the right conditions. These include an appropriate context, clarity in scientific aims, preexisting resources, strong operational and research structures that are facile, and good governance. Here, Nebraskan rapid research efforts early during the 2020 coronavirus disease pandemic, while participating in the firstuse of U.S. federal quarantine in 50 years, are described from these aspects, as the global experience with this severe emerging infection grew apace. The experience has lessons in purpose, structure, function, and performance of research in any emergency, when facing any threat.

Evaluating paediatric dermatology telephone clinics during COVID-19 from a dual clinician and patient perspective: a prospective study.

BACKGROUND: The landscape of dermatology services, already rapidly evolving into an increasingly digital one, has been irretrievably altered by the COVID-19 (SARS-CoV-2) pandemic. Data are needed to assess how best to deliver virtual dermatology services in specific patient subgroups in an era of ongoing social distancing and beyond. Initial studies of teledermatology in paediatric populations suggest that many of the problems experienced in adult telemedicine are more apparent when treating children and come with additional challenges. AIM: To evaluate the efficacy of a virtual paediatric dermatology telephone clinic in comparison to traditional face-to-face (FTF) clinics, both from the clinician and patient/parental perspective. METHODS: We carried out a prospective service evaluation examining a single centre cohort of paediatric dermatology patients managed during the COVID-19 pandemic via a telephone clinic supported by images. The study period covered June-September 2020. Data on outcomes were collected from clinicians and a qualitative patient/parental telephone survey was undertaken separately. A five-point Likert scale was used to assess both satisfaction and levels of agreement regarding whether a telephone clinic was more convenient than an FTF clinic. RESULTS: Of 116 patients included, 24% were new and 76% were follow-up patients, with a mixture of inflammatory dermatoses (75%) and lesions (25%). From the clinician's perspective, most consultations (91%) were successfully completed over the telephone. However, qualitative patient and parent feedback paradoxically illustrated that although nearly all (98%) respondents had no outstanding concerns, 52% felt highly unsatisfied and only 22% agreed that telephone clinics were more convenient. Most (65%) preferred FTF follow-up in the future. Statistical analysis using χ² test showed that among those with established follow-ups, the preference for future consultation type was independent of specific reasons for follow-up. CONCLUSIONS: Our study demonstrates a clear discrepancy between the practical successes of a virtual service from the clinician's perspective compared with the patient/parental perspective. Parental anxiety appears to be less effectively allayed virtually than with FTF. This raises the question of whether there is a role for virtual paediatric telephone clinics in the postpandemic future, which may be better left to patients/parents to decide on an individual basis.

Big4 responses to the COVID-19 crisis: an examination of Bauman's moral impulse

Purpose: The paper offers insights on the response of a Big4 firm to the COVID-19 crisis vis-à-vis moral considerations. More specifically, the authors draw on Bauman's (1990) “moral impulse” to explore how the interrelated tactics of distancing, effacement of the face and reduction of people to traits tend to weaken moral considerations and negatively influences decisions and actions. Design/methodology/approach: The authors adopt a qualitative approach that involves an interpretive textual analysis of the COVID-19 responses of a Big 4 accounting firm. Their study uses two vignettes in which they problematise aspects of the actions and ethico-social contribution of a Big4 firm in the heat of a global pandemic. Findings: The findings reveal examples of effacement of the human face (depersonalization/dehumanization) and reduction of persons to traits, as well as excessive distancing between the “doing” actors and those individuals who bear the consequences of those actions. Revealing an opportunity lost, the authors’ vignettes indicate that the reduction to traits tactics led to dissembling and dehumanizing employees into resources that perform tasks that are “value-add” for the organisation, consonant with neoliberal ideologies. Research limitations/implications: The common limitations of qualitative approach apply to the current study for generalisability. The authors also rely heavily on publicly available information given the time frame they were faced with and their chosen research approach. Social implications: Drawing on accounting delineation debates, the paper calls for societal dialogues for reshaping the “official” accounting of events. Originality/value: The authors elaborate moral impulse through the interrelated tactics of distancing, effacement of the face and reduction to traits, during a crisis. Their study mobilises a moral evaluation through which they uncover documented responses by a Big4 firm during the COVID-19 crisis. The study shows how the norms of human action have been systematically cut off from the original moral habitat and subordinated, and evaluated according, to business standards. © 2021, Emerald Publishing Limited.

A paradigm shift in trainee confidence in teledermatology and virtual working during the COVID-19 pandemic: results of a follow-up UK-wide survey.

The entire landscape of dermatology service provision has been transformed by the current SARS-CoV-2 (COVID) pandemic, with virtual working having become the new norm across the UK. A pre-pandemic UK-wide survey of dermatology registrars in training demonstrated a huge shortfall in trainee confidence in their teledermatology skills, with only 15% feeling even slightly confident, while 96% of trainees surveyed felt that more teaching in this area was needed. We carried out a follow-up trainee survey during the COVID-19 pandemic, which showed that the sudden thrust into virtual working had achieved dramatic gains in trainee confidence, propelling the percentage of trainees that now felt slightly confident to 58%. However, the shortfall remains, as does the pressing need to incorporate teledermatology into the trainee teaching timetable.

A UK-wide survey looking at teaching and trainee confidence in teledermatology: a vital gap in a COVID-19-induced era of rapid digital transformation?

Teledermatology has had an explosive impact on the provision of dermatology services in recent times, and even more so with the unprecedented situation created by the COVID-19 pandemic. Although teledermatology is not presently a feature of the Joint Royal Colleges of Physicians Training Board (JRCPTB) curriculum for dermatology training, this is due to change imminently. Specialty trainees need training in this area to be able to confidently and competently meet the demands of the changing face of dermatology services. We surveyed dermatology registrars in training across the UK, prior to the outbreak of COVID-19, to ascertain the teledermatology teaching available and trainee confidence in this area. Our survey found that only 15% of respondents felt slightly confident in their ability to deal with teledermatology referrals and almost all (96%) felt more teaching was needed.