ABSTRACT
Organ transplant recipients (OTRs) are highly vulnerable to SARS-CoV-2 infection and routine transplant consultations were converted primarily to virtual (VC) rather than face to face (F2F) from the outset of the pandemic. A similar strategy was adopted in our tertiary OTR dermatology clinic, but the implications of this on safe and effective skin cancer surveillance are uncertain. We audited clinical and patient experiences of our hybrid service with the aim of identifying the benefits and limitations of this approach, and improvements required to optimize a future hybrid VC-F2F model for skin cancer surveillance. All OTRs consultations held between 1 April 2020 to 31 March 2021 were identified through electronic patient records. Data collected included proportions and reasons for VC and F2F consultations, teledermatology requests, VC to F2F conversion rate, rates of skin cancer diagnoses and adherence to established follow-up protocols. All patients were invited to complete an online service evaluation. In total, 554 encounters (80.3% VC, 19.7% F2F) were recorded in 247 OTRs (42% with previous skin cancer). Of routine F2F consultations, this was patient preference in 17 of 109 (16%) and clinician-based risk assessment for the remainder. In 108 (25%) VCs, photographs were requested and received for 63%, of which 82% were adequate for diagnosis. Overall, 12% of VCs were converted to F2F and in 19 of 45 (42%) OTRs this was due to suspected skin cancer, which was confirmed in nine of 19 (47%). All other skin cancers were diagnosed in routine F2F consultations. Surveillance in 167 of 192 (87%) assessable OTRs adhered to established follow-up protocols. Of patients who responded to the online survey, 74% felt that there were benefits to VCs, but 41% expressed concern about the lack of skin examination and 57% reported little/no confidence in self-monitoring. Despite this, 59% expressed a preference to continue hybrid VC-F2F surveillance, with VC as routine and F2F consultation when required. Our audit provides preliminary evidence supporting the effectiveness, safety and patient acceptability of a VC-F2F hybrid model for the delivery of OTR skin cancer surveillance. We did not identify major delays in skin cancer diagnosis, although not all patients have yet been seen F2F. Certain aspects of service delivery will require optimization. In particular, despite routine skin cancer education, many patients expressed concerns about self-monitoring. Programmes specifically tailored to address this need will be required, as will information technology support for some OTRs. With this information we are redesigning our service to incorporate a VC-F2F model for routine skin cancer surveillance and are evaluating the incorporation of a patient-initiated follow-up pathway.
ABSTRACT
Background: The COVID-19 pandemic necessitated the widespread adoption of teledermatology, and this continues to account for a significant proportion of dermatology visits after clinics have reopened for in-person care. Delivery of high-quality teledermatology care requires adequate visualization of the patient's skin, with photographs being preferred over live video for remote skin examination. It remains unknown which patients face the greatest barriers to participating in a teledermatology visit with photographs. Objective: The aim of this study was to identify patient characteristics associated with type of telemedicine visit and the factors associated with participating in teledermatology visits with digital photographs versus those without photographs. Methods: We performed a cross-sectional analysis of the University of Pennsylvania Health System electronic health record data for adult patients who participated in at least 1 teledermatology appointment between March 1, 2020, and June 30, 2020. The primary outcomes were participation in a live-interactive video visit versus a telephone visit and participation in any teledermatology visit with photographs versus one without photographs. Multivariable logistic regression was performed to evaluate the associations between patient characteristics and the primary outcomes. Results: In total, 5717 unique patients completed at least 1 teledermatology visit during the study period;68.25% (n=3902) of patients participated in a video visit, and 31.75% (n=1815) participated in a telephone visit. A minority of patients (n=1815, 31.75%) submitted photographs for their video or telephone appointment. Patients who submitted photographs for their teledermatology visit were more likely to be White, have commercial insurance, and live in areas with higher income, better education, and greater access to a computer and high-speed internet (P<.001 for all). In adjusted analysis, older age (age group >75 years: odds ratio [OR] 0.60, 95% CI 0.44-0.82), male sex (OR 0.85, 95% CI 0.75-0.97), Black race (OR 0.79, 95% CI 0.65-0.96), and Medicaid insurance (OR 0.81, 95% CI 0.66-0.99) were each associated with lower odds of a patient submitting photographs for their video or telephone visit. Older age (age group >75 years: OR 0.37, 95% CI 0.27-0.50) and Black race (OR 0.82, 95% CI 0.68-0.98) were also associated with lower odds of a patient participating in a video visit versus telephone visit. Conclusions: Patients who were older, male, or Black, or who had Medicaid insurance were less likely to participate in teledermatology visits with photographs and may be particularly vulnerable to disparities in teledermatology care. Further research is necessary to identify the barriers to patients providing photographs for remote dermatology visits and to develop targeted interventions to facilitate equitable participation in teledermatology care. ©Jordan E Lamb, Robert Fitzsimmons, Anjana Sevagamoorthy, Carrie L Kovarik, Daniel B Shin, Junko Takeshita. Originally.
ABSTRACT
The incidence of melanoma and nonmelanoma skin cancer continues to rise in Ireland. This study aimed to explore the tanning and sun-protection behaviour and attitudes, as well as awareness of signs of melanoma, of the Irish population. A cross-sectional study was performed in December 2020 via an online questionnaire. Respondents were recruited according to gender, age and geographical region. In total, 1043 respondents (49% female) completed the questionnaire (mean age 41 years;range 20-72). In total, 443 sunbathe when there is sunny weather in Ireland, with 245 wearing suncream less than half of the time. Thirty-eight per cent (n = 399) have used sunbeds in the last 12 months, despite the global COVID-19 pandemic. Almost half (49%) did not believe getting a sunburn was serious. Most (87%) were aware melanoma would have serious consequences for them and 91% believed it was important to protect themselves from getting melanoma. In total, 839 know that wearing sunscreen can prevent sunburn. However, the main reasons they do not apply it include just forgetting (n = 207), to get a tan (n = 177) and they just don't like putting it on (n = 359). The main reason for limiting sunbathing was to avoid wrinkles/ skin pigmentation (n = 356), followed by a fear of getting skin cancer (n = 334). The primary reason people sunbathed was to top up their supply of vitamin D (n = 336), which was closely followed by getting a tan. Eighty-five per cent reported feeling and looking better with a tan. Despite knowledge of the risks of sunburn, 208 respondents felt it was worth getting slightly sunburnt to get a tan. Most respondents were aware of sun-protection measures (n = 729), but 484 people were not confident about what to look for when performing a self-skin examination and only 410 know the signs of a melanoma. This study found that although the majority of people are aware of the risks of sunbathing, many are happy to take these risks in order to get a tan. Tans are still considered to be attractive by the majority of respondents. Although there are high levels of awareness regarding sun protection, knowledge regarding skin self-examination and the signs of melanoma is lacking. Our results indicate that health promotion interventions for skin cancer may need to focus on education regarding the signs of melanoma and consider strategies to alter the perceptions of the beneficial factors of tanning.
ABSTRACT
Melanoma of unknown primary (MUP) was originally defined in 1963 as melanoma in the subcutaneous tissue, lymph nodes or visceral organs without the presence of a cutaneous, ocular or mucosal primary. The incidence of MUP is reported to be between 1% and 8% of all melanomas. MUP can be divided into lymph node involvement only and organ metastases. The aetiology of MUP is elusive. Possibilities proffered include an unrecognized melanoma, a previously excised melanoma that was misdiagnosed as benign, a primary melanoma that has completely regressed or the de novo malignant transformation of an aberrant melanocyte within a lymph node. We report our experience in a single tertiary referral centre. A database of all melanomas diagnosed between January 2018 and December 2021 was analysed for MUP. The total number of melanomas diagnosed in that timeframe was 298. Six patients (three males, three females) were identified as having MUP, with an incidence of 2%. Median age was 63.3 years (range 45-84). One (17%) presented with primary dermal metastatic deposits, 67% (n = 4) presented with isolated lymph node metastases, 0% presented with visceral metastases and 17% (n = 1) presented with isolated brain metastases. All six patients were reviewed by dermatology and ophthalmology. Fifty per cent (n = 3) were reviewed by ENT. One (17%) was referred to gynaecology. No primary melanoma was identified in any of the patients. All patients underwent a positron emission tomography-computed tomography (CT) scan to investigate for further metastases, and all underwent dedicated brain imaging via CT and magnetic resonance imaging. All patients underwent surgical resection of their MUP, and all were reviewed by medical oncology, with 83% (n = 5) undergoing treatment with immunotherapy. There have been no associated deaths to date. In five patients (83%) the MUP was diagnosed in 2021, and one (17%) was diagnosed in 2018. Recent studies have shown the impact of the COVID- 19 pandemic on the presentation of cutaneous melanoma, including an increased Breslow thickness at the time of presentation vs. a similar period pre-COVID-19. Our data indicate an increased rate of MUP presenting after the onset of the COVID-19 pandemic;however, given the low number overall, no conclusions can be drawn. There is no current literature regarding the increased rate of MUP since the COVID-19 pandemic. Further studies are required to investigate this. Recommendations for the evaluation of those with MUP include a full skin examination by a dermatologist and ocular examination to exclude primary melanoma. Patients should undergo imaging of the brain, thorax, abdomen and pelvis to assess disease burden. Referral to otorhinolaryngology can be considered to assess for mucosal melanoma of the nasopharynx. Gynaecology referral should be considered for those with inguinal lymphadenopathy. MUP is rare. Guidelines for the investigation of MUP are currently lacking and are needed to ensure the delivery of consistent evidence-based care for patients.
ABSTRACT
SESSION TITLE: Atypical Cases of Sepsis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pasteurella multocida is a Gram-negative coccobacillus that causes infections after animal bites or scratches. It typically manifests as cellulitis but severe infections are possible though rare. We present a case of an immunocompetent man with COVID-19 who developed septic shock due to P. multocida bacteremia and pneumonia with no evidence of wound infection. CASE PRESENTATION: A 59-year-old Hispanic man with a history of anxiety and HLD presented with 10 days of nausea, vomiting, chills, and nonproductive cough. He was initially afebrile, on room air but tachycardic. His physical exam was unremarkable. Labs revealed WBC 10x10*3/uL, procal 3.3 ng/mL, negative lactic acid, and positive COVID-19. CT chest showed a right upper lobe consolidation with bilateral patchy infiltrates. He was admitted for sepsis secondary to COVID and superimposed bacterial pneumonia. Ceftriaxone, azithromycin, remdesivir, and dexamethasone were started. Overnight, the patient desaturated to low 80s and required HFNC FiO2 65%. In the morning, FiO2 increased to 80%. ICU was called and upon their assessment, the patient was febrile, tachycardic, tachypneic, hypotensive, and saturating 87-88% on HFNC FiO2 70%. Labs showed WBC 3.1 with left shift, Cr 1.7 mg/dL, lactic acid 5 mmol/L, and procalcitonin >100. He was intubated given persistent hypoxia and increased work of breathing. Antibiotics were broadened to vancomycin, pip/tazo, and azithromycin. The patient acutely decompensated after intubation, requiring multiple high-dose pressor support. Prelim blood cultures grew Gram-negative bacteria so antibiotics were broadened to meropenem. TTE was negative for endocarditis. Pressors were eventually weaned and the patient was extubated. Blood cultures grew P. multocida in 4/4 bottles so meropenem was narrowed to penicillin. His family reported that he was living at a friend's house with cats around but was unaware of any bites or scratches and he had no history of splenectomy. No portal of entry was noted upon careful skin examination. The patient continued to improve clinically with procal that rapidly downtrended. He was eventually discharged home. DISCUSSION: The mortality for severe P. multocida presentations is about 25-30%. Severe cases are generally reported in elderly, immunocompromised, or young immunosuppressed patients. We report what is to our knowledge, the first case of a severe P. multocida infection in an immunocompetent middle-aged man in the background of a COVID-19 infection. It is unclear the degree of COVID contribution and if his bacteremia preceded the pneumonia. His morbidity was primarily driven by the P. multocida bacteremia and pneumonia given the localized right upper lobe consolidation, elevated procal that rapidly decreased with antibiotics, and quick improvement and extubation. CONCLUSIONS: P. multocida infection should be considered in any patient with septic shock and exposure to animals. Reference #1: Blain H, George M, Jeandel C. Exposure to domestic cats or dogs: risk factor for Pasteurella multocida pneumonia in older people? Journal of the American Geriatrics Society. 1998;46(10):1329-1330. Reference #2: Tseng HK, Su SC, Liu CP, Lee CM. Pasteurella multocida bacteremia due to non-bite animal exposure in cirrhotic patients: report of two cases. Journal of microbiology, immunology, and infection= Wei mian yu gan ran za zhi. 2001;34(4):293-296. Reference #3: Kofteridis DP, Christofaki M, Mantadakis E, et al. Bacteremic community-acquired pneumonia due to Pasteurella multocida. International Journal of Infectious Diseases. 2009;13(3):e81-e83. doi:10.1016/j.ijid.2008.06.023 DISCLOSURES: No relevant relationships by Joanne Lin No relevant relationships by Harjeet Singh No relevant relationships by Jose Vempilly No relevant relationships by Joshua Wilkinson