Teledermatology in South Dakota: Uses and Patient Centered Improvement in a Rural Setting.

Dermatologic conditions account for a large proportion of healthcare visits in the United States, yet there continues to be barriers to dermatologic care particularly among the rural and underserved populations. Patients among these populations are particularly vulnerable to poor outcomes and increased morbidity. Teledermatology offers a potential solution to increase access to high-quality dermatologic care. Studies have previously examined the convenience, cost-effectiveness, and clinical efficacy of teledermatology compared to in-person dermatology visits. There is a need to assess which populations are appropriate and in what settings teledermatology can be most effective. We surveyed patients of a South Dakota dermatology practice to assess perceptions and experiences with teledermatology visits in the context of the COVID-19 pandemic. Significant factors leading patients to prefer in-person visits compared to teledermatology were being over the age 65 (OR 2.9 95 percent CI 1.9,3.8 and p-value 0.036) or experiencing technical difficulties during the visit (OR 2.9 95 percent CI 1.9,3.9 and p-value 0.048). We found the chief complaint played an important role in patient preference for visit modality. Patients with acne or acne follow up compared to all other chief complaints had a strong preference for teledermatologic visits (OR 4.7 95 percent CI 4.0,5.4 and p-value 0.000018) whereas patients with possible malignant lesions strongly preferred having an in-person visit (OR 6.6 95 percent CI 5.5,7.8 and p-value 0.0004). Based on these results, we suggest a targeted use of teledermatology with pre-visit screening measures to maintain a patient center approach and avoid redundant visits.

Pembrolizumab Induced Acute Kidney Injury and Liver Injury in a Patient with Malignant Melanoma.

Immune checkpoint inhibitors (ICIs) have recently gained recognition as valuable treatment options for a variety of cancers. Pembrolizumab is a monoclonal antibody that acts as an inhibitor of programmed cell death receptor-1 (PD-1). This helps release host T-cells from regulatory inhibition by tumor neoantigens, therefore mediating antitumor effects. Pembrolizumab has been approved for a variety of cancers including melanoma, head and neck squamous cell carcinoma, non-small cell lung cancer, and urothelial cell carcinoma. It has also recently gained attention for possible use in hepatocellular carcinoma and triple negative breast cancer. Although efficacious, ICIs manifest a unique set of immune-related adverse effects (irAEs) including acute kidney injury (AKI) and acute liver injury (ALI) of which the mechanism is poorly understood. While these irAEs have been described previously in literature individually, there is a paucity of literature describing their simultaneous occurence. With the growing incorporation of ICIs in oncological regimens, it is important to characterize the presentation of irAEs to facilitate earlier recognition and intervention to avoid further complications. We present a case of a 60-year-old male who presented with concurrent AKI and ALI secondary to pembrolizumab therapy for advanced metastatic melanoma. To the authors' knowledge, this is the first reported incident in literature of AKI and ALI occurring simultaneously secondary to ICI immunotherapy with pembrolizumab, although each have been reported and characterized individually.