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.

Pubic symphysis osteomyelitis with associated vesico-symphyseal fistula: a difficult diagnosis.

Pubic symphysis osteomyelitis is an infectious complication that rarely arises in men who have undergone treatment for prostate cancer. This process may more rarely arise from a fistulous tract between the pubic symphysis and the urinary tract. In this case report, we discuss the most common clinical presentations and laboratory findings that lead to the diagnosis of this disease process, as well as the role of MRI and other imaging modalities in confirmation of the diagnosis. This case serves as a reminder to clinicians to have earlier consideration of pubic symphysis osteomyelitis in their differential diagnosis to reduce the risk of long-term complications associated with undertreatment.

Proprotein Convertase Subtilism/Kexin 9 (PCSK9) Inhibitors: Adding to the Armamentarium of the Primary Care Physician.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality worldwide, and its prevalence is expected to further increase in the next decade. It imparts a substantial burden on the healthcare system. Dyslipidemia, defined as low-density lipoprotein (LDL), total cholesterol, triglycerides, or lipoprotein levels more than 90th percentile, or an HDL level less than the 10th percentile, is significant risk factor for ASCVD and offers a therapeutic target to reduce the morbidity and mortality associated with ASCVD. While statins remain first-line therapy for the primary and secondary prevention of ASCVD, many patients may not be able to tolerate statins. Furthermore, in many patients, statin therapy alone may not be sufficient in decreasing LDL cholesterol levels. Within the past decade, several new classes of cholesterol lowering agents have been developed and studied as potential adjunctive therapy for patients who are unable to meet target LDL levels with traditional therapy alone. While many of these therapies (fibrates, bile acid sequestrants, and niacin) have demonstrated limited utility in dyslipidemia therapy, the newer proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors have proven to be some of the most potent lipid-lowering therapies available. Recent studies have demonstrated promise for these agents in the role of future management of dyslipidemia. In this review article, we aim to provide a review of recent literature of the PCSK9 inhibitors. These targets may provide additional benefit and alternative options in the treatment of dyslipidemia in the future.

Patent Foramen Ovale Closure Indications: A Clinical Update.

Patent foramen ovale (PFO) is a commonly identified congenital cardiac defect, present in 25-30 percent of adults. Though usually clinically silent, PFOs can result in paradoxical embolization, resulting in platypnea-orthodeoxia syndrome (POS), migraines, myocardial infarctions, or cerebrovascular accidents. Patients with incidentally noted PFOs should be managed conservatively, but in patients with cryptogenic stroke and amenable anatomy, closure with a percutaneous closure device is recommended.