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Background: Despite many dermatology residency programs establishing teledermatology programs, few studies have analyzed its impact on resident education. Introduction: We evaluated the University of California, San Francisco School of Medicine teledermatology program at the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). We sought to evaluate resident perspectives on teledermatology and quantify its effects on the number of cases evaluated. Materials and Methods: Each week, dermatology residents triage new teledermatology referrals under the supervision of a dermatology attending. We anonymously surveyed dermatology residents and recent graduates who participated in teledermatology and evaluated responses through inductive thematic analysis. We also used administrative records to compare the productivity ratio (cases evaluated per hour) in clinic versus in teledermatology from June to December 2017. Results: Fifteen out of 21 (71%) potential respondents completed the survey. Five primary content areas emerged through the analysis, with teledermatology providing high caseload, a low-stress learning environment, and opportunities to consider a broad differential diagnoses while developing visual diagnostic and triaging skills. Residents had a productivity ratio of 4.55 (680.7 patients/149.7 h) in dermatology clinic versus 11.49 (299.7 patients/26.1 h) in teledermatology sessions. Discussion: Our thematic analysis to identify the most valued components of teledermatology is novel and can aid the design of teledermatology programs in other settings. We also found that residents evaluated twice the number of patient cases per unit time, with the implication that teledermatology can catalyze the development of visual morphology abilities. Conclusions: Teledermatology is viewed positively by dermatology residents and enables efficient case review by residents.
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Dermatología , Enfermedades de la Piel , Telemedicina , Humanos , Derivación y Consulta , TriajeRESUMEN
Scabies is a parasitic disease of the skin that disproportionately affects disadvantaged populations. The disease causes considerable morbidity and leads to severe bacterial infection and immune-mediated disease. Scientific advances from the past 5 years suggest that scabies is amenable to population-level control, particularly through mass drug administration. In recognition of these issues, WHO added scabies to the list of neglected tropical diseases in 2017. To develop a global control programme, key operational research questions must now be addressed. Standardised approaches to diagnosis and methods for mapping are required to further understand the burden of disease. The safety of treatments for young children, including with ivermectin and moxidectin, should be investigated. Studies are needed to inform optimum implementation of mass treatment, including the threshold for intervention, target, dosing, and frequency. Frameworks for surveillance, monitoring, and evaluation of control strategies are also necessary.
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Enfermedades Desatendidas/prevención & control , Escabiosis/prevención & control , Salud Global , Humanos , Administración Masiva de Medicamentos , Vigilancia de la Población , Salud Pública , Organización Mundial de la SaludRESUMEN
BACKGROUND: Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. METHODS: We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines. RESULTS: Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/µl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%). CONCLUSIONS: A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.
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Servicios de Salud Comunitaria , Infecciones por VIH/epidemiología , Atención Primaria de Salud , Sarcoma de Kaposi/epidemiología , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Humanos , Incidencia , Kenia/epidemiología , Masculino , Persona de Mediana Edad , Pronóstico , Sarcoma de Kaposi/diagnóstico , Sarcoma de Kaposi/tratamiento farmacológico , Sarcoma de Kaposi/etiología , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
BACKGROUND: Teledermatology enables dermatologists to remotely triage and evaluate dermatology patients, but previous studies have questioned whether teledermatology is clinically efficient. OBJECTIVE: To determine whether implementation of a teledermatology system at the Zuckerberg San Francisco General Hospital and Trauma Center has improved the accessibility and efficiency of dermatology care delivery. METHODS: Retrospective, pre-post analysis of a pre-teledermatology cohort (June 2014-December 2014) compared with a post-teledermatology cohort (June 2017-December 2017). RESULTS: Our analysis captured 11,586 patients. After implementation of teledermatology, waiting times for new patients decreased significantly (84.6 days vs 6.7 days; P < .001), total cases evaluated per month increased significantly (754 vs 901; P = .008), and number of cases evaluated per dermatologist-hour increased significantly (2.27 vs 2.63; P = .010). In the post-teledermatology period, 61.8% of teledermatology consults were managed without a clinic visit. LIMITATIONS: We were unable to control for changes in demand for dermatology evaluations between the 2 periods and did not have a control group with which to compare our results. CONCLUSION: The dermatology service was more accessible and more efficient after implementation of teledermatology, suggesting that capitated health care settings can benefit from implementation of a teledermatology system.
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Dermatología/métodos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Proveedores de Redes de Seguridad/estadística & datos numéricos , Enfermedades de la Piel , Telemedicina , Servicios Urbanos de Salud/estadística & datos numéricos , Adulto , Anciano , Eficiencia , Estudios de Evaluación como Asunto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Enfermedades de la Piel/diagnósticoAsunto(s)
Infecciones Oportunistas Relacionadas con el SIDA , Prestación Integrada de Atención de Salud , Infecciones por VIH/complicaciones , Sarcoma de Kaposi/patología , Neoplasias Cutáneas/patología , África del Sur del Sahara , Biopsia , Botswana , Dermatología , Salud Global , Humanos , Kenia , Nigeria , Derivación y Consulta , Sarcoma de Kaposi/diagnóstico , Neoplasias Cutáneas/diagnósticoRESUMEN
Fueled by HIV, sub-Saharan Africa has the highest incidence of Kaposi's sarcoma (KS) in the world. Despite this, KS diagnosis in the region is based mostly on clinical grounds. Where biopsy is available, it has traditionally been excisional and performed by surgeons, resulting in multiple appointments, follow-up visits for suture removal, and substantial costs. We hypothesized that a simpler approach - skin punch biopsy - would make histologic diagnosis more accessible. To address this, we provided training and equipment for skin punch biopsy of suspected KS to three HIV clinics in East Africa. The procedure consisted of local anesthesia followed by a disposable cylindrical punch blade to obtain specimens. Hemostasis is facilitated by Gelfoam®. Patients removed the dressing after 4 days. From 2007 to 2013, 2,799 biopsies were performed. Although originally targeted to be used by physicians, biopsies were performed predominantly by nurses (62%), followed by physicians (15%), clinical officers (12%) and technicians (11%). There were no reports of recurrent bleeding or infection. After minimal training and provision of inexpensive equipment (USD 3.06 per biopsy), HIV clinics in East Africa can integrate same-day skin punch biopsy for suspected KS. Task shifting from physician to non-physician greatly increases access. Skin punch biopsy should be part of any HIV clinic's essential procedures. This example of task shifting may also be applicable to the diagnosis of other cancers (e.g., breast) in resource-limited settings.
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Biopsia/métodos , Personal de Salud/estadística & datos numéricos , Salud Pública/métodos , Sarcoma de Kaposi/diagnóstico , Análisis y Desempeño de Tareas , Adulto , África del Sur del Sahara/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Punciones , Sarcoma de Kaposi/epidemiología , Sarcoma de Kaposi/patología , PielRESUMEN
Neuromyelitis optica (NMO) is an autoimmune, relapsing central nervous system demyelinating disease. There is a known association between NMO and autoimmune disease. However, cutaneous findings in these cases and in the setting of isolated NMO have rarely been described. We report the case of a 60-year-old Chinese female who presented with nonspecific cutaneous findings and acute onset paraplegia and was subsequently found to be seropositive for aquaporin-4 (NMO IgG) antibodies, consistent with a diagnosis of NMO spectrum disorder. Serologic testing prompted by history and cutaneous stigmata revealed additional humoral derangements, together suggestive of an overlap syndrome with features of amyopathic dermatomyositis, rheumatoid arthritis and lupus erythematosus. We review the existing literature on the cutaneous manifestations of this entity. Awareness of the cutaneous signs and heralding symptoms of this devastating neurologic syndrome by dermatologists will ensure prompt diagnosis and initiation of treatment that can minimize neurologic sequelae.
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Dermatosis Facial/etiología , Dermatosis de la Mano/etiología , Neuromielitis Óptica/diagnóstico , Paraplejía/etiología , Acuaporina 4/inmunología , Artritis Reumatoide/complicaciones , Artritis Reumatoide/diagnóstico , Dermatomiositis/complicaciones , Dermatomiositis/diagnóstico , Femenino , Humanos , Inmunoglobulina G/sangre , Lupus Eritematoso Sistémico/complicaciones , Lupus Eritematoso Sistémico/diagnóstico , Persona de Mediana Edad , Neuromielitis Óptica/sangre , Neuromielitis Óptica/complicacionesRESUMEN
An important paradigm in evolutionary genetics is that of a delicate balance between genetic variants that favorably boost host control of infection but which may unfavorably increase susceptibility to autoimmune disease. Here, we investigated whether patients with psoriasis, a common immune-mediated disease of the skin, are enriched for genetic variants that limit the ability of HIV-1 virus to replicate after infection. We analyzed the HLA class I and class II alleles of 1,727 Caucasian psoriasis cases and 3,581 controls and found that psoriasis patients are significantly more likely than controls to have gene variants that are protective against HIV-1 disease. This includes several HLA class I alleles associated with HIV-1 control; amino acid residues at HLA-B positions 67, 70, and 97 that mediate HIV-1 peptide binding; and the deletion polymorphism rs67384697 associated with high surface expression of HLA-C. We also found that the compound genotype KIR3DS1 plus HLA-B Bw4-80I, which respectively encode a natural killer cell activating receptor and its putative ligand, significantly increased psoriasis susceptibility. This compound genotype has also been associated with delay of progression to AIDS. Together, our results suggest that genetic variants that contribute to anti-viral immunity may predispose to the development of psoriasis.
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Genes MHC Clase II , Genes MHC Clase I , Psoriasis/genética , Psoriasis/inmunología , Genes MHC Clase I/inmunología , Genes MHC Clase II/inmunología , Estudios de Asociación Genética , Predisposición Genética a la Enfermedad , Infecciones por VIH/genética , Infecciones por VIH/inmunología , VIH-1/genética , VIH-1/patogenicidad , Antígenos HLA-B/genética , Antígenos HLA-C/genética , Humanos , Células Asesinas Naturales/inmunología , Células Asesinas Naturales/metabolismo , Células Asesinas Naturales/virología , Polimorfismo Genético , Unión Proteica , Receptores KIR3DS1/genéticaRESUMEN
The initiation of antiretroviral treatment for individuals with HIV may be accompanied by a paradoxical flare of underlying inflammatory diseases, the recurrence of dormant infections, or worsening of prior treated opportunistic infections, termed the immune reconstitution inflammatory syndrome (IRIS). Cutaneous manifestations of IRIS are common. Pyoderma gangrenosum is a neutrophilic dermatosis postulated to reflect disrupted innate immune regulation causing altered neutrophil chemotaxis. It is uncommonly reported in association with HIV. In this case series, we present three cases of IRIS manifesting with pyoderma gangrenosum in individuals with HIV from India and the United States to raise awareness of this previously undescribed presentation and discuss the treatment challenges in the management of these patients.
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Infecciones por VIH/complicaciones , Síndrome Inflamatorio de Reconstitución Inmune/patología , Síndrome Inflamatorio de Reconstitución Inmune/virología , Piodermia Gangrenosa/patología , Piodermia Gangrenosa/virología , Adulto , Femenino , Infecciones por VIH/patología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Persons with HIV-associated Kaposi's sarcoma (KS) experience three co-existing stigmatizing health conditions: skin disease, HIV, and cancer, which contribute to a complex experience of stigmatization and to delays in diagnosis and treatment. Despite the importance of stigma among these patients, there are few proven stigma-reduction strategies for HIV-associated malignancies. Using qualitative methods, we explore how people with HIV-associated KS in western Kenya between August 2022 and 2023 describe changes in their stigma experience after participation in a multicomponent navigation strategy, which included 1) physical navigation and care coordination, 2) video-based education with motivational survivor stories, 3) travel stipend, 4) health insurance enrollment assistance, 5) health insurance stipend, and 6) peer mentorship. A purposive sample of persons at different stages of chemotherapy treatment were invited to participate. Participants described how a multicomponent navigation strategy contributed to increased knowledge and awareness, a sense of belonging, hope to survive, encouragement, and social support, which served as stigma mitigators, likely counteracting the major drivers of intersectional stigma in HIV-associated KS.
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Infecciones por VIH , Investigación Cualitativa , Sarcoma de Kaposi , Estigma Social , Humanos , Sarcoma de Kaposi/psicología , Sarcoma de Kaposi/terapia , Sarcoma de Kaposi/etiología , Sarcoma de Kaposi/epidemiología , Infecciones por VIH/psicología , Infecciones por VIH/complicaciones , Kenia/epidemiología , Masculino , Femenino , Adulto , Persona de Mediana Edad , Navegación de PacientesRESUMEN
Psoriasis is a hyper-proliferative disease of the skin in which immunological mechanisms play a direct pathogenetic role. There have been limited studies of natural killer (NK) cells in psoriasis. The aim of this study was to examine the phenotype of NK cells in skin biopsies and peripheral blood mononuclear cells from patients with psoriasis and healthy controls. CD56(+) CD16(-) and CD56(+) CD16(+) NK cells were isolated from lesional skin, unaffected skin and PBMC of psoriasis patients, and normal skin and PBMC from healthy controls. The expression of CD57, NKG2A and NKG2C was assessed by flow cytometry. NK cells in psoriasis skin lesions were skewed in their expression of CD57, a marker of NK cell maturity, with CD57 expression significantly reduced and NKG2A expression increased on NK cells in lesional and unaffected skin compared to controls. These data suggest that in this patient cohort, NK cells could be isolated from psoriasis lesions and exhibit an immature phenotype.
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Antígenos CD57/metabolismo , Células Asesinas Naturales/metabolismo , Psoriasis/inmunología , Adulto , Anciano , Anciano de 80 o más Años , Antígeno CD56/metabolismo , Diferenciación Celular , Humanos , Masculino , Persona de Mediana Edad , Subfamília C de Receptores Similares a Lectina de Células NK/metabolismo , Fenotipo , Psoriasis/sangre , Receptores de IgG/metabolismo , Piel/citología , Piel/inmunología , Adulto JovenRESUMEN
BACKGROUND: Herpes zoster (HZ) is common among HIV-infected individuals, but the impacts of highly active antiretroviral therapy (HAART) and HAART adherence on HZ risk have not been well studied. METHODS: The effects of HAART and HAART adherence on HZ incidence were evaluated by comparing HIV-infected women on HAART (HAART use group) with the HIV-infected women remaining HAART naïve (HAART naïve group) in the Women's Interagency HIV Study (WIHS). A 1:1 matching with propensity score for predicting HAART initiation was conducted to balance background covariates at index visit, including HIV disease stage. Kaplan-Meier method was used to compare the risk of HZ development between the matched pairs. Cox proportional hazard models were used to assess the effects of HAART and HAART adherence on HZ incidence. RESULTS: Through propensity score matching, 389 pairs of participants were identified and they contributed 3,909 person years after matching. The background covariates were similar between the matched pairs at the index visit. The participants had a mean age around 39 years old, and about 61% of them were Black and 22% were Latina. No significant difference in HZ risk was observed between the HAART use group and the HAART naïve group during the first year of follow-up in any analyses. In the univariate analysis, the HAART use group had marginally lower HZ risk (Hazard Ratio (HR): 0.72; 95% Confidence Interval (CI): 0.48-1.1) over the entire follow-up period. However, women with a HAART adherence level of ≥95% had significantly lower HZ risk (HR: 0.54; 95% CI: 0.31, 0.94) compared to the HAART naïve women. The association remained significant after adjusting for quality of life score and acyclovir use, but it attenuated and was no longer statistically significant after adjusting for an intermediate variable, either CD4+ T cell counts or HIV viral load. CONCLUSIONS: Among adult women, we observed a significant preventive effect of long-term HAART use on HZ incidence when a HAART adherence level of ≥95% was attained, and this effect was mediated through reduction of HIV viral load and improvement of CD4+ T cell counts.
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Kaposi's sarcoma (KS) is an endothelial cancer caused by the Kaposi's sarcoma-associated herpesvirus (KSHV) and is one of the most common cancers in sub-Saharan Africa. In limited-resource settings, traditional pathology infrastructure is often insufficient for timely diagnosis, leading to frequent diagnoses at advanced-stage disease where survival is poor. In this study, we investigate molecular diagnosis of KS performed in a point-of-care device to circumvent the limited infrastructure for traditional diagnosis. Using 506 mucocutaneous biopsies collected from patients at three HIV clinics in Uganda, we achieved 97% sensitivity, 92% specificity, and 96% accuracy compared to gold standard U.S.-based pathology. The results presented in this manuscript show that LAMP-based quantification of KSHV DNA extracted from KS-suspected biopsies has the potential to serve as a successful diagnostic for the disease and that diagnosis may be accurately achieved using a point-of-care device, reducing the barriers to obtaining KS diagnosis while increasing diagnostic accuracy.
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BACKGROUND: In sub-Saharan Africa, increased antiretroviral therapy (ART) availability has improved survival after diagnosis of Kaposi sarcoma (KS) compared to the pre-ART era, but mortality among patients with KS is still considerably higher than HIV-infected persons without KS. Furthermore, among those patients with KS who are treated initially with ART without adjunct chemotherapy and who do survive, little is known about how well they function and feel - quality of life (QOL) - compared to those without KS. METHODS: Among HIV-infected adults initiating ART in two prospective studies in Uganda, we compared those presenting with KS to those without KS. QOL was measured using the Medical Outcomes Survey-HIV instrument prior to ART initiation and at 16, 32, and 48 weeks thereafter; higher scores indicate better QOL. To ascertain the independent effect of KS versus non-KS on 11 domains of QOL and two summary scores, we created mixed effects models adjusted for directed acyclic graph-informed confounders. RESULTS: We examined 224 participants with KS and 730 without KS, among whom 64% were women and median age was 34 years. Prior to ART initiation, participants had a median CD4+ T count of 159 cells/mm3 and plasma HIV RNA of 5.1 log10 copies/ml. In adjusted analyses prior to ART initiation, those with KS had lower mean scores in 8 of 11 QOL domains and both physical and mental health summary scores compared to those without KS. After 48 weeks of ART, those with KS had higher mean QOL scores compared those without KS in 4 domains and the mental health summary score, and lower scores in only one domain. There was no significant difference in 6 domains and the physical health summary score. CONCLUSIONS: Amongst HIV-infected adults in East Africa, at time of ART initiation, those with KS had worse mean QOL compared to those without KS. Over the first year of ART, those with KS became comparable to or exceeded those without KS in most QOL domains. The findings indicate that some patients with KS can be treated with ART alone and further emphasize the need to predict those who will do well with ART alone versus those who need additional initial therapy.
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HIV-associated Kaposi's sarcoma (KS), which is caused by Kaposi's sarcoma-associated herpesvirus, usually arises in the context of uncontrolled HIV replication and immunosuppression. However, disease occasionally occurs in individuals with durable HIV viral suppression and CD4 T cell recovery under antiretroviral therapy (ART). The underlying mechanisms associated with this phenomenon are unclear. Suppression of viral infections can be mediated by CD8 T cells, which detect infected cells via their T cell receptor and the CD8 coreceptor. However, CD8 T cells exhibit signs of functional exhaustion in untreated HIV infection that may not be fully reversed under ART. To investigate whether KS under ART was associated with phenotypic and functional perturbations of CD8 T cells, we performed a cross-sectional study comparing HIV-infected individuals with persistent KS under effective ART (HIV+ KS+) to HIV-infected individuals receiving effective ART with no documented history of KS (HIV+ KSneg). A subset of T cells with low cell surface expression of CD8 ("CD8dim T cells") was expanded in HIV+ KS+ compared with HIV+ KSneg participants. Relative to CD8bright T cells, CD8dim T cells exhibited signs of senescence (CD57) and mitochondrial alterations (PGC-1α, MitoTracker) ex vivo. Mitochondrial activity (MitoTracker) was also reduced in proliferating CD8dim T cells. These findings indicate that an expanded CD8dim T cell population displaying features of senescence and mitochondrial dysfunction is associated with KS disease under ART. CD8 coreceptor down-modulation may be symptomatic of ongoing disease.
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INTRODUCTION: The experience of stigma can be multifaceted for people with HIV and cancer. Kaposi's sarcoma (KS), one of the most common HIV-associated cancers in sub-Saharan Africa, often presents with visible skin lesions that may put people at risk for stigmatization. In this way, HIV-associated KS is unique, as people with KS can experience stigma associated with HIV, cancer, and skin disease simultaneously. The aim of this study is to characterize the intersectionality of HIV-related, cancer-related and skin disease-related stigma in people living with HIV and KS. METHODS: We used a convergent mixed-methods approach nested within a longitudinal study of people with HIV-associated KS in western Kenya. Between February 2019 and December 2020, we collected quantitative surveys among all participants and conducted semi-structured interviews among a purposive sample of participants. Quantitative surveys were adapted from the abridged Berger HIV Stigma Scale to assess overall stigma, HIV-related stigma, cancer-related stigma, and skin disease-related stigma. Qualitative data were coded using stigma constructs from the Health Stigma and Discrimination Framework. RESULTS: In 88 semi-structured interviews, stigma was a major barrier to KS diagnosis and treatment among people with HIV-associated KS. Participant's stories of stigma were dominated by HIV-related stigma, more than cancer-related or skin disease-related stigma. However, quantitative stigma scores among the 117 participants were similar for HIV-related (Median: 28.00; IQR: 28.0, 34.0), cancer-related (Median: 28.0; IQR: 28.0, 34.8), and skin disease-related stigma (Median: 28.0; IQR: 27.0, 34.0). In semi-structured interviews, cancer-related and skin disease-related stigma were more subtle contributors; cancer-related stigma was linked to fatalism and skin-related stigma was linked to visible disease. Participants reported resolution of skin lesions contributed to lessening stigma over time; there was a significant decline in quantitative scores of overall stigma in time since KS diagnosis (adjusted ß = -0.15, p <0.001). CONCLUSIONS: This study highlights the role mixed-method approaches can play in better understanding stigma in people living with both HIV and cancer. While HIV-related stigma may dominate perceptions of stigma among people with KS in Kenya, intersectional experiences of stigma may be subtle, and quantitative evaluation alone may be insufficient to understand intersectional stigma in certain contexts.