Dengue NS1 antibodies are associated with clearance of viral NS1.

BACKGROUND: Dengue vascular permeability syndrome is the primary cause of death in severe dengue infections. The protective versus potentially pathogenic role of dengue NS1 antibodies are not well understood. The main goal of this analysis was to characterize the relationship between free NS1 concentration and NS1 antibody titers in primary and secondary dengue infection in order to better understand the presence and duration of NS1 antibody complexes in clinical dengue infections. METHODS: Hospitalized participants with acute dengue infection were recruited from Northern Colombia between 2018 to 2020. Symptom assessment including dengue signs and symptoms, chart review and blood collection was performed. Primary versus secondary Dengue was assessed serologically. NS1 titers and anti-NS1 antibodies were measured daily. RESULTS: Patients with secondary infection have higher antibody titers than those in primary infection, and we find a negative correlation between anti-NS1 antibody titer and NS1 protein. We demonstrate that in a subset of secondary infection, there are indeed NS1 antibody-antigen complexes at the admission day during the febrile phase that are not detectable by the recovery phase. Furthermore, dengue infection status is associated with higher circulating sialidases. DISCUSSION: The negative correlation between antibody and protein suggests that antibodies may play a role in clearing this viral protein.

Association between psoriasis and cardiometabolic comorbidities in a racially and ethnically diverse low-income primary care population.

Psoriasis is associated with cardiometabolic comorbidities, including obesity, diabetes, hyperlipidaemia and hypertension. Many studies that established these associations originated from primarily White and/or relatively affluent populations. To evaluate whether there is a differential risk for cardiometabolic comorbidities in racial/ethnic minorities, we performed a cross-sectional analysis comparing cardiometabolic comorbidities between those with and without psoriasis in a racially and ethnically diverse population of 56 987 low-income patients, stratified by race/ethnicity, and assessed whether race/ethnicity acts as an effect modifier for cardiometabolic comorbidities. We found that psoriasis was statistically significantly associated with obesity, diabetes, hyperlipidaemia and hypertension. The association of psoriasis with comorbidities did not differ significantly by race/ethnicity; thus, we did not find evidence of effect modification. However, our diverse, low-income population had an extremely high baseline prevalence of cardiometabolic comorbidities compared with previous populations studied. Our results suggest education and intervention regarding modifiable risk factors are particularly important among vulnerable populations.

Evaluation of a pilot forensic dermatology curriculum in the USA.

Physician participation in asylum medicine through forensic medical evaluations increases the likelihood that asylum seekers are granted legal status. Based on a review of existing literature and input from content experts, we designed and implemented a forensic dermatology curriculum for dermatology residents at University of California, San Francisco. Our pilot curriculum led to improvements in learners' attitudes regarding physician participation in asylum medicine and their confidence in describing skin findings of torture or abuse.

Novel Education Modules Addressing the Underrepresentation of Skin of Color in Dermatology Training.

BACKGROUND: Representative images of pathology in patients with skin of color are lacking in most medical education resources. This particularly affects training in dermatology, which relies heavily on the use of images to teach pattern recognition. The presentation of skin pathology can vary greatly among different skin tones, and this lack of representation of dark skin phototypes challenges providers' abilities to provide quality care to patients of color.In Botswana and other countries in sub-Saharan Africa, this challenge is further compounded by limited resources and access to dermatologists. There is a need for improved and accessible educational resources to train medical students and local medical providers in basic skin lesion description and diagnosis. OBJECTIVES: We examined whether online Perceptual and Adaptive Learning Modules (PALMs) composed of representative dark skin images could efficiently train University of Botswana medical students to more accurately describe and diagnose common skin conditions in their community. METHODS: Year 4 and 5 medical students voluntarily completed PALMs that teach skin morphology, configuration, and distribution terminology and diagnosis of the most common dermatologic conditions in their community. Pre-tests, post-tests and delayed-tests assessed knowledge acquisition and retention. RESULTS: PALMs training produced statistically significant (P < .0001) improvements in accuracy and fluency with large effect sizes (1.5, 3.7) and good retention after a 12.5-21-week median delay. Limitations were a self-selected group of students, a single institution, slow internet connections, and high drop-out rates. CONCLUSIONS: Overall, population-specific PALMs are a useful tool for efficient development of pattern recognition in skin disease description and diagnosis.

Persistent Joint Pain Following Arthropod Virus Infections.

PURPOSE OF REVIEW: Persistent joint pain is a common manifestation of arthropod-borne viral infections and can cause long-term disability. We review the epidemiology, pathophysiology, diagnosis, and management of arthritogenic alphavirus infection. RECENT FINDINGS: The global re-emergence of alphaviral outbreaks has led to an increase in virus-induced arthralgia and arthritis. Alphaviruses, including Chikungunya, O'nyong'nyong, Sindbis, Barmah Forest, Ross River, and Mayaro viruses, are associated with acute and/or chronic rheumatic symptoms. Identification of Mxra8 as a viral entry receptor in the alphaviral replication pathway creates opportunities for treatment and prevention. Recent evidence suggesting virus does not persist in synovial fluid during chronic chikungunya infection indicates that immunomodulators may be given safely. The etiology of persistent joint pain after alphavirus infection is still poorly understood. New diagnostic tools along and evidence-based treatment could significantly improve morbidity and long-term disability.

Treatment practices in the management of scabies in infants younger than two months.

BACKGROUND/OBJECTIVES: Efficacy and safety data of scabies treatments in infants are limited. Although topical permethrin is used in the treatment of scabies in adults, it is not approved for use in infants younger than 2 months of age in many parts of the world. This study aimed to describe treatment practices in the management of scabies in infants younger than 2 months. METHODS: An online survey was developed and distributed to physicians worldwide through the Society of Pediatric Dermatology and the Pediatric Dermatology Research Alliance. Data collected included demographics, medication availability, experience using medications, deterrents to medication use, medication administration preferences, perceived and experienced medication side effects, and preferred treatment agent in this population. RESULTS: In total, 57 physicians from seven countries responded. The majority of respondents were board-certified in pediatric dermatology (48/57, 84.2%) and resided in the United States (44/57, 77.2%). Respondents had experience using permethrin (47/57, 82.5%) and precipitated sulfur (35/57, 61.4%) most frequently. Most (38/57, 66.7%) preferred permethrin as their treatment of choice. Among those who did not use permethrin, potential side effects (8/10, 80%) were most frequently reported as a deterrent from its use. However, only 4.3% (22/47) of those who used permethrin reported side effects, including itching, erythema, and xerosis. CONCLUSIONS: Permethrin is frequently used in the treatment of infants younger than 2 months with scabies. Furthermore, our results demonstrate that permethrin is the preferred treatment agent among sampled dermatologists for infants younger than 2 months. Few side effects were reported, and none were serious.

The public health control of scabies: priorities for research and action.

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.

Ectoparasites: Pediculosis and tungiasis.

Pediculosis is an infestation of lice on the body, head, or pubic region that occurs worldwide. Lice are ectoparasites of the order Phthiraptera that feed on the blood of infested hosts. Their morphotype dictates their clinical features. Body lice may transmit bacterial pathogens that cause trench fever, relapsing fever, and epidemic typhus, which are potentially life-threatening diseases that remain relevant in contemporary times. Recent data from some settings suggest that head lice may harbor pathogens. The epidemiology, clinical manifestations, and management of body, head, and pubic louse infestation are reviewed. New therapies for head lice and screening considerations for pubic lice are discussed. Tungiasis is an ectoparasitic disease caused by skin penetration by the female Tunga penetrans or, less commonly, Tunga trimamillata flea. It is endemic in Latin America, the Caribbean and sub-Saharan Africa and seen in travelers returning from these regions. Risk factors for acquiring tungiasis, associated morbidity, and potential strategies for prevention and treatment are discussed.

Ectoparasites: Scabies.

Scabies is an ectoparasitic dermatosis caused by Sarcoptes scabiei var. hominis and is a public health issue in all countries regardless of socioeconomic status. In high-income countries, delays in diagnosis can lead to institutional outbreaks; in low- and middle-income countries, poor access to health care contributes to disease undertreatment and long-term systemic sequelae. With scabies now recognized as a neglected tropical disease by the World Health Organization, increased awareness and systematic efforts are addressing gaps in diagnosis and treatment that impede scabies control. This review summarizes the available data and provides an update on scabies epidemiology, clinical features, diagnosis, management, and public health considerations.

3D Knee Trochlear Morphology Assessment by Magnetic Resonance Imaging in Patients With Normal and Dysplastic Trochleae.

BACKGROUND: Trochlear dysplasia is recognized as a significant risk factor for patellar instability, but current imaging modalities fail to allow full visualization and classification of the complex 3-dimensional (3D) anatomy of the trochlea. The purpose of this study was to elucidate primary differences in trochlear morphology between patients with and without patellar instability by utilizing 3D magnetic resonance imaging (MRI) reconstructions of the trochlea. METHODS: An institutional review board-approved retrospective review included 24 patients with a diagnosis of patellar instability and an age-matched and sex-matched control population of 12 patients. 3D models of the femoral trochlea were created from MRI images and measurements were performed. 3D measurements were trochlear groove volume and surface area that were normalized to the femoral width. 2D measurements were performed throughout the length of the trochlea including the bony and cartilaginous sulcus angles as well as the bony and cartilaginous trochlear depths. Differences were also assessed between sex, skeletal maturity, and trochlear dysplasia severity. RESULTS: Surface topography of the trochlea varied significantly based on location with the trochlea becoming progressively more flat proximally away from the notch (P<0.05). Patients with patella instability had reduced trochlear volumes and trochlear depths compared with control patients (P<0.05). These differences were more pronounced with the cartilaginous measurements as well as more proximally within the trochlea. Patients with high-grade dysplasia had greater reductions in trochlear volumes and depth especially proximally in the trochlea (P<0.05). Once femoral size was standardized, minimal differences were observed based on sex or skeletal maturity (P>0.05). CONCLUSIONS: Novel 3D MRI reconstructions demonstrated that measurements of trochlear morphology varied significantly between patients with and without patellar instability. When trochlear dysplasia is present, it appears to affect the majority of the trochlear surface, but preferentially the proximal extent. Future trochlear dysplasia classification systems may benefit from assessment of articular cartilage surface measures rather than primarily osseous structure measurements. LEVEL OF EVIDENCE: Level III-case-control prognostic study.

Augmented Zika and Dengue Neutralizing Antibodies Are Associated With Guillain-Barré Syndrome.

The role of neutralizing antibodies in Zika-induced Guillain-Barré syndrome (GBS) has not yet been investigated. We conducted a case-control study using sera from the 2016 Zika epidemic in Colombia to determine the neutralizing antibody activity against Zika virus (ZIKV) and dengue virus serotype 2 (DENV2). We observed increased neutralizing antibody titers against DENV2 in ZIKV-infected individuals compared with uninfected controls and higher titers to both ZIKV and DENV2 in ZIKV-infected patients diagnosed with GBS compared with non-GBS ZIKV-infected controls. These data suggest that high neutralizing antibody titers to DENV and to ZIKV are associated with GBS during ZIKV infection.

Co-circulation of dengue, chikungunya, and Zika viruses in Colombia from 2008 to 2018.

OBJECTIVE: This study aimed to identify the co-circulation patterns of three viruses (dengue, Zika, and -chikungunya) in Colombia from 2008 to 2018 by using notification reports provided to the national surveillance system. METHODS: This cross-sectional study was conducted through a review of data for 2008 through 2018 from Colombia's Public Health Surveillance System (SIVIGILA). RESULTS: In 2015, when chikungunya was first detected, it had a higher incidence (1 359.0 cases per 100 000 persons) than did the two other diseases. In 2016, when the circulation of Zika virus was first found, the incidence was 296.4 cases per 100 000 persons; that incidence declined dramatically in the next two years. Between 2015 and 2018, there was a substantial decrease in the frequency of dengue circulation, with it going from 334.1 cases per 100 000 persons in 2015 to 90.7 cases per 100 000 in 2017 and 173.1 cases per 100 000 in 2018. CONCLUSIONS: The decrease in the number of dengue cases after co-circulation of the three viruses could indicate possible cross-protection. This finding should be further analyzed.

Community Health Workers, Access to Care, and Service Utilization Among Florida Latinos: A Randomized Controlled Trial.

OBJECTIVES: To determine whether a 1-year community health worker intervention improves access to care and service utilization among Latinos with diabetes. METHODS: We conducted a single-blind randomized trial of 300 adults with poorly controlled diabetes treated in 2 public hospital clinics in Miami, Florida. We began enrollment in 2010 and completed follow-up in 2015. We examined access and utilization using self-reported measures and data from electronic medical records. RESULTS: Participants randomized to the community health worker intervention self-reported fewer problems accessing needed care and prescriptions than did those in the usual care group (30% vs 43% and 28% vs 41%, respectively; P < .05 for both). Adjusting for age, gender, education, depression, and comorbidities showed similar results (odds ratio [OR] = 0.52; 95% confidence interval [CI] = 0.29, 0.93 and OR = 0.45; CI = 0.24, 0.82, respectively). We found no significant utilization differences in primary care visits, emergency department utilization, or hospitalization between the 2 groups. CONCLUSIONS: Among Latinos with poorly controlled diabetes, a 1-year community health worker intervention was associated with improvements in self-reported access to care but not service utilization.

Analysis of the immunological biomarker profile during acute Zika virus infection reveals the overexpression of CXCL10, a chemokine linked to neuronal damage.

BACKGROUND: Infection with Zika virus (ZIKV) manifests in a broad spectrum of disease ranging from mild illness to severe neurological complications and little is known about Zika immunopathogenesis. OBJECTIVES: To define the immunologic biomarkers that correlate with acute ZIKV infection. METHODS: We characterized the levels of circulating cytokines, chemokines, and growth factors in 54 infected patients of both genders at five different time points after symptom onset using microbeads multiplex immunoassay; comparison to 100 age-matched controls was performed for statistical analysis and data mining. FINDINGS: ZIKV-infected patients present a striking systemic inflammatory response with high levels of pro-inflammatory mediators. Despite the strong inflammatory pattern, IL-1Ra and IL-4 are also induced during the acute infection. Interestingly, the inflammatory cytokines IL-1ß, IL-13, IL-17, TNF-α, and IFN-γ; chemokines CXCL8, CCL2, CCL5; and the growth factor G-CSF, displayed a bimodal distribution accompanying viremia. While this is the first manuscript to document bimodal distributions of viremia in ZIKV infection, this has been documented in other viral infections, with a primary viremia peak during mild systemic disease and a secondary peak associated with distribution of the virus to organs and tissues. MAIN CONCLUSIONS: Biomarker network analysis demonstrated distinct dynamics in concurrence with the bimodal viremia profiles at different time points during ZIKV infection. Such a robust cytokine and chemokine response has been associated with blood-brain barrier permeability and neuroinvasiveness in other flaviviral infections. High-dimensional data analysis further identified CXCL10, a chemokine involved in foetal neuron apoptosis and Guillain-Barré syndrome, as the most promising biomarker of acute ZIKV infection for potential clinical application.

Teledermatology as a Means to Provide Multispecialty Care: A Case of Global Specialty Collaboration.

Telemedicine can serve as a platform for specialty collaboration and potentially address the lack of specialized and subspecialized care globally. In this article we present a case in which the use of teledermatology facilitated global collaboration between multiple specialists and subspecialists, resulting in high-quality care of a child from a remote area of Botswana. We present the lessons learned and factors that should be considered when engaging in global specialty collaboration, especially between developed and developing countries. We also discuss the potential limitations of telemedicine when used within a global context. With these considerations in mind, global specialty collaboration facilitated by telemedicine can provide a potential solution to the lack of access to specialized and subspecialized care.

Evolution of Knowledge, Awareness, and Practices regarding Zika Virus from 2016 to 2017.

Objective: Our team created a knowledge, attitudes, and practice (KAP) survey in order to assess changes over time in healthcare provider and community member awareness of Zika virus symptoms, transmission, treatment, and current and future concerns. Study Design: The cross-sectional survey was issued at an academic medical center in Washington, DC, and via an online link to healthcare providers and community members between June and August 2016. Survey distribution was then repeated the following year, from March to April 2017. Outcomes were compared by survey year and healthcare provider versus community member status using SAS Program Version 9.4. Results: Significant differences in knowledge, attitudes, and practices existed between 2016 and 2017 survey time points. By 2017, more respondents had knowledge of various Zika virus infection characteristics; however healthcare provider knowledge also waned in certain areas. Attitudes towards Zika virus infection displayed an overall decreased concern by 2017. Practice trends by 2017 demonstrated fewer travel restrictions to Zika-endemic areas and increased mosquito protective measures within the US. Conclusions: Our results provide novel insight into the transformation of knowledge, attitudes, and practice of community members and healthcare providers regarding Zika virus since its declaration as a public health emergency of international concern in 2016.

Management Considerations in Extraocular Sebaceous Carcinoma.

BACKGROUND: Extraocular sebaceous carcinoma (SC) is a rare malignancy with metastatic potential. The authors present a case of a rapidly growing extraocular SC with equivocal radiographic imaging to highlight challenges in tumor management. OBJECTIVE: To examine the existing literature for evaluation and management recommendations of extraocular SC. METHODS AND MATERIALS: A comprehensive review of relevant English articles in PubMed through May 2015. RESULTS: Tumor-specific staging system and management guidelines do not currently exist for extraocular SC. Mohs micrographic surgery or wide local excision are the most commonly used surgical treatments. Regional/distant metastasis occurs infrequently, but systemic workup with radiographic imaging or sentinel lymph node biopsy may be warranted in select cases. Adjuvant radiation therapy can be considered for recurrent and metastatic tumors. CONCLUSION: Extraocular SCs present unique challenges that may benefit from multidisciplinary management. Surgical removal with negative pathologic margins is the mainstay treatment of extraocular SC. Additional studies will help clarify the optimal diagnostic workup and adjuvant treatment of patients.