Fiabilidad de la teledermatología de almacenamiento en un escenario real / Interobserver Reliability of Store-and-Forward Teledermatology in a Clinical Practice Setting

INTRODUCCIÓN Y OBJETIVOS: Aunque existen múltiples estudios de fiabilidad diagnóstica en teledermatología de almacenamiento (TDA), aún no se ha demostrado una fiabilidad elevada para enfermedad general cutánea en un escenario real. DERMATEL-2 fue un estudio aleatorizado de concordancia diagnóstica en TDA en condiciones de práctica clínica. MATERIAL Y MÉTODOS: Pacientes remitidos desde atención primaria fueron aleatorizados en 3 grupos: TDA; híbrida videoconferencia-almacenamiento (VC-TDA) y grupo control (GC). Este artículo se centra en el grupo de almacenamiento. Médicos de atención primaria tomaron datos y fotografías clínicas remitiéndolas a distancia. Cada consulta de TDA fue evaluada por 3 dermatólogos diferentes (D1, D2, D3). Todos los pacientes fueron finalmente vistos por el mismo dermatólogo (D1) en la consulta presencial (CP). Dos dermatólogos adicionales (D4, D5) evaluaron las concordancias TDA-CP. RESULTADOS: Se aleatorizaron un total de 457 pacientes 4-4-2: 192 TDA, 176 VC-TDA y 89 GC; 200 varones y 257 mujeres, 0-86 años. Se incuyó enfermedad tumoral (49,4%), inflamatoria (25,7%), anexial (11%), infecciosa (9,4%) y otros (4,4%). Hubo 170 pacientes de TDA válidos para el análisis, rindiendo 510 teleconsultas-TDA. La imagen (71,2%), la historia clínica (91,2%) y la confianza diagnóstica (81,4%) fueron de calidad alta. En el 58,4% fue posible el manejo exclusivo on-line. Los acuerdos interobservador (completo/agregado) TDA-CP fueron 0,72/0,90 para el diagnóstico y 0,61/0,80 en el tratamiento. El acuerdo diagnóstico se correlacionó con la calidad de la imagen (p < 0,001), la confianza diagnóstica (p < 0,001), la necesidad de consulta presencial (p < 0,001) y la calidad de la historia clínica (p = 0,013). CONCLUSIÓN: La fiabilidad diagnóstica de la TDA en condiciones de práctica clínica es elevada. Los dermatólogos pueden predecir errores diagnósticos analizando su confianza diagnóstica y la calidad de las fotografías

INTRODUCTION AND OBJECTIVES: Although many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study. MATERIAL AND METHODS: Patients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data digitally. Each SF consultation package was assessed by 3 dermatologists (D1, D2, D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face (FF) consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF. RESULTS: In total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%). Since 170 patients had SF consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied. In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and FF evaluators were 0.72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P < 0.001), diagnostic confidence (P < 0.001), felt need for conventional consultation (P < .001), and the quality of the clinical record (P = 0.013). CONCLUSION: The interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images

Interobserver reliability of store-and-forward teledermatology in a clinical practice setting.

INTRODUCTION AND OBJECTIVES: Although many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study. MATERIAL AND METHODS: Patients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data electronically. Each SF consultation package was assessed by 3 dermatologists (D1,D2,D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF. RESULTS: In total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%) Since 170 patients had consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied. In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and face-to-face evaluators were 0,72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P < .001), diagnostic confidence (P<.001), felt need for conventional consultation (P<.001), and the quality of the clinical record (P=.013). CONCLUSION: The interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images.

Pilomatrixomas múltiples / Multiple pilomatricomas

El pilomatrixoma es un tumor benigno, relativamente frecuente, que deriva de las células de la matriz del pelo. En general aparece en la infancia comoun nódulo duro localizado en la cabeza y cuello. Suelen estar cubiertos por una superficie epidérmica normal pero en ocasiones es anetodérmica. Lamayoría de los pilomatrixomas son solitarios y raramente aparecen como lesiones múltiples. La presencia de pilomatrixomas múltiples puede ser esporádica,familiar o asociarse a enfermedades de las cuales solo está bien documentado con la enfermedad de Steinert. Presentamos un nuevo caso depilomatrixomas múltiples esporádicos, siendo uno de ellos anetodérmico y revisamos la literatura (AU)

Pilomatricoma is a relatively common benign neoplasm of hair matrix cells, which typically presents as a firm skin-colored nodule on the head and neckin young people. Sometimes the overlying skin may be anetodermic. While most lesions are solitary, multiple pilomatricomas may be present. Multiplepilomatricoma may be sporadic, familial o associated to myotonic dystrophy. The association of multiple pilomatricomas with myotonic dystrophy iswell documented. We report a case of multiple and sporadic pilomatricomas, being one of them anetodermic and review literature (AU)

Encías “en fresa” como manifestación inicial de enfermedad de Wegener / “Strawberry” gingiva as first manifestation of Wegener’s granulomatosisn

La enfermedad de Wegener se define como una vasculitis sistémica necrotizante granulomatosa, que afecta predominantemente al tracto respiratoriosuperior e inferior y al riñón aunque al inicio esta triada no siempre está presente. Presentamos el caso de una paciente con encías “en fresa” comomanifestación inicial. Este tipo de afectación oral es muy rara y clínicamente se caracteriza por el aspecto granular y friable de la encía afecta. El conocimientode esta infrecuente pero característica manifestación precoz del Wegener es importante para hacer un diagnóstico precoz e instaurar tratamientolo antes posible (AU)

Wegener’s granulomatosis is a systemic necrotizing and granulomatous vasculitis that predominantly affects the upper and lower respiratory tract andkidneys. Sometimes this classic triad is not present initially. We report a patient with “strawberry” gingiva as first sign of Wegener. It is characterized byan exophytic hyperplasia and friable and granular appearence. The recognition of this uncommon but characteristic sign would help in early diagnosisand treatment (AU)

Síndrome trófico del trigémino / Trigeminal trophic syndrome

El síndrome trófico del trigémino es una entidad rara, en la que se desarrollan úlceras tróficas en el territorio del trigémino como consecuencia de lalesión de dicho nervio. Los pacientes refieren de forma constante parestesias y manipulación repetida en las áreas afectas. El síndrome trófico del trigéminodebe ser incluido en el diagnóstico diferencial de las úlceras crónicas de la cara y cuero cabelludo, fundamentalmente cuando son unilaterales yasintomáticas. Presentamos un caso de STT secundario a un neurinoma del acústico (AU)

Trigeminal trophic syndrome is a rare entity in which cutaneous trophic ulcers develop in trigeminal area after a damage to this nerve. The majority ofpatients report paraesthesias and repetitive manipulation in the trigeminal area. It should be considerated in patients with chronic nonhealing ulcersof the face and scalp, specially when are unilateral and painless. We report a case of TTS following an acoustic neuroma (AU)

Hiperplasia epitelial focal / Focal epithelial hyperplasia

La hiperplasia epitelial focal es una enfermedad poco frecuente de la mucosa oral producida por el virus del papiloma humano. Aparece una proliferación epitelial benigna de predominio en la mucosa del labio inferior. Se asocia fundamentalmente a los serotipos 13 y 32 y existe un claro predominio racial, en indios americanos y esquimales. Presentamos el caso de una chica de 17 años ecuatoriana, con múltiples lesiones papulosas en labio inferior y superior compatibles clínica e histológicamente con hiperplasia epitelial focal. En el estudio por reacción en cadena de la polimerasa se detectó el virus del papiloma humano serotipo 13

Focal epithelial hyperplasia is a rare disease of the oral mucosa caused by the human papilloma virus (HPV). It appears as a benign epithelial growth, usually in the mucosa of the lower lip. It is mainly associated with HPV serotypes 13 and 32 and there is a clear racial predilection for the disease in Native Americans and Eskimos. We describe the case of a 17-year-old girl from Ecuador with multiple papular lesions in both lips that were clinically and histologically consistent with focal epithelial hyperplasia. Analysis by polymerase chain reaction detected HPV serotype 13

[Focal epithelial hyperplasia]. / Hiperplasia epitelial focal.

Focal epithelial hyperplasia is a rare disease of the oral mucosa caused by the human papilloma virus (HPV). It appears as a benign epithelial growth, usually in the mucosa of the lower lip. It is mainly associated with HPV serotypes 13 and 32 and there is a clear racial predilection for the disease in Native Americans and Eskimos. We describe the case of a 17-year-old girl from Ecuador with multiple papular lesions in both lips that were clinically and histologically consistent with focal epithelial hyperplasia. Analysis by polymerase chain reaction detected HPV serotype 13.

Múltiples pápulas vulvares / Multiple vulvar papules

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