Implementation of Direct-to-Patient Mobile Teledermatology in VA.

BACKGROUND: Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. OBJECTIVE: We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. DESIGN /PARTICIPANTS/APPROACH: Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. KEY RESULTS: Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. CONCLUSIONS: Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. CLINICAL TRIALS REGISTRATION: NCT03241589.

Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States.

Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.

The Utilization and Impact of Live Interactive and Store-and-Forward Teledermatology in a Veterans Affairs Medical Center During the COVID-19 Pandemic.

Introduction: Teledermatology has emerged as a promising method of continuing dermatologic care during the coronavirus 2019 (COVID-19) pandemic, including in the Department of Veterans Affairs (VA). Analysis of the utilization and impact of teledermatology within the San Francisco Veterans Affairs Health Care System (SFVAHCS) may elucidate the ways that teledermatology programs can continue to be optimized. Methods: We conducted a retrospective analysis of live interactive encounters, Veterans Affairs Video Connect (VVC), store-and-forward telehealth (SFT), and face-to-face (FTF) consultations, performed within the SFVAHCS from March 2020 to December 2020. To assess utilization, we analyzed numbers of encounters throughout 2020. To assess impact, we analyzed primary diagnoses for each encounter and rates of recommendations for medications and lesion biopsies. Additionally, we assessed diagnostic accuracy associated with each teledermatology type by measuring concordance between teledermatologists' clinical diagnoses and histopathological diagnoses. Results: Two thousand two hundred fifty FTF, 347 VVC, and 470 SFT encounters were conducted from March to December 2020. More female patients utilized VVC, and patients who utilized VVC were younger than SFT and FTF users (p < 0.01). SFT was utilized more by patients from rural areas (p < 0.01). Diagnoses addressed were significantly different between VVC and SFT. A majority of VVC encounters involved referrals for inflammatory conditions; primary diagnoses associated with SFT consultations were most frequently neoplasms. Comparison of VVC and SFT outcomes showed that more VVC visits resulted in a medication recommendation, while more SFT consultations resulted in a biopsy recommendation. Conclusions: Teledermatology contributed to meeting patient needs throughout 2020 and created an impact on clinical management. Patient characteristics, diagnoses, and type of impact associated with encounters varied between SFT and VVC. This analysis provides insight into teledermatology utilization within the VA system and can contribute to efforts to improve the quality of teledermatology care for veterans.

Limited impact of teledermoscopy on referrals to face-to-face dermatology.

BACKGROUND: Teledermoscopy improves teledermatology clinical outcomes, but the practical impact of this and other teleconsultation variables on patient management are unclear. We assessed the impact of these variables, including dermoscopy, on face-to-face (F2F) referrals to optimize effort by imagers and dermatologists. METHODS: Using retrospective chart review, we retrieved demographic, consultation, and outcome variables from 377 interfacility teleconsultations sent to San Francisco Veterans Affairs Health Care System (SFVAHCS) between September 2018 to March 2019 from another VA facility and its satellite clinics. Data were analyzed using descriptive statistics and logistic regression models. RESULTS: Of 377 consults, 20 were excluded due to patient F2F self-referral without teledermatologist recommendation. Analysis of consults showed that age, clinical image, and problem number but not dermoscopy were associated with F2F referral. Analysis of problems contained in consults showed that lesion location and diagnostic category were also associated with F2F referral. Skin cancer history and problems on the head/neck were independently associated with skin growths in multivariate regression. CONCLUSIONS: Teledermoscopy was associated with variables related to neoplasms but did not affect F2F referral rates. Rather than utilize teledermoscopy for all cases, our data suggests that referring sites prioritize teledermoscopy for consultations with variables associated with a likelihood of malignancy.

The Effect of Telehealth Services on Provider Productivity.

BACKGROUND: Telehealth services historically have played a small role in the provision of health care in the United States. However during the coronavirus disease 2019 (COVID-19) pandemic, public and private insurers rapidly expanded access to telehealth in order to reduce exposure and avoid transmission. It is unknown whether telehealth will become a more regular substitute for in-person care beyond the pandemic. OBJECTIVE: Our objective was to provide evidence on the value of telehealth by comparing the productivity of physicians and other specialized clinicians who provide telehealth with the productivity of those who do not. RESEARCH DESIGN: We conducted a retrospective data analysis of 17,705 unique providers in the areas of internal medicine, cardiology, dermatology, psychiatry, psychology, and optometry practicing in the US veterans affairs health care system during the period 2015 to 2018. For each year, we measured individual providers productivity by the total number of relative value units (RVUs) per full-time equivalent (FTE). We estimated the impact of providing telehealth on RVUs/FTE using fixed effects regression models estimated on a panel dataset of 58,873 provider-year observations and controlling for provider and patient characteristics. RESULTS: Overall provider productivity increased in veterans affairs over the period, particularly in cardiology and dermatology. Providers of telehealth had above average productivity by 124 RVUs/FTE, or ∼4% of average total provider productivity. For the highest quartile of telehealth providers, average productivity was 188 RVUs/FTE higher than productivity of other providers. CONCLUSION: Strategies that encourage long-term integration of telehealth into provider practices may contribute to overall health care value.

Implementing Teledermatology for Rural Veterans: An Evaluation Using the RE-AIM Framework.

Introduction: Few systematic evaluations of implementing teledermatology programs in large health care systems exist. We conducted a longitudinal evaluation of a U.S. Department of Veterans Affairs (VA) initiative to expand asynchronous consultative teledermatology services for rural veterans. Methods: The reach, effectiveness, adoption, implementation, and maintenance framework guided the evaluation, which included analysis of quantitative VA administrative data as well as an online survey completed by participating facilities. The first 2 years of the program were compared with the year before the start of funding. Results: Sixteen hub facilities expanded teledermatology's reach over the 2-year period, increasing the number of referral spoke sites, unique patients served, and teledermatology encounters. Effectiveness was reflected as teledermatology constituted an increasing fraction of dermatology activity and served more remotely located patients. Adoption through defined stages of implementation progressed as facilities engaged in a variety of strategies to enhance teledermatology implementation, and facilitators and barriers were identified. Program maintenance was assessed by Program Sustainability Index scores, which reflected the importance of executive support, and ongoing concerns about staffing and longitudinal funding. Discussion: Enabling hubs to create solutions that best fit their needs and culture likely increased reach and effectiveness. Important facilitators included organizational leadership and encouraging communication between stakeholders before and during the intervention. Conclusions: A systematic analysis of teledermatology implementation to serve rural sites in VA documented a high degree of implementation and sustainability as well as areas for improvement.

Implementation of Mobile Teledermatology: Challenges and Opportunities.

Background: While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA introduced a mobile teledermatology application (app) at three VA sites. Methods: We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys. Results: Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access. Conclusions: Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.

Teledermatology in the United States: An Update in a Dynamic Era.

BACKGROUND: Teledermatology is rapidly advancing in the United States. The last comprehensive survey of U.S. teledermatology programs was conducted in 2011. INTRODUCTION: This article provides an update regarding the state of teledermatology programs in the United States. MATERIALS AND METHODS: Active programs were identified and surveyed from November 2014 to January 2017. Findings regarding practice settings, consult volumes, payment methods, and delivery modalities were compared to those from the 2011 survey. Findings from the Veterans Affairs (VA) were reported as an aggregate. RESULTS: There were 40 active nongovernmental programs, amounting to a 48% increase and 30% discontinuation rate over five years. Academia remained the most common practice setting (50%). Median annual consultation volume was comparable with 263 consultations, but maximum annual consultation volume increased (range: 20-20,000). The most frequent payment method was self-pay (53%). Store-and-forward continued to be the most common delivery modality. In Fiscal Year 2016, the VA System consisted of 62 consultation sites and performed a total of 101,507 consultations. DISCUSSION: The limitations of this study were that consult volume and payment methods were not available from all programs. CONCLUSION: U.S. teledermatology programs have increased in number and annual consultation volume. Academia is the most prevalent practice setting, and self-pay is the dominant accepted payment method. Innovative platforms and the provision of direct-to-patient care are changing the practice of teledermatology.

Practice Guidelines for Teledermatology.

Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.

Targeting protein-trafficking pathways alters melanoma treatment sensitivity.

Protein-trafficking pathways are targeted here in human melanoma cells using methods independent of oncogene mutational status, and the ability to up-regulate and down-regulate tumor treatment sensitivity is demonstrated. Sensitivity of melanoma cells to cis-diaminedichloroplatinum II (cDDP, cis-platin), carboplatin, dacarbazine, or temozolomide together with velaparib, an inhibitor of poly (ADP ribose) polymerase 1, is increased by up to 10-fold by targeting genes that regulate both protein trafficking and the formation of melanosomes, intracellular organelles unique to melanocytes and melanoma cells. Melanoma cells depleted of either of the protein-trafficking regulators vacuolar protein sorting 33A protein (VPS33A) or cappuccino protein (CNO) have increased nuclear localization of cDDP, increased nuclear DNA damage by platination, and increased apoptosis, resulting in increased treatment sensitivity. Depleted cells also exhibit a decreased proportion of intracellular, mature melanosomes compared with undepleted cells. Modulation of protein trafficking via cell-surface signaling by binding the melanocortin 1 receptor with the antagonist agouti-signaling protein decreased the proportion of mature melanosomes formed and increased cDDP sensitivity, whereas receptor binding with the agonist melanocyte-stimulating hormone resulted in an increased proportion of mature melanosomes formed and in decreased sensitivity (i.e., increased resistance) to cDDP. Mutation of the protein-trafficking gene Hps6, known to impair the formation of mature melanosomes, also increased cDDP sensitivity. Together, these results indicate that targeting protein-trafficking molecules markedly increases melanoma treatment sensitivity and influences the degree of melanosomes available for sequestration of therapeutic agents.

Teledermatology Within the Veterans Health Administration, 2002-2014.

BACKGROUND: In order to increase veterans' access to dermatologic care, the Veterans Health Administration (VHA) has developed one of the largest teledermatology programs in the United States. This article describes the recent expansion of the VHA's teledermatology program after local and national initiatives and resource allocation. MATERIALS AND METHODS: This report describes routinely collected VHA data. RESULTS: For the first half of fiscal year 2014, the VHA recorded 31,926 teledermatology encounters, which represents 14% of all recorded teledermatology visits. Although every region in the VHA used teledermatology in the past year, four regions created 51% of the encounters. The use of store-and-forward telehealth (SFT), in which physicians view patient images after the patients were photographed, is increasing, whereas live video use is decreasing. Starting in 2012, encounters for patients in urban areas exceeded those in rural areas. The majority of patients were male veterans 60-79 years of age. Seventy-one percent of SFT consultations for the first half of 2014 were completed within 1 week. CONCLUSIONS: Although errors in and the evolution of coding encounters may distort results, the data show rapid growth of a telemedicine system that increases access to dermatology services for veterans. Most likely this growth reflects institutional commitment to telehealth via policy and resources.

Functional relevance of the histone gammaH2Ax in the response to DNA damaging agents.

The phosphorylation of H2Ax on its S139 site, γH2Ax, is important during DNA double-strand repair and is considered necessary for assembly of repair complexes, but its functional role after other kinds of DNA damage is less clear. We have measured the survival of isogenic mouse cell lines with the H2Ax gene knocked out, and replaced with wild-type or mutant (S139A) H2Ax genes, exposed to a range of agents with varied mechanisms of DNA damage. Knockout and mutant cells were sensitive to γ-rays, etoposide, temozolamide, and endogenously generated reactive oxygen species, each of which can include double-strand breaks among their spectra of DNA lesions. The absence or mutation of H2Ax had no influence on sensitivity to cisplatin or mitomycin C. Although UV light induced the highest levels of γH2Ax, mutation of S139 had no influence on UV sensitivity or the UV DNA damage response. Complete loss of H2Ax reduced the survival of cells exposed to UV light and reduced pChk1 induction, suggesting that sites other than S139 may impact the ATR-pChk1 pathway. The relative intensity of γH2Ax measured in Western blots in wild-type cells did not correlate with the functional importance of γH2Ax. The use of γH2Ax as a general biomarker of DNA damage is therefore potentially misleading because it is not an unambiguous indicator of double-strand breaks, and a significant fraction of DNA repair, especially involving nucleotide excision or crosslink repair, can occur without functional involvement of γH2Ax.

Review of Teledermatology: Lessons Learned from the COVID-19 Pandemic.

Utilization of telemedicine for dermatology has greatly expanded since the start of the COVID-19 pandemic, with over 500 new teledermatology studies published since 2020. An updated review on teledermatology is necessary to incorporate new findings and perspectives, and educate dermatologists on effective utilization. We discuss teledermatology in terms of diagnostic accuracy and clinical outcomes, patient and physician satisfaction, considerations for special patient populations, published practice guidelines, cost effectiveness and efficiency, as well as administrative regulations and policies. Our findings emphasize the need for dermatologist education, prioritization of reliable reimbursement systems, and technological innovations to support the continued development of teledermatology in the post-pandemic era.

Regulation of XPC Binding Dynamics and Global Nucleotide Excision Repair by p63 and Vitamin D Receptor.

p63 and the vitamin D receptor (VDR) play important roles in epidermal development and differentiation, but their roles and relationship in the response to ultraviolet (UV) radiation are less clear. Using TERT-immortalized human keratinocytes expressing shRNA targeting p63 in concert with exogenously applied siRNA targeting VDR, we assessed p63 and VDR's separate and combined effect on nucleotide excision repair (NER) of UV-induced 6-4 photoproducts (6-4PP). Knockdown of p63 reduced VDR and XPC expression relative to nontargeting controls, while knockdown of VDR had no effect on p63 and XPC protein expression, though alone it modestly reduced XPC mRNA. Upon UV irradiation through filters with 3 µm pores to create spatially discrete spots of DNA damage, keratinocytes depleted of p63 or VDR exhibited slower removal of 6-4PP than control cells over the first 30 min. Costaining of control cells with antibodies to XPC revealed that XPC accumulated at DNA damage foci, peaking within 15 min and gradually fading over 90 min as NER proceeded. In either p63- or VDR-depleted keratinocytes, XPC overaccumulated at spots of DNA damage so that 50% more XPC was retained at 15 min and 100% more XPC was retained at 30 min than in control cells, suggesting dissociation of XPC after binding was also delayed. Concurrent knockdown of VDR and p63 resulted in similar impairment of 6-4PP repair and XPC overaccumulation but even slower release of XPC from DNA damage sites such that 200% more XPC was retained relative to controls at 30 min post-UV. These results suggest that VDR accounts for some of p63's effects in delaying 6-4PP repair associated with overaccumulation and slower dissociation of XPC, though p63's regulation of basal XPC expression appears to be VDR-independent. The results are consistent with a model where XPC dissociation is an important step during NER and that failure to do so may inhibit subsequent repair steps. This work further links two important regulators of epidermal growth and differentiation to the DNA repair response to UV.

Vitamin D receptor cross-talk with p63 signaling promotes epidermal cell fate.

The vitamin D receptor with its ligand 1,25 dihydroxy vitamin D3 (1,25D3) regulates epidermal stem cell fate, such that VDR removal from Krt14 expressing keratinocytes delays re-epithelialization of epidermis after wound injury in mice. In this study we deleted Vdr from Lrig1 expressing stem cells in the isthmus of the hair follicle then used lineage tracing to evaluate the impact on re-epithelialization following injury. We showed that Vdr deletion from these cells prevents their migration to and regeneration of the interfollicular epidermis without impairing their ability to repopulate the sebaceous gland. To pursue the molecular basis for these effects of VDR, we performed genome wide transcriptional analysis of keratinocytes from Vdr cKO and control littermate mice. Ingenuity Pathway analysis (IPA) pointed us to the TP53 family including p63 as a partner with VDR, a transcriptional factor that is essential for proliferation and differentiation of epidermal keratinocytes. Epigenetic studies on epidermal keratinocytes derived from interfollicular epidermis showed that VDR is colocalized with p63 within the specific regulatory region of MED1 containing super-enhancers of epidermal fate driven transcription factor genes such as Fos and Jun. Gene ontology analysis further implicated that Vdr and p63 associated genomic regions regulate genes involving stem cell fate and epidermal differentiation. To demonstrate the functional interaction between VDR and p63, we evaluated the response to 1,25(OH)2D3 of keratinocytes lacking p63 and noted a reduction in epidermal cell fate determining transcription factors such as Fos, Jun. We conclude that VDR is required for the epidermal stem cell fate orientation towards interfollicular epidermis. We propose that this role of VDR involves cross-talk with the epidermal master regulator p63 through super-enhancer mediated epigenetic dynamics.

Using the RE-AIM framework to assess national teledermatology expansion.

Background: Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics. Methods: We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding. Findings: Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period. Conclusions: Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.

Defective DNA repair and cell cycle arrest in cells expressing Merkel cell polyomavirus T antigen.

The pathways by which Merkel cell polyomavirus (MCV) infection contributes to the formation of Merkel cell carcinomas are important for understanding the pathogenesis of these cancers. We hypothesized that MCV T antigen suppresses normal responses to ultraviolet radiation (UVR)-induced DNA damage. An MCV-infected cell line (MKL-1) exhibited UVR hypersensitivity, impaired repair of DNA lesions and cell cycle arrest after UVR, as well as reduced levels of the DNA damage recognition protein, XPC. When ectopically expressed in uninfected UISO cells, mutant but not wild-type T antigen resulted in loss of repair of UVR-induced cyclobutane pyrimidine dimers and reductions in XPC, p53 and p21 levels, whereas both wild-type and mutant T antigen inhibited cell cycle arrest after UVR. Similarly, only mutant T antigen in normal fibroblasts inhibited DNA repair and XPC expression, while both mutant and wild-type T antigens produced cell cycle dysregulation. Wild-type T antigen expression produced large T, 57 kT and small T antigens while mutant T antigen was only detectable as a truncated large T antigen protein. Expression of wild-type large T antigen but not small T antigen inhibited the G1 checkpoint in UISO cells, but neither wild-type large T nor small T antigens affected DNA repair, suggesting that large T antigen generates cell cycle defects, and when mutated may also impair DNA repair. These results indicate that T antigen expression by MCV can inhibit key responses to UVR-induced DNA damage and suggest that progressive MCV-mediated abrogation of genomic stability may be involved in Merkel cell carcinogenesis.

Vitamin D in cutaneous carcinogenesis: part I.

Skin cancer is the most common cancer in the United States. Exposure to ultraviolet radiation is a known risk factor for skin cancer but is also the principal means by which the body obtains vitamin D. Several studies have suggested that vitamin D plays a protective role in a variety of internal malignancies. With regard to skin cancer, epidemiologic and laboratory studies suggest that vitamin D and its metabolites may have a similar protective effect. These noncalcemic actions of vitamin D have called into question whether the current recommended intake of vitamin D is too low for optimal health and cancer prevention. Part I will review the role of vitamin D in the epidermis; part II will review the role of vitamin D in keratinocyte-derived tumors to help frame the discussion on the possible role of vitamin D in the prevention of skin cancer.

Vitamin D in cutaneous carcinogenesis: part II.

The role of vitamin D in health maintenance and disease prevention in fields ranging from bone metabolism to cancer is currently under intensive investigation. A number of epidemiologic studies have suggested that vitamin D may have a protective effect on cancer risk and cancer-associated mortality. With regard to skin cancer, epidemiologic and laboratory studies suggest that vitamin D and its metabolites may have a similar risk reducing effect. Potential mechanisms of action include inhibition of the hedgehog signaling pathway and upregulation of nucleotide excision repair enzymes. The key factor complicating the association between vitamin D and skin cancer is ultraviolet B radiation. The same spectrum of ultraviolet B radiation that catalyzes the production of vitamin D in the skin also causes DNA damage that can lead to epidermal malignancies. Part II of this continuing medical education article will summarize the literature on vitamin D and skin cancer to identify evidence-based optimal serum levels of vitamin D and to recommend ways of achieving those levels while minimizing the risk of skin cancer.

State of teledermatology programs in the United States.

BACKGROUND: Teledermatology programs in the United States have evolved over the past several decades. No systematic survey of teledermatology programs in the United States is available in peer-reviewed literature. OBJECTIVE: To provide up-to-date information regarding the state of teledermatology programs in the United States. METHODS: Active U.S. teledermatology programs were surveyed in 2011 with regards to practice models, clinical volume, and payment methods. These findings were compared with those from 2003. RESULTS: By January 2012, 37 teledermatology programs were active in the United States. Store-and-forward teledermatology was the most frequent delivery modality offered by 30 (81%) of the programs. The majority of the programs were based at academic institutions (49%), followed by Veterans Administration hospitals (27%), private practice (16%), and health maintenance organizations (HMOs) (8%). The majority of programs (67%) provided services to their home state only, whereas the rest also served additional U.S. states or abroad. The median number of consultations per program was 309 (range, 5-6500) in 2011. The most frequent payer sources were private payers, followed by self-pay, Medicaid, Medicare, and HMOs. Since 2003, with the confirmed discontinuation of 24 previously active programs, the total number of active teledermatology programs in 2011 was 60% of that in 2003. However, the annual consult volume per program nearly doubled for the sustainable programs in 2011. LIMITATIONS: Itemized billing information was not uniformly available from all programs. CONCLUSION: The turnover in teledermatology programs is relatively constant, with an increase in consult volume for sustainable programs. Store-and-forward is the dominant modality of delivery, while hybrid technology model is emerging.