Is injectable PrEP superior to oral therapy for HIV protection?

An RCT of HIV preexposure prophylaxis compared long-acting injectable cabotegravir with traditional daily oral tenofovir-emtricitabine-with clear results.

Exploring Family Medicine Residents' Experiences Teaching Medical Students.

INTRODUCTION: Near-peer teaching offered by residents is common in a medical students' educational career, so preparation of residents for their role as teachers is essential. Understanding resident perspectives on interactions with medical students may provide insight into this near-peer relationship and allow stakeholders to emphasize concepts that add value to this relationship when preparing residents to teach. This study presents the results from an inquiry focusing on a cohort of family medicine residents' experiences with medical students in their role as teachers. METHODS: Family medicine residents at a Southeastern US academic medical center participated in one of three focus groups to assess resident perceptions of their role in teaching students and approaches employed. We coded focus group transcripts for themes. RESULTS: Themes identified from questions on residents' perceptions of teaching role and employed teaching approaches focused on teaching interactions and methods. Six categories of major themes were derived from this qualitative analysis: (1) the learning environment, (2) stimulating learning, (3) supervising, (4) role modeling, (5) collaborating, and (6) transferring knowledge. Trends within these categories include creating a safe environment for clinical reasoning and inquiry, setting expectations, developing clinical reasoning skills through practical application of knowledge, providing appropriate student supervision and autonomy, and including students as part of the team. CONCLUSIONS: Residents adopted a variety of teaching approaches that assist medical students in their transition into and ability to function within a clinical environment. Findings from this study have implications for program directors and educators when preparing residents as teachers.

Analyzing Controversies in Management and Surveillance of Early-Stage Melanoma.

The incidence of cutaneous melanoma continues to rise dramatically worldwide, presenting a significant burden to the healthcare system. Despite this, there is still controversy in the guidelines regarding follow-up surveillance for patients with thin melanoma. Since there are no randomized clinical trials to support evidence-based guidelines for follow-up surveillance, dermatologic and oncologic organizations have developed their own recommendations based on expert opinion. However, these recommendations differ widely and are often vague, resulting in considerable variability in the management of early-stage melanoma among clinicians. The benefits of frequent follow-up visits are early detection of recurrent lesions, lower cost of early-stage melanoma compared to that of late-stage melanoma, decreased need for sentinel lymph node biopsy and adjuvant therapies, and the opportunity to educate patients on self-examination and sun protection. However, the high cost of screening and potential increased rates of biopsy, as well as over-imaging and overtreating, pose serious concerns about this approach. While more rigorous research is needed to resolve this controversy, currently clinicians should follow a relatively universal recommendation to tailor the follow-up regimen based on the patient's relative risk of recurrence and comfort.

Antibiotic Practices in Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery is a safe procedure with low rates of infection. OBJECTIVE: To establish current antibiotic prescribing practices amongst Mohs surgeons. METHODS AND MATERIALS: 16-question survey sent to American College of Mohs Surgery members. RESULTS: 305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%). CONCLUSION: Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695.

Methacrylate Polymer Powder Dressing for a Nasal Surgical Defect

The fusion of technology and medicine has led to the advent of advanced wound healing techniques that may be adapted to the management of surgical defects. Shortened duration of healing and ease-of-use are two potential benefits under investigation. Here we describe a 65-year-old male with a nasal alar wound that was allowed to heal with secondary intention, assisted by a novel methacrylate polymer powder dressing. J Drugs Dermatol. 2019;18(12):1274-1275.

Presurgical Curettage Improves Accuracy for Nonmelanoma Skin Cancer Excision.

BACKGROUND: Presurgical curettage before nonmelanoma skin cancer surgery may help delineate tumor subclinical extensions. OBJECTIVE: To determine histologically whether presurgical curettage appropriately or inappropriately changes excision specimen size. MATERIALS AND METHODS: One hundred fifty consecutive nonmelanoma skin cancers treated with Mohs micrographic surgery. The clinical margin (CM) was marked. Presurgical curettage was then performed and the resultant presurgical curettage margin (PCM) marked. Frozen section analysis of the CM and PCM revealed whether the curettage-induced margin change was appropriate or unnecessary. RESULTS: Presurgical curettage appropriately increased the surgical margin in 9.3% of cases, reducing the number of Mohs stages from 2 to 1. It appropriately decreased the surgical margin in 17.3% thereby conserving normal skin. In 19.4% of cases the curettage increased the margin in situations where the CM had underestimated the size of the tumor; however, in these cases, the curettage did not increase the margin sufficiently to clear the tumor. In 44.0% of cases the PCM did not change the size of the stage I specimen compared to the CM and confirmed the CM. In 10.0% of cases, preoperative curettage reduced margin accuracy by removing healthy tissue (8.0%) or underestimating tumor (2.0%). These errors were associated with eyelid location, severe background photodamage, and morpheiform/infiltrating/sclerosing basal cell carcinomas. CONCLUSION: Presurgical curettage can improve tumor excision accuracy and efficiency. Careful tumor selection is important to optimize curette utility.

Student Race and Gender and Patient Encounters in a Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine the association of students' race and gender with the race, gender, age, patient numbers, and problems encountered during a third-year family medicine clerkship across a geographically distributed clinical teaching network. METHODS: Student patient experience logbook data from two separate but adjacent 3-year periods were analyzed. Mixed-effects regression models and generalized linear mixed models were used to determine the relationship between student race and gender on number and demographics of patients encountered and odds of encountering required conditions and gender-specific conditions at least once during the clerkship. RESULTS: A total of 458 students documented 66,752 encounters during academic years 2008 through 2010, and 498 students documented 70,213 encounters during academic years 2011 through 2013. The first cohort averaged 145.8 (SD 24.0) encounters per student and the second cohort averaged 141.1 (SD 19.5) encounters per student. Females had more encounters during the first period, but no difference in the second. There was no difference in average encounters between white and nonwhite students during the first period, but during the second, nonwhite students had more encounters. A few differences were found in odds of encountering required conditions or gender-specific conditions, but none were consistent across time. CONCLUSIONS: Family medicine clerkship students in this geographically distributed network did not experience significant differences in patient demographics, conditions, or gender-specific diseases, based on their gender or race. The teaching sites in the study were monitored continuously to ensure consistent clinical experiences in volume and scope.

Ultrasound Curriculum Implementation into a State-Wide Family Medicine Clerkship.

INTRODUCTION: While point of care ultrasound (POCUS) integration into clinical clerkships provides unique educational experiences for students, there are barriers to implementation, particularly in a distributed campus medical school model in clerkships where the faculty do not often perform POCUS, like family medicine (FM). The objective of this paper is to describe the implementation and evaluation of a POCUS curriculum in an FM core clinical clerkship in a state-wide medical school campus model. METHODS: Seventeen Philips Lumify Ultrasound Systems were used in 20 clerkship sites with the requirement that students obtain abdominal aortic and inferior vena cava (IVC) images on patients evaluated during their rotation. Images were de-identified, transmitted to a university cloud-based storage account, and scored by medical school ultrasound faculty. RESULTS: Students were able to obtain adequate images of the aorta and IVC without direct ultrasound-trained faculty at the performance site. Of the 183 students, 119 (65%) were able to successfully submit images for scoring with failure to upload to the cloud-based storage account as the most common reason students were unsuccessful (42%). The majority of students (62%) scored in the top quartile of image quality scoring with the percentage of those scoring in the top quartile improving during the academic year from 57% in the first four rotations to 67% in the last four rotations. CONCLUSION: Barriers to implementation of a POCUS curriculum into a FM clerkship in a distributed campus medical school model can be challenging due to equipment availability and issues around the successful transmission of images. These challenges can be overcome however with sufficient attention to implementation design that includes equipment sharing protocols and technical options that enhance the ease of image transmission.

Association Between Surgeon-Specific Features and Number of Stages, Flaps, and Grafts in Mohs Micrographic Surgery: A Retrospective Observational Study of 59 Early-, Mid-, and Advanced-Career Mohs Surgeons.

BACKGROUND: There is limited data available to correlate Mohs surgeons' behavior and years of experience. Moreover, the recent standardization of Mohs surgery training programs may allow for the prediction of future trends in Mohs micrographic surgery surgery based on the current behavior of recently trained Mohs surgeons. OBJECTIVE: To better understand the relationship between surgeon-specific characteristics and the number of Mohs micrographic surgery total cases, stages per case, number of grafts, and number of flaps performed by each surgeon. MATERIALS AND METHODS: Procedure data of 59 early-career, mid-career, and advanced-career Mohs surgeons were obtained from the website of the Centers for Medicare & Medicaid services. RESULTS: No statistically significant differences were identified in the number of stages per case between the 3 groups. Two-proportion testing between advanced-career surgeons and early-career surgeons indicated a statistically significant difference in the number of surgeons performing flaps or grafts (p < .05). Similarly, a statistically significant difference was noticed between mid-career surgeons and early-career surgeons (p < .05). CONCLUSION: The result of this study showed that more years of experience was significantly associated with reported utilization of flaps or grafts in practice. Furthermore, no significant difference was observed between years in practice and number of stages per case.

A method for distinguishing the intended margins for a melanoma from the tissue cones after surgical excision.

BACKGROUND: Surgical excision of severely dysplastic nevi and thin cutaneous melanomas (<1 mm in depth) remains the most effective treatment to date. However, sometimes a severely dysplastic nevus may be upstaged to a melanoma in situ, or a melanoma in situ may be upgraded to an invasive melanoma once the completely excised specimen is reviewed microscopically. This then requires a re-excision around the entire scar at follow-up as the dermatological surgeon can be perplexed as to where the precise locations of the pigmented lesion and the tissue cones are, thereby generating a longer scar. OBJECTIVE: We want to introduce a simple, cost-effective and easy-to-implement approach that permits the dermatological surgeon to distinguish from a linear scar the site of the original pigmented lesion and the lengths of the tissue cones. Therefore, if a re-excision is necessary, instead of surgical removal around the entire scar, only a focal directed excision of the pigmented lesion is necessary and this will result in a shorter scar; this will be useful for cosmetically sensitive areas on the face. A case is included to illustrate our objective. RESULTS AND DISCUSSION: Using our surgical method on a patient's left cheek pigmented lesion originally diagnosed as melanoma in situ with a subsequent revised diagnosis of invasive melanoma generated a shorter scar and a favorable cosmetic outcome.

Catastrophic cutaneous carcinomatosis in the non-organ transplant patient.

BACKGROUND: The increased frequency of nonmelanoma skin cancers (NMSCs) in organ transplant recipients has been termed "catastrophic cutaneous carcinomatosis" (CCC). We have treated a cohort of immunocompetent patients with an increased number of NMSCs that meets the definition of CCC whom we have termed "catastrophic cutaneous carcinomatosis-immunocompetent" (CCC-IC). OBJECTIVE: We sought to further understand the epidemiologic characteristics of this subset of immunocompetent patients with a high burden of NMSCs. METHODS: Our pathology database was searched over a 4-year experience of a Mohs surgeon to identify patients with greater than 10 basal cell carcinomas (BCCs) and/or squamous cell carcinomas (SCCs) in a 12-month period who had no underlying systemic cause of immunosuppression or genetic predisposition to form NMSCs. Information regarding the 13 patients who met inclusion criteria was collected by questionnaire and analyzed. RESULTS: There was no statistically significant difference in the constitutional variables of this patient population. Patients with CCC-IC had a SCC:BCC ratio of 2.5:1, similar to what is seen in organ transplant recipients where the SCC:BCC ratio is 2:1 with SCC predominance. There was a statistically significant increase in the number of SCCs in patients with CCC-IC (8.77/patient) as compared with control patients (2.27/patient). Most strikingly, a 13.8-fold higher incidence of malignant melanoma in the CCC-IC group was found as compared with the general population. LIMITATIONS: Limitations to this study include a small sample size and recall bias. CONCLUSION: Our data suggest that patients with CCC-IC have skin cancer profiles of SCC and BCC similar to organ transplant recipients and have a markedly higher incidence of malignant melanoma than the general population. These patients require strict monitoring and combination therapeutic approaches toward management of cutaneous carcinomas.

Patients with drug-eluting stents and management of their anticoagulant therapy in cutaneous surgery.

Whether a patient has a drug-eluting stent (DES) implanted may not seem to be an immediate concern for a dermatologist. However, the clinician needs to consider a patient's risk of bleeding if a patient is to undergo a cutaneous surgical procedure. Patients with skin cancer are generally older with a higher risk of comorbidities such as cardiovascular disease with history of cardiac stent implantation. After DES placement, patients are typically on long-term dual antiplatelet therapy, which increases the risk of bleeding. However, stopping antiplatelet therapy prematurely can lead to serious thrombotic complications. Thus, when performing a dermatologic procedure in a patient with a DES, the physician must weigh the risks of bleeding complications with continuing antiplatelet therapy against the risk of thrombotic complications associated with stopping antiplatelet therapy. The aim of this review is to identify the issues for the dermatologist and the dermatologic surgeon surrounding the perioperative treatment of patients with a DES and to discuss the treatment of patients with an implanted DES.

Osteoinvasive subungual melanoma: a case and review.

Subungual melanoma is a relatively rare variant of melanoma, accounting for 0.7-3.5% of all melanoma cases in the Caucasian population. Curiously, it occurs in 8-33% of cases in black, Asian, Native American and Hispanic populations, which generally face a substantially lower risk of melanoma. Herein the authors report the case of a 69-year-old Hispanic female with a subungual melanoma of the acral lentiginous type that directly invaded the periosteum, cortex and medulla of the distal phalanx. In addition, we review published reports of acral lentiginous melanoma with osseous invasion and discuss the evidence, on a molecular level, for this entity's aggressive pattern of invasion. The review of cases is limited to those found through the PubMed search engine.

Soft tissue tumors of the hand. 2. Malignant.

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (previous article) and malignant tumors (this article) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.