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Background: During the COVID-19 pandemic, many pre-clinical medical school courses were conducted virtually. In order to increase exposure to basic procedures in the remote learning setting, our group developed a virtual dermatologic surgery workshop. Objective: To evaluate whether a virtual dermatologic surgery workshop increases medical student confidence in their ability to perform suturing and skin biopsies. Methods: All 147 second-year medical students at the University of Pittsburgh watched 70 minutes of pre-recorded lectures that introduced suturing, skin biopsies, and other dermatologic procedures. Each student was provided with a suturing kit to remotely practice the following skills: simple interrupted suture, simple running suture, horizontal mattress suture, vertical mattress suture, running subcuticular suture, shave biopsy, and punch biopsy. Pre- and post-workshop surveys were distributed to the students and paired using a randomized de-identified number. Results: 117 (80%) students completed the pre-survey and 71 (48%) completed the post-survey. 61 (41%) responses were paired. The average baseline level of confidence ranged from 1.0 on a 10-point scale for subcuticular running suture to 2.4 for simple interrupted suture. The average level of confidence increased after the workshop for each skill, ranging from 3.7 for subcuticular running suture to 8.0 for instrument tie. In the paired responses, the average level of confidence increased significantly for each skill by an average of 5.5 points (SD=1.1, p

Background In some settings, sensitive field diagnostic tools may be needed to achieve elimination of falciparum malaria. To this end, rapid diagnostic tests (RDTs) based on the detection of the Plasmodium falciparum protein HRP-2 are being developed with increasingly lower limits of detection. However, it is currently unclear how parasite stages that are unaffected by standard drug treatments may contribute to HRP-2 detectability and potentially confound RDT results even after clearance of blood stage infection. In this study, we assessed the detectability of HRP-2 in periods of post-treatment residual gametocytaemia. Methods A cohort of 100 Plasmodium falciparum infected, gametocyte positive individuals were treated with or without the gametocytocidal drug primaquine (PQ), alongside standard artemisinin-based combination therapy (ACT), in the context of a randomised clinical trial in Ouelessebougou, Mali. We used a quantitative ELISA to measure levels of HRP-2, and compared time to test negativity using a standard and ultra-sensitive RDT (uRDT) between residual gametocyte positive and negative groups. Findings Time to test negativity was longest by uRDT, followed by ELISA and then standard RDT. No significant difference in time to negativity was found between the treatment groups with and without residual gametocytes: uRDT (HR 0.79 [95% CI 0.52–1.21], p = 0.28), RDT (HR 0.77 [95% CI 0.51–1.15], p = 0.20) or ELISA (HR 0.88 [95% CI 0.59–1.32], p = 0.53). Similarly, no difference was observed when adjusting for baseline asexual parasite density. Quantified levels of HRP-2 over time were similar between groups, with differences attributable to asexual parasite densities. Furthermore, no difference in levels of HRP-2 was found between individuals who were or were not infectious to mosquitoes (OR 1.19 [95% CI 0.98–1.46], p = 0.077). Interpretation Surviving sexual stage parasites after standard ACT treatment do not contribute to the persistence of HRP-2 antigenaemia, and appear to have little impact on RDT results.

Background In the absence of a method to culture Plasmodium vivax, the only way to source parasites is ex vivo. This hampers many aspects of P. vivax research. This study aimed to assess the safety of apheresis, a method for selective removal of specific components of blood as a means of extracting and concentrating P. vivax parasites. MethodsAn iterative approach was employed across four non-immune healthy human subjects in single subject cohorts. All four subjects were inoculated with ~564 blood stage P. vivax (HMP013-Pv) and subjected to apheresis 10 to 11 days later. Blood samples collected during apheresis (haematocrit layers 0.5% to 11%) were tested for the presence and concentration of P. vivax by microscopy, flow cytometry, 18S rDNA qPCR for total parasites, and pvs25 qRT-PCR for female gametocyte transcripts. Safety was determined by monitoring adverse events. Malaria transmission to mosquitoes was assessed by membrane feeding assays. ResultsThere were no serious adverse events and no significant safety concerns. Apheresis concentrated asexual parasites by up to 4.9-fold (range: 0.9 - 4.9-fold) and gametocytes by up to 1.45-fold (range: 0.38 - 1.45-fold) compared to pre-apheresis densities. No single haematocrit layer contained >40% of all the recovered P. vivax asexual parasites. Ex vivo concentration of parasites by Percoll gradient centrifugation of whole blood achieved greater concentration of gametocytes than apheresis. Mosquito transmission was enhanced by up to 5-fold in a single apheresis sample compared to pre-apheresis. ConclusionThe modest level of parasite concentration suggests that the use of apheresis may not be an ideal method for harvesting P. vivax.

Background Mohs micrographic surgeons should be adept in identifying and managing perineural invasion (PNI), lymphovascular invasion (LVI), and single-cell spread (SCS), features denoting high-risk behavior of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) and microcystic adnexal carcinoma (MAC). Objective The purpose of this article is to review the literature and guidelines regarding the diagnosis of PNI, LVI, and SCS in BCC, cSCC, and MAC and examine the role of advanced diagnostic studies, adjuvant therapy, and reconstructive techniques of these high-risk tumors. Materials and methods We performed a literature search including the following terms: PNI, LVI, SCS, BCC, cSCC, keratinocyte carcinoma, MAC, sentinel lymph node biopsy, radiation, chemotherapy, and staging. Relevant studies, case reports, and review articles were included, as well as National Comprehensive Cancer Network guidelines. Results Pancytokeratin immunohistochemistry may aid in the diagnosis of high-risk features of BCC and cSCC. Reconstruction of the Mohs defect should be carefully considered to allow for thorough inspection. Radiation therapy should be considered as an adjuvant treatment option for high-risk cSCC and BCC. Close surveillance for recurrence is warranted. Conclusion The Mohs surgeon should be competent in identification of high-risk tumors and to understand how best to manage, further treat, and follow these tumors.

Nodular cutaneous amyloidosis (NCA), the least common form of primary cutaneous amyloidosis, is characterized clinically by waxy, purpuric plaques and nodules and histologically by amyloid deposits in the dermis and subcutaneous tissue. We present a patient who developed multiple, non-contiguous NCA lesions over a three year period without evidence of systemic disease. We reviewed the literature and found few other cases of this unusual presentation.

Background Approximately 150 women annually become pregnant while taking isotretinoin despite participation in the iPLEDGE program. Noncompliance with the requirement to be abstinent or use 2 contraceptive methods may be a contributing factor. Objective We sought to determine the degree of adherence to contraception or abstinence among women taking isotretinoin. Methods We conducted an anonymous survey of women of childbearing potential taking isotretinoin for at least 2 months. Results Among 75 participants, 21 (28%) chose abstinence as their primary means of pregnancy prevention, of whom 4 (19%) were sexually active during treatment. The most commonly chosen contraceptive methods among the 39 women who were sexually active were condoms (35, 90%) and oral contraceptive pills (18, 46%). Twelve women (31%) admitted to having intercourse at least once using 1 or fewer forms of contraception; 10 failed to use condoms, and 1 reported completely unprotected intercourse. Among sexually active oral contraceptive pill users, 7 (39%) reported missing 1 or more pills in the previous month. Limitations Data were self-reported, thus participants may have inaccurately reported contraception use. Conclusions Encouraging the use of highly effective, patient-independent contraception and limiting abstinence to women who have never been sexually active may further reduce the rate of isotretinoin-exposed pregnancies.

Although melanoma is a deadly cancer that is rising in incidence, the USA does not have uniform guidelines for melanoma screening. Screening for melanoma requires no specialized equipment and has little associated morbidity. However, screening has the greatest impact when performed among patients with the highest risk for melanoma incidence and mortality. Screening lower-risk patients may result in prohibitively high costs, unnecessary biopsies of benign lesions, and decreased access to a dermatologic specialist for patients who are actually at a higher risk. We advocate targeting melanoma screening efforts toward those patients at high risk of developing and dying from melanoma, as well as toward those at-risk patients who are least likely to detect their own melanoma.

RECENT advances in the treatment of infectious diseases, made possible by the discovery of bacteriostatic agents, have inspired medical investigators to study an ever increasing number of chemotherapeutic and antibiotic substances. Many different compounds have been isolated and tested in the laboratory and used clinically, but only a few of them have proved to be of definite value. The great majority have been unsatisfactory either because of their excessive toxicity or because of their failure to act specifically on the organism for which an inhibiting substance was being sought. It is our purpose in this paper to report additional studies with a relatively new antibiotic agent, bacitracin. Bacitracin was first reported by Johnson, Anker and Meleney, 1 in 1945. It had been produced by a strain of Bacillus subtilis recovered from a mixture of organisms contaminating the debrided tissue removed from a compound tibial fracture. After having investigated the properties