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Introduction: Individuals with skin of colour (SoC) have delayed diagnosis and poorer outcomes when presenting with some dermatologic conditions when compared to individuals with light skin (LS). The objective of this study was to determine if diagnostic performance bias can be mitigated by a skin-tone balanced dermatology curriculum., Methodology: A prospective randomised intervention study occurred over 2 weeks in 2020 at a Canadian medical school. A convenience sample of all first-year medical students (n = 167) was chosen. In week 1, all participants had access to dermatology podcasts and were randomly allocated to receive non-analytic training (NAT; online patient 'cards') on either SoC cases or LS cases. In week 2, all participants received combined training (CT; NAT and analytic training through workshops on how to apply dermatology diagnostic rules for all skin tones). Participating students completed two formative assessments after weeks 1 and 2., Results: Ninety-two students participated in the study. After week 1, both groups had a lower diagnostic performance on SoC (p = 0.0002 and p = 0.002 for students who trained on LS 'cards' and SoC 'cards', respectively). There was a significant decrease in mean skin tone difference in both groups after week 2 (initial training on SoC: 5.8% (SD 12.2) pre, -1.4% (14.7) post, p = 0.007; initial training on LS: 7.8% (15.4) pre, -4.0% (11.8%) post, p = 0.0001). Five students participated in a post-study survey in 2023, and all found the curriculum enhanced their diagnostic skills in SoC., Conclusions: SoC performance biases of medical students disappeared after CT in a skin tone-balanced dermatology curriculum., (© 2023 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

There is a paucity of information surrounding dermatologic care for persons experiencing homelessness (PEH). This scoping review aims to map existing literature and provide a summary of the most common cutaneous manifestations among PEH, risk factors for dermatologic disease, describe any reported interventions, as well as identify research gaps for future studies. Search strategies developed for MEDLINE and hand searching yielded 486 articles. Out of the 486 articles screened, 93 articles met the inclusion criteria. The majority were cohort studies, cross-sectional studies, and case-control studies concentrated in North America and Europe. Excluding the pediatric population, the prevalence of dermatologic conditions ranged from 16.6% to 53.5%. Common skin conditions described in PEH were: acne, psoriasis, seborrheic dermatitis, atopic dermatitis, and lichen simplex chronicus. There were no studies comparing the extent or severity of these cutaneous diseases in PEH and the general population. PEH have a higher prevalence of skin infections and non-melanoma skin cancers. This scoping review has direct implications on public health interventions for PEH and highlights the need for evidence-based interventions to provide optimum and safe dermatologic healthcare for PEH. We propose several recommendations for improved care delivery, including addressing upstream factors and comorbidities impacting skin health, providing trauma informed care, reducing barriers to care, preventing and managing skin conditions, as well as including PEH in the planning and implementation of any proposed intervention.

Background: Deliberate practice is an important method of skill acquisition and is under-utilized in dermatology training. We delivered a dermatologic morphology training module with immediate feedback for first year medical students. Our goal was to determine whether there are differences in accuracy and learning efficiency between self- regulated and algorithm-regulated groups., Methods: First year medical students at the University of Calgary completed a dermatologic morphology module. We randomly assigned them to either a self-regulated arm (students removed cases from the practice pool at their discretion) or an algorithm-regulated arm (an algorithm determined when a case would be removed). We then administered a pre-survey, pre-test, post-test, and post-survey. Data collected included mean diagnostic accuracy of the practice sessions and tests, and the time spent practicing. The surveys assessed demographic data and student satisfaction., Results: Students in the algorithm-regulated arm completed more cases than the self-regulated arm (52.9 vs. 29.3, p<0.001) and spent twice as much time completing the module than the self-regulated participants (34.3 vs. 17.0 min., p<0.001). Mean scores were equivalent between the algorithm- and self-regulated groups for the pre-test (63% vs. 66%, n = 54) and post-test (90% vs. 86%, n = 10), respectively. Both arms demonstrated statistically significant improvement in the post-test., Conclusion: Both the self-regulated and algorithm-regulated arms improved at post-test. Students spent significantly less time practicing in the self-directed arm, suggesting it was more efficient., Competing Interests: Conflicts of interest: There are no conflicts of interest to declare for Drs. Traboulsi, Hardin, and Parsons. Dr. Jason Waechter is the owner of teachingmedicine.com, the online website that provided the learning resources. This is an open access module that is publicly available.

Background: Long-term use of immunosuppressive medications by organ transplant recipients (OTRs) leads to an increased risk of non-melanoma skin cancers (NMSCs). The objective of this study was to assess photoprotective knowledge and practices among OTRs and to identify predictors of poor sunscreen adherence and barriers to photoprotection., Methods: A written survey was administered to 300 solid OTRs attending the Southern Alberta Transplant Program. Demographics, transplant and NMSC history, ultraviolet radiation (UVR) exposure, photoprotective knowledge and practices, and barriers to implementing photoprotection were collected. Relevant statistical analyses and univariate and multivariable regression models on sunscreen use were performed., Results: One hundred and seventy-nine of the 300 respondents reported not using sunscreen most days despite 79.3% recalling have received photoprotection education. Of the surveyed OTRs, 45.7% reported no barriers to implementing photoprotective practices. On average, respondents scored 74.5% on a commonly used tool to assess photoprotective knowledge (SD 30.6%). In multivariable analyses, older age, male gender, and lack of post-secondary education were associated with lower rates of self-reported sunscreen use. The most commonly patient-reported barriers to photoprotection were "hassle/time consuming" (16.7%) and "sunscreen is uncomfortable or unpleasant" (10.0%)., Conclusions: Despite OTRs self-reporting having received sufficient sun-protective knowledge and demonstrating reasonable recollection of photoprotective education on assessment, implementation of sun protection in the studied OTRs remains suboptimal., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a known clinical conundrum with limited investigation. Using a large population-based cohort, we examined the incidence, demographic profile, use of evidence-based medicines (EBM) and clinical outcomes of MINOCA patients., Methods: Patients hospitalized with a primary diagnosis of MI who underwent coronary angiography between 01/04/2002 and 31/03/2014 in Alberta, Canada, were included in the study. Comparisons were made between patients with MINOCA versus obstructive coronary disease (OCD). The primary composite endpoint was 1-year all-cause death or re-MI., Results: Of 35,928 patients hospitalized with MI, 2092 (5.8%) had MINOCA. In-hospital mortality rate was 0.8% among MINOCA, and 2.7% among patients with OCD (p < 0.0001). At 6 months, cardiovascular EBM rates were significantly lower among MINOCA patients compared to OCD patients. One-year death/re-MI rate was 5.3% in MINOCA and 8.9% in patients with OCD (adjusted hazard ratio (AHR) 0.75, 95% confidence interval (CI) 0.62-0.92, p < 0.0001). Five-year mortality rates were 10.9% in MINOCA and 16.0% in patients with OCD. Upon further stratification, 770 (36.8%) of MINOCA patients had no angiographic evidence of CAD (i.e. normal angiograms). EBM rates were even lower among these patients. One-year death/re-MI rate among these patients was 3.9% as compared to 6.1% among MINOCA patients with stenosis <50% (AHR 0.68, 95% CI 0.44-1.07, p = 0.028)., Conclusions: The population-level incidence of MINOCA is approximately 5%. Despite their apparently benign anatomic findings, efforts must be made to improve secondary prevention strategies to reduce the burden of long-term adverse outcomes in this population., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: We examined variation in hospital treatment and its relationship to clinical outcome in a large population-based cohort of ACS patients within a single payer-government funded health care system., Methods: Patients hospitalized in 106 hospitals in Alberta, Canada with a primary diagnosis of ACS were included (July 1, 2010-March 31, 2013) with comparisons made across the three cardiac catheterization-capable hospitals (Sites A-C). Cox proportional-hazard regression models were used to examine the multivariable-adjusted association between site and 1-year death or repeat cardiovascular (CV) hospitalization (primary endpoint)., Results: Of 14,155 patients, 1938 (13.7%) were admitted to a community hospital without transfer to an invasive hospital (10.7% in-hospital death). The remaining were admitted (n=4514, 36.9%) or transferred (n=7703, 63.1%) to an invasive hospital (A:5480; B:3621; C:3116) where 11,247 (92.1%) underwent catheterization. Comorbidities and angiographic disease burden differed across sites. Variation in 30-day revascularization (PCI: 71.3%, 72.0%, 68.7%, p<0.001; CABG: 6.2%, 6.4%, 9.3%, p<0.001) and drug-eluting stent use for PCI (24.3%, 54.6%, 50.5%, p<0.001) were observed. After adjustment for patient demographics and comorbidities, variation in rates of 1-year death or CV hospitalization was observed among those with 30-day revascularization (p(interaction)<0.001; B versus A: HR 0.78, 95%CI 0.66-0.91; C versus A: HR 0.77, 95%CI 0.65-0.91; B versus C: HR 1.01, 95%CI 0.84-1.21)., Conclusions: Despite a government funded health system, we have shown variation in hospital treatment exists. Following adjustment hospital site was associated with differences in clinical outcome within 1year. Hence, further efforts may be warranted to help address potential disparities in ACS care., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Terminal hair is not routinely removed for assessment of BCCs on the scalp and yet may obscure the true size of scalp BCCs. This can compromise effective management., Objective: To underscore the importance of removing terminal hair on the scalp for an accurate assessment of clinical margins of BCC on the scalp., Methods: We report 2 cases of cutaneous BCC arising on the scalp. The size of the malignancies was underestimated because they were masked by hair growth., Results: Removing terminal hair allowed for a full assessment of the extent of the tumours on hair-bearing scalp, which had been underestimated by 73% to 80% prior to shaving., Conclusion: Our cases highlight the importance of hair removal for complete assessment of cutaneous malignancy occurring on hair-bearing skin.

Sirolimus, also known as rapamycin (SRL, Rapamune®), was approved in 1999 by the US Food and Drug Administration to prevent graft rejection in renal transplantation. As a member of the mammalian target of rapamycin (mTOR) inhibitor class, its potent immunosuppressant, anti-angiogenic and anti-proliferative properties are well recognized. When compared to other immunosuppressants, SRL has a lower risk of renal, neurologic and lymphoproliferative complications. It has become a promising treatment modality for angiofibromas, Kaposi's sarcoma and other inflammatory and malignant disorders of the skin. With the recent discovery that mTOR inhibitors extend the lifespan of mice, sirolimus and other rapamycin analogs (rapalogs) are emerging as therapeutic targets for the treatment and prevention of age-related diseases.

Background & Aims: Clostridium difficile is the leading cause of nosocomial infectious diarrhea. Antibiotic resistance and increased virulence of strains have increased the number of C difficile-related deaths worldwide. The innate host response mechanisms to C difficile are not resolved; we propose that hypoxia-inducible factor (HIF-1) has an innate, protective role in C difficile colitis. We studied the impact of C difficile toxins on the regulation of HIF-1 and evaluated the role of HIF-1alpha in C difficile-mediated injury/inflammation., Methods: We assessed HIF-1alpha mRNA and protein levels and DNA binding in human mucosal biopsy samples and Caco-2 cells following exposure to C difficile toxins. We used the mouse ileal loop model of C difficile toxin-induced intestinal injury. Mice with targeted deletion of HIF-1alpha in the intestinal epithelium were used to assess the effects of HIF-1alpha signaling in response to C difficile toxin., Results: Mucosal biopsy specimens and Caco-2 cells exposed to C difficile toxin had a significant increase in HIF-1alpha transcription and protein levels. Toxin-induced DNA binding was also observed in Caco-2 cells. Toxin-induced HIF-1alpha accumulation was attenuated by nitric oxide synthase inhibitors. In vivo deletion of intestinal epithelial HIF-1alpha resulted in more severe, toxin-induced intestinal injury and inflammation. In contrast, stabilization of HIF-1alpha with dimethyloxallyl glycine attenuated toxin-induced injury and inflammation. This was associated with induction of HIF-1-regulated protective factors (such as vascular endothelial growth factor-alpha, CD73, and intestinal trefoil factor) and down-regulation of proinflammatory molecules such as tumor necrosis factor and Cxcl1., Conclusions: HIF-1alpha protects the intestinal mucosa from C difficile toxins. The innate protective actions of HIF-1alpha in response to C difficile toxins be developed as therapeutics for C difficile-associated disease., (Copyright 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)