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nas vaginitis, chancroid,1 granuloma inguinale, scabies, louse infestation, and bacterial vaginosis (among women who have sex with women) However, shigellosis,1 hepatitis A, B, and C,1 amebiasis, giardiasis,1 cryptosporidiosis,1 salmonellosis,1 and campylobacteriosis may also be transmitted by sexual (oral-anal) contact, especially in men who have sex with men Both homosexual and heterosexual contact are risk factors for the transmission of HIV (see 31) Although it is not recommended to perform tests-of-cure for those in whom STDs have been diagnosed and treated, these patients are at a high risk for reinfection and should be encouraged to be rescreened for STDs at 3 months following the initial STD diagnosis The risk of developing an STD following a sexual assault has not been established Victims of assault have a high baseline rate of infection (Neisseria gonorrhoeae, 6%; Chlamydia trachomatis, 10%; Trichomonas vaginalis, 15%; and bacterial vaginosis, 34%), and the risk of acquiring infection as a result of the assault is significant but is often lower than the preexisting rate (N gonorrhoeae, 6 12%; C trachomatis, 4 17%; T vaginalis, 12%; syphilis, 05 3%; and bacterial vaginosis, 19%) Victims should be evaluated within 24 hours after the assault, and cultures or FDA-cleared nucleic acid amplification tests for N gonorrhoeae and C trachomatis should be obtained Vaginal secretions are cultured and examined for Trichomonas If a discharge is present, if there is itching, or if secretions are malodorous, a wet mount should be examined for Candida and bacterial vaginosis In addition, a blood sample should be obtained for immediate serologic testing for syphilis, hepatitis B, and HIV Follow-up examination for STD should be repeated within 1 2 weeks, since concentrations of infecting organisms may not have been sufficient to produce a positive test at the time of initial examination If prophylactic treatment was given (see below), tests should be repeated only if the victim has symptoms If prophylaxis was not administered, the individual should be seen in 1 week so that any positive tests can be treated Follow-up serologic testing for syphilis and HIV infection should be performed in 6, 12, and 24 weeks if the initial tests are negative The usefulness of presumptive therapy is controversial, some feeling that all patients should receive it and others that it should be limited to those in whom followup cannot be ensured or to patients who request it If therapy is given, a reasonable regimen would be hepatitis B vaccination (without hepatitis B immune globulin, the first dose given at the initial evaluation and follow-up doses at 1 2 months and 4 6 months) and one dose of ceftriaxone, 125 mg intramuscularly, plus metronidazole, 2 g orally as a single dose, plus doxycycline, 100 mg orally twice daily for 7 days, or azithromycin, 1 g orally as a single dose, instead of doxycycline In premenopausal women, azithromycin should be used instead of doxycycline until the pregnancy status is determined; if the pregnancy test is positive, metronidazole should be given only after the first trimester Although seroconversion to HIV has been reported following sexual assault when this was the only known risk, this risk is believed to be low The likelihood of HIV transmission from vaginal or anal receptive intercourse.

The term atypical nevus or atypical mole has supplanted dysplastic nevus The diagnosis of atypical moles is made clinically and not histologically, and moles should be removed only if they are suspected to be melanomas

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Clinically, these moles are large ( 6 mm in diameter), with an ill-defined, irregular border and irregularly distributed pigmentation It is estimated that 5 10% of the white population in the United States has one or more atypical nevi Studies have defined an increased risk of melanoma in the following populations: patients with 50 or more nevi with one or more atypical moles and one mole at least 8 mm or larger, and patients with a few to many definitely atypical moles These patients deserve education and regular (usually every 6 12 months) follow-up Kindreds with familial melanoma (numerous atypical nevi and a strong family history) deserve even closer attention, as the risk of developing single or even multiple melanomas in these individuals approaches 50% by age 50

Example A-50. One solution to Exercise 17-1 (continued)

Dixon A Dysplastic melanocytic naevus syndrome: Aust Fam Physician 2006 Aug:35(8):601 2 [PMID: 16894434]

Ortonne JP et al Treatment of solar lentigines J Am Acad Dermatol 2006 May;54(5 Suppl 2):S262 71 [PMID: 16631967]

Seborrheic keratoses are benign plaques, beige to brown or even black, 3 20 mm in diameter, with a velvety or warty surface They appear to be stuck or pasted onto the skin They are common especially in the elderly and may be mistaken for melanomas or other types of cutaneous neoplasms Although they may be frozen with liquid nitrogen or curetted if they itch or are inflamed, no treatment is needed

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Freeman S What are these brown spots, doc Am J Med 2005 Nov;118(11):1218 20 [PMID: 16271903] Roberts WE Dermatologic problems of older women Dermatol Clin 2006 Apr;24(2):271 80, viii [PMID: 16677973] Thompson LD Seborrheic keratosis Ear Nose Throat J 2006 Feb;85(2):79 [PMID: 16579189]

The management of small congenital nevi less than a few centimeters in diameter is controversial The vast majority will never become malignant, but some experts believe that the risk of melanoma in these lesions may be somewhat increased Since 1% of whites are born with these lesions, management should be conservative and excision advised only for lesions in cosmetically nonsensitive areas where the patient cannot easily see the lesion and note any suspicious changes Excision should be considered for congenital nevi whose contour (bumpiness, nodularity) or color (different shades) makes it difficult for examiners to note early signs of malignant change Giant congenital melanocytic nevi (> 5% body surface area [BSA]) are at greater risk for development of melanoma, and surgical removal is often recommended

May be flat or raised Should be suspected in any pigmented skin lesion with recent change in appearance Examination with good light may show varying colors, including red, white, black, and bluish Borders typically irregular (Plate 1)

Solution to Exercise 17-2. Change the program you wrote in Exercise 17-1 to ensure that the event can be published to multiple handlers safely. The event keyword guarantees that the event the CountDownClock is publishing can only be subscribed to or unsubscribed from. This change is easy, so we won t show the whole code here. The relevant portion is shown in Example A-51.

Blue nevi are small, slightly elevated, and blue-black lesions They are common in persons of Asian descent, and an individual patient may have several of them If present without change for many years, they may be considered benign, since malignant blue nevi are rare However, blueblack papules and nodules that are new or growing must be evaluated to rule out nodular melanoma

(see Integer and Real examples)

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