First Evidence of Cutaneous Remodelling Induced by Synchronized Radiofrequency Aided by High-Intensity Facial Muscle Stimulation: Porcine Animal Model.

BACKGROUND: The quality of one's facial appearance diminishes with aging as skin and underlying soft tissues deteriorate. Connective tissue and musculofascial degeneration leads to skin laxity and wrinkles developing. OBJECTIVE: To evaluate the effects of synchronized radiofrequency with high intensity facial stimulation technology on dermal collagen and elastin fibers in a porcine model. MATERIALS AND METHODS: Eight sows were divided into Active (N = 6) and Control (N = 2) groups. Synchronized radiofrequency and high intensity facial stimulation were delivered to the ventrolateral abdomen. The Active group received four 20-minute treatments, once a week. Control group was untreated. Skin biopsy sample were histologically analyzed for connective tissue changes pre- and post-treatment. Data were analyzed statistically (α = 0.05). RESULTS: In the Active group: the collagen-occupied area at baseline was 1.12 ± 0.09 × 106 µm 2 and increased by +19.6% ( p < .001) at 1-month and by +26.3% ( p < .001) 2 months post-treatment; elastin-occupied area at baseline was 0.11 ± 0.03 × 106 µm 2 and increased by +75.9% ( p < .001) at 1-month and +110.8% ( p < .001) at 2-months follow-up. No significant changes ( p > .05) found in the Control samples. CONCLUSION: Collagen and elastin fiber content increased significantly after treatments. Connective tissue in the treatment area was denser up to 2-months post-treatment.

Acute Effect of High-Intensity Interval Versus Moderate-Intensity Continuous Exercise on Blood Pressure and Arterial Compliance in Middle-Aged and Older Hypertensive Women With Increased Arterial Stiffness.

Costa, EC, Kent, DE, Boreskie, KF, Hay, JL, Kehler, DS, Edye-Mazowita, A, Nugent, K, Papadopoulos, J, Stammers, AN, Oldfield, C, Arora, RC, Browne, RAV, and Duhamel, TA. Acute effect of high-intensity interval versus moderate-intensity continuous exercise on blood pressure and arterial compliance in middle-aged and older hypertensive women with increased arterial stiffness. J Strength Cond Res 34(5): 1307-1316, 2020-Hypertension and arterial stiffness are common in middle-aged and older women. This study compared the acute effect of high-intensity interval exercise (HIIE) and moderate-intensity continuous exercise (MICE) on blood pressure (BP) and arterial compliance in middle-aged and older hypertensive women with increased arterial stiffness. Nineteen women (67.6 ± 4.7 years) participated in this randomized controlled crossover trial. Subjects completed a control, MICE (30 minutes at 50-55% of heart rate reserve [HRR]), and HIIE (10 × 1 minute at 80-85% of HRR, 2 minutes at 40-45% of HRR) session in random order. Blood pressure and large and small arterial compliance (radial artery pulse wave analysis) were measured at baseline and 30, 60, 90, and 120 minutes after sessions. A p < 0.05 was considered statistically significant. Systolic BP was reduced in ∼10 mm Hg after MICE at 30 minutes and after HIIE at all time points (30, 60, 90, and 120 minutes) after exercise compared with the control session (p < 0.05). Only HIIE showed lower systolic BP levels at 60, 90, and 120 minutes after exercise compared with the control session (∼10 mm Hg; p < 0.05). No changes were observed in diastolic BP, or in large and small arterial compliance (p > 0.05). High-intensity interval exercise elicited a longer systolic postexercise hypotension than MICE compared with the control condition, despite the absence of acute modifications in large and small arterial compliance.

MRI and CT Assessment of Abdominal Tissue Composition in Patients After High-Intensity Focused Electromagnetic Therapy Treatments: One-Year Follow-Up.

BACKGROUND: Several studies investigating high-intensity focused electromagnetic (HIFEM) treatments have recently been published. However, due to the novelty of the procedure, long-term data are still missing. OBJECTIVES: The aim of this study was to evaluate changes in abdominal tissues on average 1 year after a series of HIFEM treatments, to determine the long-term durability of patients' original body responses. METHODS: Magnetic resonance imaging (MRI) or computed tomography (CT) scanning were performed on 21 patients a mean of 332.6 [88.5] days after their original HIFEM treatment series. The scans were evaluated by a blinded radiologist for abdominal muscle thickness, subcutaneous fat changes, and abdominal separation. The results were compared with the MRI/CT-assisted measurements taken at baseline and 6-week follow-up. Correlations between collected data sets were calculated and tested. The incidence of any adverse events related to earlier treatments was monitored. RESULTS: When comparing the 1-year follow-up measurements with the baseline, the MRI/CT-assisted calculations revealed mean reductions of 14.63% (2.97 [2.11] mm) in fat, 19.05% (1.89 [0.88] mm) in muscle thickening, and 10.46% (1.96 [1.71] mm) in diastasis recti. All changes were significant (P < 0.05) and not related to weight fluctuations (P > 0.05). The baseline width of diastasis positively correlated with the degree of improvement at follow-up. No adverse events were reported. CONCLUSION: The HIFEM-induced muscle hypertrophy, fat reduction, and reduction in abdominal separation were maintained 1-year posttreatment. This suggests long-term durability of the original bodily response, which needs to be verified by continuing follow-up of this group and by further studies.

Simultaneous Changes in Abdominal Adipose and Muscle Tissues Following Treatments by High-Intensity Focused Electromagnetic (HIFEM) Technology-Based Device: Computed Tomography Evaluation

Objective: This study investigates the effects of high-intensity focused electromagnetic technology for induction of changes in abdominal muscles and abdominal subcutaneous fat. Methods: 22 male and female subjects (aged 34 to 64, mean BMI, 23.5kg/m2) underwent 8 treatments of the abdomen (2 per week) with a high-intensity focused electromagnetic field device. Subjects were scanned by computed tomography (CT) at baseline and 1 month after the eighth treatment. Sub-umbilical and epi-umbilical slices were used to measure the thickness of subcutaneous fat and abdominal muscles and the abdominal separation. In addition, standardized photographs, weight, and circumference measurements were collected. Results: While comparing baseline to follow-up measurements, CT data showed on average 17.5% (-3.1±1.9mm) reduction in subcutaneous fat and simultaneous 14.8% (+1.5±0.8mm) thickening of the rectus abdominis muscle. Subjects lost on average 3.9±3.1cm in the waist circumference. Most of the waist reduction effect was achieved after the fourth treatment. The width of abdominal separation decreased by 9.5% (-2.0±1.7mm). All results were highly significant (P<0.01) while weight change was insignificant (P<0.05). Digital photographs showed aesthetic improvement in most subjects. The treatments were painless and without adverse events. Conclusion: Results suggest that the investigated device is effective for abdominal body sculpting. This technology produced rectus muscle hypertrophy and a reduction in subcutaneous abdominal fat. Data suggests 4 treatments as the ideal protocol delivering 86% of the observed improvement. J Drugs Dermatol. 2019;18(11):1098-1102.

Retrospective analysis of high-intensity focused electromagnetic procedure synchronized with radiofrequency energy for visceral fat reduction.

BACKGROUND: Visceral adipose tissue (VAT), present in the abdominal cavity, oftentimes contributes to an unpleasant aesthetic appearance and can be correlated with serious health issues. High-intensity focused electromagnetic field (HIFEM) technology with synchronized radiofrequency (RF) was recently used for abdominal body shaping through subcutaneous fat reduction and muscle growth. AIM: This study aimed to assess the effect of HIFEM + RF technology on VAT tissue. METHODS: Data of 16 men and 24 women (22-62 years, 21.2-34.3 kg/cm2 ) from the original study were retrospectively reviewed. All subjects received three 30-min HIFEM + RF abdominal treatments once weekly for three consecutive weeks. The VAT area was measured in the axial plane of MRI scans at two levels: L4-L5 vertebrae and 5 cm above this level. The VAT was identified, segmented, and calculated, yielding total area in square centimeters per scan at both specified levels. RESULTS: By thoughtful review of the subject's post-treatment MRI scans, no other changes in the abdominal cavity were found except for VAT. The evaluation showed a VAT reduction of 17.8% (p < 0.001) on average at 3-month follow-up, maintaining the results up to 6 months (-17.3%). Averaging the values obtained from both measured levels, the VAT, occupied an area of 100.2 ± 73.3 cm2 at the baseline. At the 3-month follow-up, the subjects achieved an average reduction of 17.9 cm2 , preserving the results at 6 months (-17.6 ± 17.3 cm). CONCLUSION: This retrospective analysis of MRI images objectively documented the effect of HIFEM + RF abdominal therapy on VAT. The data indicates considerable VAT reduction without serious adverse events following the HIFEM + RF procedure.

Patient and caregiver preferences and prioritized outcomes for cardiac surgery: A scoping review and consultation workshop.

OBJECTIVE(S): In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact. METHODS: Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes. RESULTS: Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop. CONCLUSIONS: Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes.

Putting patient value first: Using a modified nominal group technique for the implementation of enhanced recovery after cardiac surgery recommendations.

Objective: In 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective. Methods: Using a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities. Results: Seven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively. Conclusions: Exploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.

The effect of high-intensity focused electromagnetic procedure on visceral adipose tissue: Retrospective assessment of computed tomography scans.

BACKGROUND: High levels of visceral adipose tissue (VAT) are associated with abdominal obesity and increased risk of metabolic deterioration. Recent studies showed that intensive physical exercise results in the reduction of subcutaneous and visceral fat. AIMS: This study investigates the effect of supramaximal muscle contractions induced by a HIFEM procedure for abdominal VAT changes. METHODS: Computed tomography (CT) scans of 22 subjects (47.3 ± 8.4 years, BMI of 23.5 ± 3.5 kg/m2 ) who received 8 HIFEM treatments of the abdomen (2-3 days apart) were retrospectively evaluated for the changes in VAT. The CT scans were obtained at baseline and 1 month after the last treatment. The transverse slices at umbilical, infraumbilical, and supraumbilical levels were used to determine the cross-sectional area (CSA) of VAT through a semi-automated segmentation method. RESULTS: Analysis of the CSA revealed a significant (P = .004) and uniform reduction of the abdominal VAT area by 14.3% (-16.7 cm2 ) from 110.6 ± 69.0 cm2 to 93.9 ± 54.6 cm2 . In general, a higher relative improvement was seen infraumbilically (17.1%), followed by supraumbilical (15.5%) and umbilical (10.7%) levels. The reduction of VAT was strongly correlated to the reduction of subcutaneous fat (r(17) = 0.66; P = .002). A decrease in VAT volume contributed to the overall aesthetic enhancement visible on digital photographs. CONCLUSIONS: The outcomes indicate that HIFEM technology has a positive effect on VAT. However, further studies are necessary to validate these outcomes and to clarify the exact mechanism of a VAT reduction. Based on our results, the HIFEM procedure may be a beneficial treatment option for patients with high VAT deposits.

Characterizing Physician-Staffing Models in the Care of Postoperative Cardiac Surgical Patients in Canada.

BACKGROUND: Current intensive care unit physician-staffing (IPS) models for postoperative cardiac surgery have not been previously investigated in Canada. The purpose of this study was to determine current IPS models at 2 time points and describe the evolution of Canadian cardiac surgery IPS models. METHODS: A survey of 32 Canadian cardiovascular intensive care units (CVICUs) was undertaken in 2012 and 2017 to determine IPS models of care during "daytime" and "after-hours" in each unit. Data were collected regarding surgical volume, base specialties, and style of IPS management ("open"; "semi-open"; "closed"). In addition, we collected the overnight experience level of the bedside healthcare provider for in-house intensive care units. RESULTS: Survey responses were received from 27 of 32 CVICUs (87%). As of 2017, the style of 1 (4%) was open, 7 (26%) were semi-open, and 19 (70%) were closed in their unit IPS strategy. Base specialties of CVICU physicians varied. A medical doctor provided after-hours coverage in 81% of CVICUs. Senior residents (37%) or critical care certified attending staff (25%) typically provided after-hours coverage for in-house CVICUs. Linked Canadian Institute for Health Information data did not indicate a difference among CVICU models in mortality or rehospitalization for coronary artery bypass graft or valve procedures. CONCLUSIONS: Considerable heterogeneity is demonstrated in CVICU staffing patterns. No consensus was identified regarding the appropriate level of training for "after-hours" coverage. In-house overnight physician staffing in CVICUs varies widely. Finally, semi-open and closed style models did not demonstrate differences compared to Canadian Institute for Health Information data. Variability among CVICUs does exist; however, benefits of one model over another have not been identified.

INTRODUCTION: Les modèles actuels de dotation en médecins aux soins intensifs (DMSI) postopératoires de chirurgie cardiaque n'ont pas fait l'objet d'études antérieures au Canada. L'objectif de la présente étude était de déterminer les modèles actuels de DMSI à deux points temporels et de décrire l'évolution des modèles de DMSI de chirurgie cardiaque au Canada. MÉTHODES: Nous avons entrepris une enquête auprès de 32 unités de soins intensifs cardiovasculaires du Canada (USICC) en 2012 et en 2017 pour déterminer les modèles de soins DMSI « pendant la journée ¼ et « après les heures normales ¼ dans chaque unité. Nous avons collecté les données relatives au volume d'interventions chi- rurgicales, aux spécialités de base et au style de gestion de la DMSI (« ouvert ¼, « semi-ouvert ¼, « fermé ¼). De plus, nous avons collecté les données sur le niveau d'expérience de nuit des prestataires de soins au chevet des patients des unités intégrées de soins intensifs. RÉSULTATS: Nous avons reçu les réponses à l'enquête de 27 des 32 USICC (87 %). Depuis 2017, le style de 1 (4 %) USICC était ouvert, de 7 (26 %) était semi-ouvert et de 19 (70 %) était fermé dans leur stra- tégie de DMSI à l'unité. Les spécialités de base des médecins de l'USICC variaient. Un docteur en médecine offrait ses services après les heures normales dans 81 % des USICC. Les résidents chevronnés (37 %) ou les médecins titulaires agréés en soins aux patients en phase critique (25 %) offraient habituellement leurs services après les heures normales aux USICC intégrées. Les données liées de l'Institut canadien d'information sur la santé n'indiquaient pas de différence entre les modèles des USICC en ce qui a trait à la mortalité ou à la réhospitalisation en raison de pontages aortocoronariens ou d'interventions valvulaires. CONCLUSIONS: Les modèles de dotation en personnel aux USICC démontrent une importante hétérogénéité. Aucun consensus n'a été établi quant au niveau approprié de formation pour les services offerts « après les heures normales ¼. Le personnel médical de nuit à l'interne des USICC varie grandement. Finalement, les modèles de styles semi-ouverts et fermés ne démontraient pas de différence par rapport aux données de l'Institut canadien d'information sur la santé. Une variabilité existe entre les USICC. Toutefois, les avantages d'un modèle par rapport à un autre n'ont pas été définis.

Expanding enhanced recovery protocols for cardiac surgery to include the patient voice: a scoping review protocol.

BACKGROUND: Cardiac surgery is becoming increasingly common in older, more vulnerable adults. A focus on timely and complete medical and functional recovery has led to the development of enhanced recovery protocols (ERPs) for a number of surgical procedures and subspecialties, including cardiac surgery (ERAS® Cardiac). An element that is often overlooked in the development and implementation of ERPs is the involvement of key stakeholder groups, including surgery patients and caregivers (e.g., family and/or friends). The aim of this study is to describe a protocol for a scoping review of cardiac patient and caregiver preferences and outcomes relevant to cardiac surgery ERPs. METHODS: Using Arksey and O'Malley's et al six-stage framework for scoping review methodologies with adaptions from Levac et al. (Represent Interv: 1-18, 2012), a scoping review of existing literature describing patient- and caregiver-identified preferences and outcomes as they relate to care received in the perioperative period of cardiac surgery will be undertaken. The search for relevant articles will be conducted using electronic databases (i.e., the Cochrane Library, Medline, PsycINFO, Scopus, and Embase), as well as through a search of the grey literature (e.g., CPG Infobase, Heart and Stroke Foundation, ProQuest Theses and Dissertations, Google Advanced, and Prospero). Published and unpublished full-text articles written in English, published after the year 2000, and that relate to the research question will be included. Central to the design of this scoping review is our collaboration with two patient partners who possess lived experience as cardiac surgery patients. DISCUSSION: This review will identify strategies that can be integrated into ERPs for cardiac surgery which align with patient- and caregiver-defined values. Broadly, it is our goal to demonstrate the added value of patient engagement in research to aid in the success of system change processes.

Perineural involvement of squamous cell carcinoma presenting with formication.

Perineural involvement of a cutaneous neoplasm marks an aggressive feature. Tumors with perineural involvement share an increased propensity for local invasion via perineural spread. Formication may be an indicator of perineural involvement by cutaneous neoplasms. We present a case of an 82-year-old man with perineural involvement of a squamous cell carcinoma (SCC) identified by clinical symptoms of formication. Successful resolution of these symptoms was achieved with radiation therapy.

Safety and mechanism of action of noninvasive radiofrequency treatment for vaginal laxity: Histological study in the swine vaginal model.

BACKGROUND: Structural changes in collagen and elastin fiber density have been previously evaluated by qualitative histological studies; however, quantitative evaluations are lacking. AIM: To evaluate quantitative changes in collagen and elastin fibers in the vaginal wall in a porcine model after volumetric radiofrequency heating with an intravaginal applicator. METHODS: An animal model was used (domestic pig, multipara: 5.67 ± 0.94 deliveries, 3 years of age). Three pigs under general anesthesia were treated (8-minute, vaginal canal area) once per week for the course of three weeks. There were 2 follow-up evaluations at one and four weeks. Histology specimens were obtained via punch biopsy under ultrasound control. Ultrasound video measurements of the vaginal wall thickness were also obtained. Tissue samples were stained by H&E as well as stains for collagen and elastin fibers. RESULTS: Elastin (P < .001) and collagen (P < .01) fiber density increased after every treatment. The measured increase in fibers was highest at the one-week follow-up. Elastin accounted on average for 51.46 ± 16.86% of the tissue examined (increase of 36.8% points), while collagen accounted on average for 44.83 ± 18.92% (increase of 17.1% points). The number of synthetically active cells was increased by 16%. While vaginal wall thickness did show an increase of 1.66 mm (32%), this tendency was not statistically significant (P > .05). CONCLUSION: Results suggest that volumetric heating of vaginal tissue produced quantitative improvement in the connective tissue organization in a porcine study. Neocollagenesis and neoelastogenesis were observed with an increased number of synthetically active cells.

Immediate post-exercise blood pressure and arterial compliance in middle-aged and older normotensive females: A cross-sectional study.

This study examined whether immediate post-exercise systolic blood pressure (SBP) is associated with arterial compliance in middle-aged and older normotensive females. A total of 548 normotensive, non-frail females aged 55 years and older with no previous history of cardiovascular disease (CVD) participated in this cross-sectional study. Large and small arterial compliance were assessed by pulse wave analysis. Reduced arterial compliance was defined based on age and sex cutoffs. SBP was measured at rest and immediately following a 3-min moderate step-test. CVD risk factors were also assessed (e.g. resting systolic and diastolic BP, fasting glucose, triglycerides, cholesterol, body mass index). A total of 15.1% and 44.0% of the participants showed reduced large and small artery compliance, respectively. Immediate post-exercise SBP was associated with reduced large (OR 1.02 per 1 mmHg increase in post-exercise SBP, 95%CI 1.01-1.04; p = 0.010) and small (OR 1.02 per 1 mmHg increase in post-exercise SBP, 95%CI 1.00-1.03; p = 0.008) arterial compliance. Participants with highest immediate post-exercise SBP (quartile 4; i.e. ≥ 165 mmHg) showed increased odds ratios for reduced large (2.67, 95%CI 1.03-6.94; p = 0.043) and small (2.27, 95%CI 1.22-4.21; p = 0.010) arterial compliance compared to those with the lowest immediate post-exercise SBP (quartile 1; i.e. ≤ 140 mmHg), independent of other established CVD risk factors. Immediate post-exercise SBP following a brief moderate step-test seems to be able to discriminate reduced arterial compliance in middle-aged and older normotensive females.

Standardization of the Fried frailty phenotype improves cardiovascular disease risk discrimination.

BACKGROUND: Standardizing the Fried criteria (S-FC) using cutoffs specific to the patient population improves adverse outcome prediction. However, there is limited evidence to determine if a S-FC assessment can improve discrimination of cardiovascular disease (CVD) risk in middle-aged and older women. DESIGN: The objective of this cross-sectional analysis was to compare the ability of the Fried frailty phenotype criteria (FC) to discriminate between individuals at higher risk for CVD according to the Framingham Risk Score and Rasmussen Disease Score in comparison to the S-FC. SETTING: Asper Clinical Research Institute, St. Boniface Hospital Research Centre. PARTICIPANTS: 985 women 55 years of age or older with no previous history of CVD. MEASUREMENTS: Discrimination of individuals with high CVD risk according to the Framingham and Rasmussen Disease scores was assessed using receiver operating characteristic (ROC) curves, integrated discrimination index (IDI) and net reclassification index (NRI). RESULTS: The S-FC showed superior ability to discriminate CVD risk as assessed by area under the ROC curve (AUROC) based on the Framingham (0.728 vs 0.634, p < 0.001), but not for the Rasmussen (0.594 vs 0.552, p = 0.079) risk score. Net reclassification index identified improved discrimination for both the Framingham (67.9%, p < 0.001) and Rasmussen Disease scores (26.0%, p = 0.003). Integrated discrimination index also identified improved CVD risk discrimination with the Framingham (3.0%, p < 0.001) and Rasmussen Disease scores (1.5%, p < 0.001). CONCLUSION: In this study, the Fried frailty phenotype better discriminated cardiovascular disease risk when standardized to the study population.

Protocol for the HAPPY Hearts study: cardiovascular screening for the early detection of future adverse cardiovascular outcomes in middle-aged and older women: a prospective, observational cohort study.

INTRODUCTION: Efforts to identify individuals at a higher risk for adverse cardiovascular outcomes focus on traditional risk factors, such as age, sex, smoking status, blood pressure and and cholesterol; however, this approach does not directly assess cardiovascular function and may underestimate the risk of experiencing adverse cardiovascular outcomes in women. This prospective, observational cohort study will examine the ability of the Heart Attack Prevention Program for You (HAPPY) Hearts screening protocol, a series of non-invasive procedures to identify middle-aged and older women who are at an elevated risk for experiencing an adverse cardiovascular event in the 5-year period after screening. The predictive value of the HAPPY Hearts protocol will also be compared with the Framingham Risk Score to determine the sensitivity for estimating risk for an adverse cardiovascular outcome. METHODS AND ANALYSIS: One thousand women 55 years of age or older will be recruited to be screened by the HAPPY Hearts protocol. This involves the cardiovascular assessment of resting blood pressure, blood pressure response to 3 min of moderate intensity exercise and large and small arterial elasticity. The participants will be classified into risk categories based on these measures. The incidence of the following adverse cardiovascular outcomes will be assessed in the 5-year period after screening in both groups: ischaemic heart disease, acute myocardial infarction, stroke, percutaneous coronary intervention, coronary bypass surgery, congestive heart failure and new hypertension. ETHICS AND DISSEMINATION: Information gathered in this research will be published in peer-reviewed journals and presented in a programme evaluation report to inform Manitoba Health and key stakeholders about the outcomes of the study. The University of Manitoba Health Research Ethics Board has approved the study protocol V.2.0, dated 29 September 2014 (H2014:224). TRIAL REGISTRATION NUMBER: NCT02863211.

Treatment of recalcitrant atopic dermatitis with omalizumab.

Atopic dermatitis is a common diagnosis that presents a therapeutic challenge. Although multiple therapeutic modalities exist, there is no single monotherapy that has proven exceptional in ameliorating the symptoms of this disease. Current topical and systemic therapeutic options offer benefit but carry varying degrees of adverse effects that often limit their application. We present 3 patients with severe, recalcitrant atopic dermatitis successfully treated with omalizumab.

Borderline tuberculoid leprosy in a woman from the state of Georgia with armadillo exposure.

In the southern and southeastern United States, the 9-banded armadillo is an important reservoir for Mycobacterium leprae, the causative agent of leprosy (Hansen's disease). Here, we describe a woman living in Georgia with borderline tuberculoid leprosy who worked for many years in a garden where armadillos burrowed or were buried. There was no history of foreign travel or known exposure to a person with leprosy. Treatment with 6 once-monthly combined doses of rifampin, ofloxacin, and minocycline was successful.