Effect of a Perioperative Educational Video in Patients Undergoing Mohs Reconstruction: A Randomized Clinical Trial.

BACKGROUND: Skin cancer is the most common type of cancer in the United States, and most are treated with Mohs micrographic surgery (MMS) by fellowship-trained dermatologic surgeons. Complex reconstruction in cosmetically and functionally sensitive areas often requires a plastic surgery consult. The uncertainty regarding reconstructive options and cosmetic appearance is difficult emotionally and cognitively for patients. OBJECTIVES: To improve patient understanding about MMS reconstruction with plastic surgeons, we investigated the utility of a multimedia presentation during perioperative education. METHODS: A randomized clinical trial was conducted at a hospital-affiliated outpatient MMS clinic and surgery center in the United States. Patients in the intervention arm were given a tablet or Web site link to watch a multimedia presentation about reconstruction after MMS. All patients were given a questionnaire about their understanding of MMS reconstruction and satisfaction with the reconstructive care they received. RESULTS: A total of 46 patients were recruited for the study and completed the questionnaire. Of these patients, 22 were randomized to the test intervention arm, and the remaining 24 were in the control group. Among participants in the test intervention arm, feedback regarding the platform was positive with more than 90% of patients reporting that the video was engaging, useful, and easy to understand. Patient understanding and satisfaction scores in the test intervention arm ranked higher across all domains than those of the control group. CONCLUSIONS: This randomized clinical trial showed increases in patient understanding and satisfaction among patients undergoing MMS reconstruction with the implementation of a perioperative educational video.

Novel Biomaterial Containing Gelatin, Manuka Honey, and Hydroxyapatite Enhanced Secondary Intention Healing Versus Standard Secondary Intention Healing in Mohs Surgical Defects on the Head and Distal Lower Extremities-A Randomized Controlled Trial: Pilot Study.

BACKGROUND: Randomized, comparative studies evaluating augmented secondary intention healing (SIH) compared with conventional SIH in dermatologic surgery are limited. This study aimed to evaluate whether the use of a novel biomaterial enhances SIH, particularly in shortening time to complete re-epithelialization. OBJECTIVE: The purpose of this study was to elucidate whether a novel biomaterial containing gelatin, manuka honey, and hydroxyapatite enhances SIH when compared with conventional SIH for surgical defects after Mohs micrographic surgery (MMS) on the head and distal lower extremities. MATERIALS AND METHODS: Thirty-seven patients were enrolled in this randomized controlled trial. Patients undergoing MMS on the head or distal lower extremities were eligible for recruitment. After clear surgical margins were obtained post-MMS, patients were randomized to receive standard SIH or biomaterial enhanced SIH. Patients had regularly scheduled follow-ups with questionnaires at each visit until complete re-epithelialization was achieved. RESULTS: Overall, there was no significant difference in time to re-epithelialization between standard SIH and biomaterial-enhanced SIH. However, there was a significant decrease in pain scores and skin thickness in the biomaterial-enhanced SIH group. CONCLUSION: Biomaterial-enhanced SIH is noninferior to standard SIH and produces less pain and favorable skin thickness compared with standard SIH. ClinicalTrials.gov listing: NCT04545476.

Risk of adverse events due to high volumes of local anesthesia during Mohs micrographic surgery.

General guidelines for the maximum amounts of locally injected lidocaine exist; however, there is a paucity of data in the Mohs micrographic surgery (MMS) literature. This study aimed to determine the safety and adverse effects seen in patients that receive larger amounts of locally injected lidocaine. A retrospective chart review of 563 patients from 1992 to 2016 who received over 30 mL of locally injected lidocaine was conducted. Patient records were reviewed within seven postoperative days for complications. The average amount of anesthesia received was 40 mL, and the average patient weight was 86.69 kg. 1.4% of patients had a complication on the day of surgery, and 4.4% of patients had a complication within 7 days of the surgery. The most common complications were excessive bleeding/hematoma formation and wound infection. Only two complications could be attributable to local anesthetics. Gender, heart disease, hypertension, diabetes, and smoking were not significant risk factors for the development of complications. MMS is a safe outpatient procedure for patients that require over 30 mL of locally injected anesthesia. The safety of high volumes of lidocaine extends to patients with risk factors such as heart disease, hypertension, diabetes, and smoking.

Optical assessment of skin carotenoid status as a biomarker of vegetable and fruit intake.

Resonance Raman spectroscopy (RRS) and reflection spectroscopy (RS) are optical methods applicable to the non-invasive detection of carotenoids in human skin. RRS is the older, more thoroughly validated method, whereas RS is newer and has several advantages. Since collective skin carotenoid levels serve as a biomarker for vegetable and fruit intake, both methods hold promise as convenient screening tools for assessment of dietary interventions and correlations between skin carotenoids and health and disease outcomes. In this manuscript, we describe the most recent optimized device configurations and compare their use in various clinical and field settings. Both RRS and RS devices yield a wide range of skin carotenoid levels between subjects, which is a critical feature for a biomarker. Repeatability of the methods is 3-15% depending on the subject's skin carotenoid level and the uniformity of its local distribution. For 54 subjects recruited from an ophthalmology clinic, we first checked the validity of the relatively novel RS methodology via biochemical serum carotenoid measurements, the latter carried out with high performance liquid chromatography (HPLC). A high correlation between RS skin and serum HPLC carotenoid levels was established (R = 0.81; p < 0.001). Also, a high correlation was found between RS and RRS skin levels (R = 0.94 p < 0.001). Subsequent comparisons of skin carotenoid measurements in diverse age groups and ethnicities included 569 Japanese adults, 947 children with ages 2-5 screened in 24 day care centers in San Francisco, and 49 predominantly Hispanic adults screened at an outdoor health fair event. Depending on the particular subject group, correlation coefficients between the RRS and RS methods ranged between R ∼0.80 and R ∼0.96. Analysis of the Japanese screening showed that, on average, skin carotenoid levels are higher in women compared to men, skin levels do not depend on age, and tobacco smokers have reduced levels versus non-smokers. For the two most ethnically diverse groups with widely varying melanin levels, we investigated the effect of dermal melanin on RS and RRS skin carotenoid levels. The analysis revealed that large variations in skin carotenoid levels remain detectable independent of the particular melanin index. This behavior is consistent with the absence of melanin effects on the skin carotenoid levels generated with the instrument configurations. The RS method has an advantage over RRS in its relative simplicity. Due to its detection of skin reflection over a wide spectral range from the near UV to the near IR, it has the unique ability to quantify each of the major tissue chromophores and take them into account in the derivation of skin carotenoid levels.

Impact of the US Two-dose Varicella Vaccination Program on the Epidemiology of Varicella Outbreaks: Data from Nine States, 2005-2012.

BACKGROUND: A routine 2-dose varicella vaccination program was adopted in 2007 in the US to help further decrease varicella disease and prevent varicella outbreaks. We describe trends and characteristics of varicella outbreaks reported to the Centers for Disease Control and Prevention (CDC) during 2005-2012 from 9 states. METHODS: Data on varicella outbreaks collected by 9 state health departments were submitted to CDC using the CDC outbreak reporting worksheet. Information was collected on dates of the outbreak, outbreak setting and number of cases by outbreak; aggregate data were provided on the numbers of outbreak-related cases by age group, vaccination status and laboratory confirmation. RESULTS: Nine hundred and twenty-nine outbreaks were reported from the 6 states, which provided data for each year during 2005-2012. Based on data from these 6 states, the number of outbreaks declined by 78%, decreasing from 147 in 2005 to 33 outbreaks in 2012 (P = 0.0001). There were a total of 1015 varicella outbreaks involving 13,595 cases reported by the 9 states from 2005 to 2012. The size and duration of outbreaks declined significantly over time (P < 0.001). The median size of outbreaks was 12, 9 and 7 cases and median duration of outbreaks was 38, 35 and 26 days during 2005-2006, 2007-2009 and 2010-2012, respectively. Majority of outbreaks (95%) were reported from schools, declining from 97% in 2005-2006 to 89% in 2010-2012. Sixty-five percent of outbreak-related cases occurred among 5-year to 9-year olds, with the proportion declining from 76% in 2005-2006 to 45% during 2010-2012. CONCLUSIONS: The routine 2-dose varicella vaccination program appears to have significantly reduced the number, size and duration of varicella outbreaks in the US.

A novel outbreak enterovirus D68 strain associated with acute flaccid myelitis cases in the USA (2012-14): a retrospective cohort study.

BACKGROUND: Enterovirus D68 was implicated in a widespread outbreak of severe respiratory illness across the USA in 2014 and has also been reported sporadically in patients with acute flaccid myelitis. We aimed to investigate the association between enterovirus D68 infection and acute flaccid myelitis during the 2014 enterovirus D68 respiratory outbreak in the USA. METHODS: Patients with acute flaccid myelitis who presented to two hospitals in Colorado and California, USA, between Nov 24, 2013, and Oct 11, 2014, were included in the study. Additional cases identified from Jan 1, 2012, to Oct 4, 2014, via statewide surveillance were provided by the California Department of Public Health. We investigated the cause of these cases by metagenomic next-generation sequencing, viral genome recovery, and enterovirus D68 phylogenetic analysis. We compared patients with acute flaccid myelitis who were positive for enterovirus D68 with those with acute flaccid myelitis but negative for enterovirus D68 using the two-tailed Fisher's exact test, two-sample unpaired t test, and Mann-Whitney U test. FINDINGS: 48 patients were included: 25 with acute flaccid myelitis, two with enterovirus-associated encephalitis, five with enterovirus-D68-associated upper respiratory illness, and 16 with aseptic meningitis or encephalitis who tested positive for enterovirus. Enterovirus D68 was detected in respiratory secretions from seven (64%) of 11 patients comprising two temporally and geographically linked acute flaccid myelitis clusters at the height of the 2014 outbreak, and from 12 (48%) of 25 patients with acute flaccid myelitis overall. Phylogenetic analysis revealed that all enterovirus D68 sequences associated with acute flaccid myelitis grouped into a clade B1 strain that emerged in 2010. Of six coding polymorphisms in the clade B1 enterovirus D68 polyprotein, five were present in neuropathogenic poliovirus or enterovirus D70, or both. One child with acute flaccid myelitis and a sibling with only upper respiratory illness were both infected by identical enterovirus D68 strains. Enterovirus D68 viraemia was identified in a child experiencing acute neurological progression of his paralytic illness. Deep metagenomic sequencing of cerebrospinal fluid from 14 patients with acute flaccid myelitis did not reveal evidence of an alternative infectious cause to enterovirus D68. INTERPRETATION: These findings strengthen the putative association between enterovirus D68 and acute flaccid myelitis and the contention that acute flaccid myelitis is a rare yet severe clinical manifestation of enterovirus D68 infection in susceptible hosts. FUNDING: National Institutes of Health, University of California, Abbott Laboratories, and the Centers for Disease Control and Prevention.

Acute Flaccid Myelitis of Unknown Etiology in California, 2012-2015.

IMPORTANCE: There has been limited surveillance for acute flaccid paralysis in North America since the regional eradication of poliovirus. In 2012, the California Department of Public Health received several reports of acute flaccid paralysis cases of unknown etiology. OBJECTIVE: To quantify disease incidence and identify potential etiologies of acute flaccid paralysis cases with evidence of spinal motor neuron injury. DESIGN, SETTING, AND PARTICIPANTS: Case series of acute flaccid paralysis in patients with radiological or neurophysiological findings suggestive of spinal motor neuron involvement reported to the California Department of Public Health with symptom onset between June 2012 and July 2015. Patients meeting diagnostic criteria for other acute flaccid paralysis etiologies were excluded. Cerebrospinal fluid, serum samples, nasopharyngeal swab specimens, and stool specimens were submitted to the state laboratory for infectious agent testing. MAIN OUTCOMES AND MEASURES: Case incidence and infectious agent association. RESULTS: Fifty-nine cases were identified. Median age was 9 years (interquartile range [IQR], 4-14 years; 50 of the cases were younger than 21 years). Symptoms that preceded or were concurrent included respiratory or gastrointestinal illness (n = 54), fever (n = 47), and limb myalgia (n = 41). Fifty-six patients had T2 hyperintensity of spinal gray matter on magnetic resonance imaging and 43 patients had cerebrospinal fluid pleocytosis. During the course of the initial hospitalization, 42 patients received intravenous steroids; 43, intravenous immunoglobulin; and 13, plasma exchange; or a combination of these treatments. Among 45 patients with follow-up data, 38 had persistent weakness at a median follow-up of 9 months (IQR, 3-12 months). Two patients, both immunocompromised adults, died within 60 days of symptom onset. Enteroviruses were the most frequently detected pathogen in either nasopharynx swab specimens, stool specimens, serum samples (15 of 45 patients tested). No pathogens were isolated from the cerebrospinal fluid. The incidence of reported cases was significantly higher during a national enterovirus D68 outbreak occurring from August 2014 through January 2015 (0.16 cases per 100,000 person-years) compared with other monitoring periods (0.028 cases per 100,000 person-years; P <.001). CONCLUSIONS AND RELEVANCE: In this series of patients identified in California from June 2012 through July 2015, clinical manifestations indicated a rare but distinct syndrome of acute flaccid paralysis with evidence of spinal motor neuron involvement. The etiology remains undetermined, most patients were children and young adults, and motor weakness was prolonged.

Acute flaccid paralysis with anterior myelitis - California, June 2012-June 2014.

In August 2012, the California Department of Public Health (CDPH) was contacted by a San Francisco Bay area clinician who requested poliovirus testing for an unvaccinated man aged 29 years with acute flaccid paralysis (AFP) associated with anterior myelitis (i.e., evidence of inflammation of the spinal cord involving the grey matter including anterior horn cell bodies) and no history of international travel during the month before symptom onset. Within 2 weeks, CDPH had received reports of two additional cases of AFP with anterior myelitis of unknown etiology. Testing at CDPH's Viral and Rickettsial Disease Laboratory for stool, nasopharyngeal swab, and cerebrospinal fluid (CSF) did not detect the presence of an enterovirus (EV), the genus of the family Picornaviridae that includes poliovirus. Additional laboratory testing for infectious diseases conducted at the CDPH Viral and Rickettsial Disease Laboratory did not identify a causative agent to explain the observed clinical syndrome reported among the patients. To identify other cases of AFP with anterior myelitis and elucidate possible common etiologies, CDPH posted alerts in official communications for California local health departments during December 2012, July 2013, and February 2014. Reports of cases of neurologic illness received by CDPH were investigated throughout this period, and clinicians were encouraged to submit clinical samples for testing. A total of 23 cases of AFP with anterior myelitis of unknown etiology were identified. Epidemiologic and laboratory investigation did not identify poliovirus infection as a possible cause for the observed cases. No common etiology was identified to explain the reported cases, although EV-D68 was identified in upper respiratory tract specimens of two patients. EV infection, including poliovirus infection, should be considered in the differential diagnosis in cases of AFP with anterior myelitis and testing performed per CDC guidelines.

Mohs micrographic surgery for cutaneous lymphadenoma.

Cutaneous lymphadenoma clinically present as pink papules or plaques resembling a basal cell carcinoma on the head and neck of young adults. Surgical excision is the treatment for these benign tumors. Cutaneous lymphadenoma may occur in an anatomically sensitive area, where margin control and conservative excision are indicated. Although not previously described in the literature, Mohs micrographic surgery (MMS) is a treatment option for cutaneous lymphadenoma. We present a series of three individuals with cutaneous lymphadenoma treated with MMS.

Weight bias and weight loss treatment outcomes in treatment-seeking adults.

BACKGROUND: Few studies have explored the relationship between weight bias and weight loss treatment outcomes. PURPOSE: This investigation examined the relationship between implicit and explicit weight bias and (a) program attrition, (b) weight loss, (c) self-monitoring adherence, (d) daily exercise levels and overall caloric expenditure, (e) daily caloric intake, and (f) daily caloric deficit among overweight/obese treatment-seeking adults. METHODS: Forty-six overweight/obese adults (body mass index > or = 27 kg/m(2)) participating in an 18-week, stepped-care, behavioral weight loss program completed implicit and explicit measures of weight bias. Participants were instructed to self-monitor and electronically report daily energy intake, exercise, and energy expenditure. RESULTS: Greater weight bias was associated with inconsistent self-monitoring, greater caloric intake, lower energy expenditure and exercise, creation of a smaller caloric deficit, higher program attrition, as well as less weight loss during the self-help phase of the stepped-care treatment. CONCLUSIONS: Weight bias may interfere with overweight/obese treatment-seeking adults' ability to achieve optimal health.

Can following the caloric restriction recommendations from the Dietary Guidelines for Americans help individuals lose weight?

BACKGROUND: The Dietary Guidelines for Americans recommend creating an energy deficit of at least 500 kcal a day to facilitate weight loss. This investigation examined the relationship between creating a consistent, self-reported energy deficit of at least 500 kcal a day and weight loss. The relationship between self-monitoring adherence and daily energy intake and expenditure and weight loss was also examined. METHODS: Fifty-four overweight or obese adults (BMI>or=27 kg/m(2)) participating in a 14-week weight loss program were given a 5% total body weight loss goal and instructed to create an energy deficit of at least 500 kcal a day to facilitate weight loss. Participants provided daily records of total energy intake and expenditure, physical activity, and weekly and overall weight loss during treatment. RESULTS: Individuals who averaged an energy deficit in excess of 500 kcal per day lost nearly four times the weight as individuals whose average energy deficit was below 500 kcal per day (p<.01). Individuals who lost 5% of their body weight during the intervention self-monitored more than twice as many days than individuals who failed to lose 5% of their body weight (p<.01). CONCLUSION: Individuals interested in losing weight should continue to be advised to regularly self-monitor energy intake and expenditure as well as to create a consistent daily energy deficit (e.g., 500 kcal day).

Learning to perceive differences in solid shape through vision and touch.

A single experiment was designed to investigate perceptual learning and the discrimination of 3-D object shape. Ninety-six observers were presented with naturally shaped solid objects either visually, haptically, or across the modalities of vision and touch. The observers' task was to judge whether the two sequentially presented objects on any given trial possessed the same or different 3-D shapes. The results of the experiment revealed that significant perceptual learning occurred in all modality conditions, both unimodal and cross-modal. The amount of the observers' perceptual learning, as indexed by increases in hit rate and d', was similar for all of the modality conditions. The observers' hit rates were highest for the unimodal conditions and lowest in the cross-modal conditions. Lengthening the inter-stimulus interval from 3 to 15 s led to increases in hit rates and decreases in response bias. The results also revealed the existence of an asymmetry between two otherwise equivalent cross-modal conditions: in particular, the observers' perceptual sensitivity was higher for the vision-haptic condition and lower for the haptic-vision condition. In general, the results indicate that effective cross-modal shape comparisons can be made between the modalities of vision and active touch, but that complete information transfer does not occur.

Skipping meals and alcohol consumption. The regulation of energy intake and expenditure among weight loss participants.

Research suggests that specific eating patterns (e.g., eating breakfast) may be related to favorable weight status. This investigation examined the relationship between eating patterns (i.e., skipping meals; consuming alcohol) and weight loss treatment outcomes (weight loss, energy intake, energy expenditure, and duration of exercise). Fifty-four overweight or obese adults (BMI> or =27 kg/m(2)) participated in a self-help or therapist-assisted weight loss program. Daily energy intake from breakfast, lunch, dinner, and alcoholic beverages, total daily energy intake, total daily energy expenditure, physical activity, and weekly weight loss were assessed. On days that breakfast or dinner was skipped, or alcoholic beverages were not consumed, less total daily energy was consumed compared to days that breakfast, dinner, or alcoholic beverages were consumed. On days that breakfast or alcohol was consumed, daily energy expenditure (breakfast only) and duration of exercise were higher compared to days that breakfast or alcohol was not consumed. Individuals who skipped dinner or lunch more often had lower energy expenditure and exercise duration than individuals who skipped dinner or lunch less often. Individuals who consumed alcohol more often had high daily energy expenditure than individuals who consumed alcohol less often. Skipping meals or consuming alcoholic beverages was not associated with weekly weight loss. In this investigation, weight loss program participants may have compensated for excess energy intake from alcoholic beverages and meals with greater daily energy expenditure and longer exercise duration.

The failure of therapist assistance and stepped-care to improve weight loss outcomes.

OBJECTIVE: This investigation was designed to examine whether: (i) individuals could successfully lose 5% of their body weight with minimal assistance, (ii) weight loss would be improved by the addition of therapist assistance, and (iii) individuals unsuccessful at losing 5% total body weight during the minimal assistance phase (with or without therapist assistance) would benefit from a weekly weight loss group. METHODS AND PROCEDURES: Fifty-four overweight or obese adults (BMI > 27 kg/m(2)) initially participated in a 14-week self-help (SH) or therapist-assisted SH (TASH) weight loss program. Participants who were unsuccessful at losing 5% total body weight were stepped-up to a 3-month, group-based behavioral weight loss program (BWLP) with weekly weigh-ins. RESULTS: Although approximately 60% of the participants were successful at losing 5% of their total body weight (lb) during the minimal assistance phase (M = 10.6; s.d. = 11.5; P < 0.01), treatment outcome was not improved by the addition of therapist assistance. For individuals who were unsuccessful at losing 5% of total body weight during a minimal assistance phase, the addition of a group-based BWLP did not improve their weight loss. DISCUSSION: While many individuals were quite successful at losing weight with minimal assistance, other individuals evidenced difficulties losing weight, even when participating in a greater intensity intervention (i.e., BWLP group).

Taking control of your personal eating and exercise environment: a weight maintenance program.

The current investigation examined the impact of a weight maintenance intervention (MI) designed to empower people to create a personal healthy food and physical activity environment on weight loss treatment outcomes. It was hypothesized that behavioral weight loss program (BWLP) participants who received an additional MI would evidence superior weight loss maintenance compared to participants who received a BWLP alone (no contact [NC]). Fifty-one obese adults were randomly assigned to participate in a 16-week weight loss intervention followed by NC or a 6-week MI. Thirty-eight participants completed the six-month follow-up. Body weight, percent body fat, cardiorespiratory fitness, self-reported physical activity, and self-reported diet (i.e., calories, percent daily intake of fat, protein, and carbohydrates) were assessed. Participants significantly decreased their weight, increased physical activity/fitness, and improved dietary intake (ps<.05). MI participants had significantly greater weight loss maintenance than NC participants (ps<.05). Helping obese individuals to modify their personal eating and physical activity environment in order to reduce exposure to "obesogenic" cues may contribute to long-term weight loss maintenance.

Aging and the perception of 3-D shape from dynamic patterns of binocular disparity.

In two experiments, we investigated the ability of younger and older observers to perceive and discriminate 3-D shape from static and dynamic patterns of binocular disparity. In both experiments, the younger observers' discrimination accuracies were 20% higher than those of the older observers. Despite this quantitative difference, in all other respects the older observers performed similarly to the younger observers. Both age groups were similarly affected by changes in the magnitude of binocular disparity, by reductions in binocular correspondence, and by increases in the speed of stereoscopic motion. In addition, observers in both age groups exhibited an advantage in performance for dynamic stereograms when the patterns of binocular disparity contained significant amounts of correspondence "noise." The process of aging does affect stereopsis, but the effects are quantitative rather than qualitative.

Visual discrimination of local surface structure: slant, tilt, and curvedness.

In four experiments, observers were required to discriminate interval or ordinal differences in slant, tilt, or curvedness between designated probe points on randomly shaped curved surfaces defined by shading, texture, and binocular disparity. The results reveal that discrimination thresholds for judgments of slant or tilt typically range between 4 degrees and 10 degrees; that judgments of one component are unaffected by simultaneous variations in the other; and that the individual thresholds for either the slant or tilt components of orientation are approximately equal to those obtained for judgments of the total orientation difference between two probed regions. Performance was much worse, however, for judgments of curvedness, and these judgments were significantly impaired when there were simultaneous variations in the shape index parameter of curvature.