Adaptations of an Effective Evidence-Based Pediatric Weight Management Intervention.

Current childhood obesity treatment programs do not address medically underserved populations or settings where all members of an interdisciplinary team may not exist-either within one organization or within the community. In this paper, we describe the use of a community-academic partnership to iteratively adapt Epstein's Traffic Light Diet (TLD), into Building Healthy Families (BHF), a community-placed evidence-based pediatric weight management intervention (PWMI) and evaluate its effectiveness in reducing BMI z scores. Nine cohorts of families completed BHF. Participants included children aged 6-12 years with obesity (M = 9.46, SD = 1.74). The Framework for Reporting Adaptations and Modifications-Expanded guided our classification of modifications across BHF cohorts. Using the FRAME reporting structure, the changes that were documented were (1) planned and occurred pre-implementation, (2) based on decisions from local stakeholders (e.g., school administrator, members of the implementation team), and (3) specific to changes in content and context-with a focus on implementation and potential for local scale-up. The nature of the adaptations included adding elements (whole of family approach), removing elements (calorie counting), and substituting elements (steps for minutes of physical activity). Across 9 cohorts, 84 families initiated the BHF program, 69 families successfully completed the 12-week program, and 45 families returned for 6-month follow-up assessments. Results indicated that the BMI z score in children was reduced by 0.31 ± 0.17 at 6 months across all cohorts. Reduction in BMI z score ranged from 0.41 in cohort 4 to 0.13 in cohort 5. Iterative adaptations to BHF were completed to improve the fit of BHF to the setting and participants and have contributed to a sustained community PWMI that adheres to the underlying principles and core elements of other evidence-based PWMIs. Monitoring adaptations and related changes to outcomes can play a role in long-term sustainability and effectiveness.

Extensive mucocutaneous, oesophageal and otic lichen planus secondary to nivolumab therapy.

We report a 73-year-old female with metastatic renal cell carcinoma who developed a widespread lichenoid reaction following nivolumab treatment. The timeline of the reaction strongly correlated with the nivolumab treatment and subsequent cessation. Our patient had cutaneous, mucosal, otic, ophthalmic and oesophageal involvement, demonstrating the potentially extensive nature of lichenoid reactions to anti-programmed cell death receptor-1 (anti-PD1) therapies. Although lichenoid reactions to anti-PD1 therapies are now well recognized, there have been no previous reports of otic or oesophageal involvement in the literature. Although cutaneous lichenoid reactions do not tend to be severe or treatment limiting, more widespread systemic lichenoid reactions are challenging to manage, particularly in the context of malignancy. This very unusual case highlights the importance of considering involvement beyond the skin in all lichenoid skin reactions.

Cutaneous toxicities in patients with melanoma receiving checkpoint inhibitor therapy: a retrospective review. The experience of a single large specialist institution.

Checkpoint inhibitor (CPI) therapy has significantly improved overall survival for metastatic melanoma, and is now approved for use in the adjuvant setting. Modulating the immune system is recognized to cause cutaneous immune-related adverse events (irAEs). We conducted a retrospective observational cohort study of adult patients with melanoma at our tertiary referral centre, who received CPI therapy from 2006 to March 2018. This is the single largest study of cutaneous irAEs occurring on CPI therapy in patients with melanoma to date and encompasses 12 years. The results showed that cutaneous toxicity occurs in 24% of patients but is generally manageable, with < 5% patients discontinuing treatment.

Localized genital bullous pemphigoid.

Genital bullous pemphigoid (GBP) is a rare localized subset of bullous pemphigoid (BP). BP is characterized by autoantibodies against hemidesmosomes, which are involved in the structural integrity of the epidermis, and this results in subepidermal blistering. Typically, GBP affects women and children. We report an adult male who presented with a scrotal rash and blisters that developed into erosions. Only two previous cases in men have been reported. Immunofluoresence and histopathology confirmed the diagnosis of BP. The patient responded to mycophenolate mofetil and doxycycline.

A survey of oral medicine education, training and practice among dermatologists in the UK and Ireland.

BACKGROUND: Oral mucocutaneous diseases are common and patients with these conditions are frequently assessed by dermatologists. An accurate and comprehensive oral examination is important for a complete dermatological assessment. AIM: The aim of this study was to assess education and training, knowledge, and clinical practice of oral medicine among dermatologists in the United Kingdom (UK) and Ireland. METHODS: A cross-sectional survey was conducted by means of an internet-based survey tool. This was available to British Association of Dermatology (BAD) members in UK and Ireland on the association's website. Members were asked to respond to a 10-part questionnaire that enquired about their knowledge of oral diseases, training in oral medicine, performing an oral examination and oral biopsy. RESULTS: Completed responses were received from 95 dermatologists. The majority of respondents were consultant dermatologists (72%) who were university based. While the majority reported that knowledge of oral diseases was important, only 52% were confident in recognising the normal variants of the oral cavity. Just 55% were confident in recognising oral malignancy and even less (42%) the different forms of oral ulceration. Over three-quarters had never attended an oral medicine clinic or attended an external oral medicine course as part of their training. Two thirds had not been taught normal oral anatomy or how to perform an oral examination. The majority reported that their training in oral medicine was not adequate to perform their job. CONCLUSIONS: This study shows that in this, albeit small, group of dermatology specialists and trainees most appear ill-equipped to recognise and diagnose diseases of the oral cavity due to a lack of training in oral medicine.

Loss of Work Productivity and Quality of Life in Patients With Autoimmune Bullous Dermatoses.

BACKGROUND: Little is known about quality of life and work productivity in autoimmune bullous dermatoses (AIBDs). OBJECTIVE: To determine the impact of AIBDs on quality of life and work productivity. METHODS: An observational cross-sectional study took place between February and May 2013 at an AIBD tertiary referral centre. Ninety-four patients were included. All participants completed the Dermatology Life Quality Index and the Work Productivity and Activity Impairment-Specific Health Problem questionnaires. RESULTS: Responders to treatment had less impairment (P<.001) than nonresponders. Patients with severe AIBD had significantly more impairment that those with mild (P<.001) and moderate (P=.002) AIBD. Greater impairment was associated with higher percentage of work missed. Those with a higher Dermatology Life Quality Index score had greater work impairment and overall activity impairment (P=.041, P=.024). Nonresponders had increased impairment while working (P<.001), overall work impairment (P<.001), and activity impairment (P<.001). Severely affected patients had worse impairment in all Work Productivity and Activity Impairment Questionnaire domains. CONCLUSIONS: AIBD has the potential to be a large burden on ability to work and quality of life. Larger studies are needed to clarify how these domains change over time and whether or not they improve with treatment.

Pemphigus and associated comorbidities: a cross-sectional study.

BACKGROUND: Pemphigus is a rare autoimmune blistering disease, reported to be associated with other coexisting and autoimmune diseases, including thyroid diseases, rheumatoid arthritis, alopecia areata, vitiligo, systemic lupus erythematosus, scleroderma and rare entities such as myasthenia gravis. AIM: To identify and describe patients with pemphigus with a diagnosed comorbidity, and to quantify the risk of additional comorbidities. METHODS: This was a cross-sectional study of patients with pemphigus treated at a tertiary referral centre. Prevalence rates of 15 comorbid diseases were calculated. Age-standardized prevalence ratio (SPR) and 95% CI were calculated in comparison with prevalence rates in the general Canadian population using data from the Canadian Community Health Survey. Data were analysed using SAS software. RESULTS: In total, 295 patients were identified. An increased risk of hypothyroidism (n = 38, SPR = 1.53, 95% CI 1.08-2.10) and inflammatory bowel disease (IBD) (SPR = 1.48, 95% CI 0.40-3.80), and a two-fold increased risk of diabetes (SPR = 2.20, 95% CI 1.64-2.87) were observed. CONCLUSIONS: Patients with pemphigus have a higher incidence of hypothyroidism, IBD and diabetes compared with the general population. As part of pemphigus investigations and surveillance, investigating for these conditions may be considered.

A prediction equation for the estimation of cardiorespiratory fitness using an elliptical motion trainer.

OBJECTIVE: In the United States of America, 6.2 million individuals are using elliptical motion trainers in fitness centres. However, graded exercise test protocols to estimate peak oxygen consumption (VO(2peak)) using elliptical motion trainers have not been developed for the general population. METHODS: Fifty-nine subjects (mean age: 23.5 +/- 4.1 years) were randomly divided into a validation (VAL: n = 39) or cross-validation (XVAL: n = 20) group. Peak oxygen consumption (ml x kg(-1) x min(-1)) was measured via indirect calorimetry on an elliptical motion trainer for both groups. Subjects exercised at 150 strides x min(-1) against a resistance of four and a crossramp of 8%. The resistance was increased every two minutes by two units until exhaustion. For the VAL group, a stepwise regression analysis was used to predict VO(2peak) from resistance, maximal heart rate (HR(max)), body mass index (BMI), height and gender (female = 0, male = 1). RESULTS: The prediction equation derived from this study was VO(2peak) (ml x kg(-1) x min(-1)) = 187.39403 + 12.97271 (gender) - 1.45311 (height) - 1.21604 (BMI) - 0.19613 (HR(max)) + 1.57093 (resistance) (R2 = 0.76, SEE = 4.47, p < 0.05). Using this equation, the predicted VO(2peak) of the XVAL group was 45.18 +/- 6.42 ml x kg(-1) x min(-1), while the measured VO(2peak) was 43.55 +/- 6.23 ml x kg(-1) x min(-1) CONCLUSION: No significant difference was found between the measured and predicted VO(2peak) in the XVAL group. Therefore, it appears this protocol and equation will allow individuals to accurately estimate their VO(2peak) without using direct calorimetry. However future studies should investigate the validity of this protocol with diverse populations.

Associations between adiposity, family history of CHD and blood pressure in 3-8 year-old children.

The purpose of this study was to examine the relationships between overall and central adiposity, a family history of coronary heart disease (FHCHD), and blood pressure (BP) in young children. We were specifically interested in determining whether the relationship between adiposity and BP was modified by a FHCHD. Subjects were 130 (68 males, 62 females) young children (mean age 6.0 years). Indicators of adiposity included the body mass index, waist circumference, skinfold thickness, and body composition determined by dual energy X-ray absorbtiometry (DXA). BP was measured by standard procedures. FHCHD was reported by the parent on a questionnaire. Approximately 19% of the total sample was classified as overweight and almost 50% were classified as prehypertensive (22.4%) or hypertensive (24.8%). In the total sample, 21 of 27 correlations were significant and ranged from 0.03 to 0.52. Correlations for systolic blood pressure appeared to be stronger in female subjects. Most of the correlations for diastolic blood pressure and mean arterial pressure were significant in both sexes and, in general, ranged between 0.30 and 0.50. Overweight status was significantly associated with high BP (crude odds ratio=3.65, 95% confidence intervals 1.40-9.49). There were no significant associations between a positive FHCHD and BP, and the correlations between BMI, WC, and BP were similar in magnitude in subjects with and without a FHCHD. In conclusion, both overall and central adiposity are important determinants of resting BP in young children. A FHCHD was not associated with BP and nor were the associations between adiposity and BP modified by a FHCHD.

Active commuting to and from school and BMI in elementary school children-preliminary data.

BACKGROUND: United States National Health Objectives include increasing the proportion of trips made by walking to and from school for children who live within 1.6 km to 50%. The purpose of this objective is to increase the level of physical activity among children. However, the impact of walking, bicycling or skating (active commuting) to and from school on the prevalence of overweight is unknown. METHODS: Body mass index (BMI) was measured for 320 children (age 10.2+/-0.7 years) in September. Over 5 months, an active commuting index (SI) and daily physical activity were estimated via questionnaire. In April, BMI and body fat were measured. RESULTS: A significant positive association was found between April BMI and SI adjusting for September BMI (partial r=0.03, P<0.05). Positive associations were found between SI and physical activity before school (r=0.17, P<0.05) and daily moderate intensity physical activity (r=0.13, P<0.05). There were no significant association between SI and BF (P>0.05). CONCLUSIONS: This preliminary data suggests that active commuting does not appear to provide sufficient amounts of physical activity to attenuate BMI; however, it may contribute to the attainment of physical activity recommendations. Future research is needed to objectively measure the impact of active commuting on the prevalence of overweight.

Adherence and attrition with intermittent and continuous exercise in overweight women.

Few people are active to the levels recommended by Healthy People 2010. Intermittent exercise has been promoted as an exercise prescription which may enable more people to meet recommended guidelines. However, few data are available on intermittent exercise over the long-term. The purpose of the current study was to compare the effects of long-term (72 weeks) continuous (CON) and intermittent (INT) exercise on attrition and adherence in previously sedentary, moderately obese females. Participants were randomized to continuous walking at 60 to 75% of maximum aerobic capacity, 3 days per week, 30 minutes per session, or intermittent exercise for two 15-minute sessions, 5 days per week. Adherence was calculated as the number of sessions completed compared to the number of sessions prescribed. At 12-week intervals, attrition was calculated as the number of participants in the study compared to the total number of participants originally enrolled. For the participants who completed the study, body weight decreased for CON from 80.17 +/- 5.75 kg at baseline to 79.70 +/- 5.40 at 16 months (p < 0.05). For INT, body weight did not change from baseline (85.85 +/- 13.13 kg) to 16 months (85.05 +/- 12.90 kg). By design, INT walked significantly (p < 0.05) further (819 +/- 128 km) compared to CON (527 +/- 46 km). Attrition was 58% for both groups baseline to 72 weeks. However, attrition was greater for CON (38 %) compared to INT (16%) in the first 24 weeks. Adherence was excellent for both groups (> 83%) throughout the study. These results suggest that intermittent and continuous exercise both have considerable attrition rates within 72 weeks of exercise initiation; however, the pattern of attrition differs considerably. That is, it appears that intermittent exercise may reduce attrition in the first 24 weeks of an exercise program; however, attrition does not appear to be different than continuous exercise at 72 weeks.

The effects of 18 months of intermittent vs. continuous exercise on aerobic capacity, body weight and composition, and metabolic fitness in previously sedentary, moderately obese females.

OBJECTIVES: To compare the effects of 18 months of continuous vs intermittent exercise on aerobic capacity, body weight and composition, and metabolic fitness in previously sedentary, moderately obese females. DESIGN: Randomized, prospective, long-term cohort study. Subjects performed continuous exercise at 60-75% of maximum aerobic capacity, 3 days per week, 30 min per session, or exercised intermittently using brisk walking for two, 15 min sessions, 5 days per week. MEASURES: Aerobic capacity, body weight, body composition, and metabolic fitness (blood pressure, lipids, glucose and insulin). RESULTS: Significant improvements for aerobic capacity of 8% and 6% were shown for the continuous and intermittent exercise groups, respectively. Weight loss for the continuous exercise group was significant at 2.1% from baseline weight and the intermittent group was essentially unchanged. The continuous group showed a significant decrease in percentage of body fat and fat weight while the intermittent group did not. HDL cholesterol and insulin were significantly improved for both groups. CONCLUSIONS: In previously sedentary, moderately obese females, continuous or intermittent exercise performed long-term may be effective for preventing weight gain and for improving some measures of metabolic fitness.