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Psoriasis is a chronic inflammatory disease that affects a significant portion of the population. Aside from the well known cutaneous and joint involvements, psoriasis is associated with a host of systemic ailments and risk factors. Thus, psoriasis can diminish a patient's quality and even length of life. Various systemic agents have been developed to control this condition, including the more recent introduction of biological agents. As the pathogenesis of psoriasis becomes better understood, a new class of biological drug is being studied and shows promise in long-term disease control for psoriasis patients, namely anti-interleukin-12/interleukin-23p40 monoclonal antibodies. The new biological agent, ustekinumab, has been shown to improve moderate to severe psoriasis in patients who cannot tolerate other treatment modalities with ease or in whom these modalities have failed. A favourable side effect profile has also been shown for this agent. [ABSTRACT FROM AUTHOR]

Objective: To determine if dermoscopy, a technique widely utilized in dermatology for improved diagnosis of skin lesions, can be used comfortably for evaluating periorbital, eyelid, and conjunctival lesions., Design: Proof-of-concept study in which a technique for performing dermoscopy near the eye was developed, related educational material was prepared, and a protocol for dermoscopic image capture was created., Methods: Technicians used the developed materials to learn to take high-quality pictures with a 10x dermoscope attached to a standard cell phone camera. The images were assessed for diagnostic utility by an oculoplastic surgeon and two dermatologists., Participants: 115 patients recruited from ophthalmology clinics from July 2021 to April 2023 were photographed, yielding 129 lesions with high-quality dermoscopic images as assessed by an oculoplastic surgeon and two dermatologists., Results: Technicians reported a significant increase in confidence (measured on a 1-10 scale) with dermoscopy after training (pre-instruction mean = 1.72, median = 1, mode = 1, IQR = 1.25 vs mean = 7.69, median = 7.75, mode = 7 and 8, IQR = 1.5 post-instruction. Wilcoxon rank sum test with continuity correction, W = 0, p < 0.001, paired t = 13.95, p  < 0.0001). Incorporating a contact plate with a 4 × 4mm reticule on the dermoscope aided in photographing ocular and periocular lesions., Conclusion: Medical support staff in eye-care offices can be taught to use dermoscopes to capture high-quality images of periorbital, eyelid, and conjunctival lesions. Dermoscopy illuminates diagnostic features of lesions and thus offers a new avenue to improve decision-making in ophthalmology. Dermoscopy can be incorporated into telemedicine evaluations by ophthalmologists, oculoplastic surgeons, or affiliated dermatologists for triage of or rendering advice to patients and for planning of surgery if needed., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Competing Interests: Drs Tejasvi and Ellis are employees of the Department of Veterans Affairs. Author Dr Trupiano, Dr Scharnitz, and Dr Novice have no conflicts of interest to declare.

Background: Patients with psoriasis have elevated risk of coronary artery disease., Objective: Do patients with severe psoriasis have larger epicardial adipose tissue volumes (EAT-V) that are associated with cardiovascular risk?, Methods: For this cross-sectional study, we recruited dermatology patients with severe psoriasis and control patients without psoriasis or rheumatologic disease themselves or in a first-degree relative. Participants aged 34 to 55 years without known coronary artery disease or diabetes mellitus underwent computed tomography (CT); EAT-V was obtained from noncontrast CT heart images., Results: Twenty-five patients with psoriasis (14 men, 11 women) and 16 controls (5 men, 11 women) participated. Groups had no statistical difference in age, body mass index, various cardiovascular risk factors (except high-sensitivity C-reactive protein in men), CT-determined coronary artery calcium scores or plaque, or family history of premature cardiovascular disease. Mean EAT-V was greater in the psoriasis group compared to controls (P = .04). There was no statistically significant difference among women; however, male patients with psoriasis had significantly higher EAT-V than controls (P = .03), even when corrected for elevated high-sensitivity C-reactive protein (P = .05)., Limitations: A single-center convenience sample may not be representative., Conclusion: Males with psoriasis without known coronary disease or diabetes had greater EAT-V than controls. EAT-V may be an early identifier of those at increased risk for cardiovascular events., Competing Interests: Conflict of interest Drs Ellis, Elder, and Gudjonsson have served as consultants to various manufacturers of pharmaceuticals for psoriasis. Drs Neville, Sayyouh, Nair, Kazerooni, Rubenfire, and Agarwal and Author Ma have no conflicts of interest to disclose., (Published by Elsevier Inc.)

Background: It is unclear whether primary efficacy outcomes in plaque psoriasis clinical trials represent residual disease during treatment., Objectives: To evaluate supplementing dichotomous efficacy with residual disease activity., Methods: This post hoc analysis used pooled, patient-level data after tildrakizumab 100 mg ( N  = 616) or placebo ( N  = 309) treatment from reSURFACE 1/2 (NCT01722331/NCT01729754) phase 3 clinical trials of patients with moderate to severe plaque psoriasis., Results: Median baseline Psoriasis Area and Severity Index (PASI) was 17.9 for patients receiving tildrakizumab 100 mg. At Week 12, median PASI was 2.9, whereas dichotomous PASI 90 response rate was 36.9%, and absolute PASI <5.0, <3.0, and <1.0 were 64.0%, 50.8%, and 23.3%, respectively. At Week 28, median PASI was 1.7, whereas PASI 90 response rate was 51.9%, and absolute PASI <5.0, <3.0, and <1.0 were 75.3%, 62.8%, and 38.0%, respectively. Dermatology Life Quality Index and PASI scores were correlated through Week 28 ( r  = 0.51, p  ≤ .0001)., Conclusions: Disease activity was more reliably estimated by PASI scores than percentage PASI improvement; this may partially explain efficacy disparities between clinical trials and practice. These results suggest supplementing dichotomous PASI improvement with PASI scores and consideration of patient treatment goals could facilitate clinical decisions.

Vibrio cholerae infection provides long-lasting protective immunity, while oral, inactivated cholera vaccines (OCV) result in more-limited protection. To identify characteristics of the innate immune response that may distinguish natural V. cholerae infection from OCV, we stimulated differentiated, macrophage-like THP-1 cells with live versus heat-inactivated V. cholerae with and without endogenous or exogenous cholera holotoxin (CT). Interleukin 23A gene ( IL23A ) expression was higher in cells exposed to live V. cholerae than in cells exposed to inactivated organisms (mean change, 38-fold; 95% confidence interval [95% CI], 4.0 to 42; P  < 0.01). IL-23 secretion was also higher in cells exposed to live V. cholerae than in cells exposed to inactivated V. cholerae (mean change, 5.6-fold; 95% CI, 4.4 to 11; P  < 0.001). This increase in IL-23 secretion was more marked than for other key innate immune cytokines (e.g., IL-1β and IL-6) and dependent on exposure to the combination of both live V. cholerae and CT. While IL-23 secretion was reduced following stimulation with either heat-inactivated wild-type V. cholerae or a live isogenic ctxAB mutant of V. cholerae , the addition of exogenous CT restored IL-23 secretion in combination with the live isogenic ctxAB mutant V. cholerae , but not when it was paired with stimulation by heat-inactivated V. cholerae The posttranslational regulation of IL-23 under these conditions was dependent on the activity of the cysteine protease cathepsin B. In humans, IL-23 promotes the differentiation of Th17 cells to T follicular helper cells, which maintain and support long-term memory B cell generation after infection. Based on these findings, the stimulation of IL-23 production may be a determinant of protective immunity following V. cholerae infection. IMPORTANCE An episode of cholera provides better protection against reinfection than oral cholera vaccines, and the reasons for this are still under study. To better understand this, we compared the immune responses of human cells exposed to live Vibrio cholerae with those of cells exposed to heat-killed V. cholerae (similar to the contents of oral cholera vaccines). We also compared the effects of active cholera toxin and the inactive cholera toxin B subunit (which is included in some cholera vaccines). One key immune signaling molecule, IL-23, was uniquely produced in response to the combination of live bacteria and active cholera holotoxin. Stimulation with V. cholerae that did not produce the active toxin or was killed did not produce an IL-23 response. The stimulation of IL-23 production by cholera toxin-producing V. cholerae may be important in conferring long-term immunity after cholera., (Copyright © 2019 Weil et al.)

Engaging global key opinion leaders, the International Psoriasis Council (IPC) held a day-long roundtable discussion with the primary purpose to discuss the treatment goals of psoriasis patients and worldwide barriers to optimal care. Setting clear expectations might ultimately encourage undertreated psoriasis patients to seek care in an era in which great gains in therapeutic efficacy have been achieved. Here, we discuss the option for early treatment of all categories of psoriasis to alleviate disease impact while emphasizing the need for more focused attention for psoriasis patients with mild and moderate forms of this autoimmune disease. In addition, we encourage policy changes to keep pace with the innovative therapies and clinical science and highlight the demand for greater understanding of treatment barriers in resource-poor countries.

Introduction: Communication skills influence the quality of health care and patient experience; both may affect provider reimbursement. There are few opportunities available for practicing physicians to receive direct feedback on communication in patient encounters. The purpose of this simulation-based patient encounter workshop was for dermatologists to practice and obtain feedback on their communication skills., Methods: In March 2016, dermatologists participated in a workshop with four simulated patient encounters. Cases were developed based on a prior needs assessment. Standardized patient educators evaluated participants' communication using the Master Interview Rating Scale and provided verbal feedback. Physicians rated the usefulness of the simulation and the feedback received through a survey upon workshop completion., Results: Of the 170 physicians who registered, 103 participated in the simulation. The workshop was highly rated in meeting its three learning objectives (score of 4.5-4.6 out of a maximum score of 5). The lowest-rated communication skills were as follows: allowing the patient to share their narrative thread (3.1), summarizing the patient's history from the provider (3.8), and assessing patient understanding (3.8)., Conclusions: Participants reported that this communication workshop effectively satisfied its learning objectives. Opportunities to practice and improve communication skills as part of continuing medical education will benefit the clinical experience of patients and physicians alike, and the workshop may be formatted to serve physicians of other specialties. The lowest-scoring communication areas identified in this study present an opportunity to develop a tailored curriculum for physician-patient communication in the future.

Background: Cholera is a public health problem worldwide, and the risk factors for infection are only partially understood., Methods: We prospectively studied household contacts of patients with cholera to compare those who were infected to those who were not. We constructed predictive machine learning models of susceptibility, using baseline gut microbiota data. We identified bacterial taxa associated with susceptibility to Vibrio cholerae infection and tested these taxa for interactions with V. cholerae in vitro., Results: We found that machine learning models based on gut microbiota, as well as models based on known clinical and epidemiological risk factors, predicted V. cholerae infection. A predictive gut microbiota of roughly 100 bacterial taxa discriminated between contacts who developed infection and those who did not. Susceptibility to cholera was associated with depleted levels of microbes from the phylum Bacteroidetes. By contrast, a microbe associated with cholera by our modeling framework, Paracoccus aminovorans, promoted the in vitro growth of V. cholerae. Gut microbiota structure, clinical outcome, and age were also linked., Conclusion: These findings support the hypothesis that abnormal gut microbial communities are a host factor related to V. cholerae susceptibility.

To better understand the innate immune response to Vibrio cholerae infection, we tracked gene expression in the duodenal mucosa of 11 Bangladeshi adults with cholera, using biopsy specimens obtained immediately after rehydration and 30 and 180 days later. We identified differentially expressed genes and performed an analysis to predict differentially regulated pathways and upstream regulators. During acute cholera, there was a broad increase in the expression of genes associated with innate immunity, including activation of the NF-κB, mitogen-activated protein kinase (MAPK), and Toll-like receptor (TLR)-mediated signaling pathways, which, unexpectedly, persisted even 30 days after infection. Focusing on early differences in gene expression, we identified 37 genes that were differentially expressed on days 2 and 30 across the 11 participants. These genes included the endosomal Toll-like receptor gene TLR8 , which was expressed in lamina propria cells. Underscoring a potential role for endosomal TLR-mediated signaling in vivo , our pathway analysis found that interferon regulatory factor 7 and beta 1 and alpha 2 interferons were among the top upstream regulators activated during cholera. Among the innate immune effectors, we found that the gene for DUOX2, an NADPH oxidase involved in the maintenance of intestinal homeostasis, was upregulated in intestinal epithelial cells during cholera. Notably, the observed increases in DUOX2 and TLR8 expression were also modeled in vitro when Caco-2 or THP-1 cells, respectively, were stimulated with live V. cholerae but not with heat-killed organisms or cholera toxin alone. These previously unidentified features of the innate immune response to V. cholerae extend our understanding of the mucosal immune signaling pathways and effectors activated in vivo following cholera., (Copyright © 2018 American Society for Microbiology.)

Background: To identify patients with a high risk of 30-day mortality after elective surgery, who may benefit from referral for tertiary care, an institution-specific process using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) Risk Calculator was developed. The goal was to develop and validate the methodology. Our hypothesis was that the process could optimize referrals and reduce mortality., Study Design: A VASQIP risk score was calculated for all patients undergoing elective noncardiac surgery at a single Veterans Affairs (VA) facility. After statistical analysis, a VASQIP risk score of 3.3% predicted mortality was selected as the institutional threshold for referral to a tertiary care center. The model predicted that 16% of patients would require referral, and 30-day mortality would be reduced by 73% at the referring institution. The main outcomes measures were the actual vs predicted referrals and mortality rates at the referring and receiving facilities., Results: The validation included 565 patients; 90 (16%) had VASQIP risk scores greater than 3.3% and were identified for referral; 60 consented. In these patients, there were 16 (27%) predicted mortalities, but only 4 actual deaths (p = 0.007) at the receiving institution. When referral was not indicated, the model predicted 4 mortalities (1%), but no actual deaths (p = 0.1241)., Conclusions: These data validate this methodology to identify patients for referral to a higher level of care, reducing mortality at the referring institutions and significantly improving patient outcomes. This methodology can help guide decisions on referrals and optimize patient care. Further application and studies are warranted., (Copyright © 2017 American College of Surgeons. All rights reserved.)

Patient satisfaction has become an important measure of quality under the Patient Protection and Affordable Care Act. In this study, we assessed and analyzed patient satisfaction, nonattendance rates, and cycle times in an outpatient dermatology clinic. This study provides a snapshot of patient satisfaction in an urban dermatology clinic. Under the Patient Protection and Affordable Care Act, providers will be challenged to increase access to care and to validate quality of care through patient satisfaction.

Background: This study was performed to evaluate tolerance of liquids as discharge criteria in a perioperative enhanced recovery protocol., Methods: Patients undergoing elective colon resections were prospectively enrolled in a standardized perioperative enhanced recovery process. Patients were eligible for discharge when able to tolerate sufficient oral liquids, as determined by clinical means, that intravenous fluids were no longer needed., Results: Over an 18 month period, 94 patients were evaluated; 75 (80%) tolerated sufficient liquids such that intravenous fluids were no longer needed by the second and all by the third postoperative day. The average postoperative length of stay was 3.8 days. At discharge, 59 (63%) and 20 (21%) patients reported passage of flatus and stool respectively. On 30 day follow up, 8 (8.5%) patients had been re-admitted., Conclusion: These data suggest that after elective colon surgery, patients can be discharged when able to tolerate sufficient oral liquids., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Peripheral leukocytes in patients with atopic dermatitis (AD) have elevated phosphodiesterase-4 activity, which is associated with production of proinflammatory mediators. OPA-15406 is a phosphodiesterase-4 inhibitor with high selectivity for phosphodiesterase-4-B., Objectives: We sought to assess effectiveness and tolerability of topical OPA-15406 in patients with AD., Methods: This was a randomized, double-blind, vehicle-controlled, phase-II study. Patients 10 to 70 years of age with mild or moderate AD received topical OPA-15406 0.3% (n = 41), OPA-15406 1% (n = 43), or vehicle (n = 37) twice daily for 8 weeks., Results: The primary end point, Investigator Global Assessment of Disease Severity score of 0 or 1 with greater than or equal to 2-grade reduction, was met at week 4 in the OPA-15406 1% group (P = .0165 vs vehicle). Mean percentage improvement from baseline Eczema Area and Severity Index score for OPA-15406 1% was notable in week 1 (31.4% vs 6.0% for vehicle; P = .0005), even larger in week 2 (39.0% vs 3.0%; P = .0001), and persisted for 8 weeks. Visual analog scale pruritus scores improved from moderate to mild within the first week in the OPA-15406 1% group (36.4% mean change; P = .0011). OPA-15406 levels in blood were negligible. Incidence of adverse events was low, with most events mild in intensity., Limitations: Further confirmatory phase-III studies are required., Conclusion: OPA-15406 ointment may provide an effective therapeutic modality for patients with mild to moderate AD., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Moderate to severe plaque psoriasis (with or without psoriatic arthritis) places significant burden on patients' lives., Objective: Explore and document patients' experiences of living with psoriasis, including symptoms, treatments, impact on daily lives and patient-reported functioning., Methods: In a US-based, non-interventional study, narrative interviews were conducted at baseline and again within 16 weeks. In interviews, patients with moderate to severe psoriasis indicated symptoms, ranked symptoms according to level of bother and indicated areas of their lives affected by psoriasis. Transcripts of interviews were coded for themes. Measurements of psoriasis severity including BSA, PGA and PASI were recorded., Results: Symptoms reported most frequently included flaking/scaling (non-scalp areas), itching/scratching and rash, while the most bothersome symptoms were itching/scratching, flaking/scaling (non-scalp areas) and skin pain. Frequently reported impact areas were social and emotional., Conclusion: Broad-reaching interviews with patients with psoriasis show that these patients suffer in many aspects of their lives and in ways not indicated by typical psoriasis severity measures. Patients with psoriatic arthritis reported symptoms and disease-related complications at higher rates than those without arthritis. Physicians' explorations of the effect of psoriasis on patients' life events could aid in managing these patients.

Background: Systems for determining psoriasis severity in clinical trials have not been sufficiently validated against patients' perceived quality of life., Objective: To validate three systems of physician-determined psoriasis severity (the Lattice System Physician's Global Assessment [LS-PGA], Psoriasis Area and Severity Index [PASI] and static Physician's Global Assessment [sPGA])., Methods: Data were from a 24-week randomized, double-blind, placebo-controlled, multicenter trial of therapy with oral calcineurin inhibitors in 445 patients. Construct validity was measured by correlations of the three severity scores with patients' self-reported quality of life (QoL) from the Dermatology Life Quality Index (DLQI) and a DLQI item about psoriasis symptoms., Results: All severity systems were moderately and positively correlated with QoL, indicating construct validity. QoL was most consistently related to physicians' assessments of body surface area involved with psoriasis (iBSA) followed by, in the order of consistency, plaque elevation, erythema and scale., Conclusions: The LS-PGA weights iBSA and aspects of plaque morphology in concert with their relative effects on QoL. The LS-PGA, sPGA and PASI are validated by their relationship to QoL in a clinical trial., (© 2015 European Academy of Dermatology and Venereology.)

Background: Accurate and reliable assessment of changes in psoriasis severity is critical in clinical trials of therapies., Objective: To compare Psoriasis Area and Severity Index (PASI), static Physician's Global Assessment (sPGA), and the Lattice System Physician's Global Assessment (LS-PGA) in a trial of systemic treatments for plaque psoriasis vulgaris and to assess whether they measure change in psoriasis induced by therapy., Methods: Patients were randomized to voclosporin or cyclosporine for 24 weeks (the '24-week-treatment' group, n = 366), or placebo for 12 weeks followed by voclosporin for 12 weeks (the 'initial-placebo' group, n = 89)., Results: All scoring systems changed in concert and were sensitive enough to detect reductions in severity during placebo therapy as well as with active therapy (P < 0.01 for each measurement). At study onset, there were poorer correlations of sPGA with PASI (r = 0.45) and LS-PGA (r = 0.39) than between PASI and LS-PGA (r = 0.68). After therapy, all correlations were stronger, but sPGA continued to be less well correlated (with PASI, r = 0.85; with LS-PGA, r = 0.79) than LS-PGA with PASI (r = 0.90). Two- or three-step improvements in LS-PGA showed very good to excellent accuracy in corresponding to PASI-50 and PASI-75, respectively, and were more accurate than comparable changes in sPGA., Conclusion: PASI, sPGA and LS-PGA are responsive to the varying degrees of improvement in psoriasis induced by either placebo or active therapy. While the three systems capture similar information, each has different reasons for use in a clinical trial., (© 2015 European Academy of Dermatology and Venereology.)

Vibrio cholerae O1 is a major cause of acute watery diarrhea in over 50 countries. Evidence suggests that V. cholerae O1 may activate inflammatory pathways, and a recent study of a Bangladeshi population showed that variants in innate immune genes play a role in mediating susceptibility to cholera. We analyzed human proteins present in the small intestine of patients infected with V. cholerae O1 to characterize the host response to this pathogen. We collected duodenal biopsy specimens from patients with acute cholera after stabilization and again 30 days after initial presentation. Peptides extracted from biopsy specimens were sequenced and quantified using label-free mass spectrometry and SEQUEST. Twenty-seven host proteins were differentially abundant between the acute and convalescent stages of infection; the majority of these have known roles in innate defense, cytokine production, and apoptosis. Immunostaining confirmed that two proteins, WARS and S100A8, were more abundant in lamina propria cells during the acute stage of cholera. Analysis of the differentially abundant proteins revealed the activation of key regulators of inflammation by the innate immune system, including Toll-like receptor 4, nuclear factor kappa-light-chain-enhancer of activated B cells, mitogen-activated protein kinases, and caspase-dependent inflammasomes. Interleukin-12β (IL-12β) was a regulator of several proteins that were activated during cholera, and we confirmed that IL-12β was produced by lymphocytes recovered from duodenal biopsy specimens of cholera patients. Our study shows that a broad inflammatory response is generated in the gut early after onset of cholera, which may be critical in the development of long-term mucosal immunity against V. cholerae O1., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Colonization of vacant environments may catalyze adaptive diversification and be followed by competition within the nascent community. How these interactions ultimately stabilize and affect productivity are central problems in evolutionary ecology. Diversity can emerge by character displacement, in which selection favors phenotypes that exploit an alternative resource and reduce competition, or by facilitation, in which organisms change the environment and enable different genotypes or species to become established. We previously developed a model of long-term experimental evolution in which bacteria attach to a plastic bead, form a biofilm, and disperse to a new bead. Here, we focus on the evolution of coexisting mutants within a population of Burkholderia cenocepacia and how their interactions affected productivity. Adaptive mutants initially competed for space, but later competition declined, consistent with character displacement and the predicted effects of the evolved mutations. The community reached a stable equilibrium as each ecotype evolved to inhabit distinct, complementary regions of the biofilm. Interactions among ecotypes ultimately became facilitative and enhanced mixed productivity. Observing the succession of genotypes within niches illuminated changing selective forces within the community, including a fundamental role for genotypes producing small colony variants that underpin chronic infections caused by B. cenocepacia., (© 2014 The Author(s). Evolution published by Wiley Periodicals, Inc. on behalf of The Society for the Study of Evolution.)

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

A common phenotype within bacterial biofilms is the small, "wrinkly" colony, which may associate with worse prognoses from biofilm-associated infections. The mechanisms that produce these variants in Burkholderia are undefined. Here we report the mutational and ecological causes of wrinkly (W) colonies that evolved during experimental biofilm evolution of Burkholderia cenocepacia. Mutations clustered in a homologous pathway to the Pseudomonas wsp operon but with a distinct terminal signaling mechanism, and their parallel evolution suggested that they inhabited an equivalent biofilm niche. We tested this hypothesis of niche complementarity by measuring effects of substituting different W variants in the same evolved biofilm community. Despite phenotypic differences among W mutants growing alone, fitness of reconstituted mixed biofilms did not differ significantly. In conclusion, the evolution of small-colony variants in Burkholderia biofilms appears to be driven by an ecological opportunity that generates strong selection for constitutive wsp mutants to inhabit a common niche., (Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Virtual reality simulation for laparoscopic colectomy has been used for training of surgical residents and has been considered as a model for technical skills assessment of board-eligible colorectal surgeons. However, construct validity (the ability to distinguish between skill levels) must be confirmed before widespread implementation., Objective: This study was designed to specifically determine which metrics for laparoscopic sigmoid colectomy have evidence of construct validity., Design: General surgeons that had performed fewer than 30 laparoscopic colon resections and laparoscopic colorectal experts (>200 laparoscopic colon resections) performed laparoscopic sigmoid colectomy on the LAP Mentor model. All participants received a 15-minute instructional warm-up and had never used the simulator before the study. Performance was then compared between each group for 21 metrics (procedural, 14; intraoperative errors, 7) to determine specifically which measurements demonstrate construct validity. Performance was compared with the Mann-Whitney U-test (p < 0.05 was significant)., Results: Fifty-three surgeons; 29 general surgeons, and 24 colorectal surgeons enrolled in the study. The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 of 14 procedural metrics by distinguishing levels of surgical experience (p < 0.05). The most discriminatory procedural metrics (p < 0.01) favoring experts were reduced instrument path length, accuracy of the peritoneal/medial mobilization, and dissection of the inferior mesenteric artery. Intraoperative errors were not discriminatory for most metrics and favored general surgeons for colonic wall injury (general surgeons, 0.7; colorectal surgeons, 3.5; p = 0.045)., Limitations: Individual variability within the general surgeon and colorectal surgeon groups was not accounted for., Conclusions: The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 procedure-specific metrics. However, using virtual reality simulator metrics to detect intraoperative errors did not discriminate between groups. If the virtual reality simulator continues to be used for the technical assessment of trainees and board-eligible surgeons, the evaluation of performance should be limited to procedural metrics.

The individual, family, and public health burden of atopic dermatitis (AD) is considerable. The prevalence of AD is high, the signs and symptoms of the disease adversely affect quality of life for patients and their families, and the comorbid conditions associated with AD can increase considerably the negative impact of the disease. These comorbid conditions patients with AD are susceptible to include skin infectious, IgE-mediated diseases, and mental health disorders. New research identifies the skin barrier as not only an important initiator of atopic dermatitis but may even be a site for allergic sensitization to protein antigens. The skin barrier represents a potential new target for novel atopic prevention strategies., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Atopic dermatitis (AD) in adults is an important dermatologic disease. Even in patients in whom the clinical presentation is mild, the burden of disease can be considerable. Relatively little has been published on adult AD compared to the body of literature devoted to AD in children, although adults with severe AD are greatly affected by the disease. Even when AD is a mild clinical disease in adults, the psychosocial and economic burden of the disease can be profound. Patients are likely to find it useful if these nondermatologic comorbidities of AD are addressed by health care providers in clinical encounters. The treatment options for AD in adults are the same as those for children with AD, with some modifications., (Published by Elsevier Inc.)

Bathing and moisturization to control dryness, applications of topical anti-inflammatory agents (including corticosteroids and calcineurin inhibitors [TCIs]) to control flares, minimization of the risk for infection, and relief of pruritus are the cornerstones of effective therapy for atopic dermatitis. Education of parents and patients is crucial to enhance adherence. Strategies for reduced Staphylococcus aureus colonization may help control re-emergence of flares following cessation of antimicrobial treatment for infection; these include dilute bleach baths and minimizing the risk for contamination of topical agents. In severe, refractory cases, more aggressive therapy with systemic immunosuppressants may be considered, but appropriate laboratory testing must be included as part of patient monitoring during treatment. The value of adjuvant therapy with wet wraps to "cool down" particularly erythematous and pruritic flares is becoming increasingly recognized., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The prevalence of atopic dermatitis (AD) has increased markedly in the United States over the past 5 decades, with current reports varying from 10% to 20% prevalence in US children, and new diagnoses are estimated at almost 11% per year. Recent research in AD pathophysiology and pathogenesis has demonstrated that AD is associated with epidermal barrier dysfunction and that mutations in the filaggrin gene are implicated in barrier defects. These discoveries hold promise for future breakthroughs in the diagnosis and management of AD., (Copyright © 2012. Published by Elsevier Inc.)

Long-term adherence to carefully developed, individualized strategies is necessary for the optimum treatment outcomes in patients with atopic dermatitis (AD). However, the parents of children with AD frequently lack sufficient information about the disease and its treatment, hold incorrect and sometimes harmful beliefs about these issues, and too often do not follow through consistently with the treatment plan. The health care provider is the primary source of such education, so an effective provider relationship is fundamental to adherence. In addition to the provision of correct information and the correction of misinformation, clinicians must be aware of and must address barriers to adherence with AD therapy, especially parent anxiety about the safety of topical medications (corticosteroids and topical calcineurin inhibitors)., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In the last few years, there has been progress in identifying some of the risk genes for psoriasis. This has resulted in a major impetus toward drug development as many of the same pathways and processes identified in psoriasis have been shown to have major roles in other chronic inflammatory diseases, suggesting that psoriasis can be used as a treatment model for many other diseases. This has resulted in a shift in research toward a select number of biological processes and has been accompanied by a surge in drug development with over 20 systemic agents currently in clinical testing for psoriasis, many of which target the pathways identified through genetic and basic research. Although it is too early to tell for many of these agents how effective and safe they will be, and where they will fit into treatment algorithms, it is evident that our range of options in treating this often perplexing disease will greatly increase in the future., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Risk of gastric infection with Vibrio parahaemolyticus increases with favorable environmental conditions and population shifts that increase prevalence of infective strains. Genetic analysis of New Hampshire strains revealed a unique population with some isolates similar to outbreak-causing strains and high-level diversity that increased as waters warmed.

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.

In the past 15 years, research in dermatology has significantly increased. Dermatology-related contributions in premier medical journals such as The New England Journal of Medicine (NEJM) and The Journal of the American Medical Association (JAMA) are the representation of our field in the medical world. To analyze this representation, incidence of dermatology-related contributions in NEJM and JAMA during 3 separate years (during a 15-year period) was calculated.

Purpose: The purpose of this study was to determine how patients with anal fistulas would rank clinical scenarios describing various management options for anal fistulas., Method: A survey was administered to 74 consecutive patients with anal fistulas. On each survey, 10 clinical scenarios describing various treatment options for anal fistulas were scored from 1 (most likely to select) to 10 (least likely to select). Mean scores for each scenario were calculated and compared by use of a Student t test., Results: When combined, 74% of patients selected a sphincter-preserving technique as their primary choice compared with 26% who chose a fistulotomy (P < .0001). Compared with the highest ranking sphincter-preserving techniques, the mean scores of the scenarios involving a fistulotomy were significantly (P < .05) lower (less likely to select). The mean score of a traditional fistulotomy was the same as the mean score of a sphincter-preserving technique with a 50% success rate but no risk of diminished continence., Conclusions: These data suggest that the majority of patients with an anal fistula will select a sphincter-preserving technique to manage their fistula. This finding may indicate that, within limits, it is of greater importance for most patients to minimize their risk of diminished continence than to have a highly successful treatment strategy for their fistula.

Background: We hypothesized that simulator-generated metrics and intraoperative errors may be able to differentiate the technical differences between hand-assisted laparoscopic (HAL) and straight laparoscopic (SL) approaches., Methods: Thirty-eight trainees performed two laparoscopic sigmoid colectomies on an augmented reality simulator, randomly starting by a SL (n = 19) or HAL (n = 19) approach. Both approaches were compared according to simulator-generated metrics, and intraoperative errors were collected by faculty., Results: Sixty-four percent of surgeons were experienced (>50 procedures) with open colon surgery. Fifty-five percent and 69% of surgeons were inexperienced (<10 procedures) with SL and HAL colon surgery, respectively. Time (P < 0.001), path length (P < 0.001), and smoothness (P < 0.001) were lower with the HAL approach. Operative times for sigmoid and splenic flexure mobilization and for the colorectal anastomosis were significantly shorter with the HAL approach. Time to control the vascular pedicle was similar between both approaches. Error rates were similar between both approaches. Operative time, path length, and smoothness correlated directly with the error rate for the HAL approach. In contrast, error rate inversely correlated with the operative time for the SL approach., Conclusions: A HAL approach for sigmoid colectomy accelerated colonic mobilization and anastomosis. The difference in correlation between both laparoscopic approaches and error rates suggests the need for different skills to perform the HAL and the SL sigmoid colectomy. These findings may explain the preference of some surgeons for a HAL approach early in the learning of laparoscopic colorectal surgery.

Purpose: This study was undertaken to determine the outcomes of patients whose complex anal fistulas were managed by ligation of the intersphincteric fistula tract reinforced with a bioprosthetic graft (BioLIFT procedure)., Methods: A retrospective analysis was performed of all patients whose anal fistula was managed by use of the BioLIFT technique between May 2005 and May 2008, who had a minimum of 1 year of follow-up after their last treatment., Results: The BioLIFT technique using a bioprosthetic graft was used to treat a complex anal fistula in 31 patients (22 men, 9 women; mean age, 48 y (range, 30-68 y). Clinical healing of the fistula, defined as the absence of drainage with no evidence of residual fistula tract, occurred in 29 (94%) patients. No complications occurred that required intervention., Conclusions: The BioLIFT procedure is effective for the management of complex fistulas-in-ano. Randomized clinical trials comparing this technique with other sphincter-preserving methods for fistula management need to be performed to further determine the role of this technique in the management of anal fistulas.

Purpose: The aim of this study was to compare skills sets during a hand-assisted and straight laparoscopic colectomy on an augmented reality simulator., Methods: Twenty-nine surgeons, assigned randomly in 2 groups, performed laparoscopic sigmoid colectomies on a simulator: group A (n = 15) performed hand-assisted then straight procedures; group B (n = 14) performed straight then hand-assisted procedures. Groups were compared according to prior laparoscopic colorectal experience, performance (time, instrument path length, and instrument velocity changes), technical skills, and operative error., Results: Prior laparoscopic colorectal experience was similar in both groups. Both groups had better performances with the hand-assisted approach, although technical skill scores were similar between approaches. The error rate was higher with the hand-assisted approach in group A, but similar between both approaches in group B., Conclusions: These data define the metrics of performance for hand-assisted and straight laparoscopic colectomy on an augmented reality simulator. The improved scores with the hand-assisted approach suggest that with this simulator a hand-assisted model may be technically easier to perform, although it is associated with increased intraoperative errors.