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Introduction. When closure is not feasible, Mohs micrographic surgical wounds typically are left to heal by secondary intention and require weeks to close. Amniotic tissue–derived allograft (ATDA) has proven successful in promoting wound closure in diabetic and refractory wounds, and it may be beneficial for patients who have undergone Mohs micrographic surgery. Objective. The authors conducted a preliminary study to assess the efficacy of ATDA in speeding wound closure time and improving cosmetic outcomes in the specified patient population. Materials and Methods. Patients received an injection of amniotic fluid, an overlay of amniotic membrane, or standard of care. Photographs of wounds taken at the time of treatment and at each subsequent visit were analyzed. Results. The cosmetic outcome and time to wound closure appeared to be improved in patients treated with ATDA when compared with expected outcomes. Owing to small sample size, differences in initial defect size, and variety of body locations, the wound closure rate between treatment groups was not found to be significantly different with most comparisons. Statistical significance was seen, however, when normalized closure rates between membrane and control intervention were compared after outlier analysis (P = .0288). Conclusions. Data indicate that ATDA treatment may be beneficial and suggest that further investigation of the efficacy of ATDA to promote wound healing and improve cosmetic outcomes of post-Mohs surgical wounds is warranted. Future studies should be designed to match initial defect size and location between control and treatment groups.

This paper explores the drivers of high-rise and skyscraper construction and their impact on average happiness levels across 186 US metropolitan areas. Utilizing ordinary least squares and three-stage least squares, we find strong support that high-rise and skyscraper completion counts are a response to city economic fundamentals, but mixed results for their impact on happiness. On average, high-rises have a small negative effect, while skyscrapers exhibit a positive relationship. Further regressions suggest that skyscrapers improve sense of community and perceived health but that high-rises do not seem to positively affect any happiness subcategories. Tests on the effect of these buildings on general, mental, and physical health provide evidence of no harmful effects. The results suggest that the skyscraper benefits outweigh the possible negative externalities.

The impacts of a major hurricane on residential real estate can be devastating. Hurricane Sandy in New York City (NYC) is among the examples of how flooding can unexpectedly extend beyond FEMA flood zones. Such surprises or negative shocks can provide property owners—especially those not flooded—with new information about future flood risks, based on the difference of the property distance from the flood zone and the distance to the actual locations of flooding. We use a difference-in-differences approach to quantify the effects of these shocks on residential property values for non-flooded NYC properties after Sandy. The short-run negative “surprise” effect was lower NYC housing prices by about 6%-7% for each mile (or about 2% per standard deviation) difference between the property distance from the flood zone and the distance to the actual locations of flooding. The corresponding positive “surprise” effect is insignificant. The long-term “surprise” effects of flood risk on housing prices tend to disappear, as residents’ memories of the “surprise” fade and they seem to only recall the actual storm surge several years after the hurricane.

Micro-geographic data capturing the spatial distribution of economic activity within cities in history are difficult to access. This paper discusses how tall and durable buildings can be exploited as a source of “big data” to trace the history of the spatial structure of cities. To this end, we provide stylized evidence on how building heights correlate with land values over space and time within cities, review the related nascent literature, and suggest future research areas.

Using vacant land sales, we construct a land values index for Manhattan from 1950 to 2014. We find three major cycles (1950 to 1977, 1977 to 1993, and 1993 to 2009) with land values reaching their nadir in 1977, just after the city's fiscal crisis. Overall, we find the average annual real growth rate to be 5.5%. Since 1993, land prices have risen quite dramatically, and much faster than population or employment growth, at an average annual rate of 15.8%, suggesting that barriers to entry in real estate development are causing prices to rise faster than other measures of local well-being. Further, we estimate the entire amount of developable land on Manhattan in 2014 was worth approximately $1.74 trillion. This would suggest an average annual return of about 6.4% since the island was first inhabited by Dutch settlers in 1626.

The impacts of a major hurricane on residential real estate can be devastating. Hurricane Sandy in New York City (NYC) is among the examples of how flooding can unexpectedly extend beyond FEMA flood zones. Such surprises or negative shocks can provide property owners—especially those not flooded—with new information about future flood risks, based on the difference of the property distance from the mapped flood zone and the distance to the actual locations of flooding. We use a difference-in-differences approach to quantify the effects of these shocks on residential property values for non-flooded NYC properties after Sandy. The short-run negative “surprise” effect was to lower NYC housing prices by about 6%–7% for each mile (or about 2% per standard deviation) difference between the property distance from the flood zone and the distance to the actual locations of flooding. The corresponding positive “surprise” effect is insignificant. The long-term surprise effects of flood risk on housing prices tend to disappear, as residents’ memories of the surprise fade and they seem to only recall the actual storm surge several years after the hurricane.

A conservatively-minded campus, Liberty University's administrators have, like many college campuses, struggled with creating an appropriate weapons policy. The policies in existence prior to 2011 were more traditionally anti-weapon, while those created after 2011 have been more forgiving. This article examines the background, both national and local, for these shifts in policy.

Midtown Manhattan is the largest business district in the country. Yet only a few miles to the south is another district centered at Wall Street. This paper aims to understand when and why midtown emerged. We have created a new data set from historical New York City directories that provide the employment location, residence and job for several thousand residents in the late 19 th and early 20 th centuries. We supplement this with data from historical business directories. The data allow us to describe how, when and why midtown emerged as a center of commerce. We find that midtown arose because of economies of scale related to shopping, rather than congestion in lower Manhattan or wage differentials across the city. Specifically, the evidence suggests that firms moved to midtown to be near retail businesses and other commercial activity in order to be closer to customers, who had been moving north on the island throughout the 19 th century. Once several industries moved from lower Manhattan it triggered a spatial equilibrium readjustment in the 1880s, which then promoted the rise of skyscrapers in midtown around the turn of the 20 th century, several years before the opening of Grand Central Station in 1913.

Chloracne is characterized by acquired dioxin-induced skin hamartomas (MADISH), often involving the post-auricular skin. Chloracne classically occurs in individuals exposed to Agent Orange and dioxin-containing oils used in machinery. Since new-onset acne vulgaris is unusual in adults, a thorough occupational history must be elicited in this patient population. The herein patient is a retired tank mechanic with no known exposure to Agent Orange and presents with persistent acneiform eruptions.

Dermatitis artefacta is a self-inflicted skin condition that clinically mimics other dermatologic conditions. The etiology is multifactorial and is linked to underlying psychological conditions or psychosocial stressors with relief from automutilation. Lesions present with variable morphology depending on the type of self-harm and therefore, is a diagnosis of exclusion. We present a case of lesions that initially appeared to be pyoderma gangrenosum due to a similar presentation of nonspecific ulcers on the lower extremity. An important clue to the diagnose of dermatitis artefacta are skin lesions that do not fit a particular histopathological category. Lesions will also be resistant to conventional treatment. Once other dermatologic conditions are ruled out, it is important to consider dermatitis artefacta since early intervention is necessary for good patient outcomes.

Background Conduct a pilot study addressing the efficacy of acupuncture in the treatment of chronic idiopathic pruritus to aid in the design of a larger clinical trial. Routine laboratory tests to assess systemic inflammation in addition to subjective patient surveys were performed provide documentation of efficacy of treatment. Methods Patients with chronic pruritus who did not respond to standard treatment were recruited to participate. After exclusion of systemic or known reversible causes, each patient received up to 10 treatments which were performed approximately one week apart. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured before and after a series of acupuncture treatments to evaluate levels of inflammation and pre- and post-treatment surveys were conducted to evaluate levels of perceived itch. Results Only one of the ten patients in this study possessed an elevation of ESR before treatment. This patient's ESR value returned to normal range after treatment and this participant reported subjective relief of her pruritus. Conclusions Future studies on the efficacy of acupuncture in the treatment of chronic idiopathic pruritus should focus on those patients with measurable levels of inflammation at the initiation of the study or utilize alternative and more comprehensive values to monitor disease response.

Cutaneous angioleiomyomas (ALMs) are uncommon benign tumours of the skin which derive from the smooth muscle layer of dermal blood vessels. They usually present as tender nodules in the fifth or sixth decade of life, predominantly in the legs of females. These tumours rarely present on the head and neck, especially the ear. Head and neck ALMs differ from their more common leg counterparts in that they are painless. Additionally, they do not manifest with a female predominance. Herein, a new case of a painless auricular ALM in a 63-year-old man is reported.

Since 1978, when China instituted economic reforms, cities throughout the country have embraced skyscraper construction. Despite their importance to the domestic economy, little is understood about what has been driving skyscraper heights and frequencies in China. This work explores the degree to which skyscraper construction patterns are the result of economic fundamentals, versus political factors and intercity competition. We find a strong economic rational across China, but we also find evidence of noneconomic factors. We show that incentives for political officials, such as career promotion, are helping to contribute to the growth in China’s skylines. We also find that small cities tend to overbuild skyscrapers. Spatial autoregression results further suggest some intercity competition, especially for those within the same tier.

BACKGROUND The general public may not fully appreciate the role that plastic surgeons play in patient care. The authors sought to identify public perceptions of plastic surgery in a major US urban setting. METHODS A short, anonymous, survey was distributed to the public in all of the major boroughs of New York City. Respondents were asked to choose the surgeon they believed were experts in 12 specific clinical issues representative of required competencies by both the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. RESULTS A total of 1000 surveys were collected. Respondent demographics were similar by sex (53% women) and age (6% ages

Prolonged operative time has been associated with increased postoperative complications and higher costs. Many academic centers have a designated day for didactics that cause cases to start 1 hour later. The purpose of this study is to analyze the late-start effect of microvascular breast reconstructions on operative duration.A retrospective review was performed on all patients who underwent abdomina-based free flap breast reconstruction from 2007 to 2011 and analyzed by those who had surgery on late-start versus normal-start days. Patient demographics, average operative time, postoperative complications, and individual surgeon effects were analyzed. A Student t-test was used to compare operative times with statistical significance set at p 0.05. A multivariate regression analysis was performed to control for potential confounders.A total of 272 patients underwent 461 free flap breast reconstructions. Twenty-one cases were performed on late-start days and 251 cases were performed on normal-start days. Patient demographics and complications were not statistically different between the groups. The average operative time for all reconstructions was 434.3 minutes. The average operative times were significantly longer for late-start days, 517.6 versus 427.3 minutes (p = 0.002). This was true for both unilateral and bilateral reconstructions (432.8 vs. 350.9 minutes, p = 0.05; 551.5 vs. 461.2 minutes, p = 0.007). There were no differences in perioperative complications and multivariate regression showed no statistically significant relationship of confounders to duration of surgery.Starting cases 1 hour later can increase operative times. Although outcomes were not affected, we recommend avoiding lengthy procedures on late-start days.

Background:Practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery. The extent of this issue across the United States has yet to be examined in detail.Methods:A systematic search using Google was performed to evaluate the qualifications of c

This article is the first to rigorously test how skyscraper height and output co-move. Because builders can use their buildings for nonrational or nonpecuniary gains, it is widely believed that height competition occurs near the business cycle peaks. This would suggest that extreme building height is a leading indicator of GDP, since the tallest buildings are likely to be completed at or near the peak of a cycle. To test these claims, first we look at both the announcement and the completion dates for record-breaking buildings and find there is very little correlation with the business cycle. Second, cointegration and Granger causality tests show that while height and output are cointegrated, height does not Granger cause output. These results are robust for the United States, Canada, China and Hong Kong.

An important measure of the capital–land ratio in urban areas is the Floor Area Ratio (FAR), which gives a building's total floor area divided by the plot size. Variations in the FAR across cities remain an understudied measure of urban spatial structure. We examine how the FAR varies across the five boroughs of New York City. In particular, we focus on the FAR gradient over the 20th century. First we find that the gradient became steeper in the early part of the 20th century, but then flattened in the 1930s, and has remained relatively constant since the mid-1940s. Next we identify the slope of the gradient across space, using the Empire State Building as our core location. We find significant variation of the slope coefficients, using both ordinary least squares and geographically weighted regressions. We then identify subcenters, and show that while accounting for them can better capture New York's spatial structure, by and large, the city remains monocentric with respect to its FAR. Lastly, we find a nonlinear relationship between plot sizes and the FAR across the city.

BACKGROUND Limited data exist in the literature regarding the general incidence of secondary abdominal contour procedures and secondary abdominoplasty (excluding revisions) or specific recommendations for surgical management of these patients. METHODS The authors performed a retrospective chart review of 562 patients who underwent abdominal contouring procedures (liposuction and/or modified or full abdominoplasty) performed by a single surgeon (A.M.) from January of 2004 until October of 2012. Nonsurgical primary cases, secondary surgery that was revisional in nature, and massive weight loss patients were excluded. RESULTS Seventy-three patients (13.0 percent) underwent secondary abdominal contouring procedures. Forty-six of 73 patients had charts available to be examined in greater detail. Thirty-four of these patients underwent secondary liposuction, whereas 12 of these patients had secondary full abdominoplasty procedures. Secondary operations occurred an average of 4.98 years after the primary procedure (range, 6 months to 15 years). Patients underwent secondary liposuction (n = 34) on average 3.16 years after their initial procedure, significantly sooner than patients who underwent secondary abdominoplasty (n = 12) 8.35 years after their initial procedure (p = 0.002). Patients with a body mass index less than 25 kg/m2 (n = 26) had both secondary liposuction (n = 16) and secondary abdominoplasty (n = 10), whereas all patients who had a body mass index of 25 kg/m2 or greater (n = 20) underwent only secondary liposuction. CONCLUSIONS True secondary abdominal contouring procedures represented 13.0 percent of all abdominal contouring procedures. The most common indication for a secondary procedure was an umbilical-site closure scar. Specific recommendations for surgical management of five common scenarios for secondary abdominal procedures are discussed.

BACKGROUND The integrated model of plastic surgery education, shortly to become the standard for all 6-year programs, has set minimal but no maximal exposure to plastic surgery. The authors hypothesized that the first 3 years of integrated training will show variability among residency programs. METHODS Rotation schedules for all 42 integrated programs were analyzed for plastic surgery versus 18 nonplastic surgery rotations for postgraduate years 1, 2, and 3 as well as cumulatively for the first 3 years. Rotations "strongly suggested" by the Residency Review Committee on Plastic Surgery and American Board of Plastic Surgery were also examined. RESULTS Postgraduate years 1 through 3 spent a wide range of 3 to 19 months (SD ± 4.9 months) on plastic surgery (mean, 9.1 months). General surgery also varied dramatically, with 8 to 21 months (SD ± 4.0 months) of exposure (mean, 16.3 months). Surgical subspecialty rotations ranged substantially from 1 to 6 months (SD ± 1.0 months). Plastic surgery exposure was greater in programs based within plastic surgery departments than within divisions (13.8 versus 8.3 months, p < 0.005). Eighteen programs (42.9 percent) had dedicated hand surgery rotations, while seven (16.7 percent) had time dedicated for research. There was also wide variability in the inclusion of 18 nonplastic surgery rotations as well as specific "strongly suggested" rotations. CONCLUSIONS The plastic surgery experience in the first 3 years of residency training varies by a greater than 6-fold difference among integrated programs. This was also found in the 2.5-fold and 6-fold differences in general surgery and subspecialty surgery experiences. Since standardized residency training is an expectation by both accrediting bodies and the public, this variability may warrant closer attention.

A 46-year-old man with a history of prostatitis treated with ciprofloxacin presented with a mildly irritating rash. The rash started 10–12 days after his initiating the ciprofloxacin. The patient had also embarked on a hike through the palm springs desert of Southern California 2 days leading up

This paper investigates skyscraper competition between New York City and Chicago. The urban economics literature is generally silent on strategic interaction between cities, yet skyscraper rivalry between these cities is a part of U.S. historiography. This paper tests whether there is, in fact, strategic interaction across cities. First, I find that each city has positive reaction functions with respect to the other city, suggesting strategic complementarity. In regard to zoning, I find that height regulations negatively impacted each city, but produced positive responses by the other city, providing evidence for strategic substitutability.

Biosafety level 4 (BSL-4) suit laboratories are specifically designed to study high-consequence pathogens for which neither infection prophylaxes nor treatment options exist. The hallmarks of these laboratories are: custom-designed airtight doors, dedicated supply and exhaust airflow systems, a negative-pressure environment, and mandatory use of positive-pressure (“space”) suits. The risk for laboratory specialists working with highly pathogenic agents is minimized through rigorous training and adherence to stringent safety protocols and standard operating procedures. Researchers perform the majority of their work in BSL-2 laboratories and switch to BSL-4 suit laboratories when work with a high-consequence pathogen is required. Collaborators and scientists considering BSL-4 projects should be aware of the challenges associated with BSL-4 research both in terms of experimental technical limitations in BSL-4 laboratory space and the increased duration of such experiments. Tasks such as entering and exiting the BSL-4 suit laboratories are considerably more complex and time-consuming compared to BSL-2 and BSL-3 laboratories. The focus of this particular article is to address basic biosafety concerns and describe the entrance and exit procedures for the BSL-4 laboratory at the NIH/NIAID Integrated Research Facility at Fort Detrick. Such procedures include checking external systems that support the BSL-4 laboratory, and inspecting and donning positive-pressure suits, entering the laboratory, moving through air pressure-resistant doors, and connecting to air-supply hoses. We will also discuss moving within and exiting the BSL-4 suit laboratories, including using the chemical shower and removing and storing positive-pressure suits.

Aerosol or inhalational studies of high-consequence pathogens have recently been increasing in number due to the perceived threat of intentional aerosol releases or unexpected natural aerosol transmission. Specific laboratories designed to perform these experiments require tremendous engineering controls to provide a safe and secure working environment and constant systems maintenance to sustain functionality. Class III biosafety cabinets, also referred to as gloveboxes, are gas-tight enclosures with non-opening windows. These cabinets are maintained under negative pressure by double high-efficiency-particulate-air (HEPA)-filtered exhaust systems and are the ideal primary containment for housing aerosolization equipment. A well planned workflow between staff members within high containment from, for instance, an animal biosafety level-4 (ABSL-4) suit laboratory to the ABSL-4 cabinet laboratory is a crucial component for successful experimentation. For smooth study execution, establishing a communication network, moving equipment and subjects, and setting up and placing equipment, requires staff members to meticulously plan procedures prior to study initiation. Here, we provide an overview and a visual representation of how aerobiology research is conducted at the National Institutes of Health, National Institute of Allergy and Infectious Diseases Integrated Research Facility at Fort Detrick, Maryland, USA, within an ABSL-4 environment.

Work in a biosafety level 4 (BSL-4) containment laboratory requires time and great attention to detail. The same work that is done in a BSL-2 laboratory with non-high-consequence pathogens will take significantly longer in a BSL-4 setting. This increased time requirement is due to a multitude of factors that are aimed at protecting the researcher from laboratory-acquired infections, the work environment from potential contamination and the local community from possible release of high-consequence pathogens. Inside the laboratory, movement is restricted due to air hoses attached to the mandatory full-body safety suits. In addition, disinfection of every item that is removed from Class II biosafety cabinets (BSCs) is required. Laboratory specialists must be trained in the practices of the BSL-4 laboratory and must show high proficiency in the skills they are performing. The focus of this article is to outline proper procedures and techniques to ensure laboratory biosafety and experimental accuracy using a standard viral plaque assay as an example procedure. In particular, proper techniques to work safely in a BSL-4 environment when performing an experiment will be visually emphasized. These techniques include: setting up a Class II BSC for experiments, proper cleaning of the Class II BSC when finished working, waste management and safe disposal of waste generated inside a BSL-4 laboratory, and the removal of inactivated samples from inside a BSL-4 laboratory to the BSL-2 laboratory.

Medical imaging using animal models for human diseases has been utilized for decades; however, until recently, medical imaging of diseases induced by high-consequence pathogens has not been possible. In 2014, the National Institutes of Health, National Institute of Allergy and Infectious Diseases, Integrated Research Facility at Fort Detrick opened an Animal Biosafety Level 4 (ABSL-4) facility to assess the clinical course and pathology of infectious diseases in experimentally infected animals. Multiple imaging modalities including computed tomography (CT), magnetic resonance imaging, positron emission tomography, and single photon emission computed tomography are available to researchers for these evaluations. The focus of this article is to describe the workflow for safely obtaining a CT image of a live guinea pig in an ABSL-4 facility. These procedures include animal handling, anesthesia, and preparing and monitoring the animal until recovery from sedation. We will also discuss preparing the imaging equipment, performing quality checks, communication methods from "hot side" (containing pathogens) to "cold side," and moving the animal from the holding room to the imaging suite.

New York City historiography holds that Manhattan developed two business centers—downtown and midtown—because the bedrock is close to the surface at these locations, with a bedrock “valley” in between. This article is the first effort to measure the effect of depth to bedrock on construction costs and the location of skyscrapers. We find that while depth to bedrock had a modest effect on costs (up to 7 percent), it had relatively little influence on the location of skyscrapers. “Hour by hour the caissons reach down to the rock of the earth and hold the building to a turning planet.”Carl Sandburg, Skyscraper

Background In the pediatric patient population, both the pathology and the surgical managements of seventh cranial nerve palsy are complicated by the small size of the patients. Adding to the technical difficulty is the relative infrequency of the diagnosis, thus making it harder to become proficient in the management of the condition. The magnitude of the functional and aesthetic deficits these children manifest is significantly troubling to both the patient and the parents, which makes immediate attention, treatment, and functional restoration essential. Methods A literature search using PubMed (http://www.pubmed.org) was undertaken to identify the current state of surgical management of pediatric facial paralysis. Results Although a multitude of techniques have been used, the ideal reconstructive procedure that addresses all of the functional and cosmetic needs of these children has yet to be described. Certainly, future research and innovative thinking will yield progressively better techniques that may, one day, emulate the native facial musculature with remarkable precision. Conclusion The necessity for surgical intervention in children with facial nerve paralysis differs depending on many factors including the acute/chronic nature of the defect as well as the extent of functional and cosmetic damage. In this article, we review the surgical procedures that have been used to treat pediatric facial nerve paralysis and provide therapeutic facial reanimation.