Search

The management of incidentally found short cervical length (CL) without prior spontaneous preterm birth (PTB) can vary. While most agree on starting vaginal progesterone, management after CL shortens10 mm varies. The purpose of this study was to elucidate current practice patterns amongst maternal-fetal medicine (MFM) specialists. We conducted an online survey of MFM attending physicians and fellows in the United States from May 2019 to April 2020. The primary outcome was management of varying CL based on gestational age. Variations in management were assessed descriptively. There were 236 respondents out of 400 eligible surveyed, with a response rate of 59.2%. Universal CL screening was reported by 93.6% (49.6% abdominal and 44.1% transvaginal). Management of short CL varied based on CL measurement, rather than gestational age at presentation. At CL10 mm, management included cerclage (17.4-18.7%), vaginal progesterone (41.3-41.7%), or cerclage plus vaginal progesterone (43.4%). Between CL of 10 to 20 mm, the majority (77.4-91.9%) would start vaginal progesterone. At CL 21 to 25 mm, management varied between expectant management (45.5-48.5%) or vaginal progesterone (51.1-52.8%). Suture material used was ethylene terephthalate (47.4%) or polypropelene (31.2). Preoperative antibiotic use was reported by 22.3%, while 45.5% used them only if the amniotic membranes were exposed, and 32.2% reported no antibiotic use. Postoperative tocolytic use varied with 19.3% reporting no use, 32.6% using it always, 8.2% only after significant cervical manipulation, 22.7% after the patient is experiencing symptoms, and 17.6% using it only if the cervix is dilated on exam. After cerclage placement, 44.5% continued CL surveillance. Substantial differences of opinion exist amongst MFM physicians regarding management of incidentally found short CL in patients without history of PTB. The differences in responses obtained highlight the need for evidence-based guidelines for managing this clinical scenario.· There is lack of consensus on the management of incidentally found shortened CL.. · The purpose of this study was to elucidate current trends in CL screening and management.. · Substantial differences of opinion exist regarding management of incidentally found short CL..

Background Syphilis is increasing in prevalence in the community.1 2 Neurosyphilis has protean manifestations making recognition, diagnosis and early initiation of treatment challenging. Methods/Results We present a case of early syphilitic meningitis in a 37-year-old female presenting with multiple cranial neuropathies (V, VI, VII, VIII and XII) developing over the course of two weeks. This began with a sensation of disequilibrium and unsteady gait, and progressed to difficulty closing both eyes, right lip numbness, bilateral hearing impairment (right, followed by left), and dysarthria. She did not report headache, meningism, features of primary syphilis infection or risk factors for sexually transmitted infections (STIs). Examination confirmed the presence of right-sided trigeminal, bilateral abducens, facial, vestibulocochlear and hypoglossal nerve palsies. Cerebrospinal fluid (CSF) examination was inflammatory (protein 1.28 g/L, glucose 3.8mmol/L) with predominant lymphocytosis (76%, WCC 441 x 106/L). Magnetic resonance imaging (MRI) demonstrated post-contrast enhancement of the trigeminal nerve at the pons, as well as facial and vestibulocochlear nerves at the geniculate ganglion with no leptomeningeal enhancement. Our patient was diagnosed with neurosyphilis on serum and CSF serological testing (Serum Treponema pallidum particle agglutination assay (TPPA) positive, chemiluminescent microparticle immunoassay (CMIA) IgG and IgM positive, rapid plasma reagen 1:32. CSF TPPA positive, Venereal Disease Research Laboratory test titre of 1:8). She was treated with intravenous benzylpenicillin with rapid improvement in her cranial neuropathies. Conclusions This is the most extensive cranial neuropathy reported with syphilitic infections to date. Neurosyphilis should be considered as a differential in patients presenting with multiple cranial neuropathies. References Kojima N, Klausner J. An update on the global epidemiology of syphilis. Curr Epidemiol Rep 2018;5(1):24–38. Ghanem K, Ram S, Rice P. The modern epidemic of syphilis. N Engl J Med 2020;382(24):2379–80.

Objective This study aims to investigate accuracy of group beta Streptococcus (GBS) rectovaginal cultures at 35 to 37 weeks in predicting intrapartum colonization. Study Design Institutional review board (IRB) approved prospective cohort study of 302 women from October 2015 to May 2017. Patients had the following tests for GBS: first trimester urine culture, rectovaginal culture at 35 to 37 weeks, and intrapartum rectovaginal culture. Outcomes included accuracy of 35- to 37-week GBS rectovaginal culture in detecting results intrapartum, and accuracy of first trimester urine culture in comparison to intrapartum rectovaginal cultures. Results There was sufficient evidence of agreement between results at 35 to 37 weeks with intrapartum cultures (p = 0.001). However, agreement was weak, 11 patients (3.7%) were GBS positive intrapartum but negative at 35 to 37 weeks; and 33 patients (11%) were initially GBS positive but were negative intrapartum. Sensitivity and specificity of the 35- to 37-week culture was 69% (95% confidence interval [CI]:54–84%) and 87% (95% CI: 83–91%), respectively. There was also weak agreement between first trimester urine culture and intrapartum rectovaginal culture. Specificity for this assessment was 98% (95% CI: 97–100%) and was significantly different compared with antepartum GBS culture (p Conclusion The 35- to 37-week GBS rectovaginal culture might be a poor predictor for intrapartum colonization.

Objective This study aimed to estimate the prevalence of measles immunity in a cohort of pregnant women in New York City and determine if there is a positive correlation of measles immunity with patient demographics, rubella immunity, number of measles, mumps, and rubella vaccine (MMR) doses received, and age at last vaccination. Study Design This is a cross-sectional study of pregnant patients seen at a single institution from January 2019 to May 2019. Patients were classified as measles and rubella immune or nonimmune using commercial immunoglobulin G (IgG) tests. Patient characteristics were compared using t-tests, Chi-square tests, or Fisher's exact tests as appropriate. The association of age at last vaccination with immunity status was assessed using multivariable logistic regression adjusted for age at presentation. The utility of rubella IgG for distinguishing measles immunity was assessed using receiver operating characteristic curve analysis. Results Serologic immunity for measles and rubella was obtained for 1,366 patients. Of these, 1,047 (77%) were measles immune and 1,291 (95%) were rubella immune. Patients born after 1989 were less likely to be immune to measles, while multiparity and private insurance were associated with increased measles immunity. Documentation of MMR vaccination was available for 140 (10%) patients. Of these, 44 (31%) were serologically nonimmune to measles and 9 (6.4%) were nonimmune to rubella. In patients known to have received one dose of MMR, 62% (24/39) were immune to measles with an improvement to 72% (69/96) among those who received two or more doses. Age at last vaccination was not associated with measles immunity. Rubella IgG level was a poor predictor of positive measles titer (area under the curve = 0.59). Conclusion Approximately one of every four pregnant patients is serologically measles nonimmune, even among women with documented MMR vaccination or documented rubella immunity. These findings raise concerns that relying on vaccination history or rubella immune status may not be sufficient to assure protection from infection with measles. If further suggests that measles serology should be added to routine prenatal laboratory testing to identify nonimmune patients that may benefit from postpartum vaccination. Key Points

Syphilis is increasingly prevalent in the community. The protean manifestations of neurosyphilis make the recognition, diagnosis and early initiation of treatment challenging. We report a case of early syphilitic meningitis presenting with multiple cranial neuropathies. Cerebrospinal fluid (CSF) examination was inflammatory with predominant lymphocytosis. The patient was diagnosed with neurosyphilis based on serum as well as CSF testing. Intravenous benzylpenicillin treatment resulted in rapid improvement of neurological symptoms. Neurosyphilis should be considered in immunocompetent patients presenting with multiple cranial neuropathies, or isolated cranial neuropathies without vascular risk factors.

Hepatitis B virus (HBV) from 76 adult immigrants in Australia from Myanmar was characterized to determine the prevalence of different HBV genotypes and subgenotypes. A mutational analysis was then performed to determine the presence of clinically significant mutations and correlate them to clinical outcomes. Initial genotyping revealed 68 patients with genotype C (89.5%) and eight patients with genotype B (10.5%). Phylogenetic analysis revealed the large majority of the genotype C infections were of subgenotype C1 (67/68). Sequencing of the HBV polymerase gene (and overlapping surface gene) revealed no mutations associated with antiviral resistance. HBV surface gene mutations were detected in 10 patients with subgenotype C1. HBV BCP/PC sequencing was obtained for 71/76 (93%) patients. BCP and/or PC mutations were identified in 57/71 (80%) of PCR positive patients. Treatment had been commenced for 15/76 (18%) patients, a further 26 untreated patients were in a stage of disease where HBV treatment would be considered standard of care. It was identified that genotype C1 is the predominant sub-genotype in this population. Genotype C is known to be associated with increased risk of development of HCC. This highlights the need for screening for HCC given the potential for the development of liver cancer. It was also identified that people with HBV were potentially not receiving optimal therapy in a timely fashion.

Background/Objective Epidermal structure, function, and composition are different in white infants and adults. We investigated whether ethnicity and location contribute to differences in functional and clinical measurements of skin barrier function during the first years of life and in adults. Methods Children (n = 397, ages 3–49 mos) and women (n = 117, mean age 31 yrs) were enrolled at independent centers in Beijing, China (ethnic Chinese), Skillman, New Jersey (white, African American), and Mumbai, India (ethnic South Asian). Water barrier properties of the stratum corneum were assessed using high-frequency conductance and transepidermal water loss (TEWL) on the dorsal forearm and upper inner arm. Digital imaging was used to evaluate facial erythema and scaling. Results Despite differences in local climate, TEWL was similar in adults. In children, conductance and TEWL decreased monotonically from age 3 months to 4 years. In children from Beijing, TEWL values were higher in both arm locations than in children in Mumbai and Skillman. No significant differences were observed in TEWL or conductance between the white and African American groups. Conclusion In general, TEWL and conductance were greater on the upper inner arm than the dorsal forearm. Erythema and scaling were observed most often in subjects from Beijing and most infrequently in subjects from Mumbai. Stratum corneum water barrier properties were different in children and adults. Although there may be differences in these properties between ethnic groups in childhood, TEWL values were similar in adults across the three geographic locations and four ethnicities.

Aim Cinacalcet is effective in reducing parathyroid hormone (PTH) in patients on dialysis. Reports of biochemical profiles and other clinical outcomes in patients discontinuing cinacalcet at time of renal transplantation are limited. Methods A retrospective study assessing markers of mineral metabolism, graft and patient outcomes in renal transplant recipients to determine differences in patients discontinuing cinacalcet (C+) compared with patients not treated with cinacalcet (C−) at time of transplantation. To allow for differences between groups in pre-transplant biochemical parameters, we also analysed a matched cohort of C− with C+ recipients (2:1), matched for age, calcium and PTH levels at transplantation. Results Five hundred thirty-two recipients (460 C−, 72 C+), transplanted January 2006–December 2012, were analysed, mean age 48.0 ± 12.7 years and 64.3% were men. At a median 42.9 months follow up, there were 10 deaths (1.9%), 56 allograft loss (10.6%) and 5 parathyroidectomies post-transplant (0.8%). Median PTH immediately pre-transplant was higher in C+ versus C− (50.7(25.4–75.2) versus 28.3(13.9–49.7) pmol/L, P

Erythema and pigment responses of human skin following an acute exposure to ultraviolet radiation (UVR) are frequently used to determine the photosensitivity of the skin. In this study we investigated the responses of the skin to a micro-scale area of UVR exposure (MiR) and compared the responses to a macro-scale area of exposure (MaR). Ten human volunteers were tested with solar-simulated radiation on their upper arm or back using a beam size of 8 mm and 0.2 mm in diameter. The fluence required to produce a minimally perceptible erythema (MED) using the MiR was found to be higher than that for the MaR. The erythema response extended beyond the exposed area and this became pronounced when the beam size was microscopic. Reflectance confocal microscopy in vivo revealed that MiR induced cellular alterations within a confined area of smaller dimensions than the area of exposure. Pigment responses were confined within the areas of cellular damage. The erythema expression of exposed skin recovered faster for the sites receiving MiR even when the applied fluence was higher than the MED for the MaR. Through the use of MiR we were able to visualize spatially dissimilar skin responses of erythema and pigmentation suggesting different cellular mechanisms.

Hepatitis B virus (HBV) from 40 adult African immigrants in Australia was characterized to determine the prevalence of different HBV genotypes and subgenotypes. A mutational analysis was then performed to determine the presence of clinically significant mutations and correlate them to clinical outcomes. Initial sequencing analysis revealed 13 with genotype A (32.5%), 13 with genotype D (32.5%), and 14 with genotype E (35%). Serology showed that 37 were HBeAg negative. Phylogenetic analysis identified a high prevalence (25%) of HBV subgenotype A1 in our cohort, a subgenotype which has been associated with more aggressive clinical disease. BCP/PC sequencing was obtained for 38 patients. BCP and/or PC mutations were identified in 36/38 (95%). The median viral load of all patients was 2995 IU/mL and most of the pathology results were within the normal range. Only one patient had an increased APRI score of 1.1 suggestive of cirrhosis. We present novel information on the HBV genotypes amongst the African population in Australia along with clinical correlates. The high prevalence of A1 subgenotype in this population supports the current Australian recommendation to commence hepatocellular carcinoma screening in Africans with chronic HBV from 20 years old.

The structure of the stratum corneum (SC) and the corresponding skin barrier develops from before birth up to about 4 years of age. Large subject-to-subject variability within an age group requires a large population to observe trends in skin barrier properties over time. Barrier function, quantified by transepidermal water loss (TEWL) and SC thickness, was measured on the upper inner arm and dorsal forearm in subjects aged 3 months to 4 years (n = 171) and a subset of mothers (n = 44). The rate of skin surface area expansion as a function of age peaked before birth (∼90 cm2/week) and declined to a steady plateau (∼10 cm2/week) by 1 year of age. SC thickness increased and TEWL decreased, but did not reach adult values until 3-4 years of age. A better understanding of how skin hydration changes after birth suggests that barrier function may be related mechanistically to skin surface area expansion.

Rationale Electronic medical record (EMR) systems are commonly included in health care reform discussions. However, their embrace by the health care community has been slow.

Rationale Electronic health systems are commonly included in health care reform discussions. However, their embrace by the health care community has been slow. Methods At Addiction Research and Treatment Corporation, a methadone maintenance programme that also provides primary medical care, HIV medical care and case management, substance abuse counselling and vocational services, we describe our experience in implementing an electronic health information system that encompasses all of these areas. Results We describe the challenges and opportunities of this process in terms of change management, hierarchy of corporate objectives, process mastering, training issues, information technology governance, electronic security, and communication and collaboration. Conclusion This description may provide practical insights to other institutions seeking to pursue this technology.

The recently discovered klotho proteins have roles in a diverse range of metabolic processes with the oldest protein, α-klotho, implicated in various cellular pathways in energy, glucose, and phosphate metabolism. Circulating soluble klotho (sKl), derived from membrane α-klotho cleavage, not only has effects on ion channels and insulin signaling pathways, but is inversely associated with mortality. Effects of physical exercise on sKl have not been well studied. The effect of a single high-intensity standardized exercise on sKl and serum phosphate (sPi) levels in healthy adults was investigated. A standard Bruce protocol treadmill exercise was undertaken by 10 fasting healthy volunteers. sKl, sPi, and blood glucose levels were measured in samples collected 1-week prior, immediately pre ( T pre ), 0 ( T post ), 30 ( T 30 ), 240 ( T 240 ) min, and 1-week after exercise. Median (interquartile range) age of participants was 47.5 (44–51) years; five (50%) were male. All study participants achieved at least 90% predicted maximum heart rate (MHR). sKl increased acutely after exercise ( T pre median 448 pg/mL vs. T post median 576 pg/mL; p < 0.01). There was a nonsignificant sPi decline at T 30 ( T pre 0.94 ± 0.12 mmol/L vs. T 30 0.83 ± 0.22 mmol/L). Exercise led to a reduction in blood glucose by T 240 with median glucose levels at T pre , T post , T 30 , and T 240 of 6.0, 6.5, 6.3, and 5.7 mmol/L, respectively. In conclusion, a single high-intensity exercise session is associated with a transient increase in sKl, a delayed reduction in blood glucose, and a nonsignificant decrease in sPi levels in healthy adults. The evaluation of long-term effects of cardiovascular fitness programs on sKl and sPi in healthy individuals and disease cohorts are required to identify potential lifestyle modifications to help improve chronic disease management and long-term outcomes.

Background/purpose: Assessing the ultraviolet (UVA) protection factor of sunscreen formulations has been discussed for the past 20 years. The purpose of this study is to correlate the measurements of the UVA protection factor value (PFA value) via in vivo diffuse reflectance spectroscopy (DRS) and to compare this method with the in vitro method of measuring the PFA value, as well as with the in vivo persistent pigment darkening (PPD) and PFA methodologies. Methods: The UVA protection factor via DRS technique was assessed in two clinical studies. The first study was performed in 12 subjects and the second one consisting of 10 subjects. All subjects in these studies had Fitzpatrick skin phototypes II–IV. DRS measurements were performed using a SkinScan spectrofluorimeter (Spex SkinScan, Yvon Horiba). The in vitro PFA measurements were performed using Labsphere™ UV-1000s UV Transmission Analyzer. Results: The results obtained from the non-invasive DRS studies were used to correlate with the in vitro testing and with the in vivo PFA/PPD multicenter study. A positive relationship (regression coefficient r2=0.90) of PFA values was found between in vitro PFA testing and the in vivo DRS testing. There was also a very good correlation (regression coefficient r2=0.99) between the in vivo PFA/PPD values and UVA protection factor obtained from the DRS method. Conclusion: This paper presents studies using the DRS technique to assess the UVA protection factor in different sunscreen formulae correlating with in vitro and in vivo PFA/PPD values. It is a fast method, non-invasive and does not involve any subject irradiation. The technique is a good estimator for the in vivo UVA protection factor as well as a way to assess, in vivo, the photostability of sunscreen formulation in the UVA.

Data looking at the impact of length of stay in treatment, methadone dose, and age for treatment of opiate dependence have been evaluated separately, but the relative impact of these variables has not been examined. For this report, regression analyses of length of stay, methadone dose, and age were compiled to determine the relative effect of each variable on opiate toxicology results, which was the primary outcome measure. Regression analysis yielded statistical significance for length of stay (P < .001) and methadone dose (P < .05) but not for age. Comparing length of stay in treatment, methadone dose, and age to opiate toxicology results indicated that length of stay was the most important factor. These comparisons impact treatment strategies for opiate dependence, particularly when using a chronic disease model as a strategy for delivering care.

Cinacalcet is effective in reducing parathyroid hormone (PTH) in patients on dialysis. Reports of biochemical profiles and other clinical outcomes in patients discontinuing cinacalcet at time of renal transplantation are limited.A retrospective study assessing markers of mineral metabolism, graft and patient outcomes in renal transplant recipients to determine differences in patients discontinuing cinacalcet (C+) compared with patients not treated with cinacalcet (C-) at time of transplantation. To allow for differences between groups in pre-transplant biochemical parameters, we also analysed a matched cohort of C- with C+ recipients (2:1), matched for age, calcium and PTH levels at transplantation.Five hundred thirty-two recipients (460 C-, 72 C+), transplanted January 2006-December 2012, were analysed, mean age 48.0 ± 12.7 years and 64.3% were men. At a median 42.9 months follow up, there were 10 deaths (1.9%), 56 allograft loss (10.6%) and 5 parathyroidectomies post-transplant (0.8%). Median PTH immediately pre-transplant was higher in C+ versus C- (50.7(25.4-75.2) versus 28.3(13.9-49.7) pmol/L, P 0.001). Twelve-month post-transplant PTH was reduced but higher in C+ (11.7(6.9-21.2) vs 7.2(4.6-11.2) pmol/L, P 0.001). Mean calcium was higher for C+ versus C- at 12 months (2.50 ± 0.19 vs 2.43 ± 0.17 mmol/L, P 0.001), with differences to 4 years post-transplant. No difference was seen in renal function, graft loss, post-transplant parathyroidectomy rate and mortality. In the matched cohort (144 C- vs 72 C+), similar findings were also seen.Differences in mineral metabolism post-transplant are seen with cinacalcet pre-transplant compared with no cinacalcet. Transplant recipients discontinuing cinacalcet had higher post-transplant PTH and calcium although the clinical significance is unclear.

Objectives: The explosion in genetic technologies, including array comparative genomic hybridization (aCGH), has increased the complexity of genetic counseling. We now offer chorionic villus sampling (CVS) and aCGH to all first-trimester patients, as this allows the prenatal diagnosis of an additional 1% of anomalies not otherwise detectable and can detect genetic copy number variants at a much higher resolution than conventional cytogenetics. Here, we explored some of the determinants of how patients are deciding to use or not use this new technology and evaluate risk-benefit analyses for that decision. Methods: This is a retrospective case-control study of singleton and multiples pregnancies at our center. Those having aCGH testing along with CVS were defined as ‘testers' and those who declined aCGH but had the CVS were ‘nontesters'. Results: Demographic data of 181 educated women who chose CVS were compared. Among those carrying singletons (n = 144), older women, defined as over 35 years of age (or ‘advanced maternal age'; AMA), were more likely to choose the aCGH than younger women. Further, women who had a prior history of genetic testing and who wanted to know the gender of the fetus were more likely to choose the aCGH test. In women carrying multiples (n = 37), AMA ceases to be a predictor of choice. Having had prior genetic counseling remains a strong predictor for choosing aCGH, as does wanting to know the gender of the fetus. Neither prior abortions nor having prior children were significant for women carrying singletons or multiples. Conclusion: Offering pregnant couples an individualized choice regarding aCGH seems an appropriate approach. There are discrete patterns associated with the choice of taking the aCGH that varied depending on whether the patient was carrying a singleton or multiples.

This preliminary study attempts (1) to examine differences in posttraumatic symptomatology in predominately minority, sheltered battered women (n= 55) as a function of childhood trauma histories; and (2) to disentangle the impact of two often confounded forms of childhood trauma: exposure to family violence and direct childhood maltreatment. Controlling for current domestic violence (DV), hierarchical regression analyses showed childhood emotional abuse mediated the adverse effects of childhood exposure to family violence on PTSD symptomatology (i.e., hyperarousal, intrusion). Avoidant symptoms were most strongly predicted by current domestic violence, with psychological abuse adding significantly to the variance explained above and beyond physical abuse.

The cascade of events following an injury that significantly alters epidermal structures and leads to epidermal necrosis depends on the type of injury. We have studied epidermal necrosis caused by solar-simulated radiation, laser therapy, and liquid nitrogen (N2) with reflectance laser scanning confocal microscopy in vivo. In the present study we investigated injuries produced with liquid nitrogen (N2), or cryotherapy, a common therapeutic modality for solar lentigines, warts, and others. A 3 mm diameter skin site on the forearm of 7 healthy human volunteers was treated with liquid nitrogen for approximately 20 s, following written informed consent. The site was monitored by confocal microscopy and digital imaging until the epidermis appeared clinically fully repaired (>4 weeks). During the first 3 days following exposure to liquid nitrogen (N2), the epidermal cellular organization appears slightly perturbed and the epidermal cellular architecture becomes lost. The pigment distribution in the keratinocytes that line the papillae maintains its appearance and does not spread as the cell boundaries become imperceptible. The dead epidermis remains intact for approximately 2 weeks and protects the new restructuring epidermis under it. The wound repairs from the periphery. Approximately 2 weeks after injury, the new epidermis is infiltrated by large dendritic cells localized in the area where papillae form. The papillae appear to grow and produce the typical invaginations and surrounding structures of the dermal-epidermal junction, and the enclosed capillaries are fully engorged with flowing erythrocytes. These dendritic cells begin to disappear as the epidermis returns to normal appearance and pigment. The dendritic cells appear to play a role in tissue restructuring post-injury, as they are also present for a limited time following UV injury starting at 14 days as in the present case.

The stratum corneum (SC) serves a primary function of skin barrier and understanding the kinetics of SC formation may provide great insight for skin diagnosis and evaluation of therapies. Besides trans-epidermal water loss (TEWL), few methods have been characterized to assess skin barrier non- invasively in vivo, particularly for dynamic measurements on the same specimen over time. The objective of this study was to characterize alternative non-invasive methods to evaluate the dynamic processes involved in the recovery of normal human SC after total removal. TEWL, tryptophan fluorescence and reflectance confocal microscopy (RCM) were used to determine skin barrier function, cell turnover and epidermal morphology over a period of 10 days after total removal of the SC Abbreviations by tape stripping. The results show a biphasic recovery of TEWL over time, which contrasted with a linear increase of 2.3 lm/day in SC thickness. Tryptophan assessment of cell turnover also demonstrated a biphasic pattern attaining a maximum three to four times the levels of the control site 3 days after injury that slowly returned to baseline and displayed great correlation (R 2 > 0.95) to viable epidermis thickness that also achieved a maximum about 3 days after injury with an approximate increase of 55%. When plotting the change of TEWL versus SC thickness, a single exponential function is observed (D-TEWL = 55 exp (! 0.1579)) which contrasts with other proposed models. These methods were able to present rates for SC recovery processes beyond skin barrier (TEWL) that may provide new insights on kinetics of barrier formation for evaluation of skin conditions and treatments. Abbreviations: SC, stratum corneum; TEWL, trans-epidermal water loss; RCM, reflectance confocal microscopy; SG, stratum granulosum; ROI, region of interest.

In vivo confocal scanning laser microscopy (CSLM) is a powerful imaging technique that enables physicians and researchers to evaluate skin dynamically and non-invasively at the cellular level. Traditionally, biopsy and histological processing are required to study the cellular details of skin. This involves tissue excision and staining, which may introduce artifacts to the sample. Staining and immunostaining have been used to identify specific proteins and organelles successfully. With CSLM, the examined areas are not damaged, removed, or processed, so imaging can be performed as often as desired. Studying dynamic changes in skin over an extended period of time or as a response to treatment is feasible. Unlike the vertical sections obtained by routine histology, en face (horizontal) images are captured with CSLM. During the last 20 years, advances in technology have resulted in images that are now near histological resolution and have enough detail for histological analysis (Pellacani et al., 2008; Scope et al., 2007; Rajadhyaksha et al., 1999). CSLM has been used in dermatology to assess skin lesions and skin conditions without biopsy. Both benign and malignant melanocytic skin tumors have been described and diagnosed, and proliferative and inflammatory skin diseases have been characterized (Gonzalez & Gilaberte-Calzada, 2008; Calzavara-Pinton et al., 2008). Margins of lesions are also identifiable from non-lesional skin. For physicians, CSLM provides real-time diagnostics and the chance to follow the evolution of skin lesions over time, which would not be feasible otherwise. Whereas the majority of CSLM skin research concentrates on dermatological conditions, this chapter focuses on capturing and studying non-diseased tissue, both healthy and wounded human tissue. We first assess the effect that the incident laser wavelength has on the images captured by comparing CSLM systems of three different wavelengths. Then, we specifically discuss two studies in which we use CSLM to study skin morphology and physiology: 1) a comparison of infant and adult skin morphology and 2) the wound healing response of micro-injuries in otherwise healthy human skin. The micro-injury study focuses on dynamic responses in skin over time. Ethically we are committed to minimize biopsy collection when studying healthy human skin. CSLM is our sole alternative to studying skin morphology and physiology at the cellular level non

Electronic health systems are commonly included in health care reform discussions. However, their embrace by the health care community has been slow.At Addiction Research and Treatment Corporation, a methadone maintenance programme that also provides primary medical care, HIV medical care and case management, substance abuse counselling and vocational services, we describe our experience in implementing an electronic health information system that encompasses all of these areas.We describe the challenges and opportunities of this process in terms of change management, hierarchy of corporate objectives, process mastering, training issues, information technology governance, electronic security, and communication and collaboration.This description may provide practical insights to other institutions seeking to pursue this technology.

The stratum corneum (SC) serves a primary function of skin barrier and its maintenance is vital for the existence of terrestrial life. Few studies have been performed for evaluation of human SC repair in vivo, non-invasively. In the present study tape stripping was performed on the arms and legs of seven volunteers until all the SC was removed. The injured site and a control adjacent site were measured over a period of 10 days after the injury to assess functionality and repair. Transepidermal water loss (TEWL), tryptophan fluorescence and reflectance confocal microscopy were used to determine permeability of the skin barrier, cell turnover and epidermis morphology, respectively. The results show an exponential rate of recovery for the skin permeability (TEWL) which contrasted with a linear increase in the thickness of the SC as determined by confocal microscopy. Cell turnover increased rapidly immediately after the injury to 2.5 times the levels of the control site, attaining a maximum of 3.5-4 times greater levels after three days and slowly returned to baseline levels after the ten days. Correlation of the cell turnover to the thickness of the viable epidermis was observed and further studies are under way to interpret these results.

The minimal erythema dose induced by solar-simulated radiation is a useful measure of UV sensitivity of skin. Most skin phototests have been conducted by projecting a flat field of UV radiation onto the skin in an area greater than 15 cm × 15 cm with an increment of radiation doses. In this study, we investigated the responses of human skin to solar-simulated radiation of different field sizes. Twelve human subjects of skin phototype I-IV were exposed to solar-simulated radiation (SSR) on their upper inner arm or on their lower back with a series of doses in increments of 20% in order to determine the threshold dose to induce a minimal perceptible erythema response (MED). Each dose was delivered with a liquid light guide (8 mm diameter on the back or 6 mm on the upper inner arm) and with quartz optical fibers of 200 μm diameter. The resulting skin responses were evaluated visually and investigated with a reflectance confocal microscope and imaging. The erythema response to the microscopic challenge was always diffuse with no clear boundaries extending to several times the exposed site diameter at doses greater than 2 MED. The skin returned to normal appearance from the microscopic challenge after two weeks of exposure while change in appearance for the larger areas persisted for several weeks to months. This new modality of testing provides the possibility to study skin at the microscopic level with a rapid recovery following challenge.