Gamification and Game-Based Strategies for Dermatology Education: Narrative Review.

BACKGROUND: Game-based approaches, or gamification, are popular learning strategies in medical education for health care providers and patients alike. Gamification has taken the form of serious educational games and simulations to enable learners to rehearse skills and knowledge in a safe environment. Dermatology learners in particular may benefit from gamification methods, given the visual and procedural nature of the field. OBJECTIVE: This narrative review surveys current applications of gamification within general medical training, in the education of dermatology students, and in dermatology patient outreach. METHODS: A literature search was performed using PubMed, Google Scholar, and ResearchGate to access and review relevant medical education- and dermatology-related gamification studies published in peer-reviewed journals. Two independent researchers with education and experience in dermatology screened publications to select studies featuring a diversity of gamification approaches and study subjects for in-depth examination. RESULTS: A total of 6 general medical education-related and 7 dermatology-specific gamification studies were selected. Gamification generally increased motivation and engagement, improved reinforcement of learning objectives, and contributed to more enjoyable and positive educational experiences compared to traditional modes of instruction. Enhancing examination scores, building confidence, and developing stronger team dynamics were additional benefits for medical trainees. Despite the abundance of gamification studies in general medical education, comparatively few instances were specific to dermatology learning, although large organizations such as the American Academy of Dermatology have begun to implement these strategies nationally. Gamification may also a provide promising alternative means of diversifying patient education and outreach methods, especially for self-identification of malignant melanoma. CONCLUSIONS: Serious games and simulations in general medical education have successfully increased learner motivation, enjoyment, and performance. In limited preliminary studies, gamified approaches to dermatology-specific medical education enhanced diagnostic accuracy and interest in the field. Game-based interventions in patient-focused educational pilot studies surrounding melanoma detection demonstrated similar efficacy and knowledge benefits. However, small study participant numbers and large variability in outcome measures may indicate decreased generalizability of findings regarding the current impact of gamification approaches, and further investigation in this area is warranted. Additionally, some relevant studies may have been omitted by the simplified literature search strategy of this narrative review. This could be expanded upon in a secondary systematic review of gamified educational platforms.

The Burden of Skin and Subcutaneous Diseases in the United States From 1990 to 2017.

Importance: Skin and subcutaneous diseases affect the health of millions of individuals in the US. Data are needed that highlight the geographic trends and variations of skin disease burden across the country to guide health care decision-making. Objective: To characterize trends and variations in the burden of skin and subcutaneous tissue diseases across the US from 1990 to 2017. Design, Setting, and Participants: For this cohort study, data were obtained from the Global Burden of Disease (GBD), a study with an online database that incorporates current and previous epidemiological studies of disease burden, and from GBD 2017, which includes more than 90 000 data sources such as systematic reviews, surveys, population-based disease registries, hospital inpatient and outpatient data, cohort studies, and autopsy data. The GBD separated skin conditions into 15 subcategories according to incidence, prevalence, adequacy of data, and standardized disease definitions. GBD 2017 also estimated the burden from melanoma of the skin and keratinocyte carcinoma. Data analysis for the present study was conducted from September 9, 2019, to March 31, 2020. Main Outcomes and Measures: Primary study outcomes included age-standardized disability-adjusted life-years (DALYs), incidence, and prevalence. The data were stratified by US states with the highest and lowest age-standardized DALY rate per 100 000 people, incidence, and prevalence of each skin condition. The percentage change in DALY rates in each state was calculated from 1990 to 2017. Results: Overall, age-standardized DALY rates for skin and subcutaneous diseases increased from 1990 (821.6; 95% uncertainty interval [UI], 570.3-1124.9) to 2017 (884.2; 95% UI, 614.0-1207.9) in all 50 states and the District of Columbia. The degree of increase varied according to geographic location, with the largest percentage change of 0.12% (95% UI, 0.09%-0.15%) in New York and the smallest percentage change of 0.04% (95% UI, 0.02%-0.07%) in Colorado, 0.04% (95% UI, 0.01%-0.06%) in Nevada, 0.04% (95% UI, 0.02%-0.07%) in New Mexico, and 0.04% (95% UI, 0.02%-0.07%) in Utah. The age-standardized DALY rate, incidence, and prevalence of specific skin conditions differed among the states. New York had the highest age-standardized DALY rate for skin and subcutaneous disease in 2017 (1097.0 [95% UI, 764.9-1496.1]), whereas Wyoming had the lowest age-standardized DALY rate (672.9 [95% UI, 465.6-922.3]). In all 50 states and the District of Columbia, women had higher age-standardized DALY rates for overall skin and subcutaneous diseases than men (women: 971.20 [95% UI, 676.76-1334.59] vs men: 799.23 [95% UI, 559.62-1091.50]). However, men had higher DALY rates than women for malignant melanoma (men: 80.82 [95% UI, 51.68-123.18] vs women: 42.74 [95% UI, 34.05-70.66]) and keratinocyte carcinomas (men: 37.56 [95% UI, 29.35-49.52] vs women: 14.42 [95% UI, 10.01-20.66]). Conclusions and Relevance: Data from the GBD suggest that the burden of skin and subcutaneous disease was large and that DALY rate trends varied across the US; the age-standardized DALY rate for keratinocyte carcinoma appeared greater in men. These findings can be used by states to target interventions and meet the needs of their population.

Leveraging the electronic health record to improve dermatologic care delivery: The importance of finding structure in data.

The federal mandate for electronic health record (EHR) keeping for health care providers impacted the burden placed on dermatologists for medical documentation. The hope that EHR would improve care quality and efficiency and reduce health disparities has yet to be fully realized. Despite the significant time and effort spent on documentation, the majority of EHR clinical data remain unstructured and therefore, difficult to process and analyze. Structured data can provide a way for dermatologists and data scientists to make more effective use of clinical data-not only to improve the dermatologist's experience with EHRs, but also to manage technology-related administrative burden, accelerate understanding of disease, and enhance care delivery for patients. Understanding the importance of structured data will allow dermatologists to actively engage in how clinical data will be collected and used to advance patient care.

Descriptive Epidemiology of Injuries Sustained in National Collegiate Athletic Association Men's and Women's Volleyball, 2013-2014 to 2014-2015.

BACKGROUND: There were 18,844 volleyball players in the National Collegiate Athletic Association (NCAA) in the 2014-2015 academic year. Little research has examined sex-based differences among these athletes. PURPOSE: To examine injury epidemiology in NCAA men's and women's volleyball athletes. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 3. METHODS: Injury surveillance data from the 2013-2014 through 2014-2015 academic years were obtained from the NCAA Injury Surveillance Program for 6 men's and 33 women's collegiate volleyball teams. Injury rates per 1000 athlete-exposures (AEs) and injury rate ratios (IRRs) with 95% CIs were calculated. Time-loss (TL) injuries resulted in participation restriction for at least 24 hours, and non-time-loss (NTL) injuries resulted in participation restriction of less than 24 hours. RESULTS: Overall, 83 and 510 injuries were reported in men and women, respectively, leading to injury rates of 4.69 and 7.07 per 1000 AEs. The injury rate was greater in women than men (IRR, 1.51; 95% CI, 1.19-1.90). TL injury rates were 1.75 and 2.62 per 1000 AEs for men and women, respectively. The ankle was the most commonly injured body part among TL injuries (men, 25.8%; women, 24.3%); the knee was the most commonly injured body part among NTL injuries (men, 25.5%; women, 16.3%). Among TL injuries, common diagnoses included sprains (men, 25.8%; women, 31.2%) and concussions (men, 19.4%; women, 14.8%). Most TL concussions were due to ball contact (men, 83.3%; women, 53.6%). Compared with men, women had a greater NTL overuse injury rate (IRR, 3.47; 95% CI, 1.61-7.46). Compared with women, men had a greater TL injury rate associated with ball contact (IRR, 2.24; 95% CI, 1.07-4.68). CONCLUSION: There are differences in injury patterns and rates between male and female intercollegiate volleyball players. Although a limited-contact sport, a notable number of concussions were sustained, mostly from ball contact. CLINICAL RELEVANCE: Understanding injury patterns may aid clinicians in injury diagnosis, management, and prevention.

The facial morphology in Down syndrome: A 3D comparison of patients with and without obstructive sleep apnea.

Obstructive sleep apnea (OSA) occurs at a high prevalence in patients with Down syndrome (DS). A polysomnogram, which is often cumbersome and challenging, remains the gold standard method of diagnosing OSA. OSA in patients with DS is often attributed to skeletal and soft-tissue structural alterations that are characteristic of the DS phenotype; as such, we hypothesized that assessing anthropometric facial measurements may be predictive of OSA in patients with DS. We used the 3dMDface sterophotography system to capture and create 3D facial images, and we subsequently identified facial landmarks using a single, experienced investigator and utilizing proprietary software to calculate inter-landmark distances and angles. We compared our findings with similar data for neurotypically developing participants. We further compared the findings in participants with DS with and without OSA. Participants with DS had maxillomandibular hypoplasia with smaller ear, nose, and eye measurements compared to neurotypically developing peers. We found no statistically significant differences in 3D photogrammetric measurements between participants with DS with or without OSA.

Urinary biomarkers and obstructive sleep apnea in patients with Down syndrome.

STUDY OBJECTIVES: The study aimed to compare urinary biomarkers in patients with Down syndrome (DS) with and without obstructive sleep apnea (OSA) to those of age- and sex-matched neurotypically developing healthy controls (HC). We further investigated whether we could predict OSA in patients with DS using these biomarkers. METHODS: Urine samples were collected from 58 patients with DS the night before or the morning after their scheduled overnight polysomnogram or both, of whom 47 could be age- and sex-matched to a sample of 43 HC. Concentrations of 12 neurotransmitters were determined by enzyme-linked immunosorbent assay. Log-transformed creatinine-corrected assay levels were normalized. Normalized z-scores were compared between patients with DS vs. HC, between patients with DS with vs. without OSA, and to derive composite models to predict OSA. RESULTS: Most night-sampled urinary biomarkers were elevated among patients with DS relative to matched HC. No urinary biomarker levels differed between patients with DS with vs. without OSA. A combination of four urinary biomarkers predicted AHI > 1 with a positive predictive value of 90% and a negative predictive value of 68%. CONCLUSIONS: Having DS, even in the absence of concurrent OSA, is associated with a different urinary biomarker profile when compared to that of HC. Therefore, while urinary biomarkers may be predictive of OSA in the general pediatric population, a different approach is needed in interpreting urinary biomarker assays in patients with DS. Certain biomarkers also seem promising to be predictive of OSA in patients with DS. No clinical trial was indicated in the undertaking of this work.

A predictive model for obstructive sleep apnea and Down syndrome.

Obstructive sleep apnea (OSA) occurs frequently in people with Down syndrome (DS) with reported prevalences ranging between 55% and 97%, compared to 1-4% in the neurotypical pediatric population. Sleep studies are often uncomfortable, costly, and poorly tolerated by individuals with DS. The objective of this study was to construct a tool to identify individuals with DS unlikely to have moderate or severe sleep OSA and in whom sleep studies might offer little benefit. An observational, prospective cohort study was performed in an outpatient clinic and overnight sleep study center with 130 DS patients, ages 3-24 years. Exclusion criteria included previous adenoid and/or tonsil removal, a sleep study within the past 6 months, or being treated for apnea with continuous positive airway pressure. This study involved a physical examination/medical history, lateral cephalogram, 3D photograph, validated sleep questionnaires, an overnight polysomnogram, and urine samples. The main outcome measure was the apnea-hypopnea index. Using a Logic Learning Machine, the best model had a cross-validated negative predictive value of 73% for mild obstructive sleep apnea and 90% for moderate or severe obstructive sleep apnea; positive predictive values were 55% and 25%, respectively. The model included variables from survey questions, medication history, anthropometric measurements, vital signs, patient's age, and physical examination findings. With simple procedures that can be collected at minimal cost, the proposed model could predict which patients with DS were unlikely to have moderate to severe obstructive sleep apnea and thus may not need a diagnostic sleep study.

Symmetrical Drug-related Intertriginous and Flexural Exanthema Induced by Doxycycline.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug reaction characterized by erythema over the buttocks, thighs, groin, and flexural regions most commonly associated with the use of beta-lactam antibiotics. Although the exact pathophysiology of this disease remains unknown, it is theorized to be the result of a delayed hypersensitivity response presenting as a cutaneous eruption days to weeks after exposure to the drug. The treatment involves discontinuation of the suspected medication, symptomatic control of pruritus, and topical steroid therapy. A 51-year-old woman with homocystinuria and fibromyalgia was admitted with fevers, pancytopenia (later diagnosed to be acute myelogenous leukemia), and a targetoid cutaneous eruption in the setting of a recent tick bite. She was subsequently noted to have symmetric, pruritic, erythematous papules over the lateral neck, retroauricular regions, lateral aspects of the inframammary regions, medial upper arms, axillae, and the lower abdomen two weeks after starting doxycycline. Considering the morphology, distribution, and intense pruritis associated with the eruption, a diagnosis of SDRIFE was made. Doxycycline discontinuation along with topical steroid therapy resulted in the resolution of the eruption and pruritus. Given the widespread use of doxycycline, clinicians should be aware of this possible side effect.

Craniofacial features as assessed by lateral cephalometric measurements in children with Down syndrome.

OBJECTIVE: The objective of the present study is to examine the craniofacial development of patients with Down syndrome (DS) and compare them with a neurotypical population. METHODS: This study is a cross-sectional analysis of lateral cephalometric radiographs of participants with DS. The study population consisted of children and young adults with DS aged 3-25 years. Cephalometric data were summarized by age and sex. Raw and normalized z-scores were computed. One-sample t tests were used to test whether mean z-scores differed from zero. The demographic characteristics between those with or without lateral cephalograms among all study participants were compared by Fisher's exact tests. RESULTS: The study sample comprised of 27 participants with DS. Study subjects demonstrated a class III skeletal pattern. This was more pronounced in the older age groups as compared to younger age groups. Subjects also had an increased proportionate lower anterior face height to total facial height compared to normative standards. Gonial angles, mandibular plane angles, and airway measurements increased with age. CONCLUSIONS: Patients with Down syndrome present typically with class III skeletal pattern and long lower anterior facial heights. In patients with Down syndrome, comprehensive phase of orthodontic treatment may be best initiated following cessation of growth.

Growth-Factor Nanocapsules That Enable Tunable Controlled Release for Bone Regeneration.

Growth factors are of great potential in regenerative medicine. However, their clinical applications are largely limited by the short in vivo half-lives and the narrow therapeutic window. Thus, a robust controlled release system remains an unmet medical need for growth-factor-based therapies. In this research, a nanoscale controlled release system (degradable protein nanocapsule) is established via in situ polymerization on growth factor. The release rate can be finely tuned by engineering the surface polymer composition. Improved therapeutic outcomes can be achieved with growth factor nanocapsules, as illustrated in spinal cord fusion mediated by bone morphogenetic protein-2 nanocapsules.

Effect of cervical kyphotic deformity type on the motion characteristics and dynamic spinal cord compression.

STUDY DESIGN: Retrospective analysis of kinematic magnetic resonance images. OBJECTIVE: To provide baseline data on the segmental angular and translational motion of the degenerated cervical spine by subtype of kyphotic cervical deformity and to elucidate the relationship between motion and degree of spinal cord compression. SUMMARY OF BACKGROUND DATA: Kyphotic deformities of the cervical spine are relatively common and are classified as either global or focal. Nevertheless, the effects of kyphotic subtype on cervical segmental motion and degree of spinal cord compression are unknown. METHODS: A total of 1171 symptomatic patients (618 females, 553 males) underwent cervical kinematic magnetic resonance imaging in the neutral, flexion, and extension positions. Cervical spines demonstrating kyphosis were included and classified into 3 groups: (1) "global kyphotic deformity" (C-type) (n = 54); (2) "sigmoid deformity" (S-type) with kyphotic upper and lordotic lower cervical segments (n = 29); and (3) "reverse sigmoid deformity" (R-type) with lordotic upper and kyphotic lower cervical segments (n = 39). Translational motion, angular motion, and degree of spinal cord compression were evaluated for each cervical level along with the changes associated with flexion and extension. RESULTS: In the C- and R-types, angular motion with extension was increased in the upper cervical spine, where there was kyphosis; when compared with the S-type, in which there was lordosis in the upper segments. The results were opposite for flexion angular motion. R-type displayed more translational motion at C3-C4 and C5-C6. Degree of static spinal cord compression of R-type was higher than the others at C3-C4. The dynamic spinal cord compression increased in extension more than flexion in all subtypes. CONCLUSION: Cervical spine studies that aim to investigate kyphotic deformities should make efforts to discern the different subtypes of kyphotic deformities to more accurately characterize and study the effects that the sagittal alignment has on the kinematics of the spine and the degree of spinal cord compression.

A novel osteogenic oxysterol compound for therapeutic development to promote bone growth: activation of hedgehog signaling and osteogenesis through smoothened binding.

Osteogenic factors are often used in orthopedics to promote bone growth, improve fracture healing, and induce spine fusion. Osteogenic oxysterols are naturally occurring molecules that were shown to induce osteogenic differentiation in vitro and promote spine fusion in vivo. The purpose of this study was to identify an osteogenic oxysterol more suitable for clinical development than those previously reported, and evaluate its ability to promote osteogenesis in vitro and spine fusion in rats in vivo. Among more than 100 oxysterol analogues synthesized, Oxy133 induced significant expression of osteogenic markers Runx2, osterix (OSX), alkaline phosphatase (ALP), bone sialoprotein (BSP), and osteocalcin (OCN) in C3H10T1/2 mouse embryonic fibroblasts and in M2-10B4 mouse marrow stromal cells. Oxy133-induced activation of an 8X-Gli luciferase reporter, its direct binding to Smoothened, and the inhibition of Oxy133-induced osteogenic effects by the Hedgehog (Hh) pathway inhibitor, cyclopamine, demonstrated the role of Hh pathway in mediating osteogenic responses to Oxy133. Oxy133 did not stimulate osteogenesis via BMP or Wnt signaling. Oxy133 induced the expression of OSX, BSP, and OCN, and stimulated robust mineralization in primary human mesenchymal stem cells. In vivo, bilateral spine fusion occurred through endochondral ossification and was observed in animals treated with Oxy133 at the fusion site on X-ray after 4 weeks and confirmed with manual assessment, micro-CT (µCT), and histology after 8 weeks, with equal efficiency to recombinant human bone morphogenetic protein-2 (rhBMP-2). Unlike rhBMP-2, Oxy133 did not induce adipogenesis in the fusion mass and resulted in denser bone evidenced by greater bone volume/tissue volume (BV/TV) ratio and smaller trabecular separation. Findings here suggest that Oxy133 has significant potential as an osteogenic molecule with greater ease of synthesis and improved time to fusion compared to previously studied oxysterols. Small molecule osteogenic oxysterols may serve as the next generation of bone anabolic agents for therapeutic development.

Contribuciones de una clínica especializada para niños y adolescentes con síndrome de Down / No disponible

Investigamos cuál es el valor añadido que aporta, si es que lo hace, una clínica especializada las necesidades sanitarias de niños y adolescentes con síndrome de Down. Para ello realizamos una revisión retrospectiva de fichas de 105 pacientes nuevos con síndrome de Down, de 3 años de edad en adelante, explorados durante el año inaugural de nuestra clínica especializada. Preguntamos cuántos de nuestros pacientes estaban al día en las revisiones de salud recomendadas para personas con síndrome de Down. Analizamos también cuántos test habíamos pedido así como pases sugeridos a otros especialistas y, por último, los nuevos diagnósticos de problemas médicos que habíamos hecho. Sólo el 9,8% de los pacientes estaban al corriente de todas las recomendaciones en el seguimiento de salud para el síndrome de Down, Los padres vinieron a la clínica por una serie de problemas y, tras las pruebas de laboratorio, estudios radiológicos y pases a subespecialistas, hicimos nuevos diagnósticos de problemas gastrointestinales (p. ej., estreñimiento, enfermedad celíaca), alergias estacionales, problemas dérmicos (p. ej., xerosis), diagnósticos sobre la conducta (p. ej., trastorno del espectro autista y conductas disruptivas no especificadas), y clarificaciones de su estado neurológico. Una clínica especializada en síndrome de Down identifica y aborda muchas necesidades sanitarias de niños y adolescentes con síndrome de Down, superiores a las que se atienden en un servicio de atención primaria (AU)

No disponible

Contributions of a specialty clinic for children and adolescents with Down syndrome.

We investigated what added value, if any, a Down syndrome specialty clinic brings to the healthcare needs of children and adolescents with Down syndrome. For this quality improvement study, we performed a retrospective chart review of 105 new patients with Down syndrome, ages 3 and older, seen during the inaugural year of our specialty clinic. We asked how many of our patients were already up-to-date on the healthcare screenings recommended for people with Down syndrome. We further analyzed what tests we ordered, which referrals we suggested, and, ultimately, what new diagnoses of co-occurring medical conditions were made. Only 9.8% of our patients were current on all of the recommended Down syndrome healthcare screenings. Parents came to clinic with a variety of concerns, and after laboratory tests, radiologic studies, and subspecialty referrals, we made many new diagnoses of gastrointestinal conditions (e.g., constipation and celiac disease), seasonal allergies, dermatologic conditions (e.g., xerosis), behavioral diagnoses (e.g., autism spectrum disorder and disruptive behavior not otherwise specified), and clarifications of neurologic conditions. A Down syndrome specialty clinic can identify and address many healthcare needs of children and adolescents with Down syndrome beyond that which is provided in primary care settings.

Energetic consequences of thermal and nonthermal food processing.

Processing food extensively by thermal and nonthermal techniques is a unique and universal human practice. Food processing increases palatability and edibility and has been argued to increase energy gain. Although energy gain is a well-known effect from cooking starch-rich foods, the idea that cooking meat increases energy gain has never been tested. Moreover, the relative energetic advantages of cooking and nonthermal processing have not been assessed, whether for meat or starch-rich foods. Here, we describe a system for characterizing the energetic effects of cooking and nonthermal food processing. Using mice as a model, we show that cooking substantially increases the energy gained from meat, leading to elevations in body mass that are not attributable to differences in food intake or activity levels. The positive energetic effects of cooking were found to be superior to the effects of pounding in both meat and starch-rich tubers, a conclusion further supported by food preferences in fasted animals. Our results indicate significant contributions from cooking to both modern and ancestral human energy budgets. They also illuminate a weakness in current food labeling practices, which systematically overestimate the caloric potential of poorly processed foods.