Clinical experience with sesame oral immunotherapy and a quality-of-life assessment.

Background: Allergic reactions to sesame have increased in prevalence in the United States. Sesame oral immunotherapy (OIT) is an emerging management strategy. Few reports assessed the benefits and risks of sesame OIT in children with sesame allergy.

The Role of Advanced Practice Providers in Pediatric Emergency Care Across Nine Emergency Departments.

Objectives: Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients.

Integrative Treatment for Substance Use Disorders: Improving Outcomes Through Evidence-based Practice of Yoga-derived Breathwork and Meditation.

Background: Among 20.4 million US adults diagnosed with substance use disorders (SUDs), up to 60% return to use despite treatment or attempted abstinence. Standard care for SUDs is pharmacotherapy and/or behavioral interventions in either an inpatient or outpatient setting.

Qualitative Point-of-Care Ultrasound Enema Management for Constipation.

We discuss 10 cases where the qualitative evaluation of hard stool in the rectum with point-of-care ultrasound helped guide enema administration in a pediatric emergency department. Point-of-care ultrasound findings were especially valuable in cases where the presenting symptoms were undifferentiated, a language barrier was present, or the guardian and child denied that constipation was an active problem. When sodium phosphate enema administration was done in the pediatric emergency department, evacuation of the rectal stool burden was observed in most cases before final disposition.

Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review.

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays.

Why Do Physicians Depart Their Practice? A Qualitative Study of Attrition in a Multispecialty Ambulatory Practice Network.

Background: Physician departure causes considerable disruption for patients, colleagues, and staff. The cost of finding a new physician to replace the loss coupled with lost productivity as they build their practice can cost as much as $1 million per departure. Therefore, we sought to characterize drivers of departure from practice with the goal of informing retention efforts (with a special emphasis on the connection between electronic health record (EHR)-related stress and physician departure).

Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries.

Introduction: This study aimed to determine whether healthcare markets with higher social vulnerability have lower access to high-quality hip and knee replacement hospitals and whether hospitals that serve a higher percentage of low-income patients are less likely to be designated as high-quality.

Methods: This cross-sectional study used 2021 Centers for Medicare and Medicaid Services outcome measures and 2022 Joint Commission (JC) process-of-care measures to identify hospitals performing high-quality hip and knee replacement. A total of 2,682 hospitals and 304 healthcare markets were included.

Updates in Classification of Myelodysplastic Syndrome.

Myelodysplastic syndrome includes a broad range of myeloid neoplasms characterized by cytopenia and morphologic dysplasia. Recently, 2 new classification systems emerged to further define how these diseases are diagnosed and risk stratified. This review compares these models, provides detailed approaches, and reveals practical ways to move forward in clinical practice of myelodysplastic syndrome diagnosis.

Pearls & Oy-sters: Homozygous Complement Factor I Deficiency Presenting as Fulminant Relapsing Complement-Mediated CNS Vasculitis.

A 36-year-old man presented multiple times with fever, headache, alteration of mental status, and focal neurologic deficits. MRI revealed extensive white matter lesions that were partially reversed between episodes. Workup revealed persistently low complement factor C3, low factor B, and absent alternative complement pathway activity.

Neurocognitive Outcomes in Deformational Plagiocephaly: Is There an Association between Morphologic Severity and Results?

Background: The neurodevelopmental effects of skull asymmetry and orthotic helmet therapy for deformational plagiocephaly (DP) have had limited investigation. This study assessed the long-term neurocognitive outcomes in patients with DP and their association with orthotic helmet therapy and head shape abnormality.

Methods: A total of 138 school-age children with a history of DP, 108 of whom received helmet therapy, were tested with a neurocognitive battery assessing academic achievement, intelligence quotient, and visual-motor function.

Anatomic Navigation Using the Transverse Acetabular Ligament for Acetabular Component Positioning in Total Hip Arthroplasty Through the Direct Anterior Approach.

The transverse acetabular ligament (TAL) is a reliable native anatomic landmark that can be used to guide accurate acetabular implant positioning during total hip arthroplasty through the direct anterior approach. The accurate acetabular implant position is defined by the preoperative plan, which corresponds to the Lewinnek safe zone. This article describes the anatomy of the TAL , exposure of the TAL, and pearls and pitfalls for exposure of the acetabulum during total hip arthroplasty through the direct anterior approach.

Point-of-Care Ultrasound for Pulse Checks in Pediatric Cardiac Arrest: Two Illustrative Cases.

Cardiac arrest is an infrequent but high-stakes scenario in pediatrics. Manual central pulse checks are unreliable. Point-of-care ultrasound is a noninvasive technique to visualize the heart and central vessels during resuscitation.

Persistent Postoperative Vasoplegia After Ureteronephrectomy Due To Suspected Intravesical Gemcitabine Toxicity.

We describe a case of unusually persistent vasoplegia in the postoperative course of a patient recovering after elective right robotic nephroureterectomy with intravesical salvage gemcitabine. In the treatment of patients with intravesical adjuvant therapy, gemcitabine may precipitate persistent vasoplegia requiring further fluid resuscitative efforts, vasopressor support, and other supportive management. This potential adverse event should be considered when all common causes of persistent vasoplegia are ruled out, such as shock related to bleeding, infection, allergic reaction, or pulmonary embolic phenomenon.

Comparison of Autologous Breast Reconstruction Complications by Type of Neoadjuvant Chemotherapy Regimen.

Background: Neoadjuvant chemotherapy before mastectomy helps reduce tumor burden and pathologic response in breast cancer. Limited evidence exists regarding how neoadjuvant chemotherapy impacts outcomes following microvascular breast reconstruction. This study examines the effects of neoadjuvant chemotherapy regimens and schedules on microvascular breast reconstruction complication rates and also assesses the effects of neoadjuvant chemotherapy on circulating immune cells related to wound healing.

The serum protein renalase reduces injury in experimental pancreatitis.

Acute pancreatitis is a disease associated with inflammation and tissue damage. One protein that protects against acute injury, including ischemic injury to both the kidney and heart, is renalase, which is secreted into the blood by the kidney and other tissues. However, whether renalase reduces acute injury associated with pancreatitis is unknown.

Perspectives on the Use of Clinical Pathways in Oncology Care.

Pathways and guidelines are valuable tools to provide evidence-based care in oncology. Pathways may be more restrictive than guidelines because they attempt (where possible) to reduce cost, add efficiency, and remove unwarranted variability. Pathways offer an opportunity to measure, report, and improve quality of care; they can drive to evidence-based targeted therapy where appropriate; they can enhance efficiency through standardization; and, finally, they can be a vehicle to enhance participation in clinical trials.

Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL.

Background: Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data.

Methods And Results: We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials.

An Agenda for Improving Perioperative Code Status Discussion.

Code status discussions (CSDs) clarify patient preferences for cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. CSDs are a key component of perioperative care, particularly at the end of life, and must be both patient-centered and shared. Physicians at all levels of training are insufficiently trained in and inappropriately perform CSD; this may be particularly true of perioperative physicians.

Why the Quality Oncology Practice Initiative Matters: It's Not Just About Cost.

The nature and cost of cancer care is evolving, affecting more patients and often involving expensive treatment options. The upward cost trends also coincide with a national landscape of increasing regulatory mandates that may demand improved outcomes and value, but that often require significant up-front investment in infrastructure to achieve safety and quality. Oncology practices participating in the American Society of Clinical Oncology (ASCO) Institute for Quality's Quality Oncology Practice Initiative (QOPI) and the QOPI Certification Program (QCP) continue to grow in number and reflect changing demographics of the provision of cancer care.

The Correlation of Workplace Simulation-Based Assessments With Interns' Infant Lumbar Puncture Success: A Prospective, Multicenter, Observational Study.

Introduction: Little data are available to guide supervisors' decisions regarding when trainees are prepared to safely perform their first procedure on a patient. We aimed to describe the correlation of simulation-based assessments, in the workplace, with interns' first clinical infant lumbar puncture (ILP) success.

Methods: This is a prospective, observational subcomponent of a larger study of incoming interns at 33 academic medical centers (July 2010 to June 2012) assessing the impact of just-in-time training.