Managing medical and surgical error: an emotional survival guide.

Medical errors are common and often lead to feelings of self-doubt, helplessness, and guilt. Society thinks of physicians as healers, and physicians who see their role as offering a cure will always feel as if they haven't done enough. This article discusses five steps in the management of medical and surgical error: (1) care for the patient and family, (2) report to appropriate sources, (3) review the incident, (4) manage legal issues, and (5) engage in self-care.

Overall Survival with Pembrolizumab in Early-Stage Triple-Negative Breast Cancer.

Background: In patients with early-stage triple-negative breast cancer, the phase 3 KEYNOTE-522 trial showed significant improvements in pathological complete response and event-free survival with the addition of pembrolizumab to platinum-containing chemotherapy. Here we report the final results for overall survival.

Methods: We randomly assigned, in a 2:1 ratio, patients with previously untreated stage II or III triple-negative breast cancer to receive neoadjuvant therapy with four cycles of pembrolizumab (at a dose of 200 mg) or placebo every 3 weeks plus paclitaxel and carboplatin, followed by four cycles of pembrolizumab or placebo plus doxorubicin-cyclophosphamide or epirubicin-cyclophosphamide.

Essentials of Liver Transplantation in the Setting of Acute Kidney Injury and Chronic Kidney Disease.

Kidney dysfunction is common among liver transplant candidates with decompensated cirrhosis and has a major impact on pre- and post-liver transplant survival. Updated definitions of acute kidney injury and criteria for the diagnosis of hepatorenal syndrome allow for early recognition and intervention, including early initiation of vasoconstrictor therapy for hepatorenal syndrome. The rise of the metabolic syndrome and nonalcoholic fatty liver disease as a cause of cirrhosis has coincided with an increase in intrinsic chronic kidney disease recognized in transplant candidates and recipients.

Photodynamic Therapy with 5-aminolevulinic Acid 10% Gel and Red Light for the Treatment of Actinic Keratosis, Nonmelanoma Skin Cancers, and Acne: Current Evidence and Best Practices.

Photodynamic therapy (PDT) can be an effective treatment for actinic keratosis (AK) as well as selected non-melanoma skin cancers (NMSCs), such as Bowen's disease and superficial basal cell carcinoma. PDT has also demonstrated effectiveness in the management of acne vulgaris. Results from controlled clinical trials have shown the safety and efficacy of PDT for these conditions with the use of different photosensitizers and a wide range of light sources.

Shotgun recoil causing severe acute aortic regurgitation years after replacement of the aortic valve and ascending aorta.

Blunt chest trauma can lead to severe, life-threatening injury to chest organs, including the aorta, heart, lungs, and major airways. We describe a 64-year-old man who had undergone replacement of his aortic valve and ascending aorta 14 years earlier (at age 50) and suddenly developed severe aortic regurgitation after firing his shotgun while hunting. Such an event has not been reported previously.

The Development and Initial Findings of A Study of a Prospective Adult Research Cohort with Inflammatory Bowel Disease (SPARC IBD).

Background: Clinical and molecular subcategories of inflammatory bowel disease (IBD) are needed to discover mechanisms of disease and predictors of response and disease relapse. We aimed to develop a study of a prospective adult research cohort with IBD (SPARC IBD) including longitudinal clinical and patient-reported data and biosamples.

Methods: We established a cohort of adults with IBD from a geographically diverse sample of patients across the United States with standardized data and biosample collection methods and sample processing techniques.

Once-daily Dapsone 7.5% Gel for the Treatment of Acne Vulgaris in Preadolescent Patients: A Phase IV, Open-label, 12-week Study.

NCT02959970 Acne vulgaris in patients aged younger than 12 years is increasingly common and primarily noninflammatory (i.e., comedonal).

Exercise training with cycle ergometry in the intensive care unit after total artificial heart implantation.

A 53-year-old male mountain biker received a total artificial heart and remained in the cardiovascular intensive care unit for 56 days. To reduce functional decline caused by inactivity, he performed a six-session cycle ergometer exercise program in his hospital room. Traditional cardiac responses for exercise prescription were not applicable; therefore, a symptom-limited, monitored progression scheme in conjunction with recommendations for the artificial heart was implemented to modify duration and intensity.

Pembrolizumab for Early Triple-Negative Breast Cancer.

Background: Previous trials showed promising antitumor activity and an acceptable safety profile associated with pembrolizumab in patients with early triple-negative breast cancer. Whether the addition of pembrolizumab to neoadjuvant chemotherapy would significantly increase the percentage of patients with early triple-negative breast cancer who have a pathological complete response (defined as no invasive cancer in the breast and negative nodes) at definitive surgery is unclear.

Methods: In this phase 3 trial, we randomly assigned (in a 2:1 ratio) patients with previously untreated stage II or stage III triple-negative breast cancer to receive neoadjuvant therapy with four cycles of pembrolizumab (at a dose of 200 mg) every 3 weeks plus paclitaxel and carboplatin (784 patients; the pembrolizumab-chemotherapy group) or placebo every 3 weeks plus paclitaxel and carboplatin (390 patients; the placebo-chemotherapy group); the two groups then received an additional four cycles of pembrolizumab or placebo, and both groups received doxorubicin-cyclophosphamide or epirubicin-cyclophosphamide.

The Use of Ketamine for the Management of Acute Pain in the Emergency Department.

Ketamine has been used as an anesthetic agent for over 50 years. At the upper end of the dosing range, it displays dissociative anesthetic and amnestic effects, while at lower doses, it acts as an analgesic and demonstrates opioid-sparing capabilities. Ketamine is unique in its preservation of hemodynamic stability and respiratory function, and is used extensively in the emergency department (ED) for procedural sedation and the facilitation of brief painful procedures.

3D Printing Custom Bioactive and Absorbable Surgical Screws, Pins, and Bone Plates for Localized Drug Delivery.

Additive manufacturing has great potential for personalized medicine in osseous fixation surgery, including maxillofacial and orthopedic applications. The purpose of this study was to demonstrate 3D printing methods for the fabrication of patient-specific fixation implants that allow for localized drug delivery. 3D printing was used to fabricate gentamicin (GS) and methotrexate (MTX)-loaded fixation devices, including screws, pins, and bone plates.

Outcomes in Patients With Cirrhosis on Primary Compared to Secondary Prophylaxis for Spontaneous Bacterial Peritonitis.

Objectives: Antibiotic prophylaxis is recommended for prevention of the first episode of spontaneous bacterial peritonitis (SBP; primary prophylaxis 1°) and subsequent episodes (secondary prophylaxis 2°). We aimed to compare outcomes in cirrhotic inpatients on 1° vs 2° SBP prophylaxis.

Methods: Data from North American Consortium for the Study of End-Stage Liver Disease were evaluated for cirrhosis details, reasons for admission/medications, inpatient course recorded, and outcomes over 90 days.

The Impact of Albumin Use on Resolution of Hyponatremia in Hospitalized Patients With Cirrhosis.

Objectives: Hyponatremia is associated with poor outcomes in cirrhosis independent of MELD. While intravenous albumin has been used in small series, its role in hyponatremia is unclear. The aim of this study is to determine the effect of albumin therapy on hyponatremia.

Coronary artery fistula between the left anterior descending artery and pulmonary artery.

Coronary artery fistula is a rare anomalous connection between a coronary artery and a cardiac chamber or major vessel. Here we present the case of a 36-year-old woman who presented with sharp, substernal chest pain, dyspnea, and dizziness. A fistula between her left anterior descending artery and pulmonary trunk was found.

Plasma cell myeloma with lymphoplasmacytic morphology and cyclin D1 expression, an uncommon variant.

The genetic complexity of multiple myeloma is due in part to the accumulation of mutations, with primary and secondary events. One such secondary event is the development of a gene mutation that may result in overexpression of cyclin D1. The pathway involving cyclin D1 is intricately involved in cell cycle regulation from the G1 to S phase, and alterations may contribute to tumorigenesis.

Association of in utero magnesium exposure and spontaneous intestinal perforations in extremely low birth weight infants.

Objective: The objective of this study is to determine whether antenatal exposure to magnesium is associated with spontaneous intestinal perforation (SIP) in extremely low birth weight (ELBW) infants (⩽1000 g).

Study Design: We identified all ELBW infants admitted to 1 of 323 neonatal intensive care units from 2007 to 2013. We used multivariable conditional logistic regression to compare outcomes in the first 21 days after birth between infants exposed and unexposed to magnesium in utero.

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States.

Importance: Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States.

Objective: To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008.

Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry.

Background: Implant-based breast reconstruction is performed with both saline and silicone. In 2001, a study was conducted in which a novel implant made of highly cohesive silicone gel in anatomical shape was used. It differs from others because it holds its anatomical shape and forces tissue to conform to the implant.

Myocardial Infarction Related to Trauma.

Myocardial infarction (MI) secondary to acute coronary occlusion related to trauma is rare. A previously healthy man developed acute MI shortly after a motor vehicle accident. This case illustrates the feasibility of primary percutaneous coronary intervention for acute MI due to complete coronary artery occlusion related to trauma, including the use of manual thrombectomy, stents, and dual antiplatelet therapy.