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Hospital Pediatrics Jul 2024Although many quality improvement initiatives in health care see early and laudable success, 1 of the greatest challenges is sustaining the gains and avoiding the...
Although many quality improvement initiatives in health care see early and laudable success, 1 of the greatest challenges is sustaining the gains and avoiding the natural tendency of systems to revert to their original state, function, and outcomes. Reliability science describes a mathematical and systematic framework for understanding the level of reliability of interventions, and therefore the anticipated success and failure rate of both the steps of a process and the cumulative process overall. Successful utilization of this framework, along with the mindful organizing principles of high-reliability organizations, will facilitate ongoing and long-lasting improvement in outcomes. In this article, we describe practical methods to increase the reliability of interventions toward achieving and sustaining improvement goals.
PubMed: 38957890
DOI: 10.1542/hpeds.2023-007340 -
Cureus Apr 2024Appendicectomy is the most frequent emergency general surgical procedure. Prior research highlights the importance of histopathology analysis after appendicectomy which...
INTRODUCTION
Appendicectomy is the most frequent emergency general surgical procedure. Prior research highlights the importance of histopathology analysis after appendicectomy which is the practice in many countries including the United Kingdom (UK), aiming to prevent any oversight of vital findings and the avoidance of potential delays in patient care. Our primary objective was to audit the extent to which surgeons adhere to the NHS England patient safety guidelines from 2016 when it comes to timely reviewing and effectively communicating histopathology results to patients and/or their general practitioners following appendicectomy procedures. Our secondary objective was to amend practice, if deemed necessary, following the implementation of agreed-upon protocols, with the expected improvements being observable in the second cycle of the audit.
METHODS
In our two-cycle audit, we performed a retrospective analysis using online patient records from a single centre in the UK. The initial cycle involved cases of emergency appendectomies carried out consecutively for suspected appendicitis from April 2018 to June 2019. Following the clinical governance meeting and the implementation of recommendations, the second audit cycle covered cases between September 2020 and October 2020.
RESULTS
In the first cycle, among 418 laparoscopic appendectomies, 207 (49.52%) and 47 reports (11.24%) were reviewed within a 15-day and a 16-30-day window, respectively, following the online availability of histopathology results. Notably, 116 reports (27.75%) remained unreviewed by surgeons, and only 67 (16.02%) of these reports documented communication with patients and/or their general practitioners. In the second cycle, involving 49 patients, 38 reports (77.55%) were reviewed within the first 15 days, and 10 reports (20.4%) were reviewed between 16-30 days. Among these, 16 reports (32.65%) documented communication with patients and/or their general practitioners.
CONCLUSIONS
Our adherence to the aforementioned guidance was poor prior to this audit. This two-cycle audit highlighted the need for improvement in the timely review and communication of histopathology reports following appendectomy at our centre. The second cycle showed promising progress, suggesting that changes implemented between the cycles had a positive impact. Nevertheless, continuous efforts may be required to enhance and sustain adherence to these vital patient safety guidelines.
PubMed: 38957822
DOI: 10.7759/cureus.58539 -
Journal of Orthopaedics Nov 2024Genu recurvatum deformity after treatment of leg-length discrepancy (LLD) with tension-band plating is a recognized, but poorly described phenomenon in medical...
AIMS AND OBJECTIVES
Genu recurvatum deformity after treatment of leg-length discrepancy (LLD) with tension-band plating is a recognized, but poorly described phenomenon in medical literature. The aim of this study was to evaluate clinical and radiological features of patients treated with tension-band plating for LLD assessing the development of a recurvatum deformity and its relationship to plate and screw disposition in a transversal plane, thus attempting to establish optimal plate positioning.
MATERIALS AND METHODS
Retrospective study of children with LLD treated with tension-band plating. Primary endpoints were clinical and radiological knee recurvatum and anterior and posterior physeal areas measured drawing a line spanning from the lateral to the medial tension-band plates in the transverse plane using volumetric magnetic resonance imaging (vMRI). These findings were compared between patients with and without knee recurvatum.
RESULTS
Twelve children (mean age 11.7 years) were included. Average follow-up was 2.6 years (1.5-5.0). Tension-band plating led to a significant reduction in LLD (mean, 15 mm). Six patients (50 %) developed clinical genu recurvatum (mean, 22°). According to vMRI, patients with genu recurvatum had a larger posterior to anterior physeal area ratio in both distal femur (1.6 versus 0.9, < 0.05) and proximal tibial physes (2.2 versus 1.0, < 0.05).
CONCLUSION
The optimal position of the tension-band plates in distal femoral and proximal tibial physes should be in a point where a posterior to anterior physeal areas ratio is around 1.0, so as to achieve an even distribution of the physeal areas in the multidimensional physeal transverse plane. This point anatomically corresponds in the sagittal X-ray view to an imaginary line located just anterior to the posterior diaphyseal cortical bone on a true lateral radiograph for both femur and tibia.
PubMed: 38957798
DOI: 10.1016/j.jor.2024.06.004 -
EJC Paediatric Oncology Jun 2024Despite intensive therapies, pediatric patients with relapsed or refractory solid tumors have poor outcomes and need novel treatments. Immune therapies offer an...
Despite intensive therapies, pediatric patients with relapsed or refractory solid tumors have poor outcomes and need novel treatments. Immune therapies offer an alternative to conventional treatment options but require the identification of differentially expressed antigens to direct antitumor activity to sites of disease. B7-H3 (CD276) is an immune regulatory protein that is expressed in a range of malignancies and has limited expression in normal tissues. B7-H3 is highly expressed in pediatric solid tumors including osteosarcoma, rhabdomyosarcoma, Ewing sarcoma, Wilms tumor, neuroblastoma, and many rare tumors. In this article we review B7-H3-targeted chimeric antigen receptor (B7-H3-CAR) T cell therapies for pediatric solid tumors, reporting preclinical development strategies and outlining the landscape of active pediatric clinical trials. We identify challenges to the success of CAR T cell therapy for solid tumors including localizing to and penetrating solid tumor sites, evading the hostile tumor microenvironment, supporting T cell expansion and persistence, and avoiding intrinsic tumor resistance. We highlight strategies to overcome these challenges and enhance the effect of B7-H3-CAR T cells, including advanced CAR T cell design and incorporation of combination therapies.
PubMed: 38957786
DOI: 10.1016/j.ejcped.2024.100160 -
Open Forum Infectious Diseases Jul 2024Varicella zoster virus (VZV) can reactivate and cause meningitis, but few studies have distinguished it from meningoencephalitis regarding treatment recommendations.The... (Clinical Trial)
Clinical Trial
BACKGROUND
Varicella zoster virus (VZV) can reactivate and cause meningitis, but few studies have distinguished it from meningoencephalitis regarding treatment recommendations.The objective of this study was to assess the outcomes of a large series of patients with VZV meningitis according to their therapeutic management.
METHODS
We conducted a bicentric retrospective cohort study, in Paris, France, including all adult patients with a cerebrospinal fluid sample positive for VZV by polymerase chain reaction between April 2014 and June 2022. We distinguished meningitis from encephalitis according to the International Encephalitis Consortium criteria. Unfavorable outcome was defined as mortality or functional sequelae defined by a loss of 2 points on the modified Rankin Scale.
RESULTS
We included 123 patients with meningitis. Among them, 14% received no antivirals, while 20% were treated with oral valacyclovir alone, 41% with a short course of intravenous (IV) acyclovir before switch to valacyclovir, and 25% with a long course of IV acyclovir. Outcomes were favorable regardless of antiviral regimen. In multivariate analysis, only age, underlying immunosuppression, and cranial radiculitis appear to be predictive factors for longer IV therapy, based on the Akaike information criterion.
CONCLUSIONS
In this study, patients with VZV meningitis had a good outcome, with no evidence of any impact of the treatment strategy. However, further studies are needed to support the possibility of milder treatment in immunocompetent patients, avoiding cost and side effects of IV acyclovir.
PubMed: 38957692
DOI: 10.1093/ofid/ofae340 -
Frontiers in Plant Science 2024The genetic basis of plant response to light and heat stresses had been unveiled, and different molecular mechanisms of leaf cell homeostasis to keep high physiological...
The genetic basis of plant response to light and heat stresses had been unveiled, and different molecular mechanisms of leaf cell homeostasis to keep high physiological performances were recognized in grapevine varieties. However, the ability to develop heat stress tolerance strategies must be further elucidated since the morpho-anatomical and physiological traits involved may vary with genotype × environment combination, stress intensity, and duration. A 3-year experiment was conducted on potted plants of Sardinian red grapevine cultivars Cannonau (syn. Grenache) and Carignano (syn. Carignan), exposed to prolonged heat stress inside a UV-blocking greenhouse, either submitted to low daily UV-B doses of 4.63 kJ m d (+UV) or to 0 kJ m d (-UV), and compared to a control (C) exposed to solar radiation (4.05 kJ m d average UV-B dose). Irrigation was supplied to avoid water stress, and canopy light and thermal microclimate were monitored continuously. Heat stress exceeded one-third of the duration inside the greenhouse and 6% in C. spectroscopy, including leaf reflectance and fluorescence, allowed for characterizing different patterns of leaf traits and metabolites involved in oxidative stress protection. Cannonau showed lower stomatal conductance under C (200 mmol m s) but more than twice the values inside the greenhouse (400 to 900 mmol m s), where water use efficiency was reduced similarly in both varieties. Under severe heat stress and -UV, Cannonau showed a sharper decrease in primary photochemical activity and higher leaf pigment reflectance indexes and leaf mass area. UV-B increased the leaf pigments, especially in Carignano, and different leaf cell regulatory traits to prevent oxidative damage were observed in leaf cross-sections. Heat stress induced chloroplast swelling, plastoglobule diffusion, and the accumulation of secretion deposits in both varieties, aggravated in Cannonau -UV by cell vacuolation, membrane dilation, and diffused leaf blade spot swelling. Conversely, in Carignano UV-B, cell wall barriers and calcium oxalate crystals proliferated in mesophyll cells. These responses suggest an adaptive divergence among cultivars to prolonged heat stress and UV-B light. Further research on grapevine biodiversity, heat, and UV-B light interactions may give new insights on the extent of stress tolerance to improve viticulture adaptive strategies in climate change hotspots.
PubMed: 38957604
DOI: 10.3389/fpls.2024.1399840 -
MedEdPORTAL : the Journal of Teaching... 2024Physicians can be unaware that many US adults have intermediate or lower health literacy. Avoiding medical jargon in patient communication can improve poor outcomes...
INTRODUCTION
Physicians can be unaware that many US adults have intermediate or lower health literacy. Avoiding medical jargon in patient communication can improve poor outcomes associated with lower health literacy, but physicians may struggle to do so as health literacy education is neither standardized nor universal at US allopathic medical schools. As with other skills-based proficiencies in medical education, repeat exposure and active learning help build competency. Medical students developed the Patient Communication Challenge (PCC), an adaptation of the Hasbro game Taboo, to facilitate practice of patient-centered communication skills among medical trainees.
METHODS
Hour-long workshops were held for groups of preclinical medical students. Students watched a communication exemplar video, played the PCC game, and completed a postworkshop survey. To play, two teams competed to earn points by identifying medical concepts as explained by a teammate who described the term without using medical jargon.
RESULTS
Evaluations indicated that the game was enjoyable and reinforced didactic concepts through active learning, with self-reported participant satisfaction and competency gain. Overall, 59% of participants (53 of 90) completed postworkshop surveys; 91% (48 of 53) agreed they felt more proficient in avoiding jargon, 94% (50 of 53) would recommend the workshop to a classmate, and 100% (53 of 53) would play again.
DISCUSSION
The PCC can help early medical trainees develop health communication skills through gamification with utilization of adult learning principles and adequate frequency for skill retention. Future applications include longitudinal assessment and expanding to later stages of medical training and other health professions.
Topics: Humans; Students, Medical; Communication; Surveys and Questionnaires; Video Games; Education, Medical, Undergraduate; Physician-Patient Relations; Problem-Based Learning
PubMed: 38957534
DOI: 10.15766/mep_2374-8265.11411 -
Cureus Jul 2024Pott's puffy tumors are assumed to be infrequent concomitant intra- and extracranial abscesses, mainly secondary to complicated frontal sinusitis during infancy. Due to...
Pott's puffy tumors are assumed to be infrequent concomitant intra- and extracranial abscesses, mainly secondary to complicated frontal sinusitis during infancy. Due to the close proximity to the superior sagittal sinus, there is a risk of developing venous infections, thrombosis, and morbidity. In this case report, we present a case of an 11-year-old girl who presented with headache and face edema. After recognizing the Pott's puffy tumor pattern on the CT scan and brain MRI, the neurosurgical approach involved pus evacuation and frontal sinus blockage, and the patient received antibiotic therapy and was evaluated for total recovery. To our knowledge, the prompt diagnosis and treatment of such conditions are paramount to avoid complications, and differential diagnosis should be encouraged in medical practice.
PubMed: 38957509
DOI: 10.7759/cureus.63686 -
JGH Open : An Open Access Journal of... Jul 2024The traditional gut-centric view of coeliac disease is evolving as immune and genetic insights underscore the central importance of a systemic, T cell immune response to... (Review)
Review
The traditional gut-centric view of coeliac disease is evolving as immune and genetic insights underscore the central importance of a systemic, T cell immune response to gluten in disease pathogenesis. As the field increasingly recognize the limitations of small intestinal histology as the diagnostic standard, data supporting the accuracy of an immune (serologic) diagnosis of coeliac disease - well demonstrated in children - are growing for adults. Novel biomarkers such as interleukin-2 that identify the gluten-specific T cell demonstrate high sensitivity and specificity for coeliac disease and offer the potential for a diagnostic approach that avoids the need for gluten challenge. Asymptomatic disease and manifestations outside the gut pose considerable challenges for diagnosis using a case-finding strategy and enthusiasm for population screening is growing. The gluten-free diet remains a highly restrictive treatment and there is a paucity of controlled data to inform a safe gluten intake threshold. Ongoing symptoms and enteropathy are common and require systematic evaluation. Slowly-responsive disease is prevalent in the older patient diagnosed with coeliac disease, and super-sensitivity to gluten is an emerging concept that may explain many cases of nonresponsive disease. While there is great interest in developing novel therapies for coeliac disease, no drug has yet been registered. Efficacy studies are generally assessing drugs in patients with treated coeliac disease who undergo gluten challenge or in patients with nonresponsive disease; however, substantial questions remain around specific endpoints relevant for patients, clinicians and regulatory agencies and optimal trial design. Novel immune tools are providing informative readouts for clinical trials and are now shaping their design.
PubMed: 38957478
DOI: 10.1002/jgh3.13107 -
Neurosurgical Focus: Video Jul 2024Hemispherectomy is an effective procedure used in the treatment of drug-resistant hemispheric epilepsy, especially in the pediatric population. A number of resective and...
Hemispherectomy is an effective procedure used in the treatment of drug-resistant hemispheric epilepsy, especially in the pediatric population. A number of resective and disconnective techniques are used, and selection of surgical strategy is paramount to achieving successful results. Notably, disconnective (or functional) hemispherotomy maximizes the benefits of safe, surgical disconnection while minimizing hemispheric tissue resection, thereby avoiding some of the perioperative factors contributing to morbidity in traditional anatomical hemispherectomy procedures. In this video, the authors outline the principal surgical steps of disconnective hemispherotomy and highlight important technical factors leading to optimal outcomes in patients with refractory, oftentimes catastrophic, hemispheric epilepsy. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2436.
PubMed: 38957432
DOI: 10.3171/2024.4.FOCVID2436