ChemInform Research Articles

Caregiver Perspectives and Preferences Regarding Timely Access to Unscheduled Acute Care in Paediatric Urgent Care Centers: A Qualitative Evaluation of Save My Spot Tool.

Explore caregiver (i.e., person who provides direct care for a child and was present at the time of their medical visit) perspectives and preferences regarding timely access to unscheduled acute care as well as barriers and facilitators of the use of an online appointment tool (i.e., Save My Spot) in a satellite children's hospital five urgent care centers in the United States. A descriptive qualitative interview study. We conducted semi-structured interviews with 49 caregivers in a private room, in person and in conjunction with medical visits from June 2023 to the end of August 2023 after obtaining institutional ethical approvals. We employed deductive and inductive content analysis and used the MAXQDA data analysis tool. Average caregiver age was 37 years. Most of the caregivers were female, white, and non-Hispanic and had low income. We identified three categories: (a) Caregiver preferences for using the Save My Spot online appointment tool and their reasons for buy-in, (b) ways of promoting the Save My Spot tool and (c) enhancing the accessibility of the Save My Spot tool. The findings of this study suggest that when introduced successfully, caregivers adopt an online appointment tool and find it efficient in minimising wait times. Various approaches (e.g., social media, billboards) can be used to promote the tool to increase timely access to care. This study provides valuable insights into the utilisation of an online appointment tool in the two hospital-based and three stand-alone neighbourhood urgent care centers of a large urban children's hospital. Future studies capturing different tools and populations are recommended to gain diverse understanding. The study was reported following the Standards for Reporting Qualitative Research. Caregivers provided their perspectives and the Paediatric Emergency Medicine Disparities Working Group contributed to the interpretation of the study findings.

A randomized clinical trial of intranasal dexmedetomidine versus inhaled nitrous oxide for procedural sedation and analgesia in children

BackgroundProcedural sedation and analgesia is an important part of pediatric emergency care, safe and clinically useful alternatives for adequate management are necessary. The objective of this clinical trial was to evaluate the non-inferiority of intranasal dexmedetomidine to nitrous oxide with respect to analgesia for a painful procedure in children 3–15 years of age.MethodsThis prospective, equally randomized, open-label, non-inferiority trial was conducted at a Pediatric Emergency Department. Previously healthy children 3–15 years of age, with an extremity fracture or luxation or a burn and requiring procedural sedation and analgesia were eligible. Patients were randomized to receive either intranasal dexmedetomidine or inhaled nitrous oxide. The primary outcome measure was highest pain level during the procedure, assessed with Face, Legs, Activity, Cry, Consolability scale (FLACC). Mann-Whitney U test (continuous variables) and Fisher’s test (categorical variables) were used for statistical analysis.ResultsThe highest FLACC was median 4 (IQR 3–6) with intranasal dexmedetomidine and median 4 (IQR 2–6) with nitrous oxide. The median of the difference between samples from each group for FLACC was 0 with 95%CI (0–1), thus intranasal dexmedetomidine was not inferior to nitrous oxide with respect to the level of pain during the procedure. The same method for procedural sedation and analgesia would be accepted by 52/74 (82.5%) children and 65/74 (91.5%) parents in the intranasal dexmedetomidine group respectively 59/74 (88.1%) versus 70/74 (94.6%) with nitrous oxide. No serious adverse events were reported.ConclusionsThe results of this trial support that intranasal dexmedetomidine is not inferior to 50% nitrous oxide in providing analgesia for a painful procedure in children 3–15 years of age and can be considered as an alternative to 50% nitrous oxide for procedural sedation and analgesia.Trial registrationEudraCT 201,600,377,317, April 20, 2017. https://eudract.ema.europa.eu/.

The Association Between Maternal Vitamin D Deficiency and Postpartum Hemorrhage and Uterine Atony

(Acta Obstet Gynecol Scand. 2024;103:286–293. DOI: 10.1111/aogs.14719) Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and morbidity globally, causing about 140,000 deaths per year. PPH can be attributed to 4 primary causes: tone, trauma, tissue, and thrombin. The most common cause is an atonic uterus (70% of cases), followed by trauma (20%), tissue (10%), and thrombin (1%). Hemostasis after delivery primarily relies on uterine myometrium contraction, which compresses the large vessels in the placental bed. Vitamin D deficiency, prevalent globally and in Sweden (25% to 60%), varies with diet, season, and supplementation. It is measured by serum 25-hydroxylated vitamin D (25 OHD) levels, with insufficiency defined as <50 nmol/L and deficiency as <25 nmol/L.

Time Trends in Preeclampsia and Gestational Diabetes in Denmark and Alberta, Canada, 2005 to 2018: A Population-Based Cohort Study

(Acta Obstet Gynecol Scand. 2024;103:266–275. doi: 10.1111/aogs.14703) Preeclampsia (PEC) and gestational diabetes mellitus (GDM) have similar risk factors including increased maternal age and obesity. Both conditions are associated with adverse pregnancy outcomes and long-term health issues for mothers and children, and health care resources could be strained if the prevalence of PEC and GMA are increasing.

Transabdominal and Transvaginal Ultrasound Findings Help to Guide the Clinical Management of Placenta Accreta Spectrum Cases

(Acta Obstet Gynecol Scand. 2024;103(1):93–102. doi: 10.1111/aogs.14715) In recent years, the incidence of placenta accreta spectrum (PAS) has risen while there is no current treatment defined as the standard. The favored conservative surgery options include 1-step conservative surgery (OSCS) and triple-P surgery. Diagnosis of PAS is often accomplished through ultrasound due to ease of use, availability, and low cost. During ultrasound screening many different signs are used to examine the uteroplacental interface, abnormal lacunae, and hypervascularity. Previous studies have sought to link ultrasound signs with histopathology, but the relationship remains unclear. This study aimed to link ultrasound signs and OSCS success, in order to understand how the signs could be used as predictors.

Disseminated Bacille Calmette-Guérin Vaccine-Induced Disease in a Sample of Iranian Children: A Longitudinal Case-Series Study

Background: Approximately a quarter-million Iranian newborns receive the Bacille Calmette-Guérin (BCG) vaccine annually. However, in immunodeficient infants, this vaccine can lead to disseminated BCG disease (DBD). Objectives: This study aims to determine the clinical presentation, comorbidities, underlying immunodeficiency, and prognosis of DBD in a group of Iranian children. Methods: In a longitudinal case-series study, data were collected from the files of infants and children diagnosed with DBD from 2005 to 2017. Immunodeficiency screening was conducted for each patient. For children with normal immunodeficiency screening results, further testing for Mendelian susceptibility to mycobacterial diseases (MSMD) was performed. Detection of DBD in children was achieved by evaluating gastric lavage and bone marrow aspiration samples for mycobacterium. Results: Most of the 22 patients were immunocompromised, with the following distribution: 31.8% had severe combined immunodeficiency (SCID), 45.5% had MSMD (specifically IL-12Rβ1 deficiency), one patient (4.5%) had Wiskott-Aldrich syndrome (WAS), and the remaining 18.1% had unknown immunodeficiency types. Most patients with MSMD were successfully treated and did not show relapse during the follow-up period, even after discontinuing anti-tuberculosis (TB) medications. Conclusions: Due to the similarity of its manifestations to sepsis, diagnosing systemic infections caused by the BCG vaccine in children requires a high level of clinical suspicion and appropriate diagnostic measures, such as mycobacterial culture, biochemical speciation, or polymerase chain reaction (PCR). These diagnostic steps should be taken promptly in cases of DBD, with concurrent treatment using anti-tuberculosis drugs and, if possible, targeted therapies for underlying immunodeficiency.

Clinical validation on role of cancer diagnostic probe in detecting the involved cavity margins missed in permanent pathology of tumor side in breast cancer surgery

Cancer diagnostic probe (CDP) as a newly entered tool in real-time breast cavity margin evaluation showed great improvement in smart margin shaving intra-operatively. This system increased the rate of involved margin detection to 30% with respect to frozen section. In this study for the first time we showed the independent role of CDP in finding the involved cavity side margins which were not diagnosed by permananet pathology of their tumor side interface. Among 147 detected margins by CDP, 23 lesions with invasive component and ductal carcinoma in-situ/ductal cancerization weren’t reported as involved margins in permanent pathology of tumor side. Our gold standard was the histology of cavity margin specimen had been scored as involved lesion by CDP. It seems that even when the permanent pathology of surgical margins is used for final declaration, role of CDP is irreplaceable. This distinguished achievement has been obtained intra-operatively in real-time by CDP while involved report in permanent pathology of tumor margins induce re-surgery for the patient.

Effects of esketamine combined with dexmedetomidine on postoperative delirium and quality of recovery in elderly patients undergoing thoracoscopic radical lung cancer surgery: a randomized controlled trial.

This study aimed to investigate the effects of esketamine (Esk) combined with dexmedetomidine (Dex) on postoperative delirium (POD) and quality of recovery (QoR) in elderly patients undergoing thoracoscopic radical lung cancer surgery. In this prospective, randomized, and controlled study, 172 elderly patients undergoing thoracoscopic radical lung cancer surgery were divided into two groups: the Esk+Dex group (n=86) and the Dex group a (n=86). The primary outcome was the incidence of POD within 7days after surgery and the overall Quality of Recovery-15 (QoR-15) scores within 3days after surgery. Secondary outcomes included postoperative adverse reactions, extubation time, PACU stay, and hospitalization time. Serum levels of IL-6, IL-10, S100β protein, NSE, CD3+, CD4+, and CD8+ were detected from T0 to T5. Compared with the Dex group, the incidence of POD in the Esk+Dex group was significantly lower at 7days after surgery (14.6% vs 30.9%; P=0.013). The QoR-15 score was significantly increased 3days after surgery (P<0.01). Levels of IL-6 and CD8+ were significantly decreased, and IL-10 levels were significantly increased at T1-T2 (P<0.05). At T1-T4, NSE levels were significantly decreased, while CD3+ and CD4+/CD8+ values were significantly increased (P<0.01). At T1-T5, serum S100β protein concentration decreased significantly, and CD4+ value increased significantly (P<0.01). The incidence of nausea/vomiting and hyperalgesia decreased significantly 48hours after surgery (P<0.01). The duration of extubation, PACU stay, and postoperative hospitalization were significantly shortened. Esketamine combined with dexmedetomidine can significantly reduce the POD incidence and improve the QoR in patients undergoing thoracoscopic radical lung cancer surgery, which may be related to the improvement of cellular immune function.

Preoperative D‑dimer level and prognosis in patients diagnosed with gastric cancer and undergoing gastric cancer radical surgery: A retrospective cohort study.

Gastric cancer, one of the most aggressive tumors affecting the digestive tract, has seen a rise in both incidence and mortality rates in recent years, with a lack of clear prognostic indicators. D-dimer, a byproduct of fibrin degradation, is a conventional coagulation biomarker that has been investigated as a potential adverse prognostic factor for postoperative cancer patients. However, conflicting results exist, with some studies suggesting that D-dimer is an independent risk factor for the postoperative prognosis of gastric cancer, and others suggesting that there is no significant association between D-dimer level and gastric cancer prognosis. This controversy underscores the need for further research to determine the true influence of D-dimer level on the prognosis of postoperative cancer patients, including exploring the linear and non-linear associations, and identifying optimal critical values before surgery. The present study aimed to assess the association between preoperative D-dimer levels and 5-year overall survival (OS) rate in patients undergoing radical surgery for gastric cancer. Data was analyzed from patients diagnosed with gastric cancer who underwent a radical gastrectomy at Shanxi Cancer Hospital (Taiyuan, China) in 2017 and were followed up for 5 years until December 2022. Preoperative D-dimer levels and tumor-related indicators were collected as covariates from hospital records, with patient follow-up information obtained from the hospital's tracking system. Utilizing multivariate Cox regression, curve fitting and inflection point analysis, the present study sought to investigate the link between preoperative D-dimer levels and 5-year OS rate following radical surgery for gastric cancer. After strict admission and exclusion procedures, a total of 133 patients were included in the study and were then classified based on D-dimer level. Based on the mean value, the D-dimer levels were segregated into two distinct cohorts: The D-dimer_high group (n=66) and the D-dimer_low group (n=67). Cox multiple regression analysis was conducted using both continuous and binary variables. The results showed no effect in terms of the continuous variables, but higher preoperative D-dimer levels were significantly associated with a higher 5-year overall survival compared with lower preoperative D-dimer levels in the categorical variables. Therefore, curve fitting was performed, which indicated that the association between D-dimer level and 5-year survival rate after radical gastrectomy for cancer showed a U-shaped curve, with P<0.001, high and low D-dimer levels both indicated poorer prognosis. A curvilinear correlation was demonstrated between preoperative D-dimer levels and the 5-year survival rate following radical gastrectomy for cancer. Subsequently, an inflection point analysis found that the inflection point was located at 100-200 ng/ml. In conclusion, in patients undergoing radical gastrectomy for gastric cancer, preoperative D-dimer can be used to indicate the current state of the tumor to some extent through blood coagulation status. Notably, a U-shaped association exists between D-dimer levels and 5-year postoperative survival rate in gastric cancer. This association demonstrates varying effects across different intervals. Specifically, D-dimer levels <100 ng/ml are associated with a worse prognosis, whereas levels >200 ng/ml are associated with a better prognosis.

DESIGNING 'KIDDOCARE' APPLICATION FOR PEDIATRIC NURSING PRACTICE WITH USER CENTERED DESIGN (UCD)

This research aims to develop KiddoCare, a mobile-based pediatric nursing application designed using the User Centered Design (UCD) method. The methodology used in this study included interviews, questionnaire distribution, and documentation with the aim of filling the gap of tools and applications that specifically meet the unique needs in pediatric care. Interviews with health workers showed that one of the biggest challenges was the lack of efficient communication between nurses and parents, as well as difficult access to pediatric health information. Therefore, this app is designed to improve communication between nurses and pediatric patients and facilitate access to important health information. The UCD process includes understanding the user context, determining user needs, designing and producing solutions, and evaluating those needs. From the initial survey of 74 respondents, 50.56% agreed and 46.02% strongly agreed with the need for easier access to pediatric health information. A total of 74 respondents evaluated the app and gave positive feedback; 47.01% 'agreed', 41.17% 'strongly agreed' with the functionality of the app, and 11.82% 'moderately'. No respondents expressed 'disagree' or 'strongly disagree'. In conclusion, KiddoCare was rated as an effective and appropriate pediatric nursing tool, supporting flexible care that is adaptive to each child's individual needs.

The Influence of Fermentation Technology on the Functional and Sensory Properties of Hemp Bread.

In this work, the type of fermentation and baking technology used to make hemp bread was investigated. The physicochemical composition of flour and bread, the protein nutritional quality, fatty acids profile, texture, consumer acceptance, analysis of volatile compounds using an electronic nose and chemical compounds using an electronic tongue were determined. Differences in protein and total dietary fiber content were observed in the obtained breads. The use of sourdoughs had a minor effect on the physical properties of the bread tested (the volume and mass of the loaves, color, or crumb texture). There was no clear effect of the tested sourdoughs on the parameters of the crumb texture and its moisture, assessed physically, both on the day of baking and during storage. In this bread, the limiting amino acid was lysine (amino acid score from 56.22% to 57.63%), but the breads did not differ significantly in the value of this indicator. The n-6/n-3 ratio in breads containing hemp flour (from 3.73 to 4.48) may have a beneficial effect on human health. The best-rated bread was the HB4 with a score of 6.09. The acceptance of remaining breads were in the range from 3.91 for HB1 to 4.91 for HB2.

Trends in Overactive Bladder Therapy: Associations Between Clinical Care Pathways, Practice Guidelines, and Therapy Utilization Patterns.

Overactive bladder (OAB) is a chronic condition with significant financial and health-related consequences. Guidelines and treatment pathways were created to optimize care and provide a clinical framework for diagnosing and managing OAB. However, the impact of these efforts and patterns of medical treatment for OAB are poorly understood. Therefore, we sought to evaluate overall trends in therapy utilization before and after the 2014 American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) OAB guideline amendment and publication of the OAB clinical care pathway in 2016. In this retrospective cohort study, we analyzed data from Optum, a national administrative health and pharmacy claims database, between 2013 and 2018. All adult patients diagnosed with idiopathic OAB were identified by the International Classification of Diseases 9th and 10th Revision codes. Oral OAB therapies were identified using National Drug Codes, while third-line therapy procedures, onabotulinumtoxinA (BTX), sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS), were identified using Current Procedural Terminology (CPT) codes. The study's primary outcome was the annual number of OAB prescriptions filled by pharmacotherapy class and the number of minimally invasive therapies performed during the study period. The secondary outcome was the association between OAB therapy utilization and various clinical and sociodemographic factors. Patterns of care were analyzed from 2013 to 2018, and initial treatment with each therapy was collected, excluding repeat procedures from the analysis. 1 825 782 patients were included in the study. The mean age was 61.1 ± 16.7 years, and 1 071 420 patients were female (58.7%). The number of new OAB diagnoses increased by 369% from 2013 to 2017. During the 6-year study period, 347 052 (19%) patients were treated with oral and/or third-line therapies. The overall number of oral medications prescribed peaked in 2016, followed by a 17% decline between 2016 and 2018. In 2013, the two most prescribed oral medications were oxybutynin (46%) and solifenacin (31.8%). By 2018, mirabegron (18.5%) surpassed solifenacin (16.5%), with oxybutynin still accounting for most prescriptions written (55%). Eighty percent of all initial mirabegron prescriptions were filled by patients over the age of 65. The rate of third-line therapy procedures almost doubled between 2013 and 2018 (9-17 procedures per 1000 OAB patients, p < 0.001). Following the publication of the first OAB guidelines, there was an increase in OAB diagnoses, followed by a decrease in anticholinergic medication use, and a rise in beta-3 agonist utilization in patients over 65 years old. Additionally, there was greater adoption of third-line OAB therapies. These trends indicate that OAB therapy guidelines and clinical practice pathways may influence treatment patterns. Given the recent publication of the OAB guidelines, further studies are necessary to assess their impact on therapy utilization patterns.

Adverse events associated with the delivery of telerehabilitation across rehabilitation populations: A scoping review.

This scoping review aimed to map existing research on adverse events encountered during telerehabilitation delivery, across rehabilitation populations. This includes identifying characteristics of adverse events (frequency/physical/non-physical, relatedness, severity) and examining adverse events by different modes of telerehabilitation delivery and disease states. Telerehabilitation, a subset of telemedicine, has gained traction during the COVID-19 pandemic for remote service delivery. However, no prior scoping review, systematic review, or meta-analysis has identified and summarized the current primary research on adverse events in telerehabilitation. Understanding adverse events, such as falls during physiotherapy or aspiration pneumonia during speech therapy, is crucial for identifying limitations and optimizing delivery through risk mitigation and quality indicators. This understanding could also help to improve the uptake of telerehabilitation among clinicians and patients. This review addresses this gap by summarizing published literature on adverse events during telerehabilitation. The review followed the Joanna Briggs Institute framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The review protocol was registered and published on Open Science Framework. A comprehensive search across multiple databases (MEDLINE ALL/EMBASE/APA PsycINFO/CENTRAL/CINAHL) was conducted. Screening, extraction, and synthesis were performed in duplicate and independently. Data extraction followed the Template for Intervention Description and Replication framework and also involved extraction on authors, publication year (pre- or post-COVID), population, sample size, and modes of telerehabilitation delivery (asynchronous, synchronous, hybrid). For synthesis, data were summarized quantitatively using numerical counts and qualitatively via content analysis. The data were grouped by intervention type and by type of adverse event. This scoping review included qualitative and quantitative studies published between 2013-2023, written in English, and conducted in any geographic area. All modes of telerehabilitation delivery were included. Systematic reviews, meta-analyses, commentaries, protocols, opinion pieces, conference abstracts, and case series with fewer than five participants were excluded. The search identified 11,863 references, and 81 studies were included in this review with a total of 3,057 participants (mean age:59.3 years; females:44.6%). Modes of telerehabilitation delivery (whether asynchronous, synchronous or hybrid) used in the studies included videoconferencing (52), phone calls (25), text messaging (4), email (6), mobile apps (10), and internet-based virtual reality systems (3). A total of 295 adverse events occurred during 84,534 sessions (0.3%), with the majority being physical (e.g., falls or musculoskeletal pain), non-serious/non-severe/mild, and unrelated to (i.e., not caused by) to the telerehabilitation provided. From the 81 included studies, telerehabilitation was delivered with related adverse events being rare, and mostly characterized as mild/non-severe. A comparable occurrence of adverse events (~30%) was found between asynchronous and synchronous telerehabilitation studies. When categorized by disease type, cardiac telerehabilitation studies had the most frequent adverse events. Detailed reporting of telerehabilitation interventions and adverse event characteristics is recommended for future studies (i.e., use of TIDieR reporting guidelines). Telerehabilitation has the potential to make rehabilitation services more accessible to patients; however, more evidence on the safety of telerehabilitation is needed.

Diagnosis and Care of Children With Cerebral/Cortical Visual Impairment: Clinical Report.

Cerebral/cortical visual impairment (CVI) is a leading cause of pediatric visual impairment in nations with developed economies and is increasing in those with developing economies. Because vision is the predominant sense used for learning, delay in diagnosis of CVI can negatively affect education, making early detection and management important. The American Academy of Pediatrics has published the policy statement "Visual System Assessment in Infants, Children, and Young Adults by Pediatricians" and an accompanying clinical report that are based on identifying potential causes of ocular visual impairment in children. Yet, routine vision screening may not accurately identify the brain-based visual impairment in children with CVI. Moreover, children with CVI often have medical complexity with other neurocognitive impairments and serious medical conditions that can make the diagnosis of CVI more difficult. Strategies are necessary for early identification of CVI to promote early diagnosis and referral for vision services that may allow a child with CVI to engage more fully in school, activities of daily living, vocational pursuits, and recreational activities. Knowledge of the characteristics of CVI as well as risk factors for CVI will assist the pediatrician in identifying children with CVI. This clinical report is complementary to previous vision screening policies, allowing both ocular and brain-based visual impairments in children to be identified and addressed. Pediatricians, other primary care physicians, pediatric ophthalmologists, neurologists, and other specialized pediatric eye care clinicians can identify children with CVI and coordinate effective evaluation, diagnosis, and referrals for vision services for these children.

Timing of Palliative Care Consultation and End-of-Life Care Intensity in Pediatric Patients With Advanced Heart Disease: Single-Center, Retrospective Cohort Study, 2014-2022.

Pediatric patients with advanced heart disease (AHD) often receive high intensity medical care at the end of life (EOL). In this study, we aimed to determine whether receipt and timing of pediatric palliative care (PPC) consultation was associated with EOL care intensity of pediatric patients with AHD. Retrospective cohort study. Single-center, 16-bed cardiac ICU (CICU) in a children's hospital in the Mountain West. Pediatric patients (0-21 yr) with AHD treated in the CICU and subsequently died from January 2014 to December 2022. None. We compared demographics, EOL characteristics and care, including medical interventions and mortality characteristics for patients by receipt and timing of PPC (i.e., ≥ 30 d from [early] or < 30 d of death [late]) using chi-square and Wilcoxon rank-sum tests. Of 218 patients, 78 (36%) did not receive PPC, 76 received early PPC (35%), and 64 received late PPC (29%). Compared with patients who did not receive PPC, patients receiving PPC had lower EOL care intensity (77% vs. 96%; p = 0.004) and fewer invasive interventions within 14 days of death (74% vs. 92%; p = 0.004). Receipt of PPC, vs. not, was associated with lower rate of death during cardiopulmonary resuscitation (12% vs. 32%; p = 0.004) and more use of comfort care (23% vs. 3%; p = 0.004). Among patients receiving PPC, early PPC was associated with fewer invasive interventions within 14 days of death (65% vs. 85%; p = 0.033). Care intensity was high for patients with early and late PPC. Early PPC was associated with fewer invasive interventions within 14 days of death, yet the care intensity at EOL remained high. With early PPC, families likely receive timely psychosocial and advance care planning support without significantly altering goals of care.

Optimizing Resident Charge Capture with Disappearing Help Text in Note Templates.

To assist residents in selecting the correct Current Procedural Terminology (CPT) code for evaluation and management (E/M) services thru the addition of disappearing help text into a standardized note template. We created a disappearing text block that summarizes E/M requirements and embedded it into the note template used by residents at a pediatric urgent care clinic. An intervention cohort composed of post graduate year 1 (PGY 1) residents was instructed to use this note template, while senior residents (PGY 2-3) were instructed to use an identical template that lacked the help text. We evaluated the incidence of CPT change by the attending physician for each visit as a proxy for improvement in resident billing practices. Logistic regression with a primary outcome of whether the encounter CPT code was changed was completed. There were 2,869 encounters during the 255-day study period; the help text was used in 1,112 (38.8%) encounters. There was some crossover in note use; i.e., PGY 1s using the note without help text and PGY 2s using the note with help text. Nevertheless, all residents who used the help text had a lower unadjusted rate of CPT change (22.1% vs 30.6%, OR= 0.64, p < 0.0001). This pattern persisted when stratified by trainee level - PGY 1 (22.6% vs 45.3%, OR=0.35,p < 0.0001) and PGY 2-3 (12.2% vs 27.8%, p = 0.018). Adjusting for multiple factors, the use of help text was associated with a lower incidence of CPT change (odds ratio [OR] = 0.28, 95% confidence interval [CI]: 0.19-0.44). Residents' use of the disappearing help text was associated with a large decrease in CPT code adjustment by attending physicians, which demonstrates its promise for improved E/M coding and for other applications.

Multi-Prong Formative Evaluation of a Pediatric Clinical-Community Food Access and Nutrition Education Intervention.

To understand pediatricians', community partners', and food insecure parent/caregivers' perspectives on addressing food access and nutrition education in clinical settings, and to conduct a formative evaluation of a clinical-community food access and nutrition education intervention. A mixed-methods evaluation. Data was collected from pediatricians and parents/caregivers recruited from one urban pediatric primary care clinic, and from community partners involved in food access. Pediatricians (n = 14), parents at risk of food insecurity (n = 7), and community partner staff (n = 8) participated in qualitative interviews. A cross-sectional survey among pediatricians assessing demographics, nutrition training, and knowledge of food access programs was administered. Semi-structured virtual interviews were conducted to understand experiences with food insecurity and food access programs, and to identify content and delivery preferences for a clinical-community intervention. Descriptive statistics were used to characterize the pediatrician and parent demographics and pediatrician nutrition knowledge. A hybrid deductive-inductive thematic analysis was used to identify emerging themes from qualitative interviews. Few pediatricians (n = 3, 11%) reported receiving previous nutrition training, and knowledge-based food access program questions revealed significant gaps in pediatricians' understanding of program eligibility. Thematic analyses underscore challenges in addressing food insecurity in the clinical setting, gaps in clinical-community partnerships, and barriers to participating in food access programs. Findings provide recommendations for the development of clinical-community food access and nutrition education interventions.

Effect of endoscopic surgical skill qualification system for laparoscopic rectal surgery: Japanese multicenter analysis.

Laparoscopic rectal surgery is often technically difficult. The Endoscopic Surgical Skill Qualification System (ESSQS) was established in Japan as an objective measure of skill for laparoscopic surgeons. However, the advantages of the ESSQS qualification for laparoscopic rectal surgery have been limited. The aim of this multicenter study was to assess the effects of the ESSQS on short- and long-term outcomes for laparoscopic rectal cancer surgery. We retrospectively reviewed 933 rectal cancer patients who underwent laparoscopic surgery between 2016 and 2023. Patients were divided into two groups: those for whom surgery was performed by an ESSQS-qualified surgeon (Expert group, n = 568); and those for whom surgery was performed by an ESSQS-unqualified surgeon (Non-expert group, n = 365). After propensity score matching, 299 patients from each group were matched. Short- and long-term outcomes were compared between groups. Before matching, the Expert group showed greater frequencies of poor performance status (PS) (PS ≥ 3, 10.6% vs 4.1%, p < 0.001), lower rectum cancer (32.0% vs 18.4%, p < 0.001), preoperative treatment (17.3% vs 8.2%, p < 0.001), and pelvic lymph node dissection (30.8% vs 21.4%, p = 0.001). After matching, the Expert group showed lower frequencies of open conversion (0.3% vs 2.3%, p = 0.034) and postoperative complications (18.1% vs 26.1%, p = 0.037). Relapse-free survival (p = 0.811) and overall survival (p = 0.374) were similar between groups. Superior results such as lower conversion rates and postoperative complication rates were obtained for laparoscopic rectal surgery performed by ESSQS-qualified surgeons.

Multispectral Fluorescence Imaging as a Tool to Distinguish Pelvic Lymphatic Drainage Patterns During Robot-assisted Lymph Node Dissection in Prostate Cancer.

The invasive nature of extended pelvic lymph node dissection (ePLND) prompts the need for alternative lymphatic mapping technologies. To change the focus to "sparing nodes that are not involved," the first step is to research the feasibility of intraoperatively distinguishing the lymph drainage patterns of the prostate from healthy organs. We performed a prospective study (NCT05120973) that included 16 patients who underwent a robot-assisted radical prostatectomy + ePLND + sentinel node (using indocyanine green-99mTc-nanocolloid). After general anesthesia, a second fluorescent dye (fluorescein) was injected unilaterally in two deposits into the intradermis of the upper leg (n = 8) or abdominal wall (n = 8), because these are the most common locations of lymphedema in prostate cancer surgery. To distinguish between the drainage patterns, in vivo and ex vivo multispectral fluorescence imaging was performed by using a fluorescence endoscope. Indocyanine green and fluorescein were visible in the same regions within the ePLND-template and co-accumulated in lymph vessels in vivo. At histopathology, fluorescein was seen in only 10 of 370 lymph nodes (possibly owing to tracer properties), none of which overlapped with indocyanine green and none were tumor-positive. Administration of fluorescein did not result in discomfort or abnormal postoperative recovery. Multispectral imaging can be used to distinguish lymphatic drainage patterns. Our in vivo findings indicate that within the ePLND-template, lymphatic drainage patterns of the prostate at least partly overlap with those of upper leg and abdominal wall. The properties of fluorescein render it unsuitable for confirmation of fluorescence at histopathology.

Survival of Patients with Right-Sided and Left-Sided Colon Cancer: Insights from an Iranian Medical Center

Objectives: We aimed to describe and compare the 12-year results of patients with colon cancer based on the Shiraz Colorectal Cancer Surgery (SCORCS) registry system in patients with a pathologically confirmed diagnosis of right-sided colon cancer (RCC) and left-sided colon cancer (LCC) who had undergone surgery. Methods: A total of 443 patients with a diagnosis of colon cancer at Shahid Faghihi Hospital, Shiraz, Iran, between 2010 and 2022, who were registered in the SCORCS system, were enrolled in the current study. The data collected included the patients' demographic characteristics, tumor site and size, degree of invasion, recurrence status, metastasis, and death. The data were analyzed using SPSS software version 21. Results: Among all patients, 61% underwent laparoscopy, 30% required conversion of laparoscopy to laparotomy, and the rest (9%) underwent laparotomy. The median follow-up time was 45 (range 25 - 87) months. RCC mostly occurred in men, while LCC predominantly affected women (P = 0.04). Overall survival (P = 0.45), recurrence (P = 0.85), and metastasis (P = 0.77) were similar between the RCC and LCC groups. In both groups, the tumor stage had a significant impact on the overall survival. Conclusions: Our long-term follow-up of patients indicates that overall survival, recurrence, and metastasis are similar between RCC and LCC. However, lymphatic, vascular, and perineural invasions were more common in RCC.