Management Questions Research Articles

Can ChatGPT 4.0 reliably answer patient frequently asked questions about boxer's fractures?

Patients are increasingly turning to the internet, and recently artificial intelligence engines (e.g., ChatGPT), for answers to common medical questions. Regarding orthopedic hand surgery, recent literature has focused on ChatGPT's ability to answer patient frequently asked questions (FAQs) regarding subjects such as carpal tunnel syndrome, distal radius fractures, and more. The present study seeks to determine how accurately ChatGPT can answer patient FAQs surrounding simple fracture patterns such as fifth metacarpal neck fractures. Internet queries were used to identify the ten most FAQs regarding boxer's fractures based on information from five trusted healthcare institutions. These ten questions were posed to ChatGPT 4.0, and the chatbot's responses were recorded. Two fellowship trained orthopedic hand surgeons and one orthopedic hand surgery fellow then graded ChatGPT's responses on an alphabetical grading scale (i.e., A-F); additional commentary was then provided for each response. Descriptive statistics were used to report question, grader, and overall ChatGPT response grades. ChatGPT achieved a cumulative grade of a B, indicating that the chatbot can provide adequate responses with only minor need for clarification when answering FAQs for boxer's fractures. Individual graders provided comparable overall grades of B, B, and B+ respectively. ChatGPT deferred to a medical professional in 7/10 responses. General questions were graded at an A-. Management questions were graded at a C+. Overall, with a grade of B, ChatGPT 4.0 provides adequate-to- complete responses as it pertains to patient FAQs surrounding boxer's fractures.

Scrambling (for) Time: Experimental Diaries and Feminised Work

ABSTRACT This article examines a variety of diaristic experiments, in prose and comics form, that explore conditions of feminised, precarious work. It argues that, as working conditions historically associated with women become more widespread as forms of precarious, pervasive work, questions of time management, time famine, and optimisation are central to experiences of making a living. To investigate these temporal issues, the article compares two recent experimental prose diaries—‘From my Diaries (2006-2010) in Alphabetical Order’ (2014) by Sheila Heti and The Folded Clock by Heidi Julavits (2015)—and a number of diary comics first published on Instagram as part of the 2023 Hourly Comic Day. The different ways of manipulating key tenets of the diary form, dailiness and chronological sequence, are shown to explore the temporal paradoxes of feminised working conditions, as the diarists make art from life. Scrambling for time to create, the article demonstrates, prompts the writers and artists under discussion to scramble time in their artistic practices. To support this reading, the article draws on previous work on diaries as a feminised form, as well as recent discussions of the lyric diary, diary comics, and their overlaps with lyric poetry.

Dissolved oxygen criteria attainment in Chesapeake Bay: Where has it improved since 1985?

Many estuaries, including Chesapeake Bay, have suffered from undesirable conditions of algae blooms, poor water clarity, and low dissolved oxygen (DO). To better understand the status and trends of DO criteria attainment deficit (AD), we conducted a comprehensive assessment using monitoring data in the period of 1985–2022 and focused on the comparison of trends among 13 tidal systems. Our results provide timely and updated information to help address a critical management question, i.e., where has the DO criteria attainment improved since 1985? The overall AD showed statistically significant improvements in both the long term (1985–2022) and the short term (2006–2022), which can be mainly attributed to open water and deep channel designated uses, respectively. Among the 13 tidal systems, ten showed improving trends in the long term, with Mainstem Bay, Pocomoke, Potomac, and Tangier having statistically significant improvements. Over the short term, nine systems showed improving trends, with Chester and Upper Mainstem Bay tributaries having statistically significant improvements. The only statistically significant degrading trend was observed in York. In addition, a report card summary was produced to provide a concise depiction of the trends for the 13 systems and illustrate how their trends are affected by the designated uses, which is the first of its kind in the context of DO criteria assessment. These spatially explicit results can help target locations for further assessment and restoration. Although many of the systems and their applicable designated uses have not improved over time, the detected significant improvements in some systems present new evidence on ecosystem recovery in the context of DO criteria attainment. Overall, this work highlights the combined value of collecting long-term water-quality monitoring data and developing scientific assessment approaches, which is fundamental to understanding the status and trends of complex ecosystems, including Chesapeake Bay and other estuaries.

Performance of generative pre-trained transformer-4 on the certification test for mental health management: A factorial design

This study aimed to investigate the performance of generative pre-trained transformer-4 (GPT-4) on the Certification Test for Mental Health Management and whether tuned prompts could improve its performance. This study used a 3 × 2 factorial design to examine the performance according to test difficulty (courses) and prompt conditions. We prepared 200 multiple-choice questions (600 questions overall) for each course using the Certification Test for Mental Health Management (levels I-III) and essay questions from the level I test for the previous four examinations. Two conditions were used: a simple prompt condition using the questions as prompts and tuned prompt condition using techniques to obtain better answers. GPT-4 (gpt-4-0613) was adopted and implemented using the OpenAI API. The simple prompt condition scores were 74.5, 71.5, and 64.0 for levels III, II, and I, respectively. The tuned and simple prompt condition scores had no significant differences (Odds ratio = 1.03, 95% Confidence interval; 0.65-1.62, p = 0.908). Incorrect answers were observed in the simple prompt condition because of the inability to make choices, whereas no incorrect answers were observed in the tuned prompt condition. The average score for the essay questions under the simple prompt condition was 22.5 out of 50 points (45.0%). GPT-4 had a sufficient knowledge network for occupational mental health, surpassing the criteria for levels II and III tests. For the level I test, which required the ability to describe more advanced knowledge accurately, GPT-4 did not meet the criteria. External information may be needed when using GPT-4 at this level. Although the tuned prompts did not significantly improve the performance, they were promising in avoiding unintended outputs and organizing output formats. UMIN trial registration: UMIN-CTR ID = UMIN000053582.

Green Manufacturing for a Green Environment from Manufacturing Sector in Guangdong Province: Mediating Role of Sustainable Operations and Operational Transparency

This work investigates the manufacturing operations of focal firms to manage the enhancement of environmental sustainability (EnS). To achieve this, indirect and direct effects of operational transparency (OPT) and sustainable operations (SUP) between environmental business practices (EBPr) and EnS are proposed. By leveraging the resource-based view theory, this study seeks to clarify how integrating transparency and sustainable operations can enhance a firm’s ability to manage environmental challenges effectively. Aligning environmental business practices with sustainable operations and transparency concepts appears to be an appropriate choice for environmental sustainability. A well-designed questionnaire was formed and used to collect the observations from 1214 focal firms. FsQCA and SEM approaches are employed to analyze one of the research questions of operations management: How do OPT and SUP mediate the effects of EBPr on the environmental sustainability of a firm? The final results clarify that the indirect effects of OPT and SUP significantly completely exist and are positive. The findings describe that firms with operational transparency and sustainability perform well in resolving operational and sustainable issues.

Post-esophagectomy patients presenting for general anesthesia induction: a survey of practice among US anesthesiologists (PESO-GAIN-S).

Following esophagectomy, annually several thousand patients in the United States (US) reach a stable post-esophagectomy status. Such patients may require general anesthesia (GA) for elective procedures, but no generally accepted guidelines exist for the induction of GA in post-esophagectomy patients. A national survey describing a post-esophagectomy patient was emailed to 23,524 attending anesthesiologists who were members of the American Society of Anesthesiologists. The survey included 3 demographic and 12 anesthetic management questions. Responses were further stratified by gender, years in practice and frequency of exposure to the patient population of interest. A total of 744 (3.2%) respondents completed the survey. The respondent demographic characteristics closely reflected recent US anesthesiology workforce analyses. Endotracheal tube was the preferred method of airway management for 648 (87.1%), 419 (64.7%) used a rapid sequence induction, and 504 (67.7%) elected a reverse Trendelenburg position, withthe latter two choices being favored among anesthesiologists with routine (vs. rarely/never) exposure to post-esophagectomy patients (76.6% vs. 58.4%; p < 0.001; and 73.6% vs. 63.9%; p = 0.021, respectively). Across survey participants, induction of GA was highly variable with differential effects of gender, years in practice and exposure frequency to post-esophagectomy patients. US attending anesthesiologists' approach to induction of GA in a patient with a history of successful esophagectomy was not uniform. The majority of responses reflected a concern for aspiration in such a patient. Considering surgical and non-surgical upper gastrointestinal changes, establishment of practice guidance to optimize perioperative care is an unmet need.

Morphological and fish mesohabitat dynamics following an experimental flood under different sediment availability

AbstractExperimental floods have been increasingly used as a promising practice to rehabilitate river ecosystems downstream of dams; however, the morphological and habitat dynamics they determine under different sediment supply conditions still poses relevant research and management questions. This study investigates the morphological and fish mesohabitat dynamics following an experimental flood, in two river reaches subject to different sediment supply regimes. We chose the lower Spöl River (Switzerland) as a relevant case study, subject to an experimental flood program for several years. Downstream of the dam, a tributary supplies large amounts of sediment to the Spöl dividing the study area into two homogeneous reaches with different sediment availability but similar flow conditions during the experimental flood. We analyzed and quantified the changes in morphology and fish habitat suitability for the Brown Trout (Salmo trutta) at the mesoscale in these two reaches caused by the 2021 experimental flood, which lasted 11 h and had a peak magnitude corresponding to a 1‐year return interval in the pre‐dam flow regime. We found almost no correlation between changes in the channel morphology and in habitat suitability for this event. In the upstream reach, located immediately downstream of the dam, we observed a narrower channel with a regular longitudinal sequence featuring nearly immobile coarse rapids, interspersed with more dynamic, finer riffles. Here, reach‐scale morphodynamics and the shifts of the mesohabitat mosaic and the suitable habitats were below 10%. Conversely, the downstream reach, characterised by a wider channel and much higher sediment supply of well‐sorted, finer bed material, was dominated by alternate bar instability and migration at the reach scale, which caused a 45% shift in its pre‐flood habitat mosaic. Nevertheless, in the same reach, the overall suitability of habitats remained relatively unchanged. We attributed these different dynamics to two main factors: (i) more prolonged bedload mobility conditions and (ii) the occurrence of bar migration in the downstream reach compared to the upstream one. This study (i) underscores the critical importance of considering sediment supply from downstream tributaries when designing and monitoring the effects of experimental floods, (ii) supports the use of morphodynamic models in the related planning and monitoring phases and (iii) shows the relevance of integrating morphodynamics and eco‐hydraulic analysis to support the implementation of such flow restoration programs.

Improved Information Exchange as an Advanced Governance Tool

Whereas many organisations focus on the optimal functioning of their processes to achieve their goals, we nowadays see organisational challenges spreading to their functioning within networks. This poses a significant question for management and leadership: Are their decisions shaping or controlling their own or the network partners’ functioning? However, modern networks grant partners autonomy to make their choices, believing that the collective outcome of these autonomous decision processes can also yield results. However, cooperative decision-making between network partners is pivotal in today's society. Finding a balance between control over the network, autonomy of the partners and cooperation between them leads to what is often referred to as the emergent behaviour of the network. So, 'context is leading' requires reacting fast and efficiently to become a resilient organisational network. It is becoming evident that the resilience within network functioning lies in the exchange of information and data availability. In current practice, partners often seek solutions by striving for unity of language and/or data dictionaries. Unfortunately, this approach doesn’t lead to optimal results in day-to-day practice. We propagate the adoption of a different approach. This article presents a non-invasive perspective on micro-contexts and their emerging information systems. By engaging these systems in their current form through formalised abstractions, we suggest effectively linking information and data sources to enhance information exchange and data availability. Improving information exchange will show itself instantly as an advanced governance tool

Toward an improved causal test of network effects: Does alliance network position enhance firm innovation?

AbstractResearch SummaryAssessing whether network position causes firm outcomes is difficult because networks result from firms' strategic choices. To address this issue, we develop a research design that separates self‐driven network change from other‐driven change. Because other‐driven change suppresses the focal firm's agency, outcomes resulting from it can be interpreted as causal—under verifiable assumptions. We apply this method to reassess whether alliance network position affects firm innovation. Using data from the biotechnology industry, we find that structural holes (but not closure) increase firm innovation when self‐driven network change is involved but not when other‐driven change is involved. This raises two possibilities: network effects spuriously capture unobservable firm characteristics or network theories must be updated to account for agency.Managerial SummaryWe examine a crucial question for managers making decisions about alliance networks: Does a firm's position in its alliance network drive innovation, or is it a reflection of the firm's inherent qualities? Our research explores this question by examining network changes outside a firm's control. We find that bridging disconnected partners (structural holes) enhances innovation, but only when firms actively create these positions and not when these positions result from others' actions. Our findings suggest that network position alone does not drive innovation. Acknowledging that network position, per se, is not advantageous provides nuanced insight to better guide managerial decisions.

Holding Stakes in Water Management and Irrigation in Morocco : PIM policy Effects

The main policy reforms concerning irrigation management in Morocco over the last thirty years have been the introduction of mechanisms aimed at achieving financial autonomy of the Administration in charge of irrigation systems managemement -Offices Régionaux de Mise en Valeur Agricoles (ORMVA)- by applying appropriate water pricing and involvement of water users in the operation and maintenance of their irrigation systems, by transferring some responsibilities to water users' associations (AUEA). These policy reforms were presented by the World Bank projects (PAGI1 and PAGI 2) as crucial steps that Morocco should take to improve the productivity and sustainability of its irrigation sector. After more than thirty years, implementation of these reforms has been fraught with difficulties and many delays. Results and impacts are very timid and vague. The Moroccan GPI experience shows that an “ingredient” was missing to drive change. In fact, setting up new local organizations to participate in irrigation management and calls for new institutional arrangements to tackle the huge problems of moroccan large scale irrigation sector is not sufficient to drive change. A profound realistic thinking on irrigation governance and large concertation between water users are needed to meet the challenges of water scarcity, climate change and water security in the country. This article assesses the participation of Water Users' Associations (AUEA) established in Tadla irrigated scheme in Morocco. It reviews the contxt of adoption of the Participatory Irrigation Management (PIM) policy in Morocco and re-examines the process of initiating and developing AUEAs in large irrigated perimeters, analyzing the specific case of the Beni Amir irrigation project. The questions of participatory planning and joint management are at the heart of our analysis.

Toward “climate-driven”: innovation on legislation of modern marine fisheries law under era of blue carbon

Abstract Over the past decade, there has been increasing interest in the blue carbon project, which uses marine activities and organisms to take up carbon dioxide from the atmosphere and store it in ocean. Important question in contemporary and future fisheries management is how to coordinate the relationship among the offshore fishery, the fisheries resource conservation and blue carbon projects. Through comparative studies and normative analysis, this study explores the legislative aims of some representative international and national fisheries legislation and their creative reforms in recent years. The legislative purpose of fisheries laws has traditionally been to keep fishery resources above the Maximum Sustainable Yield (MSY) standard, while marine carbon sink resource protection is marginally inadequate. Given that the blue carbon project is inseparable from future fisheries industry development, the protection of marine carbon sink resources needs to be incorporated into the legislative aim of fisheries law in the future.

Intensity or Duration: That Is the Main Question of the Exercise Training Management in Stroke-Induced Neurological Deficit - A Systematic and Meta-analysis Study

Background: The neurological assessment plays a crucial role in evaluating stroke patients and is a skill that has been practiced by physicians for a long time, and further refined by practitioners. The purpose of the current study was to systematically review and synthesize the evidence-based neurological assessment of the different methods of treadmill-related training protocols in stroke patients. Evidence Acquisition: In this study, the appropriate studies were documented (N = 1270) using PubMed as the sole electronic database. Moreover, subgroup studies were provided based on training intensity and duration, categorized as low intensity-low duration, low intensity-high duration, high intensity-low duration, and high intensity-high duration. Training intensities were standardized to meters per second (m/s), and the training duration was calculated in terms of minutes per session, the number of sessions per week, and the total number of training weeks, which were then converted into minutes. The assessment of neurological recovery following stroke was conducted using standard neurological assessment scales. Results: This meta-analysis in humans found a notably positive standardized mean difference in protocols with high intensity and high duration (1.792; 95% CI = 0.566 to 3.02). Conclusions: In conclusion, the current meta-analysis suggests that practitioners using the high intensity-high duration protocol should regularly monitor the neurological outcomes, as they may be negatively impacted by the intensity and duration of the protocol.

Partnership or battle

University libraries live and change through interaction with the scientific community or without essential interaction they fail to evolve and grow. This article studies the effects of collaboration between professors and librarians on the strategic development of libraries, especially during times of crisis. This study was conducted at the University of Helsinki (established in 1640). It is based mostly on historical sources, such as the annual reports of the university and faculties, and documents outlining plans and decisions. The first crisis phase took place in the 1820s, when a fire destroyed academic collections and facilities and the university was relocated from Turku to Helsinki. A conflict arose between the contemporary needs of the scientific community and the need for a main library to replace the collections. Another upheaval was caused by the growing need for services for the post-war baby boomer generation. Nationwide library planning aimed for the creation of a separate national library and for merging faculty libraries with the main library. The third crisis phase involved the Finnish economic crisis of the 1990s and the digital revolution that continued into the 2000s. Solutions were sought through cooperation between the academic leadership, library management and personnel. The crisis led to the organisation of library services into two large entities. The success of extensive changes in academic libraries is one of the key questions in management. The crisis periods under examination show that significant reforms are only possible through close partnerships between the library, the research community and academic decision-makers.

The effectiveness of enhanced reality simulation on postmastectomy patient care management provided by nursing students: a quasi-experimental study

AimThe aim of this study was to evaluate the effect of enhanced reality simulation on nursing students' learning satisfaction and self-confidence and patient care management knowledge and skills regarding postmastectomy care. BackgroundBreast cancer is a common disease with increasing incidence and mastectomy is the treatment of choice. Postmastectomy patient care is a multidimensional and complex process. For various reasons, nursing students today graduate with inadequate clinical skills and do not have experience with many cases. DesignThis quasi-experimental study was conducted using a pretest–posttest design with a nonequivalent control group. MethodsThis study was conducted with fourth-year nursing students (78 students). Students were allocated to each group through a simple random allocation using IBM SPSS Statistics version 24. Research data were collected at the Clinical Simulation Training Center of the university in 2020–2021 academic year. The study group (n=39) learned using a scenario-based learning approach with moulage in a real clinical setting using enhanced reality simulation, while the control group (n=39) learned using the same scenario-based approach with the routine practice adult standard patient care model. The data were collected through the “Student Sociodemographic and Descriptive Characteristics Data Collection Form”, the “Student Satisfaction and Self-Confidence in Learning Scale”, the “Postmastectomy Patient Care Skills Checklist” and the “Pre–Post Knowledge Test on Postmastectomy Patient Care Management”. ResultsAll 78 participants completed the training course. The training significantly increased the Student Satisfaction and Self-Confidence in Learning Scale subdimension scores of both groups (p<0.05). The Postmastectomy Patient Care Management scores of the study group students who received enhanced reality simulation training significantly increased (p<0.05), while there was no significant effect on the scores of the control group students (p>0.05). While most the students in the study group increased their rates of correct answers to Postmastectomy Patient Care Management questions significantly (p<0.05) after the enhanced reality simulation training, the students in the control group showed no significant improvement (p>0.05). The training significantly (p<0.001) increased the mean postmastectomy patient care skills control scores. This increase had a high effect size on the study group. ConclusionEnhanced reality simulation is a learning method that increases nursing students' learning satisfaction and self-confidence and patient care management knowledge and skills regarding postmastectomy care. Learning with enhanced reality simulation is an effective approach for nursing education that improves nursing students' learning satisfaction and self-confidence and patient care management knowledge and skills regarding postmastectomy care.

Surgical Management of Pediatric Dog Bites: A Systematic Review and Treatment Guideline

IntroductionDog bites are a unique and unusual injury in children, associated with atypical bacterial species, high infection rates, and controversial surgical treatment. Expert recommendations currently guide management and no surgical evidence-based guidelines exist. We conducted a systematic review to answer three management questions: (1) What are the best practices for wound management? (2) In what circumstances should prophylactic antibiotics be administered? (3) In what circumstances should rabies prophylaxis be given? MethodsA structured review was performed using a keyword search querying “pediatric” “dog bite” “management”. Results were reported according to the PRISMA methodology. The quality of nonrandomized studies was evaluated according to Methodological Index for Non-Randomized Studies (MINORS). Qualitative analysis was performed. ResultsA total of 803 studies were identified and 53 studies were included in the final analysis. Current literature suggests that primary closure of bites which are well irrigated and sharply debrided within 8 h of injury, is not associated with increased infection. While dog bites are associated with an overall high rate of infection (6–25 %), routine antibiotic prophylaxis in low-risk wounds does not lower that risk. Postexposure prophylaxis for rabies is indicated for all dog bites where the rabies status of the dog cannot be determined, or the animal cannot be quarantined for 10 days. ConclusionHigh-quality evidence regarding the surgical management of pediatric dog bites is limited. Trial data have demonstrated improved outcomes in wound healing and infection rates with a focus on copious irrigation and diligent wound debridement, although independent validation is needed. Level of EvidenceLevel II – systematic review.

The association between public managers' type of education and prioritizing core service provision and communication

AbstractAn important question in public management is whether public organizations should prefer or avoid specialist managers (i.e., managers whose professional backgrounds match the work they oversee). Research has shown that specialist managers are associated with better field‐specific performance in public organizations, and theory suggests that they lead differently than nonspecialist managers. However, there is no empirical evidence to support this latter claim. To remedy this, we investigate whether specialist managers prioritize core service provision more and communicate better than nonspecialist managers. Through multilevel regressions of employee reports of leaders' behaviors in the contexts of schools, eldercare, daycare, and employment, we find that specialist managers prioritize core service provision more in all contexts but schools and communicate better in eldercare and employment but not elsewhere. These findings are consistent with the theoretical expectations and thus emphasize the importance of educational background in shaping managerial behavior.

От погрома до обретения советской «земли Обетованной»: дисперсность, миграции и кон-солидация джегонасских горских евреев на Северном Кавказе (1917 г. – начало 1930-х гг.)

The article devotes itself to establishing and describing the key events in the “migration history” of the Dzhegonassko-Evreyskoe Mountain Jews. The problem is discussed in the context of this group’s post-revolutionary history, up until the beginning of the 1930s. The article analyzes the debatable issues of the fate of the devastated settlement of the Dzhegonas Jews in 1918 and in the subsequent period, their further dispersion on the North Caucasus territory. Additional evidence has been uncovered that confirms the residency of a large portion of this group of Mountain Jews in the village of Nevinnomysskaya, as well as their links to other groups of Mountain Jews. Addi-tional facts about the attempts of the Dzhegonas Jews to return to the lands of their old village in Karachay-Cherkessia in the first half of the 1920s have been revealed. It is shown how the ques-tion of land management of the Dzhegonas Jews turned out to be connected with the regular col-lection by the Soviet, Communist Party and other structures of a variety of accounting, statistical and other information about them (as well as about the Mozdok and Grozny mountain Jews). The forms and methods of consolidation of Dzhegonas Jews in the Soviet policy of indigenization of national minorities and the settlement of Terek District by mountain Jews organized by the au-thorities are studied.

Asymptomatic pediatric presentation of S-adenosylhomocysteine hydrolase deficiency.

S-adenosylhomocysteine hydrolase deficiency is an autosomal recessive inborn error of metabolism affecting methylation by disrupting the methionine cycle. Its clinical spectrum spans from severe perinatal encephalomyopathy and liver failure to asymptomatic course in patients with isolated hypermethioninemia. We present two new cases of S-adenosylhomocysteine hydrolase deficiency from Pakistani origin clinically asymptomatic at presentation. Both siblings showed mild chronic liver failure and elevation of creatine kinase. The older patient presented at 6 years of age with isolated verbal processing difficulty and mild diffuse leukodystrophy, reversible 12 months after introduction of methionine dietary restriction. The patient showed subtle atrophy in the muscle MRI at the age of 7 years. S-adenosylhomocysteine hydrolase deficiency was confirmed with homozygous missense variant c.146G>A (p.Arg49His) in the AHCY gene, a genotype previously reported in Pakistani patients with mild presentation. Dietary methionine restriction decreased plasma methionine but not plasma S-adenosylhomocysteine and S-adenosylmethionine. This work expands the mild spectrum of S-adenosylhomocysteine hydrolase deficiency with no noticeable clinical symptoms in children, highlighting a specific hotspot variant from South Asia. This mild form of the disease is likely underdiagnosed and raises the question of therapeutic management to prevent long-term complications documented in the literature, such as hepatocellular carcinoma and myopathy in early adulthood.

To the ER? Can Patients Treat Their Anaphylaxis at Home?

To discuss if all patients who use self-injectable epinephrine outside the hospital setting require immediate emergency care. Prior to 2023, anaphylaxis management guidance universally recommended that patients who use self-injectable epinephrine outside of the hospital or clinic setting immediately activate emergency medical services and seek further care. Additional food-induced anaphylaxis management recommendations specified that all patients always carry 2 auto-injector devices and give a second dose of epinephrine if there was not immediate response within 5min of injection. Patients presenting for emergency care after epinephrine are often observed for up to 4-6h afterwards, even when completely asymptomatic. These management steps have lacked evidence for improving outcomes, and universal implementation of these approaches is not cost-effective as guidance for food allergic patients. Epinephrine pharmacokinetics and pharmacodynamics suggest that peak physiologic response is more likely to occur closer to 15min than before 5min, that few patients require a second dose of epinephrine as most stabilize within 15min of use, that 60min of observation after a patient stabilizes after epinephrine use may be adequate as patients infrequently have further sequelae, and that not everyone needs to carry 2 epinephrine auto-injectors on their person at all times. The most recent anaphylaxis practice parameter promotes a contextualized approach to these management questions, outlining the option for watchful waiting to gauge response to epinephrine before seeking emergency care, which has been proven as a more cost-effective management strategy. The recent updated anaphylaxis care guidelines support the evolution of anaphylaxis care, in that universal, immediate activation of emergency services is not required for using self-injectable epinephrine outside the hospital setting.

Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN).

Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients.