Beliefs, Practices, and Self-efficacy of US Physicians Regarding Smoking Cessation and Electronic Cigarettes: A National Survey.

INTRODUCTION: We sought to assess physician knowledge/beliefs, self-efficacy, and experience/practice patterns surrounding smoking cessation and electronic cigarettes. METHODS: An eight-page survey sent via US Postal service. The initial invitation included a $10 cash incentive and up to three invitations were sent. Fifteen hundred US physicians were identified with equal representation from primary care physicians (internal medicine and family practice), surgical care physicians (general surgeons and anesthesiologists), and pulmonologists. RESULTS: Two hundred fourteen were not included in the analysis (183 non-deliverable, one deceased, 30 not practicing). 561/1286 (44%) remaining surveys were returned for analysis. Greater than 90% agreed that advising and assisting with smoking cessation is their responsibility; 86% advise and 65% assist their patients with smoking cessation more than 75% of the time. Approximately two-thirds of respondents report that their patients ask them about electronic cigarettes at least some of the time (≥25%); 58.4% report that they ask their patients about electronic cigarette use at least some of the time. Overall, 37.9% have at some point recommended electronic cigarettes to their patients that smoke, with 11.5% reporting recommending them at least 25% of the time. Surgical care providers appear less confident and less self-efficacious with smoking cessation, as well as with electronic cigarettes and appear less likely to endorse use of electronic cigarettes. DISCUSSION: US physicians are frequently discussing electronic cigarettes in a clinical context and a substantial proportion of US physicians have recommended electronic cigarettes to their patients. IMPLICATIONS: This study documents several important previously poorly characterized aspects of the role of electronic cigarettes in clinical care. The majority of US physicians are discussing electronic cigarettes in clinical contexts and a substantial proportion of US physicians have recommended electronic cigarettes to their patients. The extent of physician engagement on the topic of electronic cigarettes should be met with increased efforts to better characterize electronic cigarettes' appropriate role in smoking cessation and reduction.

Evaluation of exhaled nitric oxide's ability to predict methacholine challenge in adults with nonobstructive spirometry.

BACKGROUND: Compared with methacholine challenge, exhaled nitric oxide is less expensive, is performed as a simpler point-of-care maneuver, and may provide treatment guiding information. OBJECTIVE: To determine whether exhaled nitric oxide levels can predict the outcome of methacholine challenge in patients without obvious baseline obstruction. METHODS: This retrospective database and medical record review included adults presenting to a tertiary care center from November 1, 2009, through August 31, 2013, who underwent methacholine challenge and exhaled nitric oxide measurement within 2 weeks of each other. Database extraction identified age, sex, body mass index, baseline corticosteroid use, testing indication, forced expiratory volume in 1 second (FEV1), and testing results. Individuals taking corticosteroid-containing medication or who had an FEV1 less than the lower limit of normal at baseline were excluded. RESULTS: A total of 1,322 individuals were identified, with 774 meeting the eligibility criteria. A total of 123 methacholine challenges (16%) had positive results. Fractional exhaled nitric oxide was statistically higher in those with positive methacholine challenge results (mean [SD], 41.9 [54.5] ppb vs 25.2 [19.7] ppb; P < .01). Receiver operating characteristic curve revealed an area under the curve of 0.572 (P < .01), suggesting a poor correlation between exhaled nitric oxide level and methacholine challenge outcome. Fractional exhaled nitric oxide of greater than 50 ppb has a sensitivity, specificity, positive predictive value, and negative predictive value of 12%, 89%, 17%, and 84%, respectively, for a positive methacholine challenge result. CONCLUSION: In this large, retrospective cohort of corticosteroid-naive pulmonary patients with normal FEV1 on baseline spirometry, exhaled nitric oxide poorly predicts the outcome of a methacholine challenge.

Can Parents Refuse a Potentially Lifesaving Transplant for Severe Combined Immunodeficiency?

If untreated, most children with severe combined immunodeficiency disorder (SCID) will die of complications of infection within the first 2 years of life. Early hematopoietic stem cell transplant (HSCT) is the current standard of care for this disease. Although potentially lifesaving, prognosis of HSCT in SCID is variable depending on a number of host and donor factors. Of the survivors, many develop secondary problems such as chronic graft-versus-host disease or even second malignancies. Posttransplant care is complex and requires great effort from parents to adhere to difficult treatment regimens. In this article, we address the difficult ethical question of what to do if parents choose not to have their child with SCID undergo HSCT but prefer palliative care.

A rare combination of undiagnosed hypertrophic cardiomyopathy revealed by intraoperative anaphylaxis resulting in acute left ventricular outflow obstruction and cardiac arrest.

A 75-year-old female presented for left total hip reimplantation and suffered pulseless electrical activity arrest upon lateral positioning and administering vancomycin. Resuscitation was achieved according to Advanced Cardiac Life Support protocol. Post-event echocardiography showed hypertrophic cardiomyopathy with asymmetrical septal thickening, an under-filled left ventricle, dynamic left ventricular outflow obstruction, and severe mitral regurgitation related to systolic anterior motion of the mitral valve. Laboratory analysis showed a tryptase level of 209 ng/mL. After multispecialty evaluation, it was concluded that the patient's arrest was due to vancomycin anaphylaxis in the setting of previously undiagnosed hypertrophic cardiomyopathy leading to acute left ventricular outflow tract obstruction. After medical optimization of the patient's cardiomyopathy and an evaluation of potential intraoperative allergic triggers, the patient underwent a successful hip reimplantation without incident. This case presents a novel combination of events leading to intraoperative cardiac arrest. Rapid identification and an understanding of the cause(s) of cardiac arrest in this setting are critical for effective perioperative care.

Pediatric Resident Preparedness and Educational Experiences With Informed Consent.

OBJECTIVE: Informed consent is an essential component of optimal patient care. Scant data exist about pediatric residents' experiences, comfort level, and educational exposure to informed consent discussions. METHODS: Electronic survey of a random selection of members of the American Academy of Pediatrics Section for Medical Students, Residents, and Fellows regarding consent practices and processes for 5 commonly encountered pediatric procedures/situations: lumbar puncture, neonatal central line, pediatric sedation, intubation, and administration of blood products. RESULTS: Overall response rate was 34.7% (1071 participants of 3084 invited). Responses from 622 active categorical pediatric residents were analyzed. Almost all respondents (99%) endorsed the importance of informed consent for best patient care. Observation was the most frequently reported educational modality. Over 90% had obtained consent for lumbar puncture and blood products but only 27.6% for intubation. Between 9% and 31% of respondents reported obtaining consent for specific procedures in which they were not expected to actively participate. Depending on the procedure, a variable number of respondents reported not feeling prepared to discuss the benefits (1-23%) or risks (2-31%) of these procedures with patients and/or parents. Respondents felt significantly less prepared to discuss risks (P < .05 for each procedure). CONCLUSIONS: A significant percentage of respondents reported not feeling comfortable with discussing key components of informed consent. A minority of respondents reported being engaged in obtaining consent for procedures in which they are not expected to actively participate. Best practices for resident involvement in informed consent discussions need to be defined and incorporated into resident education.

Innovations in technology: social media and mobile technology in the care of adolescents with asthma.

This literature review analyzed technological interventions in the adolescent asthmatic population. A PubMed search was performed with terms of asthma, adolescents, social media, Internet, website, mobile phone, text messaging, SMS, Facebook, Twitter, MySpace, and Technology during a 2.5-year period and identified 64 abstracts. Three studies fulfilled the criteria for adolescent intervention using Internet-based sites but did not provide evidence for effectiveness. Two studies focused on mobile technology. One study included text message reminders for controller medication use in asthma patients. Perceived usefulness, satisfaction, and ease of use of text messages were high, but there was no improvement in asthma control. The literature search did not find any studies exploring the use of smartphone applications or social media services. Current studies of technology use in adolescents with asthma do not provide consistent evidence of effectiveness. The positive attitude toward use of social media or mobile technology opens the possibility for future studies to further explore the potential benefits of such interventions.