Leveraging learning systems to improve quality and patient safety in allergen immunotherapy.

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Iron Deficiency Anemia as a Potential Risk Factor for Unprovoked DVT in Young Patients: A Case Series.

Deep vein thrombosis (DVT) is a serious and potentially life-threatening condition due to the occurrence of pulmonary embolism (PEs) in the acute phase. DVT can be provoked or unprovoked. Provoked DVT can be associated with transient or persistent causes. Iron deficiency anemia (IDA) with reactive thrombocytosis can act as a prothrombotic condition. We present two case reports of lower limb DVT which was associated with moderate anemia. Association between IDA and thrombosis has been reviewed.

Methods to engage patients in the modern clinic.

OBJECTIVE: To identify current patient and provider engagement methods that use technology in allergy and immunology clinics, in hospitals, and at home. DATA SOURCES: Apple App Store and Google searches for allergy and immunology technology applications and PubMed search of literature involving keywords of website, technology, electronic health record, medical devices, disparity in technology, coding for remote patient monitoring, and artificial intelligence. STUDY SELECTIONS: Studies that addressed the keywords were included and narrowed down based on their applicability in the allergy and immunology clinic. RESULTS: There has been rapid innovation in the digital health care space with expansion of electronic medical record services and the patient portal, creation of allergy and immunology-specific medical devices and applications with remote patient monitoring capabilities, and website and artificial intelligence development to interact with patients. CONCLUSION: These technological advances provide distinct advantages to the provider and patient but also have a burden of time for evaluation of the data for the provider and disparate access to certain technologies for patients. The development of these technologies has been fast-tracked since the start of the coronavirus disease 2019 pandemic. With the explosion in telehealth and medical device development, advancement of medical technology is not revealing any signs of slowing down. It is paving a new way to interact with patients in the future.

Asthma care during COVID-19: differences in attitudes and expectations between physicians and patients.

OBJECTIVE: The aim of this study was to explore differences in attitudes, behaviors and expectations related to COVID-19 between physicians and patients with asthma. METHODS: An anonymous survey was distributed through email and social media to adult patients with asthma during a three-week period in April-May 2020. A separate survey was sent to physicians. The surveys asked about demographic information, specific challenges and concerns due to COVID-19, and attitudes/behaviors during this time. RESULTS: A total of 1171 patients and 225 physicians completed the surveys. Overall, patients with asthma and physicians had large differences in expectations related to COVID-19. Patients were more likely than physicians to believe that individuals with asthma are at a higher risk to get COVID-19 (37.5% vs. 12.0%, p < 0.001), have increased anxiety due to COVID-19 (79.6% vs 70.0%, p = 0.002), and should not go to work (62.7% vs 11.9%, p < 0.001). Neither patients nor physicians felt confident they could distinguish COVID-19 symptoms from asthma (61.2% and 74.5% did not feel confident, respectively). Patients with severe asthma were significantly more impacted by the pandemic (e.g., became unemployed [OR 2.15], had difficulty getting asthma medications [OR 2.37]) compared to those with nonsevere asthma. CONCLUSION: Patients with asthma and their physicians have markedly different attitudes and opinions regarding care during the COVID-19 pandemic. Such differences have important implications when providing patient-centered care.Supplemental data for this article can be accessed at publisher's website.

Post-COVID Interstitial Lung Disease - The Looming Epidemic.

INTRODUCTION: As India recovers from the two waves of the Covid-19 pandemic, its sequelae are posing a new challenge to the physician. These may vary from fatigue and myalgia to persistent, and even worsening breathlessness, due to pulmonary fibrosis. Management of post-COVID-19 pulmonary fibrosis is currently limited to symptomatic management and largely an unexplored aspect. OBJECTIVES: To draw attention to the imminent threat of post-COVID-19 interstitial lung disease (PC-ILD) in COVID survivors through a case series. METHODS: A retrospective analysis of data was done in patients admitted with severe COVID in December 2020 at our tertiary care hospital, and who had a prolonged stay with symptoms and signs suggestive of pulmonary fibrosis. HRCT was done to make a diagnosis of pulmonary fibrosis or ILD. Three such patients were identified. RESULTS: All the three cases were laboratory proven SARS CoV-2 positive cases and had developed pulmonary fibrosis, with traction bronchiectasis, termed here as PC-ILD (Post Covid-Interstitial Lung Disease). Two of them survived and had improved oxygen saturation on room air at three-month follow-up, while one patient had developed arrhythmia and died. CONCLUSION: PC- ILD is one of the emerging complications of COVID-19 pneumonia. A proactive follow-up programme should be undertaken to identify and manage this looming epidemic.

Pancreatic Injury in COVID-19 Patients.

BACKGROUND AND AIM: Coronavirus disease 2019 (COVID 2019) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause multisystem dysfunction. We studied pancreatic injury (serum amylase and serum lipase levels) in COVID-19 patients. METHODS: A retrospective study involving 42 COVID-19 patients (diagnosed by real-time PCR) admitted to a tertiary care hospital was conducted. Serum amylase and serum lipase levels were analysed in relation to severity of COVID-19 and mortality. RESULTS: Mean age of patients was 50 ± 16 years, with male to female ratio of 3.7:1. Serum amylase was elevated in 14 patients (33%). Serum lipase was elevated in 7 out of 29 patients (24.1%). Mortality was seen in 18 patients (42.8%). Serum amylase or lipase did not correlate with severity of COVID-19 or its mortality. However, both patients who had high lipase (>3times) died. CONCLUSION: The prevalence of hyperamylasemia in patients of COVID-19 was 33%, while that of elevated lipase was 24.1%. Pancreatic injury failed to show any statistically significant relation to severity or outcome of COVID-19.

Neuromodulation with single-element transcranial focused ultrasound in human thalamus.

Transcranial focused ultrasound (tFUS) has proven capable of stimulating cortical tissue in humans. tFUS confers high spatial resolutions with deep focal lengths and as such, has the potential to noninvasively modulate neural targets deep to the cortex in humans. We test the ability of single-element tFUS to noninvasively modulate unilateral thalamus in humans. Participants (N = 40) underwent either tFUS or sham neuromodulation targeted at the unilateral sensory thalamus that contains the ventro-posterior lateral (VPL) nucleus of thalamus. Somatosensory evoked potentials (SEPs) were recorded from scalp electrodes contralateral to median nerve stimulation. Activity of the unilateral sensory thalamus was indexed by the P14 SEP generated in the VPL nucleus and cortical somatosensory activity by subsequent inflexions of the SEP and through time/frequency analysis. Participants also under went tactile behavioral assessment during either the tFUS or sham condition in a separate experiment. A detailed acoustic model using computed tomography (CT) and magnetic resonance imaging (MRI) is also presented to assess the effect of individual skull morphology for single-element deep brain neuromodulation in humans. tFUS targeted at unilateral sensory thalamus inhibited the amplitude of the P14 SEP as compared to sham. There is evidence of translation of this effect to time windows of the EEG commensurate with SI and SII activities. These results were accompanied by alpha and beta power attenuation as well as time-locked gamma power inhibition. Furthermore, participants performed significantly worse than chance on a discrimination task during tFUS stimulation.

Effects of transcranial focused ultrasound on human primary motor cortex using 7T fMRI: a pilot study.

BACKGROUND: Transcranial focused ultrasound (tFUS) is a new non-invasive neuromodulation technique that uses mechanical energy to modulate neuronal excitability with high spatial precision. tFUS has been shown to be capable of modulating EEG brain activity in humans that is spatially restricted, and here, we use 7T MRI to extend these findings. We test the effect of tFUS on 7T BOLD fMRI signals from individual finger representations in the human primary motor cortex (M1) and connected cortical motor regions. Participants (N = 5) performed a cued finger tapping task in a 7T MRI scanner with their thumb, index, and middle fingers to produce a BOLD signal for individual M1 finger representations during either tFUS or sham neuromodulation to the thumb representation. RESULTS: Results demonstrated a statistically significant increase in activation volume of the M1 thumb representation for the tFUS condition as compared to sham. No differences in percent BOLD changes were found. This effect was spatially confined as the index and middle finger M1 finger representations did not show similar significant changes in either percent change or activation volume. No effects were seen during tFUS to M1 in the supplementary motor area or the dorsal premotor cortex. CONCLUSIONS: Single element tFUS can be paired with high field MRI that does not induce significant artifact. tFUS increases activation volumes of the targeted finger representation that is spatially restricted within M1 but does not extend to functionally connected motor regions. Trial registration ClinicalTrials.gov NCT03634631 08/14/18.

Papillary muscle rupture following acute myocardial infarction: Anatomic, echocardiographic, and surgical insights.

Papillary muscle (PM) rupture is a rare complication of acute myocardial infarction which carries an excessive mortality rate. Optimal outcomes require rapid diagnosis and prompt surgical referral, and in this regard, echocardiography plays a crucial role. Comprehensive echocardiographic examination of the patient with PM rupture consists of identification of the ruptured PM segment, visualization of flail mitral valve segment(s), evaluation of mitral regurgitation severity, and assessment of left ventricular systolic function. This article discusses anatomic and echocardiographic features as well as the surgical management of PM rupture.

The Role of Patient Satisfaction Scores in Clinical Care and Physician Wellness.

Patient satisfaction scores have become an integral part of the vocabulary of medical practitioners. Patient satisfaction scores are a domain far ignored, but which have recently gained prominence as patients have demanded a fair share of their own assessments of their medical caregivers. This has created a complex interplay of meeting patients' demands and satisfying their wants and needs, which at times may not completely align with the best possible approach to management and standard of care algorithms. Here we present a commentary on patient satisfaction scores and their impact on physician well-being. We present historical aspects from both patient and provider perspectives and how they vary in private versus academic practice, and create some guidance for future refinement and implementation of these scores to serve two purposes: first, to allow for optimal doctor-patient relationships; and second, to enhance overall satisfaction for the patient as well as the physician.

Electrochemical Sensors for Detection of Phytomolecules: A Mechanistic Approach.

High demand and ongoing technological advancements have created a market for sensors that is both varied and rapidly evolving. Bioactive compounds are separated systematically to conduct an in-depth investigation, allowing for the profiling or fingerprinting of different Plantae kingdoms. The profiling field is significant in elucidating the complex interplay of plant traits, attributes, and environmental factors. Flexible technology advancements have enabled the creation of highly sensitive sensors for the non-destructive detection of molecules. Additionally, very specialized integrated systems that will allow multiplexed detection by integrating many hybrid approaches have been developed, but these systems are highly laborious and expensive. Electrochemical sensors, on the other hand, are a viable option because of their ability to accomplish exact compound detection via efficient signal transduction. However, this has not been investigated because of some obstacles to learning minimum metabolites' fundamentals and nonredox properties. This article reviews the electrochemical basis of plants, contrasting it with more conventional techniques and offering both positive and negative perspectives on the topic. Because few studies have been devoted to the concept of merging the domains, we've expanded the scope of this work by including pertinent non-phytochemical reports for better report comparison.

A Diagnosis of Sheehan's Syndrome: Better Late Than Never.

A middle-aged woman presented with history of fatigue, low mood, swelling of limbs, and facial puffiness. On detailed history taking, she also complained of salt craving, secondary amenorrhea, and loss of libido for almost a decade. Investigations revealed pan-hypopituitarism. She was started on appropriate hormonal therapy which saw a rapid resolution of symptoms within 2 weeks. Sheehan's syndrome may have an acute presentation or chronic. The symptoms may be subtle like fatigue or overt like hypotension and syncope. A high degree of suspicion of Sheehan's syndrome is essential for its timely management, and goes a long way in preserving the quality of life.

Breakthrough COVID-19 Infection Among the General Community, Frontline Workers, and Healthcare Workers During the Second and Third Wave in North India: A Longitudinal Study.

BACKGROUND: Vaccination is among the most important public health tools for preventing the harm caused by communicable diseases. This was particularly true in the case of COVID-19 vaccination during the COVID-19 pandemic. However, no vaccine is 100% effective, and all carry the risk of breakthrough infection in vaccinated individuals. METHODOLOGY: This longitudinal observational study was done on COVID-19-vaccinated individuals at a vaccination site in a tertiary care hospital. The study participants were categorized into the general community, frontline workers, and healthcare workers and were followed up during the study period from June 2021 to May 2022 post-vaccination. They were interviewed by telephone regarding adverse effects and breakthrough infections post-vaccination during the second and third wave of the COVID-19 pandemic in India. Incidence of breakthrough infection was calculated in all three categories after they received their first, second, and booster doses of vaccination. RESULTS: Fever was the most common adverse effect among all the categories of participants after the first and second doses. Incidence of breakthrough infection after the second dose of vaccination among frontline workers (RR: 5.7, 95% CI: 0.7-44.2) and healthcare workers (RR: 18.9, 95% CI: 2.6-138.6) was observed to be higher compared to the general community, but no such difference was observed among the three categories after the first dose of vaccination. CONCLUSIONS: The incidence of breakthrough infection was found to be the highest in healthcare workers, followed by frontline workers compared to the general community, justifying their work profile and the risk associated with it.

Allergic Diseases and Mental Health.

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

The Impact of Prior Authorization on Clinical Practice and Patient Care Outcomes: A Work Group Report of the AAAAI Prior Authorization Task Force.

The Prior Authorization Task Force of the American Academy of Allergy, Asthma & Immunology (AAAAI), a presidential initiative of David Khan, MD, FAAAI, was established to develop an AAAAI position statement outlining ways to improve health care for our patients, to support legislation that advocates for prior authorization (PA) reform and identify the impact PA has on its membership using a questionnaire survey. This article describes the results of this survey. An electronic anonymous survey questionnaire was developed to assess the impact and burden of PA on AAAAI members and their staff and patients. Surveys were sent to randomly selected members and fellows of the AAAAI in the United States. Descriptive statistics were used to analyze the results by the Information Services team of the AAAAI and the authors of this work group report. The questionnaire responses from allergy immunology specialists demographically reflected the AAAAI membership and indicate that PAs can significantly affect patient care delivery and increase administrative burden to clinical practices, leading to serious adverse events in some circumstances. Differential responses regarding PAs for various medication classes likely reflect the physician's patient population, which can shift prescribing patterns. Prior authorization is a serious health care problem that is wasting financial resources and needlessly placing patients in danger when they are unable to access medications or medical services required for clinical management. The results of this questionnaire study support the recommendations made in the recent AAAAI position statement on PA.