JAK inhibitors for inflammatory bowel disease: recent advances.

Inflammatory bowel disease (IBD) commonly requires immunosuppressive treatments to induce and maintain durable remission. Janus kinase inhibitors (JAKis) are a novel group of orally administered, small molecule drugs that work by attenuating multiple cytokine signalling pathways to mediate dysregulated immune responses involved in the pathogenesis of IBD. Tofacitinib, filgotinib and upadacitinib have demonstrated efficacy against placebo and are licensed for the treatment of moderate to severe ulcerative colitis; upadacitinib is the only JAKi also currently approved for the treatment of Crohn's disease. Safety concerns stratified by age have led to class-wide regulatory restrictions for JAKi use across all inflammatory diseases. It is important for gastroenterologists managing patients with IBD to be aware of the key pivotal trial outcomes, to identify appropriate patients in whom to commence a JAKi, and to understand the safety considerations and ways to mitigate these risks in the patients they treat. This review provides a contemporaneous overview of this emerging therapeutic class and provides a practical guide for healthcare practitioners for initiating and monitoring JAKi in IBD.

Reassessing acquired neonatal intestinal diseases using unsupervised machine learning.

BACKGROUND: Acquired neonatal intestinal diseases have an array of overlapping presentations and are often labeled under the dichotomous classification of necrotizing enterocolitis (which is poorly defined) or spontaneous intestinal perforation, hindering more precise diagnosis and research. The objective of this study was to take a fresh look at neonatal intestinal disease classification using unsupervised machine learning. METHODS: Patients admitted to the University of Florida Shands Neonatal Intensive Care Unit January 2013-September 2019 diagnosed with an intestinal injury, or had imaging findings of portal venous gas, pneumatosis, abdominal free air, or had an abdominal drain placed or exploratory laparotomy during admission were included. Congenital gastroschisis, omphalocele, intestinal atresia, malrotation were excluded. Data was collected via retrospective chart review with subsequent hierarchal, unsupervised clustering analysis. RESULTS: Five clusters of intestinal injury were identified: Cluster 1 deemed the "Low Mortality" cluster, Cluster 2 deemed the "Mature with Inflammation" cluster, Cluster 3 deemed the "Immature with High Mortality" cluster, Cluster 4 deemed the "Late Injury at Full Feeds" cluster, and Cluster 5 deemed the "Late Injury with High Rate of Intestinal Necrosis" cluster. CONCLUSION: Unsupervised machine learning can be used to cluster acquired neonatal intestinal injuries. Future study with larger multicenter datasets is needed to further refine and classify types of intestinal diseases. IMPACT: Unsupervised machine learning can be used to cluster types of acquired neonatal intestinal injury. Five major clusters of acquired neonatal intestinal injury are described, each with unique features. The clusters herein described deserve future, multicenter study to determine more specific early biomarkers and tailored therapeutic interventions to improve outcomes of often devastating neonatal acquired intestinal injuries.

Emergence of Monkeypox (MPX): A Close Relative of Small Pox During COVID-19 Era.

After the eradication of smallpox (SPX), a new zoonotic threat that can trigger outbreaks has emerged. It may be fatal during the COVID19 outbreak. Humanity continues to be threatened due to re-emergence of the outbreaks. In most cases, new emerging viral agents originate from nonhuman hosts with zoonotic origins. Recent outbreaks of zoonotic infectious diseases with the potential to cause epidemics and pandemics continue to pose a major threat to the health security of entire regions, continents, and the world at large. Around five decades backthat Monkeypox (MPX) was reported for the first time in the Democratic Republic of the Congo (DRC) and was then confined to Central Africa only. Over the time, it has spread to other regions of Africa as well as outside Africa. As of August 2022, 40398 infections have been confirmed in almost 68 countries that have never reported MPX before. The majority of infections have been reported in Europe and Southeast Asia. On 23rd August 2022, MPX was declared a public health emergency of international concern, a step below declaring any disease as a pandemic. The article discusses the recent history of MPX outbreaks, as well as the evolving clinical manifestations of the disease, and the possible causes of the increase in cases, including the cessation of SPX vaccinations.

Sympathetic Ophthalmia in Patients with Enucleation or Evisceration: Pathology Laboratory and IRIS® Registry Experience.

Introduction: Sympathetic ophthalmia (SO) is a rare bilateral granulomatous panuveitis that can follow surgical or nonsurgical ocular trauma in one eye. Because its diagnosis requires clinical-pathologic correlation, the true incidence of SO is unknown, and there is a need to understand the recent trends in risk factors and frequency of this condition. Methods: Pathology records of all enucleated or eviscerated (ENEV) eyes at three pathology laboratories were reviewed. Data collected included patient demographics, procedure indication, pathology diagnosis, and clinical history of trauma and uveitis. IRIS® Registry (Intelligent Research in Sight) was searched for all patients with SO, acquired absence of eye (AAE), and/or ENEV. Data obtained included patient demographics, ocular procedures, and preoperative diagnoses within 30 days of AAE/ENEV. Results: In the pathology laboratory setting, the incidence of SO over a 36-year period in patients who underwent ENEV was 0.2% (20/9,092); the 5-year incidence ranged from 0.0 to 0.3%. Among the 20 eyes with SO, the inciting event was surgical trauma in 50% (10/20), nonsurgical trauma in 45% (9/20), and missing/undetermined in 5% (1/20). SO was suspected preoperatively in 7/20 (35%) patients. Clinical concern for SO and ruptured globe were indications for ENEV in 50/9,092 (0.5%) and 872/9,092 (10%) patients, respectively. In the IRIS Registry, 0.7% (199/27,830) of patients with AAE/ENEV had diagnosis of SO. The frequency of SO between 2015 and 2020 was 0.01% (7,371/62,318,249); of these 7,371 cases, 199 (3%) had AAE/ENEV. In 25,975 patients with available data, injury and SO were listed as diagnoses less than 30 days prior to AAE/ENEV in 909 (4%) and 63 (0.2%) cases, respectively. Conclusion: The frequency of SO in recent decades has been low. Most cases of SO are not managed with eye removal. In histopathology-confirmed SO, surgical trauma is as frequent as nonsurgical trauma as an inciting etiology of disease.

Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda.

BACKGROUND: Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies. METHODS: Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus. RESULTS: Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05). CONCLUSIONS: Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.

Neurotrophic keratopathy following rhegmatogenous retinal detachment surgery.

OBJECTIVE: To describe clinical characteristics and visual outcomes of eyes developing neurotrophic keratopathy (NK) following rhegmatogenous retinal detachment (RRD) repair. METHODS: All eyes with NK at Wills Eye Hospital following RRD repair from June 1, 2011, to December 1, 2020 were included. Patients with prior ocular procedures (other than cataract surgery), herpetic keratitis, and diabetes mellitus were excluded. RESULTS: During the study period, 241 patients were diagnosed with NK, and 8179 eyes underwent RRD surgery, giving a 9-year prevalence rate of 0.1% (95% CI, 0.1%-0.2%). Mean age was 53.4 ± 16.6 years during RRD repair and 56.5 ± 13.4 years during NK diagnosis. Mean time to NK diagnosis was 3.0 ± 5.6 years (range, 6 days to 18.8 years). Mean visual acuity before NK was 1.10 ± 0.56 logMAR (20/252 Snellen), and it was 1.01 ± 0.62 logMAR (20/205 Snellen) at final visit (p = 0.75). Six eyes (54.5%) developed NK <1 year following RRD surgery. Mean final visual acuity was 1.01 ± 0.53 logMAR (20/205 Snellen) in this group versus 1.01 ± 0.78 logMAR (20/205 Snellen) in the delayed NK group (p = 1.00). CONCLUSIONS: NK may present acutely or up to several years following surgery, with severity of corneal defects ranging from stage 1 to stage 3 NK. Surgeons should be mindful of the potential for this rare complication following RRD repair.

Premature Emulsification of Silicone Oil After Retinal Detachment Repair in the Setting of High-Intensity Exercise.

PURPOSE: To describe a rare case of silicone oil emulsification which occurred only three months postoperatively. We discuss the implications for postoperative counseling. METHODS: Retrospective chart review of a single patient. RESULTS: 39-year-old female who presented with a right eye macula-on retinal detachment which was repaired with scleral buckle, vitrectomy, and silicone oil tamponade. Her course was complicated by extensive silicone oil emulsification within 3 months postoperatively, most likely due to shear forces induced by her daily CrossFit exercise regimen. CONCLUSION: Typical postoperative precautions after a retinal detachment repair include no heavy lifting or strenuous activity for one week. These restrictions may need to be more stringent and long-term for patients with silicone oil to prevent early emulsification.

The Effect of a Mock Medical Visit on Refugee Health Self-Efficacy and Medical Trainee Communication Apprehension.

INTRODUCTION: As refugees adjust to a new country, their health care can take a toll. Refugees may have difficulty navigating a new health care system and experience low health self-efficacy. Another potential contributor is inadequate medical trainee curriculum addressing refugee health. METHODS: We devised simulated clinic experiences called mock medical visits. Surveys were utilized before and after the mock medical visits to assess the Health Self-Efficacy Scale for refugees and the Personal Report of Intercultural Communication Apprehension for trainees. RESULTS: Health Self-Efficacy Scale scores increased from 13.67 to 15.47 (P = 0.08, n = 15). Personal Report of Intercultural Communication Apprehension scores decreased from 27.1 to 25.4 (P = 0.40, n = 10). DISCUSSION: While our study did not reach statistical significance, the overall trends suggest mock medical visits can be a valuable tool to increase health self-efficacy in refugee community members and decrease intercultural communication apprehension in medical trainees.

Trends in Utilization of Vitreoretinal Services Following the Initial Phase of the 2020 COVID-19 Pandemic.

BACKGROUND: To identify vitreoretinal practice patterns in the months following the initial 2020 national shutdown due to the COVID-19 pandemic in the United States (US). STUDY DESIGN: Retrospective analysis of vitreoretinal practice patterns from multiple retinal centers across the US from January 1, 2018 to December 31, 2020. RESULTS: The lowest utilization of retina care occurred during the week of March 23, 2020, after which utilization returned to pre-pandemic levels by July 2020. Patients with retinal detachments (RDs) presented with worse visual acuity during March, April, and May 2020 compared to the same time periods of 2018 and 2019 (P values < 0.05). However, only comparing eyes that presented in March 2018 to March 2020, was the year 1 vision significantly worse (P = 0.008). CONCLUSION: The COVID-19 pandemic significantly impacted vitreoretinal care. The vision of patients with RDs may not have been affected by the delayed presentation. [Ophthalmic Surg Lasers Imaging Retina 2023;54:15-23.].

After "The Talk": Adolescents' Perspectives Reveal Need for Improvement in Hospital Sexual Health Care Delivery.

OBJECTIVES: To fill access gaps for adolescents, addressing sexual and reproductive health (SRH) is recommended in nontraditional settings. In previous improvement work, we increased documentation of sexual history to >80% of adolescents hospitalized on our pediatric hospital medicine (PHM) service. This study assessed adolescents' perception of SRH conversations with hospital providers and the extent to which they were helpful. METHODS: Postdischarge survey of patients 13 to 17 years discharged from the PHM service at an academic children's hospital between August 2019 and March 2020. Survey items included demographics; whether confidential discussion of sexual health topics such as contraception, sexually transmitted infection (STI), and sexual orientation occurred; perceptions of these discussions, and sexual history. RESULTS: Eighty-three patients enrolled and 44 (53%) completed the survey after discharge. A total of 68% of respondents were female and median age was 15 years (interquartile range 14-16). A total of 77% reported discussing SRH privately with a PHM provider. A total of 18% recalled discussing condoms, and 63% rated the discussion helpful. A total of 27% of females reported discussing birth control, and 40% rated it helpful. A total of 57% recalled discussing sexual orientation, and 40% rated it helpful. None reported discussions of STI testing with PHM. Of the 23% who were sexually active, none reported being given condoms. CONCLUSIONS: Analysis of adolescent patient experiences identified opportunities for continued improvement in the content and quality of SRH discussions, specifically regarding offering STI testing, condom distribution, and sexual orientation conversations. Our work highlights the importance of incorporating patient-reported data into improvement work to ensure providers are addressing targeted gaps in adolescent care.

Outcomes of Retinectomy without Lensectomy in Rhegmatogenous Retinal Detachments with Proliferative Vitreoretinopathy.

PURPOSE: To report the anatomic and functional outcomes of retinectomy without lensectomy in eyes with rhegmatogenous retinal detachment (RRD) and proliferative vitreoretinopathy (PVR). DESIGN: Retrospective, noncomparative, and interventional case series. SUBJECTS: One hundred twelve eyes of 112 patients with RRD complicated by PVR who underwent retinectomy without lensectomy. METHODS: Retrospective review of patients treated with vitrectomy and retinectomy without lensectomy from January 1, 2015, to January 1, 2020. MAIN OUTCOME MEASURES: The primary outcome was the final attachment rate and single surgery anatomic success (SSAS) at 3 and 6 months after retinectomy. Secondary outcomes included predictors of final visual acuity (VA), the mean number of subsequent operations required for complete retinal reattachment, cataract surgery, and the number of eyes that ultimately had successful silicone oil removal. RESULTS: Complete final retinal reattachment was achieved in 111 of 112 (99.1%) patients, with a mean (standard deviation [SD]) follow-up of 29 (14) months (range, 8-62 months) after retinectomy. The SSAS was achieved in 84 of 112 (75%) patients at 3 months and 73 of 112 (65.2%) patients at 6 months. The final VA improved or stabilized in 76 of 112 (67.9%) eyes. Silicone oil removal was performed in 72 of 112 patients (64.3%) at a mean (SD) of 6.6 (3.3) months, and cataract surgery was performed on 101 (90.2%) eyes before the last follow-up visit. CONCLUSIONS: Retinectomy without lensectomy to repair RRDs complicated by PVR showed acceptable anatomic and functional results. This study suggests that removing the lens when there is no significant cataract may not be necessary in these cases to obtain reasonable outcomes.

Authorship Trends of Women in Retina: A 25-Year Analysis.

OBJECTIVE: To examine the trends in first and last authorship of women within clinical retina research over the last 25 years. DESIGN: Cross-sectional study. PARTICIPANTS: First and last author names were retrieved from original articles published between January 1, 1995, and January 1, 2021, in the American Journal of Ophthalmology, JAMA Ophthalmology (Archives of Ophthalmology), Ophthalmology, and Retina. METHODS: The medical subject heading major term "retina" was used in PubMed to filter publications specific to the field of retina. Publications by single authors and collaborative study groups and those classified as comments, letters, and editorials were excluded. First and last author names were obtained, and Gender API was used to assign sex. Names were crosschecked with the American Society of Retina Specialists (ASRS) directory for United States-based authors. MAIN OUTCOME MEASURES: The proportion of male and female first and last authors throughout the study period and the association between first and last authorship gender were assessed. RESULTS: A total of 4142 articles were included. The percentage of women in first and last authorship positions significantly increased from 23% to 37.7% and 14.2% to 24.6%, respectively, over 25 years (P < 0.001 and P < 0.001, respectively). When the last authors were women, 32.5% of the first authors were women, and when the last authors were men, 27.1% of the first authors were women (P = 0.002). Based on the ASRS 2020 directory, 17% of practicing retina specialists in the United States were women in 2020. For publications in 2020, 28.2% of the first authors and 22.3% of the last authors of retina publications from the United States were women (P < 0.001 and P < 0.001, respectively). CONCLUSIONS: Although a disparity in authorship persists in the subspecialties of ophthalmology, this data suggest that retina is a field where the gap is improving. Mentorship by senior female authors is associated with a higher proportion of female first authors.

PREVALENCE, CHARACTERISTICS, AND OUTCOMES OF RHEGMATOGENOUS RETINAL DETACHMENT IN EYES WITH TRABECULECTOMY OR GLAUCOMA DRAINAGE DEVICES.

PURPOSE: To describe the prevalence, management, and outcomes of rhegmatogenous retinal detachment (RRD) after incisional glaucoma filtering surgery. METHODS: All patients with a history of trabeculectomy or glaucoma drainage device surgery who were subsequently diagnosed with an RRD from January 1, 2016, to January 1, 2021, at the Wills Eye Hospital were identified. RESULTS: Forty-six eyes met the inclusion criteria. The mean age was 60.7 ± 19.6 years, and 15 patients (32.6%) were female. Of all eyes, 34 (73.9%) were diagnosed with primary open-angle glaucoma. The mean time from most recent incisional glaucoma surgery to RRD diagnosis was 1,133 ± 1,644 days. There were 19 eyes (41.3%) with preoperative proliferative vitreoretinopathy (9 eyes [19.6%] with Grade C proliferative vitreoretinopathy) and 35 eyes (76.1%) had macula-off RRD at the time of presentation. At RRD presentation, 4 eyes (8.7%) had concomitant endophthalmitis, 5 (10.9%) had concurrent choroidal detachment, and 2 (4.7%) had concurrent vitreous hemorrhage. Primary vitrectomy was performed in most (91.3%) cases. Silicone oil tamponade was often required (71.1%). The single surgery success rate was 65.2% (30 of 46). The mean preoperative logarithm of the minimum angle of resolution visual acuity was 1.72 ± 0.78 (Snellen acuity 20/1,050), and the mean final postoperative logarithm of the minimum angle of resolution was 1.59 ± 0.89 (20/778, P = 0.2853). Of glaucoma surgeries performed, the 5-year prevalence of RRD was 0.71% (26 of 3,664, 95% Poisson confidence interval 0.48%-1.04%). CONCLUSION: The 5-year prevalence of RRDs after trabeculectomy or glaucoma drainage device was 0.71%. Most patients presented with macula-involving detachments, often with proliferative vitreoretinopathy. Anatomical and visual outcomes were poor.

Characteristics and Treatment of Patients Diagnosed With Paradoxical Adipose Hyperplasia After Cryolipolysis: A Case Series and Scoping Review.

BACKGROUND: Paradoxical adipose hyperplasia (PAH), a rare side effect of CoolSculpting (cryolipolysis), is characterized by fatty enlargement of the treatment area occurring months after the procedure. OBJECTIVES: The purpose of this study was to report a retrospective case series of patients diagnosed with PAH at the authors' institution, increase the collective understanding of this complication and subsequent management, and raise the question of who should ethically perform cryolipolysis. METHODS: All participants diagnosed with PAH by a plastic surgeon at a large academic medical center were identified. Demographic information, medical history, procedure details, time to PAH diagnosis, and corrective surgical intervention details were collected. Mean duration of time from cryolipolysis treatment to diagnosis of PAH was calculated, along with other descriptive statistics. A scoping review of all PAH literature published in PubMed, Embase, and Web of Science was also conducted. RESULTS: Four patients diagnosed with PAH after cryolipolysis were identified for inclusion in this study. The calculated incidence of PAH at our center was 0.67%. All patients requested therapy for PAH and subsequently underwent either liposuction, abdominoplasty, or both. The mean duration of in-person follow-up time after final surgical treatment of PAH was 13.8 + 19.8 months (range, 2.8-43.5). Fortunately, no patients showed signs of PAH recurrence, and 3 out of 4 patients did not show signs of residual deformity. CONCLUSIONS: Findings from this patient cohort and scoping review provide evidence that although revisions may be required, conventional body contouring methods, not in the armamentarium of non-plastic surgeon practitioners, effectively alleviated PAH.

Factors Associated With Good Visual Acuity Outcomes After Retinectomy in Eyes With Proliferative Vitreoretinopathy.

PURPOSE: To investigate factors associated with good visual acuity (VA) following repair of rhegmatogenous retinal detachments (RD) with proliferative vitreoretinopathy (PVR) undergoing retinectomy. DESIGN: Interventional, retrospective, case-control study. METHODS: This single-institution study evaluated patients who underwent retinectomy during repair of RD with PVR from January 1, 2015 to December 31, 2019. A good VA cohort was identified based on a final VA ≥20/70. A 2:1 age-matched and gender-matched poor VA cohort with VA <20/70 was subsequently identified. Metrics compared between the two cohorts included time from primary and recurrent RD diagnosis to surgery, lens status, initial RD size, macula involvement, PVR grade, and size of retinectomy. RESULTS: A total of 5355 eyes were diagnosed with primary RD during the study period, of which 345 had PVR and underwent retinectomy. The good VA cohort included 62 eyes with a mean final logMAR VA of 0.32 [Snellen 20/42], while the poor VA cohort included 119 eyes with a mean final logMAR VA of 1.54 [Snellen 20/693; P < .0001]. On multivariate analysis, smaller initial RD size (P = .0090), fewer surgeries (P = .0002), shorter time between recurrent RD diagnosis and subsequent surgeries (P = .0006), better preoperative VA (P = .0276), and pseudophakia at final visit (P = .0049) remained significant predictors of good vision. CONCLUSION: Eyes undergoing retinectomy during repair of RD with PVR can achieve good VA outcomes. The primary modifiable factor associated with better VA was shorter delay between redetachment diagnosis and surgery, particularly in the absence of silicone oil tamponade.

Covid-19 update: Omicron variant - a new emerging threat.

A new health threat in the form of a new variant of Covid-19 called Omicron has emerged globally in this holiday season. This new variant has been declared a variant of concern (VOC) by the World Health Organization and experts are expecting another wave of the pandemic. A lot still unknown about this variant and researchers worldwide are conducting studies to find the nature and characteristics of this mutated strain. Cases have begun to rise dramatically around the world and many countries have already imposed travel restrictions again to prevent disease transmission. It is being speculated that this particular variant has got tendency of immune escape and therefore can even infect fully vaccinated individuals. Vaccination and adhering to Covid-19 guidelines and protocols can curtail the spread of the virus. The present paper focuses on what is currently known about this variant, antigen diagnostic tests, importance of getting fully vaccinated and having booster dose etc. If we want to emerge from this pandemic, countries should practice vaccine equality and solidarity for the good of mankind.

FACTORS AFFECTING RETINAL REDETACHMENT AFTER SILICONE OIL REMOVAL FOR RHEGMATOGENOUS RETINAL DETACHMENTS.

PURPOSE: To report factors affecting the retinal redetachment rate after silicone oil removal (SOR) following rhegmatogenous retinal detachment (RRD) repair. METHODS: Retrospective cohort study from December 1, 2014, to March 1, 2020, of 205 consecutive patients treated for RRD with silicone oil (SO) tamponade and subsequent SOR with at least 6-month follow-up. Primary outcome measure was the rate of retinal redetachment after SOR. RESULTS: The retinal redetachment rate after SOR was 18.5%. Preoperative macula and lens status, proliferative vitreoretinopathy, previous retinectomy, retinal detachment size, concomitant phacoemulsification, previous scleral buckling, and endolaser during SOR did not affect the redetachment rate after SOR. Previous SO exchange was associated with increased redetachment (OR 2.53, 95% CI [1.11-5.80], P = 0.0278). Twelve months of SO tamponade had lower redetachment rates compared with 3 months (OR 0.25, 95% CI [0.04-0.09], P = 0.048). Shorter SO tamponade (3 vs. 12 months) had better final visual outcomes after SOR (0.80 ± 0.61 vs. 1.41 ± 0.66, P < 0.0001). CONCLUSION: No preoperative or intraoperative factors in this analysis influenced the risk of redetachment after SOR except duration of SO tamponade and previous SO exchange. Although longer SO tamponade duration may be associated with lower rates of redetachment, visual outcomes may be worse.

Quality Initiative to Increase Delivery of Adolescent Hospital-Based Reproductive Health Care.

OBJECTIVES: Hospitals are an important nontraditional setting in which to address adolescent reproductive health. However, opportunities for intervention are frequently missed, especially for boys and patients hospitalized for noningestion complaints. Our global aim was to increase delivery of reproductive health care to adolescents hospitalized through our children's hospital Pediatric Hospital Medicine service. METHODS: We performed 2 quality improvement intervention cycles: (1) provider education and monthly reminder e-mails and (2) an automated electronic health record (EHR) adolescent history and physical note template with social history prompts while discontinuing reminder e-mails. The primary outcome measure was sexual history documentation (SHD). Secondary measures were sexually transmitted infection (STI) testing and contraception provision. Statistical process control charts were used to analyze effectiveness of interventions. RESULTS: From July 2018 through June 2019, 528 Primary Hospital Medicine encounters were included in this study and compared with published baseline data on 150 encounters. Control charts revealed a special cause increase in SHD from 60% to 82% overall, along with 37% to 73% for boys and 57% to 80% for noningestion hospitalizations. Increased SHD correlated with cycle 1 and was maintained through cycle 2. Percent STI testing significantly increased but did not shift or trend toward special cause variation. Contraception provision, length of stay, and patient relations consultations were not affected. CONCLUSIONS: The interventions were successful in increasing SHD, including among boys and noningestion hospitalizations. The EHR enhancement maintained these increases after reminder emails were discontinued. Future interventions should specifically address STI testing and provision of contraception.

Anesthetic Management of Children With Propionic Acidemia Undergoing Esophagogastroduodenoscopy.

Propionic acidemia is a rare genetic disorder of metabolism that predisposes patients to metabolic acidosis, lethargy, neurologic dysfunction, developmental delays, and cardiomyopathy. Perioperative anesthetic management is guided toward mitigating the effects of preoperative fasting times, maintaining normovolemia, and preventing cardiovascular complications secondary to underlying cardiomyopathy. Commonly used anesthetic agents may have undesirable side effects in these patients. Propofol, the lactate in Lactated Ringer's, and neuromuscular blocking agents that undergo ester hydrolysis are poorly metabolized and can lead to metabolic acidosis. Opioids, such as fentanyl and morphine, should be used judiciously in patients with coexisting developmental delays to avoid oversedation and delayed time to resuming oral intake postanesthesia. In addition, inhaled anesthetics have direct myocardial depressive effects and can compromise cardiac function in the setting of pre-existing cardiomyopathy. The perioperative period represents a critical time in this population and appropriate planning is crucial to prevent perioperative morbidity. We present a case of an eight-year-old child undergoing esophagogastroduodenoscopy under general anesthesia and describe the anesthetic concerns we addressed to provide a safe perioperative course.