Extended reality navigation for pain procedures: a narrative review.

BACKGROUND: Extended reality (XR) technology, encompassing virtual reality, augmented reality, and mixed reality, has been widely studied for procedural navigation in surgical specialties. Similar to how ultrasound transformed regional anesthesia, XR has the potential to reshape how anesthesiologists and pain physicians perform procedures to relieve pain. OBJECTIVE: This narrative review examines the clinical benefits of XR for navigation in various pain procedures. It defines key terms and concepts related to XR technology and explores characteristics of procedures that are most amenable to XR-based navigation. Finally, it suggests best practices for developing XR navigation systems and discusses the role of emerging technology in the future of XR in regional anesthesia and pain medicine. EVIDENCE REVIEW: A search was performed across PubMed, Embase, and Cochrane Central Register of Controlled Trials for primary literature investigating the clinical benefits of XR navigation for pain procedures. FINDINGS: Thirteen studies using XR for procedural navigation are included. The evidence includes randomized controlled trials, retrospective studies, and case series. CONCLUSIONS: Early randomized controlled trials show potential for XR to improve procedural efficiency, but more comprehensive research is needed to determine if there are significant clinical benefits. Case reports demonstrate XR's utility in generating patient-specific navigation plans when difficult anatomy is encountered. Procedures that facilitate the generation and registration of XR images are most conducive to XR navigation, whereas those that rely on frequent re-imaging will continue to depend on traditional modes of navigation.

The modern anesthesiologist's manual: the development and maintenance of an anesthesia case reference application.

Anesthesia clinicians care for patients undergoing a wide range of procedures, making access to reliable references crucial. However, existing resources have key limitations. This technical report describes the development of an in-house anesthesia case reference application designed for use in a tertiary academic hospital. Additionally, it details our experiences in maintaining this system over a 22-month period and compares this system to alternative resources. Utilizing JavaScript and the React library, we developed a cross-platform perioperative reference application. Over fifty articles, encompassing anesthetic considerations for various surgical disciplines, have been created. Furthermore, we conducted a preliminary analysis of analytics data. In the 22 months since the application's inception, the application has garnered over 22,000 views from local users. While there are more than 150 registered users, the number of unregistered users accessing the application on the hospital network remains unknown. Notably, 70% of users accessed the application through a mobile device. The most popular articles centered around procedures with diverse and specific surgeon preferences. Currently, the reported case reference application is routinely utilized by anesthesia clinicians at our institution. Future endeavors will concentrate on establishing a robust content management workflow to broaden the coverage of topics.

Progressive multifocal leukoencephalopathy as the presenting feature in a patient with occult low-count monoclonal B-cell lymphocytosis.

Introduction: Low Count Monoclonal B-Cell Lymphocytosis (LC-MBL) is a relatively poorly understood entity which has been suggested to be very common in asymptomatic adults and possibly related to infectious complications despite not progressing to CLL. Methods: We describe the first case of Progressive Multifocal Leukoencephalopathy (PML) presenting in a 72-year-old man with LC-MBL but no other immunocompromising conditions. Results: A diagnosis of PML was confirmed with classic MRI findings in association with a high CSF John Cunningham polyomavirus (JCV) viral load (4.09' 105 copies/mL). An extensive search for underlying immunocompromising conditions only demonstrated LC-MBL representing approximately 4% of total leukocytes (0.2' 109/L). Discussion: This is the first report of PML in association with LC-MBL. Careful review of peripheral blood flow cytometry results is necessary to identify this disorder. Further study of the epidemiology and infectious complications of LC-MBL are warranted.

Introduction: La lymphocytose monoclonale à cellules B (LMB) est une maladie relativement mal comprise qui serait très courante chez des adultes asymptomatiques et qui pourrait être liée à des complications infectieuses, même si elle n'évolue pas en leucémie lymphocytique chronique. Méthodologies: Nous décrivons le premier cas de leucoencéphalopathie multifocale progressive (LEMP) observé chez un patient (72 ans) atteint de LMB, mais ne présentant pas d'autres pathologies induisant une immunodéficience. Résultats: Des résultats d'IRM classiques et une forte charge du virus JC (John Cunningham) dans le liquide céphalorachidien (4,09 × 105 copies/mL) ont confirmé un diagnostic de LEMP. De nombreux tests visant à révéler une immunodéficience sous-jacente ont seulement montré que les cellules B monoclonales représentaient environ 4% des leucocytes totaux (0,2 × 109/L). Discussion: Il s'agit du premier cas observé de LEMP en association avec une LMB. Il faut analyser soigneusement les résultats d'une cytométrie en flux du sang périphérique pour diagnostiquer ce trouble. Il convient de continuer d'étudier l'épidémiologie et les complications infectieuses de la LMB.

Utilizing the Subunit Concept to Achieve Better Outcomes in Lower Limb Reconstruction: A Clinical Experience in an Asian Population.

Background: The goals of reconstruction have progressed from filling a defect to enhancing function and aesthetic appearance. We aimed to achieve better aesthetic and functional outcomes in terms of shoe fitting and mobility. This is accomplished via a classification of the subunits and aesthetic considerations of the lower limb. Methods: Between April 2017 and December 2021, 66 cases of lower extremity free fasciocutaneous flap reconstruction cases were included in this retrospective study. Data parameters include age, sex, comorbidities, etiology of lower limb wounds, choice of free flap reconstruction, recipient arterial vessels, complications of flap reconstruction, and need for secondary debulking procedures. Physiotherapy records were also examined to determine the time to independent ambulation. Results: In total, 66 subjects were identified. The mean age was 48.6. An estimated 74.2% (n = 49) were men, 50% (n = 33) had diabetes, and 16.6% (n = 11) had peripheral vascular disease. Of the total wounds, 65.1% (n = 43) were caused by infection, whereas the remaining 34.9% (n = 23) were due to trauma. Of the cases, 72.7% (n = 48) had free anterolateral thigh flap reconstruction, 25.8% (n = 17) were reconstructed with superficial circumflex iliac artery perforator flaps, and 1.5% (n = 1) was reconstructed with medial sural artery perforator flaps. Cases that required secondary debulking procedures comprised 7.6% (n = 5). Conclusions: Free fasciocutaneous flaps are useful in lower extremity reconstruction. Based on the subunit principle and aesthetic considerations for lower limb reconstruction, it can aid in optimizing functional rehabilitation and decreasing secondary procedures.

Initial experience with enhanced recovery after surgery (ERAS) and early discharge protocols after robotic extended totally extraperitoneal (eTEP) hernia surgery.

BACKGROUND: Though robotic adoption for eTEP surgery has decreased technical barriers to minimally invasive repairs of large ventral hernias, relatively few studies have examined outcomes of robotic-specific eTEP surgery. This study evaluates safety, feasibility, and early outcomes of ERAS/same-day discharge protocols for robotic eTEP ventral hernia repairs. METHODS: A retrospective chart review was performed for all robotic eTEP hernia surgeries at a single institution between 2019 and 2022. Analysis included patient demographics, hernia characteristics, intraoperative data, and post-operative outcomes at 30 days. ERAS protocol included: judicious use of urinary catheters with removal at end of case if placed, bilateral transversus abdominus plane (TAP) blocks, post-operative abdominal wall binder, and opioid-sparing perioperative analgesia. Patients were discharged same day from post-anesthesia care unit (PACU) if they lacked comorbidities requiring observation post-anesthesia and demonstrated stable vital signs, adequate pain control, ability to void, and ability to ambulate. Hospital length of stay (LOS) was considered 0 for same-day PACU discharges or hospitalizations < 24 h. RESULTS: 102 patients were included in this case series. 69% (70/102) of patients were discharged same-day (mean LOS 0.47 ± 0.80 days). Within 30 post-operative days, 3% (3/102) of patients presented to the ER, 2% (2/102) were readmitted to the hospital, and 1% (1/102) required reoperation. There was 1 serious complication (Clavien-Dindo grade 3/4) with an aggregate complication rate of 7.8%. CONCLUSIONS: Our initial experience with ERAS protocols and same-day discharges after robotic eTEP repair demonstrates this approach is safe and feasible with acceptable short-term patient outcomes. Compared to traditional open surgery for large ventral hernias, robotic eTEP may enable significant reductions in hospital LOS as adoption increases.

Effect of Intermittent Fasting on Cardiometabolic Health in the Chinese Population: A Meta-Analysis of Randomized Controlled Trials.

The efficacy of intermittent fasting (IF), as an emerging weight management strategy, in improving cardiometabolic health has been evaluated in various populations, but that among Chinese individuals has not been systematically studied. A comprehensive search on multiple databases was performed to identify eligible randomized controlled trials (RCTs) up to October 2022. The primary outcome was post-intervention weight loss, and secondary outcomes included changes in cardiometabolic indicators. Effect estimates were meta-analyzed using a random-effects model. In total, nine RCTs with 899 Chinese participants were included. Time-restricted eating was the most adopted IF protocol in this study (six out of nine), followed by alternate-day fasting. The IF intervention significantly reduced body weight, body mass index, body fat mass, homeostatic model assessment of insulin resistance, low-density lipoprotein cholesterol, and triglycerides when compared with control groups. However, no statistically significant reductions in waist circumference, total cholesterol, high-density lipoprotein cholesterol, fasting glucose, systolic blood pressure, and diastolic blood pressure were found. To sum up, IF can be a weight management strategy and may improve the cardiometabolic health of Chinese adults, but more long-term trials using different IF strategies are required to generate robust evidence of its efficacy.

Does the Adoption of Molecular Testing Cause Decreased Thyroidectomy Rates in a National Cohort? A Quasiexperimental Study of High- Versus Low-Adoption States.

Background: Over the last decade, the utilization of molecular testing (MT) for the evaluation of thyroid nodules has increased. Rates and patterns of adoption of MT and its effect on thyroidectomy rates nationally are unknown. Varying rates of MT adoption at the state level provide an opportunity to study the effects of MT on thyroidectomy rates using a quasiexperimental study design. Methods: We performed a retrospective analysis of American adult patients in the Merative™ MarketScan® Research Databases who underwent thyroid fine-needle aspiration (FNA) from 2011 to 2021. MT included commercially available DNA and RNA platforms and traditional targeted mutational analysis. Interrupted time series analysis was used to evaluate the inflection of MT adoption and thyroidectomy rates after 2015. Difference-in-differences (DID) analysis was used to causally analyze the effect of MT adoption on thyroidectomy rates in high-adoption (at least a 10% increase in MT utilization) versus low-adoption states (no more than 5% increase in MT utilization) from 2015 to 2021. Results: We identified 471,364 patients who underwent thyroid FNA. The utilization of MT increased over the study period from 0.01% [confidence interval, CI: 0.00% to 0.02%] to 10.1% [CI: 9.7% to 10.5%], in 2021, with an immediate (ß2 = 1.61, p = 0.002) and deeper (ß3 = 0.6, p < 0.001) increase in MT adoption after 2015. Utilization of MT was lower in black patients, the elderly, rural areas, and patients with Medicaid (p < 0.05). Thyroidectomy rates were inversely correlated with MT utilization (r = -0.98, p < 0.0001). From 2015 to 2021, the average MT utilization rate increased from 2.4% to 15.3% in high-adoption states and 1.6% to 5.6% in low-adoption states. In low-adoption states, thyroidectomy rates decreased more but to similar levels (18.5-13.2%) compared with high-adoption states (15.9-13.4%) with an adjusted DID rate of -3.3% [CI -5.6% to -0.8%]. Conclusions: The acceleration in adoption of MT after 2015 likely coincides with the publication of American Thyroid Association guidelines. Black, elderly, and rural patients are less likely to receive MT. Although thyroidectomy rates were inversely correlated with MT utilization, our study suggests that this correlation is not causal. The effect of MT on thyroidectomy rates may be overshadowed by decreasing aggressiveness of thyroid nodule evaluation.

Curricular Reform in Serious Illness Communication and Palliative Care: Using Medical Students' Voices to Guide Change.

PURPOSE: To gather and leverage the voices of students to drive creation of required, integrated palliative care curricula within undergraduate medical education in Massachusetts, which is lacking in a majority of U.S. medical schools. METHOD: The study was conducted by the Massachusetts Medical Schools' Collaborative, a working group committed to ensuring all medical students in Massachusetts receive foundational training in serious illness communication (SIC) and palliative care. Eight focus groups (2 per participating medical school) were conducted during January-May 2021 and included a total of 50 students from Boston University Chobanian & Avedisian School of Medicine, Harvard Medical School, Tufts University School of Medicine, and the UMass Chan Medical School. Data collected from focus groups were discussed and coded. Themes were identified using the immersion/crystallization qualitative data analysis approach. RESULTS: Six key themes emerged. Students viewed SIC as essential to high-quality medical practice regardless of specialty, and believed training in SIC skills and palliative care should be required in medical school curricula. Students preferred to learn and practice these skills using frameworks, particularly in real-world situations. Students recognized the expertise of palliative care specialists and described them as a scarce, often misunderstood resource in health care. Students reported it was mostly "luck" if they were included in family meetings and observed good role models. Finally, students desired practice in debriefing after difficult and emotional situations. CONCLUSIONS: This study confirms long-standing themes on students' experiences with SIC and palliative care topics, including feeling inadequately prepared to care for seriously ill patients as future physicians. Our study collected students' perspectives as actionable data to develop recommendations for curricular change. Collaborative faculty also created recommendations based on the focus group data for immediate and ongoing SIC and palliative care curricular change in Massachusetts, which can apply to medical schools nationwide.

A Call to Action: Using Curriculum Mapping at Four Medical Schools in Massachusetts to Advance Serious Illness Communication Training in Undergraduate Medical Education.

Background: Practicing physicians require serious illness communication (SIC) skills to ensure high-quality, humanistic care for patients and families as they face life-changing medical decisions. However, a majority of U.S. medical schools do not require formal training in SIC and fail to provide students deliberate practice before graduation. The Massachusetts Medical Schools' Collaborative was created to ensure that students receive foundational SIC training in undergraduate medical education. This Collaborative developed a curriculum-mapping tool to assess SIC at four medical schools. Objective: We aimed to understand existing educational activities across four medical schools and identify opportunities to build longitudinal, developmentally based curricular threads in SIC. Design: From July 2019 to April 2021, faculty, staff, and medical students assessed current educational activities related to five core competencies in SIC, adapted for students from national competencies for palliative medicine fellows, using a curriculum mapping tool. Measurements: The group selected 23 keywords and collected metrics to describe the timing, instruction and assessment for each school's educational activities. Results: On average, there were only 40 hours of required curricula in SIC over four years. Over 80% of relevant SIC hours occurred as elective experiences, mostly during the postclerkship phase, with limited capacity in these elective experiences. Only one school had SIC educational activities during the clerkship phase when students are developing clinical competencies. Assessment methods focused on student participation, and no school-assessed clinical performance in the clerkship or postclerkship phase. Conclusions: Medical schools are failing to consistently train and ensure basic competency in effective, compassionate SIC. Curriculum mapping allows schools to evaluate their current state on a particular topic such as SIC, ensure proper assessment, and evaluate curricular changes over time. Through the deliberate inclusion of SIC competencies in longitudinal curriculum design, we can fill this training gap and create best practices in undergraduate medical education.

Performance measurement part I: Foundational knowledge for measure development.

As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.

Performance measurement part II: A guide to developing dermatology performance measures.

Throughout the 21st century, national and local governments, private health sectors, health insurance companies, healthcare professionals, labor unions, and consumers have been striving to develop an effective approach to evaluate, report, and improve the quality of healthcare. As medicine improves and health systems grow to meet patient needs, the performance measurement system of care effectiveness must also evolve. Continual efforts should be undertaken to effectively measure quality of care to create a more informed public, improve health outcomes, and reduce healthcare costs. As such, recent policy reform has necessitated that performance systems be implemented in healthcare, with the "performance measure" being the foundation of the system in which all of healthcare must be actively engaged in to ensure optimal care for patients. The development of performance measures can be highly complex, particularly when creating specialty-specific performance measures. To help dermatologists understand the process of creating dermatology-specific performance measures to engage in creating or implementing performance measures at the local or national levels, this article in the two-part continuing medical education series reviews the types, components, and process of developing, reviewing, and implementing performance measures.

Online Forums as a Tool for Broader Inclusion of Voices on Health Care Communication Experiences and Serious Illness Care: Mixed Methods Study.

BACKGROUND: Existing health care research, including serious illness research, often underrepresents individuals from historically marginalized communities. Capturing the nuanced perspectives of individuals around their health care communication experiences is difficult. New research strategies are needed that increase engagement of individuals from diverse backgrounds. OBJECTIVE: The aim of this study was to develop a mixed methods approach with qualitative online forums to better understand health communication experiences of individuals, including people from groups historically marginalized such as Black and Latino individuals; older adults; and people with low income, disability, or serious illness. METHODS: We used a multiphase mixed methods, community-informed research approach to design study instruments and engage participants. We engaged a diverse group of collaborators with lived experience of navigating the health care system who provided feedback on instruments, added concepts for testing, and offered guidance on creating a safe experience for participants (phase 1). We conducted a national quantitative survey between April and May 2021 across intrapersonal, interpersonal, and systems-level domains, with particular focus on interpersonal communication between patients and clinicians (phase 2). We conducted two asynchronous, qualitative online forums, a technique used in market research, between June and August 2021, which allowed us to contextualize the learnings and test concepts and messages (phase 3). Using online forums allowed us to probe more deeply into results and hypotheses from the survey to better understand the "whys" and "whats" that surfaced and to test public messages to encourage action around health. RESULTS: We engaged 46 community partners, including patients and clinicians from a Federally Qualified Health Center, to inform study instrument design. In the quantitative survey, 1854 adults responded, including 50.5% women, 25.2% individuals over 65 years old, and 51.9% individuals with low income. Nearly two-thirds identified as non-Hispanic white (65.7%), 10.4% identified as non-Hispanic Black, and 15.5% identified as Hispanic/Latino. An additional 580 individuals participated in online forums, including 60.7% women, 17.4% individuals over 65 years old, and 49.0% individuals with low income. Among the participants, 70.3% identified as non-Hispanic white, 16.0% as non-Hispanic Black, and 9.5% as Hispanic/Latino. We received rich, diverse input from our online forum participants, and they highlighted satisfaction and increased knowledge with engagement in the forums. CONCLUSIONS: We achieved modest overrepresentation of people who were over 65 years old, identified as non-Hispanic Black, and had low income in our online forums. The size of the online forums (N=580) reflected the voices of 93 Black and 55 Hispanic/Latino participants. Individuals who identify as Hispanic/Latino remained underrepresented, likely because the online forums were offered only in English. Overall, our findings demonstrate the feasibility of using the online forum qualitative approach in a mixed methods study to contextualize, clarify, and expound on quantitative findings when designing public health and clinical communications interventions.

Impairment and Disability Identity and Perceptions of Trust, Respect, and Fairness.

Importance: Most studies use impaired functioning alone to specify populations with disabilities. However, some people with functional impairments do not identify as disabled. With functional status-based definitions, studies have shown disparate care quality for people with disabilities. Objective: To examine whether impairment and disability identity have different associations with perceived health care experiences and explore factors associated with disability identification. Design, Setting, and Participants: This cross-sectional study used a nationally representative survey of US adults conducted from April 20 through May 31, 2021, and analyzed between June 1 and August 31, 2022. Survey participants were 1822 English- or Spanish-speaking adults responding either online or via telephone. Exposures: Using 8 survey questions, participants were grouped according to presence of impairment and disability identity. Main Outcomes and Measures: Likert scale measures of trust, respect, and fairness (henceforth, procedural justice measures) were dichotomized. Sociodemographic characteristics and rates of procedural justice responses were compared across groups. Multivariable logistic regressions adjusting for baseline characteristics were performed to (1) estimate associations of impairment and disability identity with perceptions of procedural justice and (2) explore factors associated with disability identification. Analyses applied survey weights. Results: Of 6126 individuals invited to participate, 1854 (30.3%) completed the survey. Thirty-two were excluded due to unreportable gender, for a final analytic sample of 1822 participants. Participants with impairments (n = 816; mean [SD] age, 48.1 [17.0] years; 51.2% women, 48.8% men) had worse perceptions on 7 of 10 procedural justice measures (crude) compared with those without impairments (n = 1006; mean [SD] age, 49.6 [18.1] years, 55.1% female, 44.9% male). Among respondents with impairments, those who did (n = 340) vs did not (n = 476) identify as disabled gave better ratings for clinician communication efforts (a lot of effort, 38.8% vs 31.0%) and having health goals understood (understood very or fairly well, 77.2% vs 70.1%) but gave worse ratings for respect (almost never felt inferior or talked down to, 66.1% vs 59.1%). Disability identification was associated with more reports of unfair treatment (31.0% vs 22.4%; adjusted odds ratio, 1.65; 95% CI, 1.12-2.42) and of being unafraid to ask questions or disagree (50.5% vs 40.1%; adjusted odds ratio, 1.51; 95% CI, 1.04-20.19). Income and employment were associated with disability identification. Conclusions and Relevance: In this cross-sectional survey study of US adults, health care perceptions differed between groups defined by impairment status and disability identity. These findings suggest that, alongside functional measures, health systems should capture disability identity to better address disparities for people with impairments.

Assessing Health Care Utilization and Spending Among Older Medicare Beneficiaries With and Without HIV.

Improvements in treatment have made HIV a manageable chronic condition, leading to increased life expectancy and a growing share of people with HIV who are older. Older people with HIV have higher rates of many chronic conditions, yet little is known about differences in health care utilization and spending. This study compared health care utilization and spending for Medicare beneficiaries with and without HIV, accounting for differential mortality. The data included demographic characteristics and claims-based information. Estimated cumulative spending for beneficiaries with HIV aged 67 to 77 years was 26% higher for Medicare Part A and 39% higher for Medicare Part B compared with beneficiaries without HIV; most of these differences would be larger if not for greater mortality risk among people with HIV (and therefore fewer years to receive care). Future research should disentangle underlying causes for this increased need and describe potential responses by policymakers and health care providers.

Treatment times for delivering adjuvant breast radiotherapy at a cancer centre in Ontario, Canada.

BACKGROUND: Time is a valuable commodity that impacts hospital flow, patient experience and economic resources. This study aims to identify factors that affect daily treatment time over a course of radiation therapy (RT) in patients who underwent adjuvant breast RT. METHODS: In all adjuvant breast/chestwall RT patients treated from October 2017 to May 2018, daily set-up, beam delivery time, and overall treatment times were collected. A multivariable linear regression analysis was conducted to identify significant predictive factors related to treatment time. A general linear regression model was used to determine whether there was a learning curve effect throughout the course of treatment that decreased treatment time as patient and staff familiarity with the treatment procedure increased. RESULTS: A total of 567 patients were included with a median age of 61 years. The average overall treatment time for 2-field and 4-field RT was 8.3 (SD 2.4) and 13.1 (SD 5.6) minutes, respectively. Factors that significantly increased overall treatment times in patients prescribed 2-field RT were: bilateral techniques, breath-hold (BH) techniques, prone techniques (PR), reverse decubitus techniques (RD), wide tangents techniques, the use of bolus and number of segments delivered. (p < 0.05). Factors that significantly increased overall treatment times in patients who received 3-field and 4-field RT were: wide tangents volumes, a higher number of monitor units (MUs), bilateral techniques and BH techniques (p < 0.05). Older patients (≥60) who underwent 3-field and 4-field RT demonstrated a statistically significant increase in set-up time (p < 0.0001). Overall treatment time decreased from 10.0 to 9.3 min over the course of treatment, suggesting a minor learning curve (p = 0.009). CONCLUSION: The use of bilateral RT, BH, PR, RD, wide tangents, bolus, increasing treatment volumes, and increasing plan complexity were associated with increased treatment times. Future research should quantify the impact of other factors (BMI, mobility, patient care assessments, and imaging protocols) and utility of technological tools (time-predicting models, machine learning tools, and operations research models) on treatment time to optimize RT scheduling and improve resource management.

A food product as a potential serious cause of liver injury.

INTRODUCTION: Drug-induced liver injury can be challenging to diagnose, as it can develop following the use of many prescription and nonprescription medications, herbals, and dietary supplements. Food products may not be routinely considered as a potential cause of hepatotoxicity. We describe the clinical features of two cases of acute liver injury following consumption of a smoothie product. CASE PRESENTATIONS: Two patients independently presented to the hospital with epigastric pain and acute liver injury. Both patients had consumed a new smoothie product in the same month that they presented to the hospital, with a recurrence of acute liver injury with further consumption. A diagnosis of drug-induced liver injury was established after the evaluation excluded other causes of liver injury. It was thought that a natural ingredient in the smoothie, tara flour, was the cause of hepatotoxicity based on prior news reports. Both patients stopped drinking the smoothie product with subsequent normalization of liver enzyme activities and no further recurrence of epigastric pain. CONCLUSION: The diagnosis of drug-induced liver injury largely relies on a compatible history and exclusion of other causes of liver injury. We demonstrate the importance of considering new food products in the differential diagnosis of acute liver injury.

Uniportal thoracoscopic sympathicotomy for hyperhidrosis.

Video-assisted thoracoscopic sympathicotomy is the most widely used technique in the modern era for the treatment of primary hyperhidrosis. Primary hyperhidrosis is characterized by excessive sweating and significantly affects the quality of life in those who suffer from it. This video tutorial details a uniportal, drainless sympathicotomy performed by the cardiothoracic surgical team at St George Hospital, Sydney, Australia.

The Application of Relational Frame Theory to Teaching Early Piano Skills to Children on the Autism Spectrum.

Music is a unique form of verbal stimuli (Reynolds & Hayes, The Psychological Record, 67(3), 413-421, 2017) and the literature has indicated some success in using procedures involving the frame of coordination or stimulus equivalence to teach early piano skills to learners with and without autism spectrum disorder (ASD; Hill et al., Journal of Applied Behavior Analysis, 53(1), 188-208, 2020). However, these studies only targeted narrow skills rather than a complete repertoire. Also, whether such teaching procedure is effective for young children with ASD at different ages, with different needs, and with common accompanied diagnosis, is unknown. The current study (a) explored the possibility of applying relational frame theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001) in piano program development that aims to teach a complete early piano repertoire, and (b) confirmed the effectiveness of an adjusted teaching procedure using the frame of coordination on teaching early piano skills to six young children on the autism spectrum. A multiple probe across participants design was used. After direct training of two relations (AC & AE), post-instructional tests were conducted on eight relations. The results showed that with remedial training, five out of six participants demonstrated mutual entailment, combinatorial entailment, and transformation of stimulus function in these relations. All participants could read and play the song on keyboard without extra training. The study provided practical guidance on applying the procedure to these young learners. Implications of RFT in piano curriculum development were also discussed. Supplementary Information: The online version contains supplementary material available at 10.1007/s40616-022-00175-8.