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A Breathtaking Case of Chemotherapy-Induced Pneumonitis.
No full textMedication-induced pulmonary toxicity is a rare adverse event that may occur with many chemotherapeutic agents, including etoposide. This agent has been found to cause various toxicities, including anaphylaxis, angioedema, hypotension, and pneumonitis. Etoposide is used in chemotherapy regimens for multiple cancers, including germ-cell tumors. Proper diagnosis of chemotherapy-induced pulmonary toxicity is imperative and should be considered in patients who develop acute respiratory failure during or after chemotherapy. Here, we discuss an unexpected case of etoposide-induced pneumonitis after a short course of IV etoposide in a patient with metastatic seminoma
Letter to the Editor: Accurate diagnosis of ischemic heart disease without exposure to radiation using non-stress unshielded magnetocardiography (MCG)
No full textCost as a barrier to eyeglasses in pediatric population: a cross-sectional survey analysis
No full textEyeglasses are an essential medical device to maximize visual potential and learning in children. We surveyed parents and pediatric ophthalmologists regarding their perspectives on the cost of pediatric eyeglasses. Parents and ophthalmologists identified cost as a barrier to obtaining eyeglasses. Despite over 80% of patients having some insurance coverage for eyeglasses, less than 1 in 4 reported that insurance fully covered the cost, and parents most frequently spent $100-200 per pair. More than 1 in 4 parents deferred purchasing recommended eyeglasses due to cost. Although over 80% of parents felt comfortable discussing the price of eyeglasses with the ophthalmologist, less than half of ophthalmologists felt comfortable discussing cost
Office-Based Facial Plastic Surgery
No full textOffice-based facial plastic surgery involves a wide array of procedures from esthetic surgeries such as facelifting and blepharoplasty to reconstructive procedures including scar revision and local tissue flaps. The cornerstone to a successful outcome is a thorough history and physical examination with an emphasis on assessment of a patient\u27s ability to tolerate an office-based procedure. Room set-up, equipment, and personnel play an especially important role in these procedures. Anesthetic considerations as well as a heightened attention to safety are paramount in ensuring an excellent patient experience and an optimal result
Change in Urine Albumin-Creatinine Ratio and Occurrence of Hyperkalemia in Patients Initiating Finerenone in the USA: A Cohort Study from the FOUNTAIN Platform
No full textINTRODUCTION: In 2021, finerenone - a novel, selective nonsteroidal mineralocorticoid receptor antagonist - was approved in the USA to treat adults with chronic kidney disease (CKD) and type 2 diabetes (T2D). This study aimed to describe characteristics and short-term outcomes of patients prescribed finerenone since regulatory approval.
METHODS: This was a retrospective cohort study using claims and electronic health records data from the OM1 Real-World Data Cloud™. A total of 15,948 US adults with a previous diagnosis of CKD and T2D who initiated 10 mg or 20 mg finerenone between July 2021 and August 2023 were included. Dosing was evaluated at baseline and over up to 12-month follow-up. Change from baseline in urine albumin-to-creatinine ratio (UACR) was evaluated at 4 and 12 months (among 913 and 443 patients, respectively, with available repeat UACR values). Hyperkalemia occurrence was determined at 12 months and over total follow-up.
RESULTS: Median follow-up was 7.2 months. Mean age was 70.3 years, and 44.1% were female. At baseline (-365; 0 days), 70% had CKD stage 3; for patients with UACR measurements, 80.8% had moderate/severe albuminuria (≥30 mg/g). Median UACR was 203 mg/g. Co-medication use was ACE inhibitors/ARBs (51%), SGLT2is (38%), and GLP-1 RAs (26%). 86% of patients initiated 10 mg finerenone, and among 2,212 patients still under observation at 12 months, 70% were on 10 mg. For finerenone initiators with available UACR data, UACR was reduced by 33% at 4 months and 38% at 12 months. Hyperkalemia occurred in 1.2% of the cohort by 12 months (incidence 2.0 per 100 person-years).
CONCLUSION: Patients who initiated finerenone had a notable reduction in median UACR at 4 months, sustained at 12 months; hyperkalemia occurrence appeared to be low. These initial findings from US clinical practice should be complemented by results from other real-world cohorts of patients started on finerenone
Zero Suicide Model Implementation and Suicide Attempt Rates in Outpatient Mental Health Care
No full textIMPORTANCE: Suicide is a major public health concern, and as most individuals have contact with health care practitioners before suicide, health systems are essential for suicide prevention. The Zero Suicide (ZS) model is the recommended approach for suicide prevention in health systems, but more evidence is needed to support its widespread adoption.
OBJECTIVE: To examine suicide attempt rates associated with implementation of the ZS model in outpatient mental health care within 6 US health systems.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study with an interrupted time series design used data collected from January 2012 through December 2019, from patients aged 13 years or older who received mental health care at outpatient mental health specialty settings within 6 US health systems located in 5 states: California, Oregon, Washington, Colorado, and Michigan. Analyses were conducted from January through December 2024.
EXPOSURE: The ZS model was implemented in 4 health systems at different points during the observation period (2012-2019) and compared with health systems that implemented the model before the observation period (postimplementation). Implementation included suicide risk screening, assessment, brief intervention (safety plan, means safety protocol), and behavioral health treatment.
MAIN OUTCOMES AND MEASURES: The primary outcome was a measure of standardized monthly suicide attempt rates captured using health system records and government mortality records. Suicide death rates were also measured as a secondary outcome.
RESULTS: There was a median of 309 107 (range, 55 354-451 837) unique patients per month. In 2017, there were 317 939 eligible individuals (63.2% female). Baseline suicide attempt rates were at least 30 to 40 per 100 000 individuals at each implementation site and decreased to less than 30 per 100 000 individuals at 3 sites by 2019. Decreases in suicide attempt rates were observed at 3 intervention health systems after site-specific implementation: health systems A and B had decreases of 0.7 per 100 000 individuals per month and C, 0.1 per 100 000 individuals per month. System D evidenced a similar suicide attempt rate after implementation (before implementation: median rate: 35.0 [range, 11.0-50.3] per 100 000 patients per month; after implementation: median rate: 34.3 [range, 18.5-42.0] per 100 000 patients per month). The 2 postimplementation health systems maintained low or declining suicide attempt rates throughout the observation period. The rate at system Y decreased by 0.3 per 100 000 individuals per month across the observation period. The rate at system Z began at 11 per 100 000 individuals per month and declined by 0.03 per 100 000 individuals per month during the observation period. Two systems evidenced reductions in the suicide death rate after implementation: system B declined by 0.2 per 100 000 individuals per month and system C by 0.1 per 100 000 individuals per month.
CONCLUSIONS AND RELEVANCE: In this quality improvement study, ZS model implementation was associated with a reduction in suicide attempt rates among patients accessing outpatient mental health care at most study sites, which supports widespread efforts to implement the ZS model in these settings within US health systems
Skincare ingredients recommended by cosmetic dermatologists: A Delphi consensus study
No full textBACKGROUND: There is ambiguity regarding the topical cosmetic ingredients preferred for common skin complaints.
OBJECTIVE: To determine which topical ingredients are frequently recommended by cosmetic dermatologists for fine lines and wrinkles, acne, redness, dark spots, large pores, dry skin, and oily skin.
METHODS: Literature review to develop long list of ingredients. Reduced by expert panel to most salient ingredients. Two rounds of Delphi consensus survey with second expert panel of clinicians and teachers. Comparative literature review to summarize published evidence supporting each consensus ingredient.
RESULTS: List of 318 ingredients reduced by a panel of 17 dermatologists to 83. Two Delphi rounds completed by 62 dermatologists at 43 centers. Consensus achieved for 23 ingredients, including the following: azelaic acid (acne, dark spots); benzoyl peroxide (acne, oily skin); glycolic acid (acne, dark spots); mineral sunscreen (fine lines and wrinkles, redness); niacinamide (redness, dark spots); retinoids (fine lines and wrinkles, acne, dark spots, large pores, oily skin); salicylic acid (acne, oily skin); vitamin C (fine lines and wrinkles, dark spots). Most consensus ingredients supported by level 1b or 2b evidence.
LIMITATIONS: Some ingredients based on expert opinion.
CONCLUSION: Consensus exists among expert cosmetic dermatologists regarding ingredients most useful for common dermatologic concerns
Protocol-Driven Best Practices and Cardiogenic Shock Survival in Asian Patients.
No full textBACKGROUND: Cardiogenic shock carries high mortality. This study investigated the relationship between protocol-advocated best practices and outcomes. METHODS: Patients with cardiogenic shock supported by Impella CP in an Asian tertiary cardiac center were evaluated for 30-day post percutaneous ventricular assist device (PVAD) survival after adopting a standardized protocol emphasizing early mechanical circulatory support (shock-to-PVAD time ≤180 minutes), pulmonary artery catheterization for invasive hemodynamics, and safe vascular access. RESULTS: Of 109 consecutive patients (mean age 58.5±11.2, 80.7% male, 67% acute myocardial infarction, 33% acute decompensated heart failure), 45 (41.3%), 33 (30.3%), and 31 (28.4%) were in SCAI Shock Stages C, D, and E, respectively. A suggestive trend of improving 30-day survival was observed (56.8%, 63.9%, and 72.2% in successive one thirds, P1, P2, and P3 of patients), paralleling a similar trend in achievement of best practices. Patients achieving all 3 best practices significantly increased from 35.1% (P1) to 52.8% (P3) (P=0.026). Median shock-to-PVAD time reduced from 5 [interquartile range: 2-23] hours (P1) to 1.5 [1-5] hours (P3) (P for trend=0.014), whereas pulmonary artery catheterization utilization (80.6-86.1%) and device-related major vascular complications (5.6-8.4%) remained relatively stable. Achieving more best practices was significantly associated with better 30-day survival, with patients achieving all 3, 2, and ≤1 best practices had 30-day survival rates of 75.0%, 63.6%, and 35.7%, respectively (P=0.043). In multivariate Cox regression analysis, shock-to-PVAD time \u3e180 minutes remained an independent predictor of mortality (P=0.031). CONCLUSIONS: Achievement of protocol-advocated best practices, especially early shock recognition and prompt PVAD support in appropriate patients, was associated with improved outcomes with PVAD use in cardiogenic shock. Future studies are suggested to confirm the benefits of a protocolized approach and evaluate the value of individual best practices
International consensus statement on the use of ultrasound in hidradenitis suppurativa
No full textBACKGROUND: So far, the evidence on the use of ultrasound (US) in hidradenitis suppurativa (HS) demonstrates the utility of US in the diagnosis, scoring and assessment of HS; however, to date, there is no international consensus statement on the use of US in HS, and several published guidelines do not include this topic.
OBJECTIVES: To create an international consensus statement on using US in HS that can cover and validate relevant aspects.
METHODS: A three-round Delphi study with a panel of international experts representing four continents and working with US in HS in their daily practice. The inclusion criteria of the experts and the set of questions in the survey were defined by a steering committee. A consensus of recommendation was defined when the percentage of agreement (sum of strongly agree and agree) was ε 70%. In between 50% and 69% of agreement, a suggestion was considered. Lower than 50% meant no consensus.
RESULTS: Twenty-four international experts from 14 countries participated in the study. A high percentage of consensus (96.4%) was achieved for important aspects of the use of US in HS, including the ultrasonographic indications, technical considerations, training, diagnostic criteria, staging systems, monitoring, support of US-guided procedures and planning of surgery, and the need for US in research and clinical trials.
CONCLUSIONS: An international group of experts created a consensus statement with validated recommendations on the use of US in HS. Despite the challenges of the implementation of ultrasound in HS, this task force highly recommends the use of US in HS
Impaired Molecular Mechanisms Contributing to Chronic Pain in Patients with Hidradenitis Suppurativa: Exploring Potential Biomarkers and Therapeutic Targets
No full textHidradenitis suppurativa (HS) is a chronic skin condition that primarily affects areas with dense hair follicles and apocrine sweat glands, such as the underarms, groin, buttocks, and lower breasts. Intense pain and discomfort in HS have been commonly noted, primarily due to the lesions\u27 effects on nearby tissues. Pain is a factor that can influence DNA methylation patterns, though its exact role in HS is not fully understood. We aim to identify molecular markers of chronic pain in HS patients. We performed DNA methylome of peripheral blood DNA derived from a group of 24 patients with HS and 24 healthy controls, using Illumina methylation array chips. We identified 253 significantly differentially methylated CpG sites across 253 distinct genes regulating pain sensitization in HS, including 224 hypomethylated and 29 hypermethylated sites. Several genes with pleiotropic roles include transporters (ABCC2, SLC39A8, SLC39A9), wound healing (MIR132, FGF2, PDGFC), ion channel regulators (CACNA1C, SCN1A), oxidative stress mediators (SCN8A, DRD2, DNMT1), cytochromes (CYP19A, CYP1A2), cytokines (TGFB1, IL4), telomere regulators (CSNK1D, SMAD3, MTA1), circadian rhythm (IL1R2, ABCG1, RORA), ultradian rhythms (PHACTR1, TSC2, ULK1), hormonal regulation (PPARA, NR3C1, ESR2), and the serotonin system (HTR1D, HTR1E, HTR3C, HTR4, TPH2). They also play roles in glucose metabolism (POMC, IRS1, GNAS) and obesity (DRD2, FAAH, MMP2). Gene ontology and pathway enrichment analysis identified 43 pathways, including calcium signaling, cocaine addiction, and nicotine addiction. This study identified multiple differentially methylated genes involved in chronic pain in HS, which may serve as biomarkers and therapeutic targets. Understanding their epigenetic regulation is crucial for personalized pain management and could enhance the identification of high-risk patients, leading to better preventative therapies and improved maternal and neonatal outcomes