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Insertion of tubes in an office setting and automated tube insertion devices were identified as high-priority quality improvement opportunities during the update process for the 2013 clinical practice guideline on tympanostomy tubes from the American Academy of Otolaryngology-Head and Neck Surgery. The guideline update group, however, decided to avoid any recommendations on these topics, based on limited research evidence, and instead selected a subset of group members to author this state of the art review, with the goal of facilitating informed decisions in clinical practice.PubMed through September 2021, Google search of device manufacturer websites, and SmartTots research website for articles on anesthesia neurotoxicity.A state of the art review format emphasizing evidence from the past 5 years, with manual cross-checks of reference lists of identified articles for additional relevant studies.The existing literature is too sparse to make recommendations about procedure setting and optimal technique or assess long-term outcomes. The role of automated devices is uncertain, given the increased equipment cost and limited information on characteristics of the proprietary preloaded tubes, including intubation duration and rates of otorrhea, obstruction, medialization, granulation tissue, and persistent perforation.Whether to undertake in-office tube insertion in awake children should be based on clinician experience, clinician ability to interact with and reassure caregivers, shared decisions with caregivers, and judgment regarding the level of cooperation (or lack thereof) to be expected from a given child. Clinicians should remain alert to new research and expect increasing queries from patients and families.

Background Encephalitis is widely recognized as a challenging condition to diagnose and manage. The care of patients with encephalitis typically involves multiple disciplines, including neurologists and infectious disease (ID) physicians. Our objective was to describe the perspectives and needs of ID physicians regarding encephalitis, using a cross-sectional questionnaire survey. Methods We performed a survey among physician members of the Infectious Diseases Society of America's (IDSA) Emerging Infections Network (EIN). Results Response rate was 33% (480 among 1472 active EIN physician members). More than 75% of respondents reported caring for patients with suspected encephalitis. Although one-third were involved in the care of multiple patients with autoimmune encephalitis (AE) annually, comfort in diagnosing and managing encephalitis, and in particular AE, was low. Experience with advanced diagnostic tools was variable, as were approaches toward deployment of such tools. Respondents noted that training could be improved by incorporating a multidisciplinary approach taking advantage of online and virtual platforms. ID physicians report a heavy reliance on the 2008 IDSA guidelines for the management of encephalitis, and indicated strong support for a formal update. Conclusions ID physicians play an important role in the diagnosis and management of all-cause encephalitis. Despite exposure to AE, few ID physicians are comfortable in recognizing, diagnosing, and treating AE. Moreover, comfort with and use of advanced diagnostic tools for infectious encephalitis was highly variable. Training in encephalitis should include a focus on use and stewardship of advanced diagnostic tools and on collaborative approaches with neurologists and other practitioners on mechanisms and clinical presentations of AE. There is a need for a formal update of 2008 guidelines on the management of encephalitis.

Young children learn language at an incredible rate. Although children come prepared with powerful statistical-learning mechanisms, the statistics they encounter are also prepared for them: Children learn from caregivers motivated to communicate with them. How precisely do parents tune their speech to their children’s individual language knowledge? To answer this question, we asked parent–child pairs ( N = 41) to play a reference game in which the parents’ goal was to guide their child to select a target animal from a set of three. Parents fine-tuned their referring expressions to their children’s knowledge at the lexical level, producing more informative references for animals they thought their children did not know. Further, parents learned about their children’s knowledge over the course of the game and tuned their referring expressions accordingly. Child-directed speech may thus support children’s learning not because it is uniformly simplified but because it is tuned to individual children’s language development.

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.The guideline development group made

Context: Differential testing is a useful approach that uses different implementations of the same algorithms and compares the results for software testing. In recent years, this approach was successfully used for test campaigns of deep learning frameworks. Objective: There is little knowledge on the application of differential testing beyond deep learning. Within this article, we want to close this gap for classification algorithms. Method: We conduct a case study using Scikit-learn, Weka, Spark MLlib, and Caret in which we identify the potential of differential testing by considering which algorithms are available in multiple frameworks, the feasibility by identifying pairs of algorithms that should exhibit the same behavior, and the effectiveness by executing tests for the identified pairs and analyzing the deviations. Results: While we found a large potential for popular algorithms, the feasibility seems limited because often it is not possible to determine configurations that are the same in other frameworks. The execution of the feasible tests revealed that there is a large amount of deviations for the scores and classes. Only a lenient approach based on statistical significance of classes does not lead to a huge amount of test failures. Conclusions: The potential of differential testing beyond deep learning seems limited for research into the quality of machine learning libraries. Practitioners may still use the approach if they have deep knowledge about implementations, especially if a coarse oracle that only considers significant differences of classes is sufficient., Under review

Atrophic alveolar ridges of five patients were augmented with allografts and autografts on opposite sites, followed by dental implantation. Both augmentation materials led to equivalent bone gains. Allografts did not compromise the clinical outcome.

This executive summary of the guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The summary and guideline are intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.The purpose of this executive summary is to provide a succinct overview for clinicians of the key action statements (recommendations), summary tables, and patient decision aids from the update of the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)." The new guideline updates recommendations in the prior guideline from 2013 and provides clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. This summary is not intended to substitute for the full guideline, and clinicians are encouraged to read the full guideline before implementing the recommended actions.The guideline on which this summary is based was developed using methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action," which were followed explicitly. The guideline update group represented the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the termThe purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research.In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.The GUG made

Achondroplasia, the most common skeletal dysplasia, is characterized by a variety of medical, functional and psychosocial challenges across the lifespan. The condition is caused by a common, recurring, gain-of-function mutation in FGFR3, the gene that encodes fibroblast growth factor receptor 3. This mutation leads to impaired endochondral ossification of the human skeleton. The clinical and radiographic hallmarks of achondroplasia make accurate diagnosis possible in most patients. However, marked variability exists in the clinical care pathways and protocols practised by clinicians who manage children and adults with this condition. A group of 55 international experts from 16 countries and 5 continents have developed consensus statements and recommendations that aim to capture the key challenges and optimal management of achondroplasia across each major life stage and sub-specialty area, using a modified Delphi process. The primary purpose of this first International Consensus Statement is to facilitate the improvement and standardization of care for children and adults with achondroplasia worldwide in order to optimize their clinical outcomes and quality of life. Achondroplasia is the most common skeletal dysplasia and is characterized by various lifelong clinical, functional and psychosocial challenges for affected individuals. This first International Consensus Statement on the care of children and adults with achondroplasia aims to facilitate the global standardization and improvement of achondroplasia clinical care.

An important tenet of competency-based medical education is that the educational continuum should be seamless. The transition from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless, however. Current practices around this transition drive students to focus on appearing to be competitively prepared for residency. A communication at the completion of UME-an educational handover-would encourage students to focus on actually preparing for the care of patients. In April 2018, the American Medical Association's Accelerating Change in Medical Education consortium meeting included a debate and discussion on providing learner performance measures as part of a responsible educational handover from UME to GME. In this Perspective, the authors describe the resulting 5 recommendations for developing such a handover: (1) The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance, (2) the process used to create an educational handover should be philosophically and practically aligned with the learner's continuous quality improvement, (3) the educational handover should be learner driven with a focus on individualized learning plans that are coproduced by the learner and a coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement. These recommendations are shared to encourage implementation of the educational handover and to generate a potential research agenda that can inform policy and best practices.

This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clinical Practice Guideline: Nosebleed (Epistaxis)." This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

Rapid response teams have become necessary components of patient care within the hospital community, including for airway management. Pediatric patients with an increased risk of having a difficult airway emergency can often be predicted on the basis of clinical scenarios and medical history. This predictability has led to the creation of airway consultation services designed to develop airway management plans for patients experiencing respiratory distress and who are at risk for having a difficult airway requiring advanced airway management. In addition, evolving technology has facilitated airway management outside of the operating suite. Training and continuing education on the use of these tools for airway management is imperative for clinicians responding to airway emergencies. We describe the comprehensive multidisciplinary, multicomponent Pediatric Difficult Airway Program we created that addresses each component identified above: the Pediatric Difficult Airway Response Team (PDART), the Pediatric Difficult Airway Consult Service, and the pediatric educational airway program. Approximately 41% of our PDART emergency calls occurred in the evening hours, requiring a specialized team ready to respond throughout the day and night. A multitude of devices were used during the calls, obviating the need for formal education and hands-on experience with these devices. Lastly, we observed that the majority of PDART calls occurred in patients who either were previously designated as having a difficult airway and/or had anatomic variations that suggest challenges during airway management. By instituting the Pediatric Difficult Airway Consult Service, we have decreased emergent Difficult Airway Response Team calls with the ultimate goal of first-attempt intubation success.

Few validated methods that are grounded in educational theory exist to effectively teach medical knowledge, clinical skills, and diagnostic reasoning to learners at different stages of medical training. The goal of this Perspective was to address potential gaps in clinical education pedagogy by modeling new concepts for teaching in the field of infectious diseases. Our approach involved synthesizing the relevant literature, identifying proven approaches, and enhancing an existing educational microskills model — the one-minute preceptor. Our strategy was to emphasize the essential core elements of the one-minute preceptor using a descriptive acronym — DEFT (Diagnosis, Evidence, Feedback, Teaching), meaning skillful — as a potentially helpful reminder to improve the quality of interactions between learners and preceptors. The need for learners to discuss risk factors, mechanisms of disease, and potential complications, and for preceptors to model analytical and diagnostic skills, was further illustrated using a practical example of a teacher–learner interaction about a child with a respiratory infection. The one-minute preceptor/DEFT approach is experiential, adaptable, case-driven, and skills-focused, and also applicable to clinical training in other specialties.

SummaryBackgroundSchool-based COVID-19 contacts in England are asked to self-isolate at home. However, this has led to large numbers of missed school days. Therefore, we trialled daily testing of contacts as an alternative, to investigate if it would affect transmission in schools.MethodsWe performed an open-label cluster randomised controlled trial in students and staff from secondary schools and further education colleges in England (ISRCTN18100261). Schools were randomised to self-isolation of COVID-19 contacts for 10 days (control) or to voluntary daily lateral flow device (LFD) testing for school contacts with LFD-negative contacts remaining at school (intervention). Household contacts were excluded from participation.Co-primary outcomes in all students and staff were symptomatic COVID-19, adjusted for community case rates, to estimate within-school transmission (non-inferiority margin: FindingsOf 99 control and 102 intervention schools, 76 and 86 actively participated (19-April-2021 to 27-June-2021); additional national data allowed most non-participating schools to be included in the co-primary outcomes. 2432/5763(42.4%) intervention arm contacts participated. There were 657 symptomatic PCR-confirmed infections during 7,782,537 days-at-risk (59.1/100k/week) and 740 during 8,379,749 days-at-risk (61.8/100k/week) in the control and intervention arms respectively (ITT adjusted incidence rate ratio, aIRR=0.96 [95%CI 0.75-1.22;p=0.72]) (CACE-aIRR=0.86 [0.55-1.34]). There were 55,718 COVID-related absences during 3,092,515 person-school-days (1.8%) and 48,609 during 3,305,403 person-school-days(1.5%) in the control and intervention arms (ITT-aIRR=0.80 [95%CI 0.53-1.21;p=0.29]) (CACE-aIRR 0.61 [0.30-1.23]). 14/886(1.6%) control contacts providing an asymptomatic PCR sample tested positive compared to 44/2981(1.5%) intervention contacts (adjusted odds ratio, aOR=0.73 [95%CI 0.33-1.61;p=0.44]). Rates of symptomatic infection in contacts were 44/4665(0.9%) and 79/5955(1.3%), respectively (aOR=1.21 [0.82-1.79;p=0.34]).InterpretationDaily contact testing of school-based contacts was non-inferior to self-isolation for control of COVID-19 transmission. COVID-19 rates in school-based contacts in both intervention and control groups were

Background The goal of this study was to determine if difficult airway risk factors were similar in children cared for by the difficult airway response team (DART) and those cared for by the rapid response team (RRT). Methods In this retrospective database analysis of prospectively collected data, we analyzed patient demographics, comorbidities, history of difficult intubation, and intubation event details, including time and place of the emergency and devices used to successfully secure the airway. Results Within the 110-patient cohort, median age (IQR) was higher among DART patients than among RRT patients [8.5 years (0.9-14.6) versus 0.3 years (0.04-3.6); P < 0.001]. The odds of DART management were higher for children ages 1-2 years (aOR, 43.3; 95% CI: 2.73-684.3) and >5 years (aOR, 13.1; 95% CI: 1.85-93.4) than for those less than one-year-old. DART patients were more likely to have craniofacial abnormalities (aOR, 51.6; 95% CI: 2.50-1065.1), airway swelling (aOR, 240.1; 95% CI: 13.6-4237.2), or trauma (all DART managed). Among patients intubated by the DART, children with a history of difficult airway were more likely to have musculoskeletal (P = 0.04) and craniofacial abnormalities (P < 0.001), whereas children without a known history of difficult airway were more likely to have airway swelling (P = 0.04). Conclusion Specific clinical risk factors predict the need for emergency airway management by the DART in the pediatric hospital setting. The coordinated use of a DART to respond to difficult airway emergencies may limit attempts at endotracheal tube placement and mitigate morbidity.

ObjectiveOpioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead...

Every transaction has the potential to go wrong and international commercial contracts are not spared this plight. It is when an international commercial contract fails – irrespective of the reasons, that the impact of different legal and cultural backgrounds of the parties come to light. The obvious venue for commercial disputes to be decided is generally understood to be in court (litigation) or before an arbitral tribunal (arbitration). However, there are numerous other alternative dispute mechanisms4 available to parties that are less well known and also deserve consideration; not least because they offer parties methods of resolving the dispute between them in a more time and cost-efficient manner, and with a stronger focus on the commercial interest of the parties. Mediation is one of these mechanisms. This chapter provides an overview of the basic concepts of mediation; how it distinguishes itself from but can also be employed together with other dispute resolution mechanisms such as, in particular, arbitration; the legal framework; and practical guidelines when drafting a mediation agreement in the context of international commercial contracts.