BACKGROUND: Vascular malformations (VaMs) are caused by errors in vascular morphogenesis. Diagnosis and treatment can be complex. Few specialized centers care for these patients, and limited literature exists regarding their characteristics and clinical course. The vascular anomalies clinic (VAC) at the Instituto Nacional de Pediatría (National Institute for Pediatrics) is a multidisciplinary team and has been a reference center for patients with VaMs since 2012. We sought to describe the characteristics of patients cared for at the VAC, types of VaMs, treatments used, and clinical course.
METHODS: This was a descriptive, observational, retrospective, and cross-sectional study conducted from 2012 to 2022.
RESULTS: We included 435 patients with VaMs; the median age of presentation was 1 month. The most frequent signs and symptoms were increased volume (97.2%), superficial color change (65.5%), and pain (43.3%). The most common VaMs were lymphatic (36.7%) and venolymphatic (18.3%). Sclerotherapy was the most frequent treatment (73.4%), followed by medical treatment with sirolimus (18.5%); response to both was excellent/good in > 85% of cases.
CONCLUSIONS: In this retrospective study of children with VaMs, we found that low-flow malformations were the most common, and sclerotherapy and sirolimus were the most frequently used treatments. The therapeutic response was excellent/good in most cases.
UNASSIGNED: Las malformaciones vasculares (MaV) son secundarias a errores en la morfogénesis vascular. El diagnóstico y tratamiento puede ser complejo. Existen pocos centros especializados en su atención y escasa literatura respecto a características y evolución clínica. La Clínica de Anomalías Vasculares (CAV) del Instituto Nacional de Pediatría es un equipo multidisciplinario y centro de referencia para estos pacientes desde 2012. Buscamos describir las características de los pacientes atendidos en la CAV, tipo de MaV, tratamiento y evolución clínica.
UNASSIGNED: Estudio descriptivo, observacional, retrospectivo y transversal del periodo 2012 al 2022.
RESULTS: Se incluyeron 435 pacientes con MaV, con edad mediana de presentación de 1 mes de vida. Los síntomas y signos más reportados fueron aumento de volumen (97.2%), cambio en coloración de la piel (65.5%) y dolor (43.3%). Las MaV más comunes fueron linfáticas (36.7%), siguiéndoles las venolinfáticas (18.3%). La escleroterapia fue el tratamiento más frecuente (73.4%) y el tratamiento médico más utilizado fue sirolimus (18.5%), ambos con excelente/buena respuesta en > 85% de los pacientes.
CONCLUSIONS: En este estudio retrospectivo de niños con MaV encontramos que las más frecuentes son de bajo flujo y el tratamiento más usado escleroterapia y sirolimus. La respuesta terapéutica de la mayoría fue excelente/buena.

BACKGROUND: Systemic sclerosis (SSc) is a very heterogeneous, chronic, rare, but socioeconomically important disease with a severe disease course and severe impairment of the quality of life of affected patients.
OBJECTIVE: Overview of the current state of research on the pathogenesis, diagnosis and therapy of SSc.
METHODS: A literature search was performed.
RESULTS: The pathogenesis of SSc is not fully understood. ACR/EULAR criteria allow the diagnosis of early forms of SSc. Classification into limited cutaneous SSc and diffuse cutaneous SSc is of prognostic and therapeutic relevance. New organ-specific treatment options for SSc have led to improved quality of life and prognosis.
UNASSIGNED: HINTERGRUND: Die systemische Sklerose (SSc) stellt eine sehr heterogene, chronische, zwar seltene, jedoch sozioökonomisch bedeutsame Erkrankung mit schwerem Krankheitsverlauf und starker Einschränkung der Lebensqualität betroffener Patienten dar.
UNASSIGNED: Es wird eine Übersicht zum aktuellen Forschungsstand zu Pathogenese, Diagnostik und Therapie der SSc gegeben.
UNASSIGNED: Es erfolgte eine Literaturrecherche.
UNASSIGNED: Die Pathogenese der SSc bleibt bislang weiterhin nicht gänzlich geklärt. ACR(American College of Rheumatology)/EULAR(European League Against Rheumatism)-Kriterien erlauben eine Diagnose auch früher SSc-Formen. Die Klassifikation in limitierte kutane systemische Sklerose (lcSSc) und diffuse kutane systemische Sklerose (dcSSc) ist von prognostischer und therapeutischer Relevanz. Neue organspezifische Therapiemöglichkeiten der SSc haben zu einer verbesserten Lebensqualität und Prognose geführt.

BACKGROUND: Current guidelines emphasize the diagnostic value of non-cardiac or possibly cardiac chest pain. The goal of this analysis was to determine whether German chest pain units (CPUs) adequately address conditions with \"atypical\" chest pain in existing diagnostic structures.
METHODS: A total of 11,734 patients from the German CPU registry were included. The analyses included mode of admission, critical time intervals, diagnostic steps, and differential diagnoses.
RESULTS: Patients with unspecified chest pain were younger, more often female, were less likely to have classic cardiovascular risk factors and tended to present more often as self-referrals. Patients with acute coronary syndrome (ACS) mostly had prehospital medical contact. Overall, there was no difference between these two groups regarding the time from the onset of first symptoms to arrival at the CPU. In the CPU, the usual basic diagnostic measures were performed irrespective of ACS as the primary working diagnosis. In the non-ACS group, further ischemia-specific diagnostics were rarely performed. Extra-cardiac differential diagnoses were not specified.
CONCLUSIONS: The establishment of broader awareness programs and opening CPUs for low-threshold evaluation of self-referring patients should be discussed. Regarding the rigid focus on the clarification of cardiac causes of chest pain, a stronger interdisciplinary approach should be promoted.
UNASSIGNED: HINTERGRUND: Aktuelle Leitlinien betonen die diagnostische Wertigkeit auch des nichtkardialen oder möglicherweise nichtkardialen Thoraxschmerzes. In der aktuellen Arbeit wird untersucht, ob die deutschen Chest Pain Units (CPU) Erkrankungen mit „atypischen“ Brustschmerzen innerhalb der bestehender Diagnosestrukturen bereits angemessen behandeln.
METHODS: Eingeschlossen wurden 11.734 Patienten aus dem deutschen CPU-Register. Die Analysen umfassten Aufnahmeart, kritische Zeitintervalle, diagnostische Schritte und Differenzialdiagnosen.
UNASSIGNED: Patienten mit nicht näher bezeichneten Brustschmerzen waren jünger, häufiger weiblich, wiesen seltener klassische kardiovaskuläre Risikofaktoren auf und stellten sich tendenziell häufiger als Selbsteinweiser vor. Patienten mit akutem Koronarsyndrom (ACS) hatten meist bereits präklinischen Kontakt zum Gesundheitssystem. Insgesamt gab es keinen Unterschied hinsichtlich des Auftretens der ersten Symptome bis zum Eintreffen in der CPU. Innerhalb der CPU wurden bei allen Patienten und unabhängig von der initialen Arbeitsdiagnose ACS die üblichen Basisdiagnostikmaßnahmen durchgeführt. In der Nicht-ACS-Gruppe wurde selten weitere Ischämiediagnostik durchgeführt. Extrakardiale Differenzialdiagnosen wurden nicht weiter differenziert.
UNASSIGNED: Die Einrichtung umfassenderer Awarenessprogramme und die niederschwellige Selbstvorstellungsmöglichkeit in die CPU sollten intensiver diskutiert werden. Angesichts der häufig starren Fokussierung auf die Abklärung ischämischer/kardialer Ursachen des akuten Thoraxschmerzes sollte ein stärkerer interdisziplinärer Ansatz gefördert werden.

Postpartum hypertension can significantly increase maternal morbidity and mortality, and hence it requires prompt interdisciplinary evaluation and interventions. We present a case of a gravid patient with significant comorbidities who required multiple treatments and care from several specialists following a complicated vaginal delivery. The outcome of this case depended on a focused differential diagnosis and interdisciplinary consultation with the several teams involved. This case report illustrates the importance of effective communication and an interdisciplinary approach in the management of postpartum hypertensive emergencies. Such an approach is crucial in reducing maternal complications following postpartum hypertension, as well as reducing the length of hospital stay to improve maternal and fetal outcomes.

Sensory food aversion, an early childhood eating disorder, is a serious, permanent form of picky eating, in which the infant or the child consistently and persistently refuses certain foods based on specific characteristics, following one or more previous aversive experiences. Biological (sensory processing disorder, taste sensitivity) and environmental factors contribute to its development. Due to limited diet, specific dietary deficiencies may occur but weight gain is usually normal. Behavioral problems, anxiety disorder, autism spectrum disorder are often associated. Diagnosis can usually be made based on a detailed history, but further assessment may include pediatric examination, nutritionist consultation, and psychologic and occupational therapy assessment. Treatment is based on parent education and support in order to minimize mealtime battles and anxiety and to think together about strategies for expanding the child\'s diet and to help them to accept new foods. As part of the interdisciplinary team, the pediatrician\'s role is to monitor appropriate growth and development, exclude dietary deficiencies or prescribe supplementation if necessary. In our article, the screening and treatment of sensory processing disorder as part of the assessment of eating problems are introduced as an example of good clinical practice at the Early Childhood Eating and Sleep Disorder Outpatient Clinic at the Heim Pál National Institute of Pediatrics. Orv Hetil. 2023; 164(45): 1767-1777.
A kora gyermekkori evészavarok közé tartozó szenzoros ételelutasítás a válogatósság egy súlyos, perzisztáló formája, melyben a gyermek következetesen és kitartóan utasít el bizonyos ételeket valamely tulajdonságaik alapján, egy vagy több korábbi averzív élményt követően. Kialakulásában biológiai adottságok (szenzoros feldolgozási zavar, fokozott ízérzékenység) és környezeti hatások együttesen játszanak szerepet. A beszűkült étrend miatt egyes tápanyagok abszolút vagy relatív hiánya fordulhat elő, de súlygyarapodási zavar nem jellemző. Az evészavar gyakran társul viselkedésproblémákkal, szorongásos zavarral, autizmus spektrum zavarral. A diagnózis a részletes anamnézis alapján már többnyire valószínűsíthető, a kivizsgálást gyermekorvosi vizsgálat, dietetikai és pszichológiai konzultáció, gyógypedagógiai felmérés egészítheti ki. A terápia alapja a szülők edukációja és támogatása elsősorban az étkezések körüli szorongás csökkentése, másodsorban pedig az ételrepertoár bővítésének és az új ételek elfogadásának lehetőségeiről való közös gondolkodás érdekében. Az interdiszciplináris ellátás keretein belül a társszakmákkal együttműködve a gyermekorvos feladata a gyarapodás és a fejlődés ellenőrzése, a tápanyagok és a vitaminok hiányának kizárása, szükség esetén ezek pótlása. A tanulmányban jó gyakorlatként ismertetjük, hogy a Heim Pál Országos Gyermekgyógyászati Intézet Koragyermekkori Evés-alvászavar Ambulanciájának protokolljába hogyan épült be a szenzoros feldolgozási zavar szűrése és ellátása az evésproblémák kezelésének részeként. Orv Hetil. 2023; 164(45): 1767–1777.

The World Health Organization claims that rehabilitation is important to meet the needs of persons with dementia. Rehabilitation programmes, however, are not routinely available. Person-centred, multidimensional, and interdisciplinary rehabilitation can increase the opportunities for older adults with dementia and their informal primary caregivers to continue to live an active life and participate in society. To our knowledge, staff team experiences of such rehabilitation programmes, involving older adults with dementia and their informal caregivers has not been previously explored.
The aim of this qualitative focus group study was to explore the experiences of a comprehensive staff team providing person-centred multidimensional, interdisciplinary rehabilitation to community-dwelling older adults with dementia, including education and support for informal primary caregivers. The 13 staff team members comprised 10 professions who, during a 16-week intervention period, provided individualised interventions while involving the rehabilitation participants. After the rehabilitation period the staff team members were divided in two focus groups who met on three occasions each (in total six focus groups) and discussed their experiences. The Grounded Theory method was used for data collection and analysis.
The analysis resulted in four categories: Achieving involvement in rehabilitation is challenging, Considering various realities by acting as a link, Offering time and continuity create added value, and Creating a holistic view through knowledge exchange, and the core category: Refining a co-creative process towards making a difference. The core category resembles the collaboration that the staff had within their teams, which included participants with dementia and caregivers, and with the goal that the intervention should make a difference for the participants. This was conducted with flexibility in a collaborative and creative process.
The staff team perceived that by working in comprehensive teams they could provide individualised rehabilitation in creative collaboration with the participants through interaction, knowledge exchange, time and continuity, coordination and flexibility, and a holistic view. Challenges to overcome were the involvement of the person with dementia in goal setting and the mediating role of the staff team members. The staff pointed out that by refinement they could achieve well-functioning, competence-enhancing and timesaving teamwork.

BACKGROUND: A variety of clinicians practice in emergency departments (EDs). Although most ED patients prefer seeing physicians, a subset sees no physician.
OBJECTIVE: We sought to determine the factors that predict when an ED patient is seen by at least one physician and compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.
METHODS: We used 11 years of cross-sectional data from the National Hospital Ambulatory Medical Care Survey and focused on the sample of ED patient visits seen by at least one physician and those seen by no physician. We used bivariate statistics to compare characteristics between samples and used multivariate logistic regression analysis to identify the factors that predicted being seen by a physician. Finally, we compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.
RESULTS: Approximately 10% of the sample was not seen by any physician. Patients seen by at least one physician had, on average, 0.8 more diagnostic services ordered/provided and 0.1 more procedures provided compared with patients who were not seen by any physician. Patients seen by at least one physician had longer visits by 29.4 min, on average, and had increased odds of being hospitalized (adjusted odds ratio 3.9, 95% confidence interval 2.9-5.2).
CONCLUSIONS: A variety of patient and hospital characteristics influenced whether ED patients were seen by physicians. Diagnostic services, procedures, visit length, and hospital admission differed by physician presence. Findings have implications for ED practice and future research.

UNASSIGNED: Individuals with palliative care needs face increased risk of discontinuity of care as they navigate between healthcare settings, locations and practitioners which can result in poor outcomes. Little is known about interactions that occur between specialist and generalist palliative care teams as patients are transition from hospital to community-based care after hospitalisation.
UNASSIGNED: To understand what happens between inpatient specialist palliative care teams and the generalist teams who provide post-discharge palliative care for shared patients.
UNASSIGNED: A constructivist grounded theory approach, using semi-structured interviews and constant comparative analysis, including coding, memo-writing and diagram construction.
UNASSIGNED: Interviews (n = 21) with specialist palliative care clinicians and clinicians in other specialties providing generalist palliative care. Specialists had training in palliative care and worked in specialty palliative care practices; other clinicians worked in primary care or oncology and did not have specialised palliative care training.
UNASSIGNED: A grounded theory of interdependence between specialist and generalist palliative care teams across healthcare settings was constructed. Two states of inter-team functioning were found which related to how teams perceived themselves: separate teams or one cross-boundary team. Three conditions influenced these two states of inter-team functioning: knowing the other team; communicating intentionally; and acknowledging and valuing the role of the other team.
UNASSIGNED: Teams need to explicitly consider and agree their mode of functioning, and enact changes to enhance knowledge of the team, intentional communication and valuing other teams\' contributions. Future research is needed to test or expand this theory across a range of cultures and contexts.

An interprofessional group of healthcare practitioners sought a new approach to the early detection, prevention, and resolution of \"difficult cases\" in the inpatient care context. An action research project addressed this need by developing a narrative re-framing tool that helped reveal entrenched assumptions regarding the root causes of difficult cases in the hospital. The intervention method that emerged from the project - the Difficult Case Consultation (DCC) - is a theoretically-grounded process that helps teams to analyze and address complex communication problems in interprofessional healthcare contexts. Collaborative processes grounded in theory have proven to be the most successful when seeking to optimize healthcare team communication. The article describes the collaborative development of the DCC, presents two cases illustrating the process, and describes systemic factors that exacerbated the emergence of difficult cases in the inpatient context.

In the United States, one in six children has an intellectual and/or developmental disability (I/DD), including attention deficit hyperactivity disorder (ADHD), autism, cerebral palsy, learning disabilities, seizures, and developmental delays, with or without intellectual impairment. Individuals with I/DDs experience disproportionate rates of immune, metabolic, cardiovascular, and neurological disorders, as well as anxiety, depression, functional somatic symptoms, and other co-occurring physical and mental health conditions. During the coronavirus disease 2019 (COVID-19) pandemic, having an I/DD emerged as one of the strongest predictors of contracting and dying from COVID-19. These findings spurred increased attention toward the myriad health inequities affecting this population well before the pandemic. While inequities for individuals with I/DD can be traced to many factors, social determinants of health (SDOH) - the underlying social, economic, and environmental conditions that lead to poor health outcomes and high healthcare costs - are key contributors. Our interdisciplinary combined internal medicine and pediatrics (Med-Peds) team of physicians, psychologists, and researchers within a large, diverse, academic health system aimed to pilot-test the implementation of a five-item SDOH screener within a Med-Peds specialty clinic focused on the developmental needs of individuals with I/DD and their families (Leadership Education in Neurodevelopmental Disabilities {LEND}) and a general primary care practice (PCP). The SDOH screener tested in this initiative includes five items from the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool (HRSN) assessing social isolation, food insecurity, transportation, and paying for basic needs, such as housing and medical care. In this study, we describe the process of implementing this screener and collecting initial pilot data from 747 patients between October 2022 and April 2023 across the LEND and the primary care practice. We also highlight the challenges and opportunities identified during the mid-way point of implementation and pilot testing. The results of this pilot study revealed low response rates among SDOH screeners, spurring several measures to increase uptake, including increasing the accessibility of the screener and ensuring the screener results in effective referrals. We call on additional Med-Peds healthcare teams without universal SDOH screening protocols in place - particularly those serving the I/DD population - to consider adopting these practices.