OBJECTIVES To assess the potential impact of using screening recommendations for bleeding disorders in patients with Noonan syndrome on perioperative bleeding complications. STUDY DESIGN We performed a retrospective, single-site cohort study; patients were identified by query of the electronic medical record. All patients with a clinical diagnosis of Noonan syndrome over a 10-year period were included. Data on surgeries, hematologic evaluation, bleeding symptoms, and bleeding complications were extracted. Surgeries were graded as major or minor. RESULTS We identified 101 patients with Noonan syndrome, 70 of whom required surgery for a total of 164 procedures. Nine patients (9/70; 12.8%) had bleeding complications, occurring in those without comprehensive testing or perioperative intervention and undergoing major or dental surgery. Based on these findings, the risk of a bleeding complication for patients with Noonan syndrome who did not have comprehensive testing or perioperative intervention was 6.2% (95% CI 2.3%-10.1%), indicating the number needed to treat or screen would be 16 to prevent 1 bleeding complication (95% CI 9.9-43.9). The majority of patients had either no or incomplete evaluation (59 of 101; 58.4%). CONCLUSIONS With proper evaluation and management, the bleeding risk in patients with Noonan syndrome can be minimized. Efforts are needed to address the knowledge and implementation gap in this evaluation. A hepatobiliary iminodiacetic acid (HIDA) scan is frequently used in an attempt to exclude biliary atresia in infants who are cholestatic. We present 6 cases of confirmed biliary atresia in infants who had biliary patency reported on HIDA scan. We demonstrate that misinterpreted HIDA scans led to delayed diagnosis and surgical intervention for biliary atresia. OBJECTIVE To determine the frequency that non-first-line antibiotics, safety-net antibiotic prescriptions (SNAPS), and longer than recommended durations of antibiotics were prescribed for children ≥2 years of age with acute otitis media and examine patient and system level factors that contributed to these outcomes. STUDY DESIGN Children age ≥2 years with acute otitis media seen at Denver Health Medical Center outpatient locations from January to December 2018 were included. The percentages of patients who received first-line antibiotics, SNAPs, and recommended durations of antibiotics were determined.  https://www.selleckchem.com/  Factors associated with non-first-line and longer than recommended antibiotic durations were evaluated using multivariate logistic regression modeling. RESULTS Of the 1025 visits evaluated, 98.0% were prescribed an antibiotic; only 4.5% of antibiotics were SNAPs. Non-first-line antibiotics were prescribed to 18.8% of patients. Most antibiotic durations (94.1%) were longer than the institution recommended 5 days and 54.3% were ≥10 days. Private insurance was associated with non-first-line antibiotics (aOR, 1.89; 95% CI, 1; 14-3.14, P = .01). Patients who were younger (2-5 years; aOR 2.01; 95% CI, 1.32-3.05; P less then .001) or seen in emergency/urgent care sites (aOR, 1.73; 95% CI, 1.26-2.38; P less then .001) were more likely to receive ≥10 days of antibiotic compared with those in pediatric clinics. CONCLUSIONS Antibiotic stewardship interventions that emphasize the duration of antibiotic therapy as well as the use of SNAPs or observation may be higher yield than those focusing on first-line therapy alone. Numerous system and patient level factors are associated with off-guideline prescribing. OBJECTIVE To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge. STUDY DESIGN This was a retrospective cohort study of 732 mothers of 866 preterm infants (5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use. Methotrexate is used to treat autoimmune and oncologic diseases in children with Down syndrome. However, increased methotrexate-related toxicity is reported in this population. We evaluated differences in the concentrations and distribution of erythrocyte folates in children with Down syndrome as a potential basis for this enhanced toxicity. Propofol infusion syndrome is a rare condition that mainly affects critically ill patients who receive high doses of this hypnotic for a long time. We describe the case of a patient who presented hepatotoxicity in the immediate postoperative period of two surgeries in which she had received conventional doses of propofol for a short period of time. After studying the patient and monitoring her evolution, we arrived at a differential diagnosis of propofol infusion syndrome due to increased susceptibility. This syndrome should be considered in patients presenting hepatotoxicity in the immediate postoperative period, even when low doses of propofol have been administered. BACKGROUND The impact of sound-activated noise meters to decrease the noise level in the operating room is not clear. The aim of this study was to determine whether a sound-activated, visual noise meter would decrease noise levels, decrease postoperative morbidity, and improve surgeons' feelings of well-being. METHODS This prospective, single-center study proceeded in 2 phases. First, sound levels were compared during a 6-month period with noise measurement only and without a visual feedback function. Second, we conducted a subsequent 6-month phase with noise meters providing direct feedback. Surgeon disturbance during the operation was assessed by a questionnaire after each procedure. RESULTS Of the 664 procedures included in this analysis, 447 (67.3%) were in phase 1 and 217 (32.7%) in phase 2. The noise levels in the operating room were decreased by 3.8 dB(A) from 54.6 ± 4.5 dB(A) in phase 1 to 50.8 ± 2.8 dB(A) in phase 2 after intervention with the feedback device (P less then .001). During the procedures, there was an increase of 0.7 dB(A) (P less then .001), with mean noise levels of 53.5 dB(A) at the beginning of the procedures and 54.2 dB(A) at the end. There was a correlation between the disturbance of the surgeon and the noise level (P less then .001). CONCLUSION The application of a visual noise warning device in an operating room decreased both the noise levels and surgeon stress and may offer sustained decreases in ambient and peak sound levels, potentially leading to improved quality outcomes in visceral surgery.