Central DuPage Hospital

A Consensus Conference sponsored by the Archstone Foundation of Long Beach, California, was held February 17-18, 2009, in Pasadena, California. The Conference was based on the belief that spiritual care is a fundamental component of quality palliative care. This document and the conference recommendations it includes builds upon prior literature, the National Consensus Project Guidelines, and the National Quality Forum Preferred Practices and Conference proceedings.

The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheterdirected thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome.

Obtaining predictable, stable fixation of revision femoral implants is important for the long-term success of revision hip arthroplasty. The authors report on minimum 10 years clinical and radiographic followup of 170 patients with extensively coated cementless revision femoral components. With a range of followup of 10 to 16 years and a mean of 13.2 years, a survivorship of greater than 95% was reported. Clinically, the average Postel-D'Aubigne pain and walking score improved from a preoperative score of 5.4 points to 10.8 points postoperatively. Eighty-two percent of the hips had radiographic evidence of a bone-ingrown prosthesis and 13.9% had evidence of stable fibrous fixation. Four percent of stems were unstable as seen on radiographs. Six stems were revised to larger extensively coated stems and one stem is causing pain and is unstable but has yet to be revised. The overall mechanical failure rate was 4.1%. Stress shielding was greatest in patients with stems larger than 16.5 mm and in osteoporotic bone (Dorr Type C). Nine percent of patients had significant thigh pain including all of the patients with unstable stems. In the presence of bone loss in the proximal metaphyseal region of the femur, fixation of the femoral component is predictable when optimizing prosthetic-bone fit in the diaphyseal region of the femur using an extensively coated femoral component.

There has been a substantial change in the population demographics of patients who potentially will require total joint replacements. We studied data regarding temporal trends in physical condition, life expectancy, education, and other population demographics of individuals most likely to receive total joint replacements. Changes in this population during the last several decades correlate with temporal changes in the prevalence of joint disease and the incidence of total hip and knee replacements. Compared with several decades ago, patients currently receiving total joint replacements are almost 20% heavier, more physically active, three times more likely to have a high school or college education, and live more than 25% longer. Patients needing total joint replacements are more likely to be female, and twice as likely to receive a total knee replacement than a total hip replacement. Treatment choices and outcome expectations are best determined with accurate knowledge of current surgical science and current patient demographics. Therefore, it is important to realize that today's population most likely to receive total joint replacements is demographically different than in the past.

Femoral revision total hip arthroplasty is a technically demanding procedure. In addition to these technical issues, preoperative planning can be challenging and with multiple reconstructive options available, the decision-making process can be complex. The ability to preoperatively determine the most appropriate option for reconstruction greatly assists with ensuring that the appropriate implants and instruments are available at the time of surgery. A classification of femoral bone loss is presented that guides the surgeon in selecting an appropriate method of reconstruction.

BACKGROUND: This study assessed functional performance, calf muscle characteristics, peripheral nerve function, and quality of life in asymptomatic persons with peripheral arterial disease (PAD). METHODS AND RESULTS: PAD participants (n=465) had an ankle brachial index <0.90. Non-PAD participants (n=292) had an ankle brachial index of 0.90 to 1.30. PAD participants were categorized into leg symptom groups including intermittent claudication (n=215) and always asymptomatic (participants who never experienced exertional leg pain, even during the 6-minute walk; n=72). Calf muscle was measured with computed tomography. Analyses were adjusted for age, sex, race, ankle brachial index, comorbidities, and other confounders. Compared with participants with intermittent claudication, always asymptomatic PAD participants had smaller calf muscle area (4935 versus 5592 mm(2); P<0.001), higher calf muscle percent fat (16.10% versus 9.45%; P<0.001), poorer 6-minute walk performance (966 versus 1129 ft; P=0.0002), slower usual-paced walking speed (P=0.0019), slower fast-paced walking speed (P<0.001), and a poorer Short-Form 36 Physical Functioning score (P=0.016). Compared with an age-matched, sedentary, non-PAD cohort, always asymptomatic PAD participants had smaller calf muscle area (5061 versus 5895 mm(2); P=0.009), poorer 6-minute walk performance (1126 versus 1452 ft; P<0.001), and poorer Walking Impairment Questionnaire speed scores (40.87 versus 57.78; P=0.001). CONCLUSIONS: Persons with PAD who never experience exertional leg symptoms have poorer functional performance, poorer quality of life, and more adverse calf muscle characteristics compared with persons with intermittent claudication and a sedentary, asymptomatic, age-matched group of non-PAD persons.

: Study 1, NCT01863186; Study 2 NCT00235729. URL: https://clinicaltrials.gov/.

Thirty-five patients who had had a primary total hip replacement with a porous-coated acetabular component inserted without cement had a revision procedure to treat pelvic osteolysis. The mean age at the time of the revision operation was forty-nine years (range, twenty-nine to eighty-five years). Forty-six distinct pelvic osteolytic lesions were noted radiographically around the thirty-five cups. These lesions ranged in size from 0.5 by 0.5 centimeter to 6.3 by 2.7 centimeters (mean, 2.6 by 1.7 centimeters). Fourteen of the thirty-five patients had no or only slight occasional pain at the time of diagnosis of the pelvic osteolysis, fifteen patients had pain attributed to a loose femoral component, one had pain related to a spontaneous fracture of the greater trochanter, and one had pain related to recurrent subluxation. The remaining four patients had pain in the groin despite radiographically stable implants. All of the metal-backed porous-coated acetabular components were stable according to the preoperative radiographs, and the stability was confirmed at the time of the revision. The metal shell was left in place and the acetabular liner was exchanged in all thirty-five patients. The osteolytic lesions were debrided, and thirty-four of the forty-six lesions were filled with allograft bone chips. The patients were evaluated a minimum of two years (range, two to five years; mean, 3.3 years) after the revision operation, and all thirty-five sockets were found to be radiographically stable. The bone grafts appeared to have consolidated, and none of the osteolytic defects had progressed. One-third of the lesions were no longer visible on radiographs, regardless of whether or not they had been filled with bone graft. The remaining lesions had decreased in size. It appears that, in the short-term, exchange of the liner and debridement of the granuloma, with or without use of allograft bone chips in the osteolytic defect, is a reasonable alternative to revision of the socket provided that the metal shell is solidly fixed at the time of the revision operation. If the metal shell has been markedly damaged by the femoral head, the locking mechanism for the polyethylene liner is not intact, or a satisfactory replacement liner is not available, then revision of the porous-coated acetabular component is indicated. These results must be considered preliminary. Since osteolysis may take several years to redevelop after a revision, additional follow-up is required.

Importance: Urate elevation, despite associations with crystallopathic, cardiovascular, and metabolic disorders, has been pursued as a potential disease-modifying strategy for Parkinson disease (PD) based on convergent biological, epidemiological, and clinical data. Objective: To determine whether sustained urate-elevating treatment with the urate precursor inosine slows early PD progression. Design, Participants, and Setting: Randomized, double-blind, placebo-controlled, phase 3 trial of oral inosine treatment in early PD. A total of 587 individuals consented, and 298 with PD not yet requiring dopaminergic medication, striatal dopamine transporter deficiency, and serum urate below the population median concentration (<5.8 mg/dL) were randomized between August 2016 and December 2017 at 58 US sites, and were followed up through June 2019. Interventions: Inosine, dosed by blinded titration to increase serum urate concentrations to 7.1-8.0 mg/dL (n = 149) or matching placebo (n = 149) for up to 2 years. Main Outcomes and Measures: The primary outcome was rate of change in the Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS; parts I-III) total score (range, 0-236; higher scores indicate greater disability; minimum clinically important difference of 6.3 points) prior to dopaminergic drug therapy initiation. Secondary outcomes included serum urate to measure target engagement, adverse events to measure safety, and 29 efficacy measures of disability, quality of life, cognition, mood, autonomic function, and striatal dopamine transporter binding as a biomarker of neuronal integrity. Results: Based on a prespecified interim futility analysis, the study closed early, with 273 (92%) of the randomized participants (49% women; mean age, 63 years) completing the study. Clinical progression rates were not significantly different between participants randomized to inosine (MDS-UPDRS score, 11.1 [95% CI, 9.7-12.6] points per year) and placebo (MDS-UPDRS score, 9.9 [95% CI, 8.4-11.3] points per year; difference, 1.26 [95% CI, -0.59 to 3.11] points per year; P = .18). Sustained elevation of serum urate by 2.03 mg/dL (from a baseline level of 4.6 mg/dL; 44% increase) occurred in the inosine group vs a 0.01-mg/dL change in serum urate in the placebo group (difference, 2.02 mg/dL [95% CI, 1.85-2.19 mg/dL]; P<.001). There were no significant differences for secondary efficacy outcomes including dopamine transporter binding loss. Participants randomized to inosine, compared with placebo, experienced fewer serious adverse events (7.4 vs 13.1 per 100 patient-years) but more kidney stones (7.0 vs 1.4 stones per 100 patient-years). Conclusions and Relevance: Among patients recently diagnosed as having PD, treatment with inosine, compared with placebo, did not result in a significant difference in the rate of clinical disease progression. The findings do not support the use of inosine as a treatment for early PD. Trial Registration: ClinicalTrials.gov Identifier: NCT02642393.

One of the primary steps in revision hip arthroplasty is the extraction of retained components before surgical reconstruction. In revision arthroplasty, the removal of well-fixed components and cement can be extremely demanding, time consuming, and damaging to the remaining host bone. The aims of the current study were to examine the numerous operative techniques used during extraction of acetabular and femoral components and review the results of revision hip arthroplasty after cementless component removal. A review of 157 acetabular components and 113 femoral components removed from 219 patients during hip revision arthroplasty between 1985 and 2000 was done. The average age of the patients was 64.3 years. The average followup was 5 years (range, 0.7-12.5 years). An extended proximal femoral osteotomy was done in 37 (33%) of the femoral revisions. There were 14 (5%) acetabular failures for which the patients required reoperation. There were no femoral rerevisions. Complications included dislocation (6% after acetabular revision and 9% after femoral revision), infection (6%), femoral fracture (6%), hematoma (3.5%), acetabular fixation failure (2.5%), and femoral osteolysis (1%). The removal of cemented and well-fixed porous-coated implants can be done with adequate preoperative planning and a thorough knowledge of numerous implant removal techniques.

BACKGROUND: Initial reports with short-term followup of porous tantalum acetabular components and augments for Paprosky IIIA acetabular defects demonstrate high hip scores, low rates of aseptic loosening, and low rates of complications. However, longer-term followup with a larger cohort is needed to determine the durability of these reconstructions. QUESTIONS/PURPOSES: We therefore determined the functional scores, rates of aseptic loosening, and complications in patients with Paprosky IIIA acetabular defects treated with porous tantalum acetabular components and augments. METHODS: We retrospectively reviewed 37 acetabular revisions in 36 patients (one patient with bilateral revisions) treated with a porous tantalum acetabular component and augment. All patients had defects classified as Type IIIa using the system of Paprosky et al. Harris hip scores were obtained and radiographic examination was performed before surgery and through most recent followup. The minimum followup was 26 months (mean, 60 months; range, 26-106 months). RESULTS: One patient developed aseptic loosening of the acetabular reconstruction requiring revision; seven other patients required further surgery for periprosthetic femoral fracture (two), acute infection (three), and recurrent dislocation (two). Thirty-five of 37 hips had no or occasional pain at final followup. Mean Harris hip scores improved from 33.0 preoperatively (range, 12.6-58.7) to 81.5 postoperatively (range, 27.0-99.8). CONCLUSIONS: Although the complication rate requiring further surgery was considerable, most patients with these reconstructions had pain relief and reasonable function with low rates of loosening at midterm followup. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND: Panobinostat is a histone deacetylase inhibitor with antineoplastic and antiangiogenic effects in glioma that may work synergistically with bevacizumab. We conducted a multicenter phase II trial of panobinostat combined with bevacizumab in patients with recurrent high-grade glioma (HGG). METHODS: Patients with recurrent HGG were treated with oral panobinostat 30 mg 3 times per week, every other week, in combination with bevacizumab 10 mg/kg every other week. The primary endpoint was a 6-month progression-fee survival (PFS6) rate for participants with recurrent glioblastoma (GBM). Patients with recurrent anaplastic glioma (AG) were evaluated as an exploratory arm of the study. RESULTS: At interim analysis, the GBM arm did not meet criteria for continued accrual, and the GBM arm was closed. A total of 24 patients with GBM were accrued prior to closure. The PFS6 rate was 30.4% (95%, CI 12.4%-50.7%), median PFS was 5 months (range, 3-9 months), and median overall survival (OS) was 9 months (range, 6-19 months). Accrual in the AG arm continued to completion, and a total of 15 patients were enrolled. The PFS6 rate was 46.7% (range, 21%-73%), median PFS was 7 months (range, 2-10 months), and median OS was 17 months (range, 5 months-27 months). CONCLUSIONS: This phase II study of panobinostat and bevacizumab in participants with recurrent GBM did not meet criteria for continued accrual, and the GBM cohort of the study was closed. Although it was reasonably well tolerated, the addition of panobinostat to bevacizumab did not significantly improve PFS6 compared with historical controls of bevacizumab monotherapy in either cohort.

BACKGROUND: Stabilization of a pelvic discontinuity with a posterior column plate with or without an associated acetabular cage sometimes results in persistent micromotion across the discontinuity with late fatigue failure and component loosening. Acetabular distraction offers an alternative technique for reconstruction in cases of severe bone loss with an associated pelvic discontinuity. QUESTIONS/PURPOSES: We describe the acetabular distraction technique with porous tantalum components and evaluate its survival, function, and complication rate in patients undergoing revision for chronic pelvic discontinuity. METHODS: Between 2002 and 2006, we treated 28 patients with a chronic pelvic discontinuity with acetabular reconstruction using acetabular distraction. A porous tantalum elliptical acetabular component was used alone or with an associated modular porous tantalum augment in all patients. Three patients died and five were lost to followup before 2 years. The remaining 20 patients were followed semiannually for a minimum of 2 years (average, 4.5 years; range, 2-7 years) with clinical (Merle d'Aubigné-Postel score) and radiographic (loosening, migration, failure) evaluation. RESULTS: One of the 20 patients required rerevision for aseptic loosening. Fifteen patients remained radiographically stable at last followup. Four patients had early migration of their acetabular component but thereafter remained clinically asymptomatic and radiographically stable. At latest followup, the average improvement in the patients not requiring rerevision using the modified Merle d'Aubigné-Postel score was 6.6 (range, 3.3-9.6). There were no postoperative dislocations; however, one patient had an infection, one a vascular injury, and one a bowel injury. CONCLUSIONS: Acetabular distraction with porous tantalum components provides predictable pain relief and durability at 2- to 7-year followup when reconstructing severe acetabular defects with an associated pelvic discontinuity. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Prolonged bed rest in hospitalized patients leads to deconditioning, impaired mobility, and the potential for longer hospital stays. OBJECTIVE: The purpose of this study was to determine the effectiveness of a nurse-driven mobility protocol to increase the percentage of patients ambulating during the first 72 hours of their hospital stay. DESIGN: A quasi-experimental design was used before and after intervention in a 16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult intermediate care unit (IMCU) at a large community hospital. METHOD: A multidisciplinary team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential. Based on the assessments, the protocol empowers the nurse to consult physical therapists or occupational therapists when appropriate. Daily ambulation status reports were reviewed each morning to determine each patient's activity level. Retrospective and prospective chart reviews were performed to evaluate the effectiveness of the protocol for patients 18 years of age and older who were hospitalized 72 hours or longer. RESULTS: In the 3 months prior to implementation of the Move to Improve project, 6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients ambulated during the first 72 hours of their hospitalization. During the 6 months following implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of 358), respectively. LIMITATIONS: The study was carried out at only one center. CONCLUSION: The initial experience with a nurse-driven mobility protocol suggests that the rate of patient ambulation in an adult ICU and IMCU during the first 72 hours of a hospital stay can be increased.

INTRODUCTION: Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety. OBJECTIVES: We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA. METHODS: 10 hospitals of various sizes using smart pumps from a range of vendors participated. Data were collected using a prospective point prevalence approach to capture errors associated with medications administered via smart pumps and evaluate their potential for harm. RESULTS: A total of 478 patients and 1164 medication administrations were assessed. Of the observed infusions, 699 (60%) had one or more errors associated with their administration. Identified errors such as labelling errors and bypassing the smart pump and the drug library were predominantly associated with violations of hospital policy. These types of errors can result in medication errors. Errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). 1 error of category E (0.1%), 4 of category D (0.3%) and 492 of category C (excluding deviations of hospital policy) (42%) were identified. Of these, unauthorised medication, bypassing the smart pump and wrong rate were the most frequent errors. CONCLUSION: We identified a high rate of error in the administration of intravenous medications despite the use of smart pumps. However, relatively few errors were potentially harmful. The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process.

Importance: Recent large infarct thrombectomy trials used heterogeneous imaging modalities and time windows for patient selection. Noncontrast computed tomographic (CT) scan is the most common stroke imaging approach. It remains uncertain whether thrombectomy is effective for patients with large infarcts identified using noncontrast CT alone within 24 hours of stroke onset. Objective: To evaluate the effect of thrombectomy in patients with a large infarct on a noncontrast CT scan within 24 hours of onset. Design, Setting, and Participants: Open-label, blinded-end point, bayesian-adaptive randomized trial with interim analyses for early stopping (futility or success) or population enrichment, which was conducted at 47 US academic and community-based stroke thrombectomy centers. Three hundred patients presenting within 24 hours with anterior-circulation, large-vessel occlusion and large infarct on noncontrast CT scan, with Alberta Stroke Program Early CT Scores of 2 to 5, were randomized to undergo thrombectomy or usual care. Enrollment occurred July 16, 2019 to October 17, 2022; final follow-up, January 25, 2023. Intervention: The intervention patients (n = 152) underwent endovascular treatment using standard thrombectomy devices and usual medical care. Control patients (n = 148) underwent usual medical care alone. Main Outcomes and Measures: The primary efficacy end point was improvement in 90-day functional outcome measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores (range, 0 [death or severe disability] to 10 [no symptoms]; minimum clinically important difference, 0.3). A bayesian model determined the posterior probability that the intervention would be superior to usual care; statistical significance was a 1-sided posterior probability of .975 or more. The primary adverse event end point was 90-day mortality; secondary adverse event end points included symptomatic intracranial hemorrhage and radiographic intracranial hemorrhage. Results: The trial enrolled 300 patients (152 intervention, 148 control; 138 females [46%]; median age, 67 years), without early stopping or enrichment; 297 patients completed the 90-day follow-up. The mean (SD) 90-day UW-mRS score was 2.93 (3.39) for the intervention group vs 2.27 (2.98) for the control group with an adjusted difference of 0.63 (95% credible interval [CrI], -0.09 to 1.34; posterior probability for superiority of thrombectomy, .96). The 90-day mortality was similar between groups: 35.3% (53 of 150) for the intervention group vs 33.3% (49 of 147) for the control group. Six of 151 patients (4.0%) in the intervention group and 2 of 149 (1.3%) in the control group experienced 24-hour symptomatic intracranial hemorrhage. Fourteen patients of 148 (9.5%) in the intervention group vs 4 of 146 (2.7%) in the control group experienced parenchymal hematoma type 1 hemorrhages; 14 (9.5%) in the intervention group vs 5 (3.4%) in the control group experienced parenchymal hematoma type 2 hemorrhages; and 24 (16.2%) in the intervention group vs 9 (6.2%) in the control group experienced subarachnoid hemorrhages. Conclusions and Relevance: Among patients with a large infarct on noncontrast CT within 24 hours, thrombectomy did not demonstrate improvement in functional outcomes. But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study. Trial Registration: ClinicalTrials.gov Identifier: NCT03805308.

BACKGROUND: Prior studies evaluating the Wingspan stent for treatment of symptomatic intracranial atherosclerotic disease have included patients with a spectrum of both on-label and off-label indications for the stent. The WEAVE trial assessed 152 patients stented with the Wingspan stent strictly by its current on-label indication and found a 2.6% periprocedural stroke and death rate. OBJECTIVE: This WOVEN study assesses the 1-year follow-up from this cohort. METHODS: Twelve of the original 24 sites enrolling patients in the WEAVE trial performed follow-up chart review and imaging analysis up to 1 year after stenting. Assessment of delayed stroke and death was made in 129 patients, as well as vascular imaging follow-up to assess for in-stent re-stenosis. RESULTS: In the 1-year follow-up period, seven patients had a stroke (six minor, one major). Subsequent to the periprocedural period, no deaths were recorded in the cohort. Including the four patients who had periprocedural events in the WEAVE study, there were 11 strokes or deaths of the 129 patients (8.5%) at the 1-year follow-up. CONCLUSIONS: The WOVEN study provides the 1-year follow-up on a cohort of 129 patients who were stented according to the current on-label use. It provides a more homogeneous patient group for analysis than prior studies, and demonstrates a relatively low 8.5% 1-year stroke and death rate in stented patients.

We sought to determine if acetabular cages prevented rerevision and loosening in acetabular reconstructions in the setting of pelvic discontinuity. We followed 15 patients with 16 acetabular cage reconstructions for an average 5 years (range, 2-8 years). Acetabular classifications included two Type 2C, six Type IIIA, and eight Type IIIB. We assessed Merle d'Aubigné scores, rerevisions, radiographic loosening, and complications. We treated seven patients with structural allograft and six patients with cancellous allograft. Five hips (31%) were revised or resected because of aseptic loosening (4 hips) and sepsis (1 hip) at an average 46 months. Three additional hips were loose. Merle d'Aubigné scores for pain and walking increased from 3.7 points preoperatively to 6.8 points at the final followup. Complications included one infection, four nerve palsies, and one dislocation. Acetabular cages in the setting of pelvic discontinuity were associated with a high failure rate at intermediate-term followup.

UNLABELLED: Pelvic discontinuity is encountered frequently during acetabular revision in patients with severe acetabular bone loss. Prompt recognition of the discontinuity and appropriate intraoperative treatment are essential for a successful clinical outcome. The treatment of the discontinuity is dependent on the remaining host bone, the potential for healing of the discontinuity, and the potential for biologic ingrowth of acetabular components. If healing potential of the discontinuity exists, the discontinuity should be treated in compression with a posterior column plate and structural allograft or with the use of trabecular metal acting as an internal plate. If healing potential for the discontinuity does not exist, the discontinuity should be bridged and treated in distraction with an acetabular transplant supported with a cage, a trabecular metal component with trabecular metal augmentation, or with the use of a custom triflange implant. LEVEL OF EVIDENCE: Therapeutic study, Level III-1 (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Background Food allergy is an important public health problem because it affects children and adults, can be severe and even life-threatening, and may be increasing in prevalence. Beginning in 2008, the National Institute of Allergy and Infectious Diseases, working with other organizations and advocacy groups, led the development of the first clinical guidelines for the diagnosis and management of food allergy. A recent landmark clinical trial and other emerging data suggest that peanut allergy can be prevented through introduction of peanut-containing foods beginning in infancy.Objectives Prompted by these findings, along with 25 professional organizations, federal agencies, and patient advocacy groups, the National Institute of Allergy and Infectious Diseases facilitated development of addendum guidelines to specifically address the prevention of peanut allergy.Results The addendum provides 3 separate guidelines for infants at various risk levels for the development of peanut allergy and is intended for use by a wide variety of health care providers. Topics addressed include the definition of risk categories, appropriate use of testing (specific IgE measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider’s office or at home. The addendum guidelines provide the background, rationale, and strength of evidence for each recommendation.Conclusions Guidelines have been developed for early introduction of peanut-containing foods into the diets of infants at various risk levels for peanut allergy.