United States

Background: 
Pediatric primary care is an ideal setting to prevent mental and behavioral health disorders given the high frequency of contacts through well-child visits birth to age 5. Bjelland et al have detailed that childhood mental and behavioral health have strong associations with adult well-being1. As such, early detection and intervention is key to addressing the secondary effects of behavioral health issue; however, many barriers, such as family circumstances and lack of awareness of behavioral health programs, hinder successful access to behavioral healthcare resources in pediatric practice2. The goal of this study was to examine the perspectives of families with young children on barriers to accessing behavioral health care and how to improve access. 
Methods:
Semi-structured one-on-one virtual interviews were used to qualitatively explore the perspectives of families with young children regarding access to behavioral healthcare. Participants were recruited from the CHP-Primary Care Center (PCC) in Oakland, a clinic serving a high proportion of Medicaid-eligible families (&gt;85%). Interviews focused on thoughts and experiences related to accessing behavioral healthcare for children, with demographic information collected at the end of each interview. Deductive and inductive methods were used to develop a codebook followed by content and thematic analysis techniques to identify recurring themes and patterns, utilizing the program Nvivo.
Results: 
Participants included 27 caregivers (M age=30.7, SD=6.3) of at least one child under the age of 5. Eleven percent of caregivers identified as Hispanic. Seventy percent identified as African American and 30% as white. Forty-four percent reported an income below 40k and 48% were employed full-time. The analysis of the interviews revealed several interconnected barriers that families face when accessing behavioral healthcare for their young children, categorized into logistical, financial, and psychosocial challenges. Logistical barriers included 1) childcare, 2) time, 3) transportation, and 4) employment-related issues. Financial barriers were evident in the form of 1) inadequate insurance coverage, and 2) broader financial constraints that made affording care difficult. Psychosocial barriers included 1) education and understanding of behavioral health issues and 2) pride and stigma, which deterred some parents from seeking care due to concerns about judgment.
Conclusions: 
These findings underscore the need for a multifaceted approach addressing the diverse challenges families face in accessing behavioral healthcare services for their children. Comprehensive solutions must consider both systemic and individual factors, such as improving insurance coverage and financial support, enhancing public transportation options, and providing flexible appointment scheduling, while also advising initiatives aimed at increasing education about behavioral health and reducing stigma. Addressing these barriers in a coordinated manner could significantly enhance access to behavioral healthcare services for young children.


AMA Research Challenge 2024 

Exploring Caregiver’s Perspectives on the Barriers to Accessing Behavioral Healthcare for their Children

Background: 
Pediatric primary care is an ideal setting to prevent mental and behavioral health disorders given the high frequency of contacts through well-child visits birth to age 5. Bjelland et al have detailed that childhood mental and behavioral health have strong associations with adult well-being1. As such, early detection and intervention is key to addressing the secondary effects of behavioral health issue; however, many barriers, such as family circumstances and lack of awareness of behavioral health programs, hinder successful access to behavioral healthcare resources in pediatric practice2. The goal of this study was to examine the perspectives of families with young children on barriers to accessing behavioral health care and how to improve access. 
Methods:
Semi-structured one-on-one virtual interviews were used to qualitatively explore the perspectives of families with young children regarding access to behavioral healthcare. Participants were recruited from the CHP-Primary Care Center (PCC) in Oakland, a clinic serving a high proportion of Medicaid-eligible families (>85%). Interviews focused on thoughts and experiences related to accessing behavioral healthcare for children, with demographic information collected at the end of each interview. Deductive and inductive methods were used to develop a codebook followed by content and thematic analysis techniques to identify recurring themes and patterns, utilizing the program Nvivo.
Results: 
Participants included 27 caregivers (M age=30.7, SD=6.3) of at least one child under the age of 5. Eleven percent of caregivers identified as Hispanic. Seventy percent identified as African American and 30% as white. Forty-four percent reported an income below 40k and 48% were employed full-time. The analysis of the interviews revealed several interconnected barriers that families face when accessing behavioral healthcare for their young children, categorized into logistical, financial, and psychosocial challenges. Logistical barriers included 1) childcare, 2) time, 3) transportation, and 4) employment-related issues. Financial barriers were evident in the form of 1) inadequate insurance coverage, and 2) broader financial constraints that made affording care difficult. Psychosocial barriers included 1) education and understanding of behavioral health issues and 2) pride and stigma, which deterred some parents from seeking care due to concerns about judgment.
Conclusions: 
These findings underscore the need for a multifaceted approach addressing the diverse challenges families face in accessing behavioral healthcare services for their children. Comprehensive solutions must consider both systemic and individual factors, such as improving insurance coverage and financial support, enhancing public transportation options, and providing flexible appointment scheduling, while also advising initiatives aimed at increasing education about behavioral health and reducing stigma. Addressing these barriers in a coordinated manner could significantly enhance access to behavioral healthcare services for young children.


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Selective mutism (SM), categorized under anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), presents challenges in timely identification and treatment, which is especially crucial for pediatricians as early intervention can significantly improve a child’s social and emotional development. SM is characterized by a child’s inability to speak in certain situations but speaks adequately in other settings. While recorded SM diagnoses may not be largely prevalent within the US, affecting approximately 0.2-1.6% of people. SM's significance lies in its potential impact on a child's social, academic, and emotional well-being. This retrospective observational study explores pediatrician referrals to a specialized program for adolescents with SM, aiming to address awareness gaps and improve early intervention. Findings reveal a notable 11.5% contribution from pediatricians, compared to the other referring parties-- searching online (33.7%), other (32.6%), psychologist (8.6%), friend (8.5%), other therapist (4.6%), and recruitment event (0.5%)--emphasizing the need for targeted clinician awareness initiatives. Recognizing the potential benefits of early intervention, this research underscores the importance of collaborative efforts, education, and specialized programs in enhancing referral patterns by pediatricians for improved outcomes in selective mutism, as children are more likely to see their pediatrician before any of the other previously listed referral parties. The study acknowledges limitations in its design and suggests avenues for future research to explore factors influencing clinician awareness and the long-term outcomes of early SM treatment.

Retrospective Analysis of Pediatrician Referral Patterns for Selective Mutism Intervention: Unveiling Silent Echoes in Clinical Practice

Abstract Title: Stool Sphingomyelin Analysis to Predict Parenteral Nutrition-Associated Cholestasis in Very Low Birth Weight Neonates

Authors: Esrig, A., Shenoy, A., Marrs, A., Kolling, G., Moore, S., Papin, J., Sullivan, B. 

Background: Parenteral Nutrition-Associated Cholestasis (PNAC), diagnosed by elevated serum conjugated bilirubin, occurs in preterm infants with very low birthweight (VLBW, <1500g) requiring prolonged parenteral nutrition. Previous untargeted fecal metabolomics from our group identified 12 sphingomyelins as potential PNAC biomarkers. Successful identification of a stool biomarker for PNAC risk could reduce reliance on blood tests and promote preventative interventions to mitigate liver damage.

Methods
We enrolled VLBW infants admitted to a level IV NICU with written consent from a parent. Stool samples were collected biweekly, and clinical data were recorded in a REDCap database. We analyzed stool samples using mass spectrometry for targeted fecal sphingomyelin quantification. Conjugated bilirubin (C. Bili) levels were obtained at the discretion of the clinical team. We identified study participants with PNAC (C. Bili > 1.0 mg/dl) and matched each PNAC case with two controls (enrolled VLBW infants without PNAC) of similar gestational age, birthweight, and sex. We used summary statistics and non-parametric statistical tests to compare clinical variables and sphingomyelin concentrations between cases and controls. The main objective is to validate and quantify fecal sphingomyelins as PNAC biomarkers through targeted metabolomics.
Results

We enrolled 55 VLBW infants, of whom 3 developed PNAC. We matched two controls with these 3 cases and analyzed their biweekly stool samples for sphingomyelin concentrations. Demographics were similar for cases and controls, and cases had more days on TPN Peak sphingomyelin concentrations were higher for cases than controls, but the timing of the peaks relative to PNAC timing varied. Sphingomyelin concentrations were weakly positively correlated with TPN days.


Conclusion
We identified fecal sphingomyelins using targeted mass spectrometry analysis of stool samples from VLBW preterm infants at risk for PNAC. Our preliminary results show variable timing of sphingomyelin elevations relative to PNAC diagnosis and age in controls without PNAC. PNAC is a rare disease requiring large cohorts to determine the utility of fecal sphingomyelin to predict PNAC risk. Successful identification of fecal biomarkers that predict cholestasis before the onset of PNAC could reduce blood testing & liver damage

Stool Sphingomyelin Analysis to Predict Parenteral Nutrition- Associated Cholestasis in Very Low Birth Weight Neonates

Background: Laparoscopic hysterectomy is a common surgical procedure associated with postoperative pain. The Quadratus Lumborum (QL) block has been used as a regional anesthetic during hysterectomy, yet its efficacy remains unexplored. This systematic review and meta-analysis of randomized control trials (RCTs) evaluates the efficacy of QL block in reducing opioid consumption and visual analogue scale (VAS) scores. The aim is to understand its potential benefits in the postoperative period.

Methods: Electronic search was conducted through PubMed, Embase, Scopus, Cochrane, and Web of Science. Relevant articles published from inception until May 20, 2024 were searched. Primary outcome included total opioid consumption within 24 hours and VAS scores within 2, 6, 12, and 24 hours post-operation. Secondary outcomes included time to first opioid demand, time to first ambulation, and adverse events.

Results: Nine RCTs were included. QL block significantly reduced total opioid consumption within the first 24 hours (MD = -10.1mg, 95% CI: -15.2 to -3.6, p = .008). VAS scores were significantly lower within the first 2 hours (MD = -3.6, 95% CI: -4.0 to -0.9, p = 0.046), 6 hours (MD = -2.3, 95% CI: -2.0 to -0.7, p = 0.031), and 12 hours (MD = -1.5, 95% CI: -1.9 to -0.3, p = 0.024). There was no significant difference in time to first opioid demand (MD = 120min, 95% CI: -10 to 50, p = 0.20), time to first ambulation (MD = 120min, 95% CI: -10 to 65, p = 0.15), or adverse events (OR = .78, p = .85).

Conclusion: QL block is an effective analgesia for reducing total opioid consumption and reducing VAS scores in hysterectomy. It does not have a significant impact on time to first opioid demand, time to first ambulation, or adverse events. QL block should be considered for postoperative pain management in hysterectomy.

Efficacy of Quadratus Lumborum Block on Postoperative Analgesia in Hysterectomy: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

Background
Cleft lip and palate (CLP) is the most prevalent congenital malformation in the United States. Approximately 75% of CLP patients will have an alveolar cleft that can impair support of palatal and dental structures. Alveolar bone grafting (ABG) is standard management for alveolar defects, typically with iliac cancellous bone. Previous operative planning has been limited in terms of quantification of alveolar clefts and the amount of graft to obtain sufficient bony bridging across the defect. Here, we examine the potential use of Cone-Beam Computed Tomography (CBCT) and 3-Dimensional (3D) segmentation for volumetric quantification of alveolar clefts.
Methods
A retrospective chart review was performed for patients who underwent ABG since 2018 and CBCT imaging studies for operative planning and outcomes assessment were collected. Peri-operative data, cleft characteristics, demographics, and post-operative data were collected along with CBCT images. ITK-Snap neuroimaging software (University of Pennsylvania, 2023) was used in 3-Dimensional segmentation of CBCT imaging, obtaining measurements of volume and widths of alveolar clefts pre- and post-operatively. Anatomic landmarks were agreed upon by craniofacial orthodontists and surgeons.
Results
68 post-operative studies were identified, with 66 studies demonstrating measurable bony bridging. 11 post-operative studies had enough residual cleft volume to undergo 3D segmentation, 9 of which had measurable bony bridging. 33 pre-operative CBCT studies for patients who underwent ABG were available for 3D segmentation. 21 pre-operative studies were conducted for clefts undergoing primary ABG and 12 were conducted for revisions. 40% of patients who underwent grafting had a bilateral cleft and alveolar defect. For post-operative segmentations of successful ABG, original cleft width averaged 5.35mm, cleft residual volume averaged 559.1mm3, and bony bridging height averaged 6.06mm. Cleft width in patients who required revision was significantly higher compared to those who did not (8.02mm vs. 5.35mm, p=0.011). A comparison between the residual volume of clefts which required revision and those that did not approached, but did not meet, statistical significance (980.2mm3 vs. 559.1 mm3, p=0.058).
Conclusion
3D segmentation has potential in pre-operative planning of alveolar bone grafting. Preliminary results from 3D analysis of CBCT indicate width of cleft may be more influential in ABG success than cleft volume. Comparison of these characteristics of cleft defects may help determine if a threshold exists for increased risk of bone graft failure. Continued analysis will include regression analysis of cleft width and volume corresponding to ABG outcomes, as well as receiver operating characteristic curves to investigate thresholds of failure risk.

3D Volumetric Analysis of Alveolar Clefts Using Cone-Beam Computed Tomography

Background:
Complications following tissue expander (TE) placement for staged oncologic breast reconstruction remain a challenge. Innovations such as dual-port TEs with both filling and drainage ports mitigate seroma risk. Acellular dermal matrix (ADM) has also gained popularity due to superior structural support and cosmesis. ADM is a sterile, bioengineered soft tissue graft used for dermal reinforcement and regeneration. The purpose of this study was to compare outcomes between dual- and single-port TEs with the use of ADM.

Methods:
Retrospective chart review was completed for patients who underwent TE breast reconstruction by a single surgeon between January 2018 and November 2023. Demographics, cancer treatment modality, implant data, and postoperative outcomes were examined. Analysis included descriptive statistics, F-distribution tests, Welch's t-tests, Chi-squared, and Fisher Exact tests.

Results:
154 breasts were included: 118 single-port TEs (74 with ADM, 62.7%) and 36 dual-port TEs (11 with ADM, 31.0%). Premature explant was needed for 15.3% of single-port and 28.5% of dual-port TEs (p=0.328). Explant in both groups was due to infection, wound healing problems, rupture, and seroma. However, premature explant of dual-port TEs occurred predominantly without ADM (p=0.0075), contrasting single-port TEs where ADM use showed no significant difference in explant rate. Further, incidence of infection was higher in dual-port expanders without ADM (p-value=0.0071), whereas single-port TE infection trended higher with ADM use.

Conclusions:
Both single and dual-port tissue expanders are safe and effective for staged breast reconstruction, without significant differences in the rate of premature explantation. In this cohort, ADM appears protective when used with dual-port TEs. It is possible that ADM’s homogenous surface safeguards the drain port from clogging with subcutaneous fat or other tissue, decreasing risk of fluid collection and infection. Routine ADM use with dual-port TEs could reduce complications and improve patient outcomes. Additional research is needed to facilitate evidence-based decision-making on single versus dual-port TE placement and utility of ADM.

Enhanced Performance of Dual-Port Tissue Expanders with Use of Acellular Dermal Matrix

Introduction: 
Heterotopic ossification (HO) is the formation of extra-skeletal bone within soft tissue that occurs after injuries like severe burns. Development of HO complicates healing after injury. We aimed to elucidate factors influencing the development of HO in burn survivors and effects on recovery. 

Methods: 
Using the TriNetX database, a large, federated research network of de-identified patient data, we compared burned patients who developed HO after injury and those who did not. Cohorts were propensity-matched by age, gender, race, ethnicity, and % total body surface area (TBSA) burned. We then evaluated incidences of outcomes after injury among both cohorts.

Results:
Of the population, 0.12% developed HO after injury with most identified greater than 6 months from injury. HO was more common in those with head, upper extremity, or lower extremity burn involvement (p<0.0001). The HO group was older (48.1 vs 19.5 yrs. vs 32.5 vs 22.8 yrs., p<0.001), and male (60.3% vs 51.1%, p<0.001). African American burn patients were more likely to develop HO (22.2% vs 17.5%, p<0.001) than not. Additionally, those with HO exhibited a more than doubled risk of neuropathy, limited joint mobility, and documented edema than those who did not. Additionally, risk of skin breakdown, pain, and depression was higher in those who developed HO while additional reconstructive operations was interestingly lower. 

Discussion: 
Burn survivors more likely to develop HO are older, male, and have greater injury severity. Identification of HO was more likely greater than 6 months from injury. After propensity matching for burn severity and demographic factors, those with HO have comparatively poorer outcomes.

Heterotopic Ossification After Burn Injury Results in Worse Outcomes

Introduction: Plastic surgeons face an elevated risk of involvement in malpractice cases compared to other specialties. Fear of malpractice litigation may influence surgeon behavior and decision-making, potentially contributing to heightened healthcare costs. This study aimed to determine the prevalence and characteristics of malpractice litigation associated with breast implants. 

Methods: A comprehensive search involving the Westlaw Campus Research legal database was conducted to identify all cases involving malpractice complaints and breast implants. All available malpractice cases involving breast implants/prostheses from the earliest available documentation to February 1st, 2024 were retrieved and screened. Cases were included if a patient initiated a medical malpractice or negligence case after undergoing breast augmentation or reconstruction involving implants. Class action suits and cases with limited information were excluded. The extracted data from the cases included the date of the earliest available documentation, initiation location, patient gender, patient vital status, indication for implant(s), involved medical specialties, types of alleged negligence, diagnostic and postoperative complaints, autoimmune-related complaints, involvement of capsular contracture along with subsequent open/closed capsulectomy, and case outcomes. Descriptive statistics were calculated. 

Results: 650 cases were identified after the exclusion of duplicates; 128 cases met the inclusion criteria. Cases were most commonly initiated in the state of Texas (N=17, 13.3%) and New York (N=13, 10.2%) and documentation was dated 1967-2023. All of the cases involved female patients; one woman identified as transgender. Three (2.3%) patients were deceased at the time of the trial. Plastic surgeons were most commonly the defendant(s) (N=113, 88.3%). Malpractice claims were most frequently associated with the initial breast implant placement (N=89, 69.5%), rather than a breast implant removal with or without replacement (N=26, 20.3%). Negligent technique, improper informed consent, and poor postoperative management were cited as reasons for alleged malpractice in 90 (70.3%), 65 (50.8%), and 64 (50.0%) of the cases, respectively. Patients alleged that they did not receive the type of implant (saline vs. silicone) or size of implant they requested in 7 (5.5%) and 5 (3.9%) of the cases, respectively. 20 (15.6%) of the cases were ruled in favor of the plaintiff prior to appeal; 5 cases involved implant-based reconstruction, while 15 cases involved cosmetic implant-based augmentation. Eight patients claimed that their implants led to the development of cancer, autoimmune conditions, or other health conditions; only one case led to a ruling in favor of the plaintiff in 2001. 

Conclusion: 
These findings underscore the importance of comprehensive preoperative education, specifically addressing implant types, demystifying information about breast implant-associated illness, and setting realistic goals surrounding implant sizing. Surgeons should maintain heightened vigilance when patients present with abnormal postoperative changes in the breast tissue. Thorough work-up and placement of appropriate referrals should be conducted to prevent delays in potential breast cancer diagnoses. 


Implant Injustice: An Analysis of Breast Implant Malpractice Litigation

Background: Soft tissue sarcomas (STS) are malignant tumors that originate in soft tissues, managed with surgical resection as first-line treatment. Time to intervention (TTI) is crucial to the overall survival as metastases can develop in about 50% of STS patients. In the US, the median TTI is 22 days for STS patients, with longer TTI associated with poorer outcomes.1-3 While low-income public insurance and academic centers have individually been associated with increased TTI, no studies have investigated the combined impact of these factors.2,4-5 

Methods: We performed a single academic institution retrospective chart review of patients who underwent surgical STS resection between 2013 and 2023 with Medicaid or Medicare insurance. TTI was calculated from date of diagnosis to date of surgical resection. 

Result: Data was collected from 69 patients who underwent surgical STS resection; 20 patients were diagnosed and referred from outside hospitals, and 28 patients received preoperative radiation therapy (PRT). 90% of STS patients were diagnosed by biopsy and 10% by imaging. The most common STS diagnoses included “undifferentiated pleomorphic sarcoma” (25%) and “myxofibrosarcoma” (20%). Of the 41 patients that underwent STS surgical resection only, 56% had high grade (grade 2 or 3) STS and had a median TTI of 40 days. Among the PRT patients, 89% had high grade STS and median TTI of 104 days. 

Conclusion: The median TTI for surgical resection of STS in Medicare and Medicaid patients at a single academic institution was higher compared to the median TTI for STS in the US.

Increased Time to Intervention for Medicaid and Medicare Patients with
Localized Soft Tissue Sarcoma at a Single Academic Institution

Optimizing the ACS NSQIP Risk Calculator in Microsurgical Free Flap Breast Reconstruction

Background: Pre-operative risk indexes such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) have become increasingly popular for predicting patient-specific postoperative risks in plastic surgery. This study aimed to assess the accuracy of the ACS NSQIP tool in microsurgical breast reconstruction with subsequent analysis of the most significant patient-level risk variables that drive these predictions. 

Methods: A retrospective review of 98 microvascular free flap breast reconstructions performed between 2018-2022 was completed. 94 patients were included in the analysis. Univariate analysis between complication and non-complication groups was completed to identify significant differences in predictions. Receiver operating characteristic (ROC) curves on these predictions were subsequently completed to evaluate the accuracy of ACS NSQIP. Multivariate regression analysis was performed on pre-operative patient data utilized in the NSQIP risk calculator to identify any significant relationships between predictor variables and observed adverse postoperative events.

Results: Univariate analysis revealed the ACS NSQIP calculator most accurately predicted any complication (p=0.0432) and surgical site infection (p=0.0216) of the 12 outcomes analyzed by the authors. ACS NSQIP predicted “any” complications with a diagnostic accuracy of 63.1%, sensitivity of 61.3%, and specificity of 71.0%. It also predicted surgical site infection with a diagnostic accuracy of 71.6%, sensitivity of 57.1%, and specificity of 84.9%. Subsequent multivariate linear regression analysis of significant predictions revealed that non-white individuals were 6.68 times more likely to have any complication (95% CI 1.89-23.62; p=.003) and 6.38 times more likely to have a serious complication (95% CI 1.81-22.53; p=.004).

Conclusion: The NSQIP Risk Calculator was found to be significant in predicting “any complications” and “surgical site infections'' amongst our institution’s microsurgical breast reconstruction cohort, with minorities experiencing an approximate seven-fold increase in complications. Further analysis of the patient-level risk factors that drive these predictions may optimize the accuracy of this index and provide a powerful tool in pre-operative counseling by plastic surgeons.

Optimizing the ACS NSQIP Risk Calculator in Microsurgical Free Flap Breast
Reconstruction

Background
The Goldilocks mastectomy is a breast reconstruction technique that utilizes the remaining breast tissue post-mastectomy to create a new, smaller breast mound. For this reason, the Goldilocks technique is well-suited for patients with large, ptotic breasts. This procedure is often paired with free nipple grafting (FNG), a technique in which the nipple-areolar complex (NAC) is removed entirely and relocated as a skin graft. In cases where only one NAC can be preserved, the nipple can be split into halves and fashioned into two separate nipples prior to graft placement.

When FNG is employed in conjunction with Goldilocks mastectomy, it is often performed as a secondary procedure. However, the surgical risks and recovery time can be reduced when these procedures are performed concurrently. A single-stage operation can also allow for earlier radiation treatment or the avoidance of grafting on irradiated skin.

Case Presentation
Here, we present the successful application of FNG in conjunction with the Goldilocks mastectomy in a single-stage procedure. The patient was a 55-year-old female with bilateral, retropectoral breast implants who wore a DD size bra. After presentation with microcalcifications in the left breast and diagnosis of ductal carcinoma in situ, bilateral mastectomy was suggested. The patient requested a reconstructive procedure in which her implants could be removed while still preserving the shape and aesthetics of her breasts. Because cancer was present in the left NAC, only the right nipple could be preserved for grafting. Therefore, single-stage, bilateral Goldilocks mastectomy with nipple-splitting and subsequent FNG was suggested as a treatment option. The procedure was explained to the patient, and she was informed of the associated risks. She chose to proceed with surgery. The procedure was successfully performed using a single-stage approach. The patient did not suffer any complications and had good wound healing, which led to a pleasing cosmetic result and eliminated the need to return to the hospital for further treatment.

Discussion
The decision to perform FNG concurrently with a Goldilocks mastectomy provides several benefits. A FNG addresses the cosmetic impact of NAC removal, and the single-stage approach reduces overall recovery time, minimizes infection risk, and promotes a faster return to daily life. In this case, the patient’s desire for implant removal was accommodated while also providing total breast reconstruction in a single operation. The single-stage method helped to minimize postoperative complications and optimize the aesthetic outcome, ultimately yielding high patient satisfaction and improved quality of life.

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Retrospective Analysis of Pediatrician Referral Patterns for Selective Mutism Intervention: Unveiling Silent Echoes in Clinical Practice

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