Complex Cases Research Articles

Soft tissue sarcomas: Disease burden and health system response in Peru.

e23557 Background: The management of soft tissue sarcomas (STS) presents a challenge in Peru, with a fragmented health system and few centers specialized in sarcoma care. There is no national cancer registry, which does not allow us to have a real view of the most prevalent types. Our aim was to determine the incidence in Instituto Nacional de Enfermedades Neoplásicas (INEN) and to know the real care capacity of cancer centers nationwide. Methods: A retrospective study was carried out in INEN between 2009 and 2015 to know the incidence of STS. Also, a survey was carried out to determine the real capacity of diagnosis and treatment care of cancer centers located in different regions of our country. Results: We were able to determine the anatomopathological diagnosis in 1804 (100%) patients. 52,1% were male (n = 899). Median age was 43 years (15-96). The most frequent sarcoma was undifferentiated pleomorphic sarcoma with 482 patients(27.9%), followed by liposarcoma in 269 (15,6%) and leiomyosarcoma in 159 (9%). The most common primary location was the limbs with 892 patients (51.7%), followed by the abdomen and pelvis with 423 (24.5%), and the least common was the head and neck with 207 patients (12%), followed immediately by the thorax with 205 patients (11.9%). According to the region of origin, 551 (31.9%) patients came from the northern region, 175 (10.1%) from the south, 35 (2%) from the east, 308 (17.8%) from the central region, and 658 (38.1%) from Lima and Callao. We obtained responses from 20 oncology centers of the Ministry of Health along 12 regions operating nationwide. Eight (40%) oncology centers are located in Lima and twelve (60%) in the rest of Peru. 100% (n = 20) of centers have medical oncologists, 70% (n = 14) have surgical oncologists, 65% (n = 13) have traumatologist and pathologist. About capacity of resolution: 100% (n = 20) perform direct biopsy of soft tissue tumors and 60% (n = 12) perform image-guided biopsies; regarding pathology, 95% (n = 19) performed morphological approach and 45% (n = 9) immunohistochemistry studies. 100% (n = 20) can perform ultrasound studies, 95% (n = 19) tomography, and 35% (n = 7) magnetic resonance imaging. 90% (n = 17) accomplish radical surgeries and 60% (n = 12) limb sparing surgeries. 85% (n = 17) enforce chemotherapy treatment. Only 50% (n = 10) have a radiotherapy service. 25% (n = 5) hold multidisciplinary meetings continuously while 40% (n = 8) hold them occasionally for complex cases. Only 8 oncology centers (out of a total of 20) have all the services to care for the complexity of a patient with soft tissue sarcoma, the majority (n = 3) located in Lima. Conclusions: Nearly 1,800 patients have been diagnosed in this reference institution in a period of 5 years, however it represents an underestimation of the real incidence. Cancer centers that can provide complete care for patients with soft tissue sarcomas are scarce, creating a gap in care for this pathology.

Evaluation of a technology enhanced breast multidisciplinary cancer conference (MCC).

e23202 Background: Tumor board meetings have been a standard approach for managing complex cases. In 2020, a digital platform, navify® Tumor Board Solution (NTBS), was implemented at a comprehensive academic cancer center. The objectives of this study were to assess the impact of NTBS (1) on quality of patient information and case deliberation, (2) rate of change in care plans by the MCC, (3) compliance of care plans with national guidelines, and (4) concordance of treatment received with MCC recommendations. Methods: We conducted a prospective study from September 2020 to February 2022, before and after implementation of NTBS. We used a validated tool, “Metric for the Observation of Decision-Making", to assess the impact of the platform on the quality of breast MCC case presentation and discussion. We reviewed medical records to compare the rate of change in care plans, compliance with national guidelines, and concordance of treatment received with MCC recommendations. Results: There were 39 and 47 patient cases in the pre- and post-NTBS groups, respectively. We found that implementation of technology led to an improvement in the overall quality of the MCCs (mean composite scores: 56.4 vs 67.5; p < .001). Specific components that were significantly improved include case history, reason for presentation, radiology and pathology presentations, and medical oncology contribution to case discussions (mean scores: 3.4 vs 3.9; p < .001, 3.3 vs 3.9; p < .001, 2.7 vs 4.1; p < .001, 3.1 vs 4.2; p < .001 & 3.7 vs 4.1; p = .05). Pre- vs post-NTBS, rate of change in care plans decreased from 57.1% to 51.1%, compliance of MCC care plans with NCCN guidelines increased from 80.0% to 81.4%, and concordance of treatment received with MCC recommendations increased from 83.9% to 86.5%, though they were not statistically significant. Conclusions: Technology increases the quality of patient information presentation and case discussion at Breast MCCs, but in this small study we did not demonstrate an impact on MCC decision making. Areas for further development include assessment of improved efficiency of MCCs, opportunities for asynchronous MCC evaluation using this platform, establishment of automated case summaries, and technology-driven matching of detailed patient characteristics to established national guidelines.

The Use of Titanium Pins for the Management and Fixation of Free Gingival Grafts and Apically Repositioned Flaps During Vestibuloplasty. A Technique Report.

The presence of adequate keratinized mucosa (KM) around dental implants and natural dentition is pivotal for the long-term success of dental restorations. Despite various techniques to augment KM, challenges persist in achieving stable, keratinized, and adherent mucosa, especially in the context of significant muscle pull or compromised tissue conditions. This study introduces a novel application of titanium pins for the fixation of free gingival grafts (FGG) and apically repositioned flaps (APF) during vestibuloplasty, aiming to overcome important limitations associated with traditional suturing methods and shorten the treatment time and patient morbidity. Three patients with insufficient KM width, presenting discomfort during oral hygiene and inflammation around implant restorations and natural teeth, underwent soft tissue augmentation using titanium pins traditionally used in guided bone regeneration (GBR) for the stabilization of FGGs and APFs. This method ensures intimate contact between the graft and the periosteum, facilitating proper graft perfusion and revascularization, minimizing shrinkage and the risk for necrosis of the graft. Postoperative follow-up revealed successful integration of the grafts, with minimal shrinkage and increased width and depth of KM. The use of titanium pins allowed for reliable fixation in challenging surgical sites, where traditional suturing methods were impractical due to the presence of extensive muscle pull and an unstable recipient bed. The application of titanium pins for the fixation of FGGs and APFs during vestibuloplasty provides a promising alternative to traditional suturing techniques, particularly in complex cases where the recipient bed is suboptimal for suturing. This method simplifies and shortens the procedure, offering a predictable outcome with increased mechanical stability and minimal shrinkage of the graft. Randomized clinical trials are recommended to further evaluate the efficacy of this technique.

Medoid splits for efficient random forests in metric spaces

An adaptation of the random forest algorithm for Fréchet regression is revisited, addressing the challenge of regression with random objects in metric spaces. To overcome the limitations of previous approaches, a new splitting rule is introduced, substituting the computationally expensive Fréchet means with a medoid-based approach. The asymptotic equivalence of this method to Fréchet mean-based procedures is demonstrated, along with the consistency of the associated regression estimator. This approach provides a sound theoretical framework and a more efficient computational solution to Fréchet regression, broadening its application to non-standard data types and complex use cases.

A Free-Floating Aortic Thrombus: An Uncommon Approach to Handle a Rare Clinical Entity.

Thrombotic material in the non-aneurysmatic and non-atherosclerotic aorta is a rare entity without any recommended standard treatment so far. We present a successful treatment strategy for patients who do not fit into any of the common approaches. A free-floating thrombus in the descending aorta was found as source of embolism in an 82-year-old female patient with lower limb ischemia. After initial heparinization of the patient without relevant reduction of the thrombotic mass, the thrombus was removed using an interdisciplinary approach. Under echocardiographic guidance to locate the thrombus, the AngioVac device, usually licensed to remove floating thrombi from the venous system, was used off-label to remove the thrombus by a transfemoral approach. To avoid rebuilding of a new thrombus, the attachment point with an exulcerated plaque in the descending aorta was covered by a stent graft via the same femoral access. The patient did not experience any further embolic events, and the postoperative course was uncomplicated. Patients with uncommon aortic diseases, such as the reported free-floating thrombus, should be treated by an individualized, interdisciplinary approach. Besides the recommended treatment options, there are other uncommon approaches that might offer an alternative in complex cases. Evidence is rare for the treatment of a free-floating thrombus in the descending aorta and the treatment strategy remains discussed controversially. We present a rather uncommon approach of successful off-label treatment for patients who do not fit into any of the common approaches (operative, endovascular, or conservative treatment based on patient's comorbidities). The AngioVac System has already been successfully used off-label in the arterial system but not in the above presented way of treating a free-floating thrombus in a patient with high embolization risk and treatment-limiting comorbidities.

Transthoracic echocardiography evaluation of double outlet left ventricle: Unique case report and review of literature

Double-outlet left ventricle (DOLV) is a rare cardiac malformation in which both great arteries originate from the morphological left ventricle. DOLV is associated with high mortality, generally due to heart failure, myocardial infarction, or aortic thrombosis. With surgery, the 5-year survival rate is estimated at 70%–75%. Most patients will continue to present with residual cardiac anomalies, such as aortic or mitral valve regurgitation, arrhythmias, or hypertension. We are reporting a complex case of cyanotic congenital heart disease in a 5 month old female infant suffering from DOLV, who presented to us with recurrent chest infections and bluish colouration of skin.

Paradoxical tuberculous reaction to anti-tnfα discontinuation: a complex case of miliary tuberculosis and macrophagic activation syndrome with hepatic manifestations

Tuberculosis reactivation during anti-TNF-alpha therapy paradoxically worsened following reconstitution of pathogen-specific immune responses after cessation of TNFα antagonist treatment and initiation of anti-bacillary therapy. We report the case of a 46-year-old woman who was prescribed a tumor necrosis factor blocker (anti-TNF) for a relapse of Behçet's disease. The patient developed pulmonary miliary tuberculosis following the reactivation of latent tuberculosis, despite a normal pre-therapeutic work-up. Discontinuation of anti-TNF and initiation of anti-bacillary drugs triggered a paradoxical tubercular reaction (PTR). The diagnosis of paradoxical reaction to anti-tuberculosis drugs was evoked by the clinical and biological deterioration and the appearance of miliary cerebral tuberculosis and cerebral venous thrombosis after a period of clinical improvement. Although this phenomenon has been documented, it represents a major challenge for clinicians. The peculiarity of this case lies in its association with a macrophagic activation syndrome (MAS) with hepatic involvement, retained on clinical-biological and histological criteria. The overlap between MAS and PTR makes it difficult to diagnose these two entities with certainty. The patient responded favorably to moderate-dose systemic corticosteroid therapy with progressive degression, and the reintroduction of anti-tuberculosis drugs.This work aims to highlight the importance of close monitoring of TB patients on anti-TNFα therapy for early diagnosis and management of complications to improve the prognosis of these complex patients.

Management and treatment of perioperative hypersensitivity.

Perioperative hypersensitivity reactions are rare but potentially catastrophic events. This review acts to summarize recent recommendations for both immediate and poststabilization management of suspected reactions, alongside practical advice for anaesthetists who may be faced with these events. Prompt treatment is essential but may be hampered by delay in recognition. This can occur because there are multiple differential diagnoses for the observed clinical signs as well as variations in clinical presentation. Resuscitation is dependent on the use of adrenaline and fluids. Adrenaline should be administered in small, titrated intravenous boluses. Low-dose infusions should be commenced early if the response to boluses is poor. Large volume fluid resuscitation may be required to maintain adequate circulating volume. Chest compressions are recommended when there is evidence of inadequate perfusion, rather than waiting until cardiac arrest is confirmed. Antihistamines and corticosteroids are no longer recommended in the immediate management phase. Once the patient has been stabilized, it is important to obtain serial tryptase concentrations to aid the subsequent clinic investigation. The decision to proceed or abandon surgery will be based on an individual risk-benefit analysis. All cases of suspected perioperative hypersensitivity, including fatal cases, must be referred for formal investigation. There have been recent updates to management guidelines in perioperative hypersensitivity. Treatment algorithms, treatment packs and referral packs can all help the anaesthetist manage these complex cases, aid the subsequent investigation and ensure patient safety in the future.

Evaluating Imaging Techniques for Diagnosing and Drainage Guidance of Psoas Muscle Abscess: A Systematic Review.

Background: Psoas muscle abscess (PMA) is an uncommon yet severe condition characterized by diagnostic and therapeutic challenges due to its varied etiology and nonspecific symptoms. This study aimed to evaluate the effectiveness and accuracy of various imaging techniques used in the image-guided percutaneous drainage (PD) of PMA. Methods: A systematic review was conducted following the PRISMA guidelines. We searched PubMed, Google Scholar, and Science Direct for studies published in English from 1998 onwards that reported on the use of PD in treating PMA, detailing outcomes and complications. Imaging modalities guiding PD were also examined. Results: We identified 1570 articles, selecting 39 for full review. Of these, 23 met the inclusion criteria; 19 were excluded due to unspecified PMA, absence of imaging guidance for PD, or inconclusive results. Eleven studies utilized computed tomography (CT) for PD, with six also using magnetic resonance imaging (MRI). Ten studies implemented ultrasound (US)-guided PD; variations in diagnostic imaging included combinations of US, CT, and MRI. A mixed approach using both CT and US was reported in two articles. Most studies using CT-guided PD showed complete success, while outcomes varied among those using US-guided PD. No studies employed MRI-guided PD. Conclusions: This review supports a multimodal approach for psoas abscess management, using MRI for diagnosis and CT for drainage guidance. We advocate for Cone Beam CT (CBCT)-MRI fusion techniques with navigation systems to enhance treatment precision and outcomes, particularly in complex cases with challenging abscess characteristics.

Classifying Emergency Patients into Fast-Track and Complex Cases using Machine Learning

Emergency medicine is a lifeline specialty at hospitals that patients head to for various reasons, including serious health problems, traumas, and adventitious conditions. Emergency departments are restricted to limited resources and personnel, complicating the optimal handling of all received cases. Therefore, crowded waiting areas and long waiting durations result. In this research, the databases of MIMIC-IV-ED and MIMIC-IV were utilized to obtain records of patients who visited the Beth Israel Deaconess Medical Center in the USA. Triage data, dispositions, and length of stay of these individuals were extracted. Subsequently, the urgency of these cases was inferred based on standards stated in the literature and followed in developed countries. A comparative framework using four different machine learning algorithms besides a reference model was developed to classify these patients into complex and fast–track categories. Moreover, the relative importance of employed predictors was determined. This study proposes an approach to deal with non-urgent visits and lower overall waiting times at the emergency by utilizing the powers of machine learning to identify high-severity and low-severity patients. Given the provision of the required resources, the proposed classification would help improve the overall throughput and patient satisfaction.

Out-Patient versus In-Patient Arteriovenous Fistula Creation for Dialysis: Assessing Cost-Effectiveness Alongside Clinical Implications.

(1) Background: The surgical procedure to create an arteriovenous fistula (AVF) can be performed in either an ambulatory or in-patient hospital setting, depending on the case's complexity, the anesthesia type used, and the patient's comorbidities. The main scope of this study is to assess the cost-effectiveness and clinical implications of surgically creating an AVF in both ambulatory and in-hospital settings. (2) Methods: We conducted a retrospective observational study, in which we initially enrolled all patients with end-stage kidney disease (ESKD) admitted to the Vascular Surgery Department, Emergency County Hospital of Targu Mures, Romania, to surgically create an AVF for dialysis, between January 2020 and December 2022. The primary endpoint of this study is to assess the cost-effectiveness of surgically creating an AVF in an ambulatory vs. in-hospital setting by comparing the costs required for the two types of admissions. Further, the 116 patients enrolled in this study were divided into two groups based on their preference for hospitalization: out-patients and in-patients. (3) Results: Regarding in-patient comorbidities, there was a higher prevalence of peripheral artery disease (PAD) (p = 0.006), malignancy (p = 0.020), and previous myocardial infarction (p = 0.012). In addition, active smoking (p = 0.006) and obesity (p = 0.018) were more frequent among these patients. Regarding the laboratory data, the in-patients had lower levels of white blood cells (WBC) (p = 0.004), neutrophils count (p = 0.025), lymphocytes (p = 0.034), and monocytes (p = 0.032), but there were no differences between the two groups regarding the systemic inflammatory biomarkers or the AVF type. Additionally, we did not register any difference regarding the outcomes: local complications (p = 0.588), maturation failure (p = 0.267), and primary patency (p = 0.834). In our subsequent analysis, we discovered no significant difference between the hospitalization type chosen by patients regarding AVF primary patency failure (p = 0.195). We found no significant association between the hospitalization type and the recorded outcomes (all ps > 0.05) in both multivariate linear regression and Cox proportional hazard analysis. (4) Conclusions: In conclusion, there are no significant differences in the clinical implications, short-term and long-term complications of AVF for out-patient and in-patient admissions. Additionally, we found no variation in the costs associated with laboratory tests and surgical supplies for an AVF creation. Therefore, it is safe to perform ambulatory AVFs, which can reduce the risk of hospital-acquired infections and provide greater comfort to the patient.

Коморбидность и «маски» в неврологии

The purpose of the study is to demonstrate the difficulties faced by a primary care physician at the time of diagnosis in making a diagnosis and the need for medical compliance for the proper management of patients with comorbid pathology. Materials and methods. 3 clinical cases of patients examined from complaints and objective data to laboratory and instrumental examination methods are presented. Analysis of patient outpatient records under observation and treated at the Voronezh City Clinical Polyclinic No. 4. Study of the provided medical documentation, anamnesis data, and conclusions of specialist doctors. The results of ECG, EEG, ultrasound, MRI and RCT of the brain, ENMG, CT of the OGK, and laboratory data were analyzed. Results. The importance of the clinical picture totality in every case, close attention to routine blood tests in the practice of a neurologist, the importance of the data obtained together and separately, close cooperation with related specialists as part of the medical commission is shown. Conclusion. Neurological manifestations of the disease occur in various other pathologies. Therefore, it is very important to take into account all deviations when examining a patient, since sometimes the true diagnosis is masked by other diseases. Only an integrated approach in the examination of patients with complex cases allows us to make a correct diagnosis and conduct adequate therapy.

Diagnostic Dilemma of a Complex Case of Cerebral Vasculitis: A Rare Probable Drug-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Large Vessel Involvement

Diagnostic Dilemma of a Complex Case of Cerebral Vasculitis: A Rare Probable Drug-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Large Vessel Involvement

Exploring the frontier in robotic pediatric cancer surgery: when to move forward and when to stop.

In recent years, the use of robotic-assisted minimally invasive surgery in pediatric oncology has increased. Despite its benefits, its adoption remains limited. This single-center retrospective analysis examines technical nuances, indications, and surgical limitations to prevent complications. Data from cancer patients treated robotically in 2015-2016 (Group A) and 2020-2022 (Group B) were compared. Decision-making considered tumor characteristics and risks, guided by multidisciplinary tumor board discussions. Data collected included demographics, intra/post-operative details, and tumor classifications. Statistical analysis evaluated influencing factors. Thirty-eight pediatric patients underwent robotic-assisted tumor resection, the median age was 5years and weight 21.5kg. Group A had higher median age and weight. Lesions included 23 malignant, 9 borderline, 5 benign cases; neuroblastoma (n = 19) was prevalent procedure and adrenalectomy was the predominant (28.94%). Open conversion occurred in 12 patients (31.58%), mainly due to vascular challenges (23.68%). Intraoperative complications were 10.53%, postoperative 7.9%. About 27% discharged by the third postoperative day; longer stays were needed for complex cases. All resumed post-op chemotherapy as scheduled, and all alive during follow-up. Our study confirms the safety and efficacy of robotic-assisted tumor resections in pediatric oncology, even during the learning phase, emphasizing the importance of learning curve, patient selection, and trocar positioning.

Case Series and Review Article: Perfluorocarbon Heavy Liquid as a Short-Term Tamponade after Vitrectomy for Inferior Rhegmatogenous Retinal Detachment

This is to report outcomes of three cases with inferior rhegmatogenous retinal detachment (RRD) which were treated with vitrectomy and perfluorocarbon heavy liquid (PFCHL) insertion as short-term tamponade. We also aim to summarise the surgical outcomes and complications from the recent studies in PFCHL usage in vitrectomy surgeries. The mean tamponade period for our case series was 11 days. Two patients developed ocular hypertension, while another developed hypotony with subsequent retinal redetachment. Migration to the anterior chamber causing pupillary block glaucoma also occurred in one patient, requiring laser peripheral iridotomy. Previous studies reported that PFCHL is particularly useful for more complex cases of retinal detachment including giant retinal tears, inferior retinal tears, chronic rhegmatogenous retinal detachment (RRD), inferior RRD and proliferative vitreoretinopathy (PVR) due to its unique physical properties. However, it is not recommended as tamponade for long duration due to possible retinal toxicity. Otherwise, most of the complications due to PFCHL can be managed either medically or surgically. PFCHL can be a useful post-operative tamponade agent in vitreoretinal surgeries. Close post-operative monitoring is crucial for the potential complications from PFCHL.

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review

SummaryBackgroundA fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention.Case presentationA 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4.ConclusionsThe clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient’s condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

Possible Role of Cytomegalovirus in Gastric Cancer Development and Recurrent Macrolide-Resistant Campylobacter jejuni Infection in Common Variable Immunodeficiency: A Case Report and Literature Discussion.

Common variable immunodeficiency (CVID) is the most common symptomatic immunodeficiency in adults. It comprises a group of syndromes whose etiology involves genetic, epigenetic, microbiota, and environmental factors. We present the case of a 46-year-old Caucasian male patient with CVID and an immune dysregulation phenotype. The particular elements of the case consisted of an atypical clinical course, which undoubtedly demonstrates the great variability of clinical manifestations that these types of patients can suffer from, including bacterial and viral infections, autoimmune phenomena, and neoplasia. Notably, the patient suffered from recurrent gastrointestinal infection with macrolide-resistant Campylobacter jejuni and gastroduodenal disease and viraemia by cytomegalovirus (CMV). In addition, CMV was postulated as the main pro-oncogenic factor contributing to the development of early-onset intestinal-type gastric adenocarcinoma, for which the patient underwent gastrectomy. The patient's evolution was difficult, but finally, as a result of the multidisciplinary approach, clinical stabilization and improvement in his quality of life were achieved. Based on our brief literature review, this is the first reported case of this clinical complexity. Our experience could help with the management of future patients with CVID and may also update current epidemiological data on CVID.

Characteristics of Patients Receiving Complex Case Management in an Acute Care Hospital.

Improving transitions in care is a major focus of health care planning. In the research team's prior intervention study, the length of stay (LOS) was reduced when patients at high risk for readmission were identified early in their acute care stay and received complex management. This study will describe the characteristics of patients receiving complex case management in an urban acute care hospital. Acute care hospital. This was a retrospective chart review of patients in a previous quality assurance study. A random selection of patients who previously underwent high-risk screening using the LACE (Length of stay; Acuity of the admission; Comorbidity of the patient; Emergency department use) index and received complex case management (the intervention group) were reviewed. The charts of a random selection of patients from the previous comparison group were also reviewed. Patient characteristics were collected and compared using descriptive statistics. In the intervention group, more patients had their family physicians (FPs) documented (93.1% [81/87] vs. 89.2% [66/74]). More patients in the intervention group (89.7% [77/87] vs. 85.1% [63/74]) lived at home prior to admission. More patients in the intervention group had a family caregiver involved (44.8% [39/87] vs. 41.9% [31/74]). At discharge, more patients in the intervention group (87.1% [74/85]) were discharged home compared with the comparison group (78.4% [58/74]). (1) Having an identified FP, living at home, and having family caregiver(s) characterized those with lower LOS and discharged home. (2) Case management, risk screening, and discharge planning improve patient outcomes. (3) This study identified the importance of having a FP and engaged family caregivers in improving care outcomes.

Characteristics of Patients Receiving Complex Case Management in an Acute Care Hospital.

Characteristics of Patients Receiving Complex Case Management in an Acute Care Hospital.

A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient

BackgroundHepatitis B virus (HBV) infection can cause liver failure, while individuals with Acquired Immunodeficiency Virus Disease (AIDS) are highly susceptible to various opportunistic infections, which can occur concurrently. The treatment process is further complicated by the potential occurrence of immune reconstitution inflammatory syndrome (IRIS), which presents significant challenges and contributes to elevated mortality rates.Case presentationThe 50-year-old male with a history of chronic hepatitis B and untreated human immunodeficiency virus (HIV) infection presented to the hospital with a mild cough and expectoration, revealing multi-drug resistant pulmonary tuberculosis (MDR-PTB), which was confirmed by XpertMTB/RIF PCR testing and tuberculosis culture of bronchoalveolar lavage fluid (BALF). The patient was treated with a regimen consisting of linezolid, moxifloxacin, cycloserine, pyrazinamide, and ethambutol for tuberculosis, as well as a combination of bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) for HBV and HIV viral suppression. After three months of treatment, the patient discontinued all medications, leading to hepatitis B virus reactivation and subsequent liver failure. During the subsequent treatment for AIDS, HBV, and drug-resistant tuberculosis, the patient developed disseminated cryptococcal disease. The patient’s condition worsened during treatment with liposomal amphotericin B and fluconazole, which was ultimately attributed to IRIS. Fortunately, the patient achieved successful recovery after appropriate management.ConclusionEnhancing medical compliance is crucial for AIDS patients, particularly those co-infected with HBV, to prevent HBV reactivation and subsequent liver failure. Furthermore, conducting a comprehensive assessment of potential infections in patients before resuming antiviral therapy is essential to prevent the occurrence of IRIS. Early intervention plays a pivotal role in improving survival rates.