Difficult Clinical Situations Research Articles

Iatrogenic migration of iliac stent graft that was implanted for the reason of iliac artery perforation at the beginning of TAVI into the ascending aorta during the procedure

Abstract Introduction Vascular complications are one of the substantial complications of transcatheter aortic valve implantation (TAVI). Stent graft implantation is a powerful tool for managing them. Case presentation This article describes a case of iliac artery perforation by 10 Fr sheath in an 86-year-old female at the beginning of the TAVI procedure that was solved by stent graft implantation. However, the stent graft was later unintentionally dislocated into the ascending aorta during repeated attempts of sheath and guiding wire introduction. Finally, the migrated stent graft was successfully extracted using a loop snare device. Conclusions This article highlights the fact that armamentarium passage through an implanted stent graft, especially when newly deployed, can be tricky and should be done gently and carefully, optimally under fluoroscopic guidance. The permanent multidisciplinary team realizes TAVI can be advantageous for immediate management of difficult clinical situations.

Local FK506 delivery induces osteogenesis in rat bone defect and rabbit spine fusion models

Bone grafting procedures are commonly used for the repair, regeneration, and fusion of bones in a wide range of orthopaedic surgeries, including large bone defects and spine fusion procedures. Autografts are the clinical gold standard, though recombinant human bone morphogenetic proteins (rhBMPs) are often used, particularly in difficult clinical situations. However, treatment with rhBMPs can have off-target effects and increase surgical costs, adding to patients' already high economic and mental burden. Recent studies have identified that FDA-approved immunosuppressant drug, FK506 (Tacrolimus), can also activate the BMP pathway by binding to its inhibitors. This study tested the hypothesis that FK506, as a standalone treatment, could induce osteogenic differentiation of human mesenchymal stromal cells (hMSCs), as well as functional bone formation in a rat segmental bone defect model and rabbit spinal fusion model. FK506 enhanced osteogenic differentiation and mineralization of hMSCs in vitro. Standalone treatment with FK506 delivered on a collagen sponge produced consistent bone bridging of a critically sized rat femoral defect with functional mechanical properties comparable to naïve bone. In a rabbit single level posterolateral spine fusion model, treatment with FK506 delivered on a collagen sponge successfully fused the L5-L6 vertebrae at rates comparable to rhBMP-2 treatment. These data demonstrate the ability of FK506 to induce bone formation in human cells and two challenging in vivo models, and indicate FK506 can be utilized to treat a variety of spine disorders.

Possibilities of using the accelerated rehabilitation program (ERAS) for gastric cancer in elderly patients

The aim of this work is to evaluate the possibility of implementing the concept of enhanced recovery after surgery (ERAS) in perioperative treatment of an 80-year-old female patient with gastric stump carcinoma.Analysis of the clinical case and available literature data was performed. The concept of ERAS demonstrates its effectiveness not only in standard oncosurgical practice, but also can be successfully extended to difficult clinical situations including in elderly patients. However, personalized approach to development of a specific ERAS protocol is necessary taking into account surgery volume, concomitant pathology and individual patient characteristics.The use of individually selected points of the ERAS protocol taking into account oncological diagnosis, comorbidity, the type and technical features of the upcoming operation make the surgical stage of treatment not only safe, devoid of postoperative complications, but also more comfortable for the patient, positively affecting their quality of life. Оur experience can be successfully applied in real clinical practice.

Management of the peri-intubation period in patients with pulmonary arterial hypertension and respiratory failure.

The endotracheal intubation of patients with pulmonary arterial hypertension (PAH) in respiratory distress is a highly morbid procedure that can precipitate hemodynamic collapse. Here we review our strategy for confronting this difficult clinical situation. There are no clinical trials that explore best practices in the management of patients with PAH and respiratory failure. Here we provide a practical approach to respiratory support, inopressor and pulmonary vasodilator selection, hemodynamic considerations, point-of-care ultrasound monitoring, and endotracheal intubation in patients with PAH in respiratory failure.

Медицинская реабилитация: исследование проблем этического и правового характера

Medical rehabilitation is currently in an active phase of its development. This relevant area of domestic medicine is essential for human health. It helps patients recover from long-term illnesses, effects of injuries and diseases of the musculoskeletal system, peripheral nervous system and has a huge impact on the prognosis and outcome of treatment in general. This publication provides a comprehensive analysis of the ethical aspects of medical rehabilitation with an emphasis on legal definitions in medicine, which will improve understanding and regulation of relationship between rehabilitation, prevention and treatment. The research includes the study of domestic and international regulatory legal acts concerning medical rehabilitation, history of the specialty, the formulations that laid the foundation for the concept further development, consolidating an integrated approach to the issue of medical rehabilitation, as well as review of the problem-associated scientific papers. Explaining the principles of medical rehabilitation will help doctors avoid legal risks associated with their professional activity and serve as a guideline for taking ethically sound decisions in difficult clinical situations, whereas patients will get a full picture of their rights within the framework of medical rehabilitation.

Slovene Translation of the Difficulties in Suicidal Behaviors Intervention Questionnaire (DSBQ).

Background: Mental health professionals encounter numerous difficulties when working with suicidal clients. To understand these difficulties in clinical practice better, a valid instrument measuring them is needed. Aims: This study aimed to translate the Difficulties in Suicidal Behaviors Intervention Questionnaire (DSBQ) to Slovene, validate it, and explore Slovenian professionals' experiences with it. Method: The participants were 106 professionals (19 men, 87 women), aged 26-66 years. Apart from the DSBQ, scales on attitudes toward suicide prevention and coping strategies in difficult clinical situations were used. The data were collected between October 2017 and January 2019. Results: Although slightly diverging from the originally reported component structure, the Slovene translation of the DSBQ measures difficulties in working with suicidal clients with acceptable/good reliability and sensitivity, and adequate construct validity. Slovenian professionals most commonly experience difficulties related to working with children, followed by technical, system and setting, and other types of difficulties. Limitations: The sample of participants was relatively heterogeneous. Conclusion: Further studies of the DSBQ structure and validity, as well as difficulties, especially those related to working with children/adolescents and facing the theme of death, are warranted. Considering the difficulties most frequently reported in this investigation, more efforts are also needed in Slovenia to address technical and logistic aspects.

Copper-doped magnesium phosphate nanopowders for critical size calvarial bone defect intervention.

Calvarial defects of bone present difficult clinical situations, and their restoration using biocompatible materials requires special treatments that enable bone regeneration. Magnesium phosphate (MgP) is known as an osteoinductive biomaterial because it contains Mg2+ ions and P ions that enhance the activity of osteoplast cells and help in bone regeneration. In this study, MgP and CuO-doped MgP were fabricated and characterized for their physicomechanical properties, particle size, morphology, surface area, antibacterial test, and in vitro bioactivity evaluation using the following techniques: X-rays diffraction, Fourier-transformer infrared, TEM, and Brunauer, Emmett and Teller (BET) surface area, X-rays photoelectron spectroscopy (XPS), and Scanning electron microscopy (SEM). Furthermore, these nanopowders were implanted in adult inbred male Wistar rats and studied after two periods (28 and 56 days). The results demonstrated that the obtained semiamorphous powders are in nanoscale (≤ 50 nm). XPS analysis ensured the preparation of MgP as mono MgP and CuO were incorporated in the structure as Cu2+ . The bioactivity was supported by the observation of calcium phosphate layer on the nanopowders' surface. The in vivo study demonstrated success of MgP nanopowders especially those doped with CuO in restoration of calvarial defect bone. Therefore, fabricated biomaterials are of great potential in restoration of bone calvarial defects.

Novel beagle model of gastric local fibrotic target lesions for the evaluation and training of endoscopic techniques

BackgroundNovel endoscopic techniques used in the treatment of gastric lesions with local submucosal fibrosis need preclinical evaluation and training due to safety limitations. Therefore, the purpose of our study was to establish an animal model of gastric local fibrotic target lesions and assess its feasibility in the evaluation and training of endoscopic techniques.MethodsIn six experimental beagles, a 50% glucose solution was injected into three submucosal areas of the fundus, body, and antrum of the stomach to create gastric local fibrotic target lesions (experimental group). On post-injection day (PID) 7, the injection sites were assessed endoscopically to confirm the presence of submucosal fibrosis formation, and the dental floss clip traction assisted endoscopic submucosal dissection (DFC-ESD) procedure was performed on the gastric local fibrotic target lesions to confirm its feasibility after endoscopic observation. The normal gastric mucosa of six control beagles underwent the same procedure (control group). All the resected specimens were evaluated by histological examination.ResultsAll 12 beagles survived without postoperative adverse events. On PID 7, 16 ulcer changes were observed at the injection sites (16/18) under the endoscope, and endoscopic ultrasonography confirmed the local submucosal fibrosis formation in all ulcer lesions. The subsequent DFC-ESD was successfully performed on the 32 gastric target lesions, and the mean submucosal dissection time in the ulcer lesions was greater than that in the normal gastric mucosa (15.3 ± 5.6 vs. 6.8 ± 0.8 min; P < 0.001). There was no difference in rates of en bloc resection, severe hemorrhage, or perforation between the two groups. Histological analysis of the ulcer lesions showed the absence of epithelial or muscularis mucosae and extensive submucosal fibrous tissue proliferations compared with normal gastric mucosa. Overall, endoscopists had high satisfaction with the realism and feasibility of the animal model.ConclusionWe developed a novel animal model of gastric local fibrotic target lesions to simulate difficult clinical situations, which strongly appeared to be suitable for the preclinical evaluation and learning of advanced endoscopic techniques.

Psychopathology of the Situation in Gestalt Therapy: A Field-Oriented Approach (2023) Edited by Margherita Spagnuolo Lobb and Pietro Andrea Cavaleri. Routledge. ISBN: 9781032322025

Reviewed by the founder and former co-director of Gestalt Therapy Brisbane, Psychopathology of the Situation in Gestalt Therapy: A Field-Oriented Approach (2023) addresses the suffering experienced by people in a post-pandemic world. Representing the work of the Italian Gestalt Institute, this book is applicable to all psychotherapists. It is written in two parts. The first part advances an exciting, relational gestalt therapy theory that can inform modern practice. The second part offers in 11 chapters case studies and theoretical discussions to working with clients in difficult clinical situations. Moving beyond the intra-psychic to a holistic, embodied perspective, this collection of works by experienced practitioners and researchers blends practical applications with theories encompassing neuroscience, identity, diversity, reciprocity, aesthetics, anthropology, phenomenology, and sociology.

Wet adhesive hydrogels to correct malacic trachea (tracheomalacia) A proof of concept

Tracheomalacia (TM) is a condition characterized by a weak tracheal cartilage and/or muscle, resulting in excessive collapse of the airway in the newborns. Current treatments including tracheal reconstruction, tracheoplasty, endo- and extra-luminal stents have limitations. To address these limitations, this work proposes a new strategy by wrapping an adhesive hydrogel patch around a malacic trachea. Through a numerical model, first it was demonstrated that a hydrogel patch with sufficient mechanical and adhesion strength can preserve the trachea's physiological shape. Accordingly, a new hydrogel providing robust adhesionon wet tracheal surfaces was synthesized employing the hydroxyethyl acrylamide (HEAam) and polyethylene glycol methacrylate (PEGDMA) as main polymer network and crosslinker, respectively. Exvivo experiments revealed that the adhesive hydrogel patches can restrain the collapsing of malacic trachea under negative pressure. This study may open the possibility of using an adhesive hydrogel as a new approach in the difficult clinical situation of tracheomalacia.

Keeping It Legal: Empowering Physicians and Trainees Through the Creation of State-specific Legal Primers.

State policies on obstetrics and gynecology issues vary widely across the nation and dramatically affect the care physicians can offer depending on where they practice. A 2020 study demonstrates that many obstetrics and gynecology residents surveyed across the United States felt that their exposure to medical-legal topics was limited. The purpose of this initiative was to create legal primers on state-specific laws regarding obstetric and gynecologic care and evaluate their educational utility for residents and attendings across specialties. Ten primers with relevant Virginia state laws and their clinical relevance were created on the following topics: adolescent rights, emergency contraception, expedited partner therapy, mandatory reporting situations, close-in-age exemptions, medical students performing pelvic examinations, abortion, transgender rights, and paternity rights. The primers were presented to residents and attendings in obstetrics and gynecology, family medicine, and emergency medicine. Knowledge pretests and posttests were administered, with an opinion survey on comfort level of topics to assess usefulness of the primers. A total of 49 participants from obstetrics and gynecology and emergency medicine participated in the project. Participants from family medicine were presented the primers before data collection. The mean change in pretest-posttest scores was 3.6 of 10 (SD 1.8, P <.001). A total of 97.9% of participants found the primers very helpful or somewhat helpful. Participants reported an increased comfort level on all 10 topics after participating. Anecdotally, many residents and attendings referenced the primers afterward in clinical situations to guide their practice. State-specific legal primers are useful learning tools for understanding the nuances of laws regarding obstetric and gynecologic care. These primers can be used as quick resources for providers in difficult clinical situations. They can also be modified to reflect other state laws to reach a wider audience.

Evolution and interdisciplinary interaction of early childhood cardiac surgery in the Republic of Tatarstan

Surgical treatment of congenital heart defects is one of the most difficult tasks. The article shows the way of development of this direction in Kazan and in the Republic of Tatarstan. The benefits of using the ways and methods adopted in cardiac surgery for the treatment of patients in difficult clinical situations are described. The positive influence of the scientific study of medical activity on the development of the general situation is reflected.

Krevjande situasjonar i psykisk helsevern for born og unge – behandlarar si erfaring med og haldning til målretta trening og virtuell røyndom

Objective: Explore experiences of and attitudes towards deliberate practice and virtual reality (VR) among therapists in child and adolescent psychiatry, and what clinical situations are perceived as particularly relevant for practice. Methods: 59 therapists completed an anonymous online survey. Results: Participants had limited experience with deliberate practice and VR, but were generally very positive to trying this framework to develop therapeutic skills. Situations where caregivers were angry were perceived as the most challenging, while situations where clients were quiet and passive were the most frequent. The perceived challenge of different situations varied widely among participants. Implications: The results are used to reflect upon development of therapeutic skills among licensed therapists in general, and within mental health care in particular. Keywords: therapist development, deliberate practice, VR, difficult clinical situations, child and adolescent mental health care

Nove preporuke Američkog udruženja anesteziologa (2022) za zbrinjavanje otežanog disajnog puta

Difficulty establishing an airway and lung ventilation is one of the most urgent conditions in medicine, which can lead to severe complications, including permanent neurological damage and death. To facilitate handling this difficult clinical situation, various guides and recommendations were created to increase patient safety, help doctors, and protect them from criminal liability. The American Society of Anesthesiologists (ASA) issued new recommendations in 2022, which cover all segments of this problem, starting with the clear definition of different clinical situations (difficult laryngoscopy, difficult tracheal intubation, difficult face mask ventilation, difficult placement supra, and infraglottic means), through recommendations for the preparation of care for difficult airway, to algorithms and strategies for solving anticipated and unanticipated difficult airway. The paper presents the most important aspects of the mentioned segments of the new ASA recommendations, as well as their comparison with previous ASA recommendations and recommendations of other associations.

Issues of improving the management of patients with ischemic stroke on the background of atrial fibrillation

The article discusses the clinical features of cardioembolic stroke (CES). Approaches to the examination of a patient with clinical suspicion of CES are discussed within the framework of the concept of atrial cardiopathy and its main markers. The principles for choosing the timing of oral anticoagulant administration for the purpose of secondary prevention are presented. The article discusses the special aspects of direct oral anticoagulants prescription in difficult clinical situations, in particular, in elderly and senile patients, after reperfusion therapy, with the development of hemorrhagic transformation, in the presence of combined atherosclerosis, cerebral microangiopathy, anamnesis of intracerebral hemorrhage, as well as severe cognitive impairment. Approaches to the choice of oral anticoagulant in terms of purely clinical benefit are presented.

Role of ribociclib in treatment of luminal Her-2-negative mBC with CNS metastases

For patients with the metastatic subtype of luminal HER-2-negative (HR+/HER2-) breast cancer (mBC) in the absence of visceral crisis, the gold standard of treatment is a combination of CDK4/6 inhibitors and aromatase inhibitors, regardless of their menopausal status and the sites of metastasis. The effectiveness of this approach was confirmed in the MONARCH, PALOMA, MONALEESA study cycles for the drugs abemaciclib, palbociclib and ribociclib, respectively. Metastasis in the central nervous system (CNS) in breast cancer complicates the treatment of patients and leads to the search for new approaches to the choice of therapy. To date, neurosurgical and radiosurgical techniques are actively used, however, drug therapy still stands for the leading positions. Data on the use of CDK4/6 inhibitors or aromatase inhibitors in patients with CNS metastases are limited. Most studies did not include patients with CNS metastases, only PALOMA-2,3 and MONALEESA-3 studies allowed the inclusion of patients with either “inactive” CNS metastases or after exposure to local treatment methods (for example, radiosurgery, radiotherapy, or surgery). In the study of real clinical practice of combined endocrine therapy with ribociclib (CompLEEment-1) allowed the inclusion of patients with active brain metastases (n = 51), while the subgroup analysis demonstrated the benefits of using a combination of ribociclib and aromatase inhibitors in patients in this difficult clinical situation. In the article, the authors review the available data from randomized clinical trials and real clinical practice, and also illustrate with their own observation.

Caring for Caregivers Experiencing Secondary Trauma: A Call to Action.

Secondary traumatic stress (STS) is the emotional duress caused by indirect exposure to distressing events experienced by others. Health care providers are particularly susceptible to secondary stress due to regular exposure to difficult and painful clinical situations that evoke intrinsic empathy necessary to provide effective care. Understanding STS as a normal stress response not only helps to make sense of the symptoms but also suggests a way forward. Opportunities for those in health care to address STS can be found among our colleagues and in our own settings and may provide a meaningful source of support if accessed effectively.

Clinical and laboratory assessment of the effect of hygiene products on the condition of periodontal tissues and hard tooth tissues in the treatment of caries by indirect method

Relevance. According to statistics, the widespread use in modern dental practice of indirect restoration methods in the treatment of caries of the frontal group of teeth leads to an increase in the incidence of marginal periodontal disease. According to modern data, the most important etiological factor in the development of complications from the hard tissues of the tooth and periodontal is the microflora of plaque.The main link in carrying out preventive measures and the guarantee of the quality of the rehabilitation period is an adequate choice of personal oral hygiene products. It is for this reason that, when choosing a preventive program and personal hygiene products, especially in patients with extensive restorations (including indirect ones), more and more attention is currently being paid to toothpastes based on medicinal herbs, aluminum lactate, which have an anti-inflammatory, astringent effect, reducing bleeding gums and hyperesthesia of hard tooth tissues.Aim. Comparison of the clinical effectiveness of the standard prevention program and the prevention program using individual oral hygiene products based on aluminum lactate in the treatment of caries by the indirect method, as well as improving the effectiveness of indirect methods of caries treatment by preventing its recurrence and inflammatory complications from periodontal tissues by developing practical recommendations.Materials and methods. The work was carried out in the design of an open comparative three-stage prospective nonrandomized study. The necessary material was collected using clinical, laboratory and statistical methods. The material for the study was 98 patients with indirect restorations of the frontal group of teeth, of which 46 people had restoration from metal-free ceramics E-max and 52 people from pre-polymerized composite and divided into groups according to the hygienic means used and the type of restoration. A micronuclear test in the gingival epithelium with the establishment of the frequency of occurrence and spectrum of nuclear aberrations in the cells of the gingival epithelium was carried out in vitro. Statistical data processing was carried out using standard packages Statistika 8.1 and SPSS-11.Results. Based on the results of 2236 clinical and 550 laboratory studies stating the condition of the hard tissues of the tooth, the tooth-restoration boundary, the tissues of the marginal periodontal and the evaluation of the effectiveness of the hygiene product used, the results of statistical processing and the use of high technologies to solve the tasks, it can be said that traditional means of individual oral hygiene have sufficient effectiveness when used in preventive program of recurrence of carious process and periodontal diseases, but significantly higher with a statistically significant difference in effectiveness, especially in terms of anti-inflammatory action, are products containing aluminum lactate, which has a direct and direct impact on the quality of restoration and dental rehabilitation of the patient even 24 months after treatment.Conclusions. Personal oral hygiene products containing aluminum lactate, which has pronounced astringent and antiinflammatory properties. These remedies should be the subject of choice in the most difficult clinical situations, such as diagnosed periodontal diseases with the preservation of complaints (pain, bleeding gums, unpleasant odor, etc.), low level of oral hygiene, rehabilitation period after periodontal treatment, prevention of periodontal diseases in patients with extensive restorations. The use of personal oral hygiene products containing aluminum lactate will significantly improve the effectiveness of treatment and prevention of caries including indirect methods, reduce the risk of repeated invasions and ensure full-fledged dental rehabilitation of the patient directly affecting his quality of life.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients

BackgroundTibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. MethodsA retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. ResultsOf the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). ConclusionData from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Building resilience in oncology teams: Protocol for a realist evaluation of multiple cases.

BackgroundTeams caring for people living with cancer face many difficult clinical situations that are compounded by the pandemic and can have serious consequences on professional and personal life. This study aims to better understand how a multi-component intervention builds resilience in oncology teams. The intervention is based on a salutogenic approach, theories and empirical research on team resilience at work. This intervention research involves partnership between researchers and stakeholders in defining situations of adversity and solutions appropriate to context.MethodsThe principles of realist evaluation are used to develop context-mechanism-outcome configurations of a multi-component intervention developed by researchers and field partners concerned with the resilience of oncology teams. The multiple case study involves oncology teams in natural contexts in four healthcare establishments in Québec (Canada). Qualitative and quantitative methods are employed. Qualitative data from individual interviews, group interviews and observation are analyzed using thematic content analysis. Quantitative data are collected through validated questionnaires measuring team resilience at work and its effect on teaming processes and cost-effectiveness. Integration of these data enables the elucidation of associations between intervention, context, mechanism and outcome.DiscussionThe study will provide original data on contextual factors and mechanisms that promote team resilience in oncology settings. It suggests courses of action to better manage difficult situations that arise in a specialized care sector, minimize their negative effects and learn from them, during and after the waves of the pandemic. The mechanisms for problem resolution and arriving at realistic solutions to professional workforce and team effectiveness challenges can help improve practices in other settings.