Multidisciplinary Research Articles

Overcoming challenges into miraculous motherhood: successful pregnancy outcomes in patients with SLE: A case series

Systemic lupus erythematosus is a multisystem autoimmune disorder associated with multiple positive antibodies. Reproductive age group women have been found to develop SLE more commonly so than males, and pregnancy is associated with an increased rate of flare ups. The rate of pregnancy loss has decreased from 43% to 17% in recent years due to optimization of treatment and management during pre-pregnancy period. Recent studies have reported that both maternal and foetal outcome are favourable if SLE has been quiescent for at least 6 months prior to pregnancy. The effects of SLE over pregnancy and impact of pregnancy over SLE patients can be managed by optimization of pre-pregnancy treatment and management in antenatal period and follow-up. A multi-disciplinary team approach by an obstetrician, medical specialist and paediatrician for a successful management. Management of SLE to be continued in post-partum period and risk of flares and thrombotic events can be avoided by optimization of treatment in post-partum period till 6 weeks after delivery. Comprehensive maternal and new-born care has improved survival and quality of life outcomes in pregnant patients with SLE. Here, we present a series of three cases of SLE in pregnancy that had successful obstetric outcomes with an interdisciplinary management plan.

Mainstreaming cancer genetics: feasibility of an advanced nurse practitioner-led service diagnosing Lynch syndrome from colorectal cancer in Ireland.

Colorectal cancer (CRC) is a common cancer in Ireland. Of all CRCs, 2-4% are attributable to Lynch Syndrome (LS), the most common CRC predisposition syndrome. LS is caused by constitutional pathogenic variants (PVs) affecting mismatch repair (MMR) genes with resultant MMR protein deficiency (dMMR). Screening of all CRCs with MMR immunohistochemistry (IHC) testing is advocated to increase the detection of LS. However, successful implementation requires appropriate downstream management. In Ireland the traditional pathway involves referral to cancer genetics services to assess eligibility for genetic testing. Cancer genetics services in Ireland face many challenges in providing uniform access to timely healthcare with current wait times for assessment in excess of 1 year. An increasingly adopted pathway is that of mainstreaming, whereby genetic testing is managed locally by a multidisciplinary team member. Our institution therefore implemented an Advanced Nurse Practitioner (ANP)-led service with responsibility for the LS Diagnostic Pathway and mainstream genetic testing. Data was extracted from a prospectively maintained database of all newly diagnosed CRC patients discussed at our institutions CRC multidisciplinary meeting (MDM) between January 1st, 2023, and May 31st, 2024. MMR IHC testing was performed in 97.9% of the 385 patients diagnosed with CRC. The median time from histological confirmation of CRC to the availability of the MMR IHC report was 6 days. All 51 patients (100%) who required sequential tumor testing underwent BRAF V600 ± MLH1 promoter methylation testing. Additionally, 100% of the 14 patients eligible for mainstream genetic testing were referred to the ANP-led genetics service. The median time from the initial MDM discussion to the initiation of genetic testing was 69 days, while the median time from testing to the availability of results was 19 days. Patients received their results within a median of 21 days. MMR IHC testing increases the detection of LS through identification of dMMR tumours. Successful downstream delivery of clinical services, however, requires appropriate subsequent management, in a resource-limited environment. Our institutional experience demonstrates the feasibility, efficiency, and effectiveness of an ANP-led mainstreaming model of care for hereditary colorectal cancer.

Mapping Implementation Strategies to Address Barriers to Pre-Exposure Prophylaxis Use Among Women Through POWER Up (Pre-Exposure Prophylaxis Optimization Among Women to Enhance Retention and Uptake): Content Analysis.

Black cisgender women (hereafter referred to as "women") experience one of the highest incidences of HIV among all populations in the United States. Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option, but uptake among women is low. Despite tailored strategies for certain populations, including men who have sex with men and transgender women, Black women are frequently overlooked in HIV prevention efforts. Strategies to increase PrEP awareness and use among Black women are needed at multiple levels (ie, community, system or clinic, provider, and individual or patient). This study aimed to identify barriers and facilitators to PrEP uptake and persistence among Black cisgender women and to map implementation strategies to identified barriers using the CFIR (Consolidated Framework for Implementation Research)-ERIC (Expert Recommendations for Implementing Change) Implementation Strategy Matching Tool. We conducted a secondary analysis of previous qualitative studies completed by a multidisciplinary team of HIV physicians, implementation scientists, and epidemiologists. Studies involved focus groups and interviews with medical providers and women at a federally qualified health center in Chicago, Illinois. Implementation science frameworks such as the CFIR were used to investigate determinants of PrEP use among Black women. In this secondary analysis, data from 45 total transcripts were analyzed. We identified barriers and facilitators to PrEP uptake and persistence among cisgender women across each CFIR domain. The CFIR-ERIC Implementation Strategy Matching Tool was used to map appropriate implementation strategies to address barriers and increase PrEP uptake among Black women. Barriers to PrEP uptake were identified across the CFIR domains. Barriers included being unaware that PrEP was available (characteristics of individuals), worrying about side effects and impacts on fertility and pregnancy (intervention characteristics), and being unsure about how to pay for PrEP (outer setting). Providers identified lack of training (characteristics of individuals), need for additional clinical support for PrEP protocols (inner setting), and need for practicing discussions about PrEP with women (intervention characteristics). ERIC mapping resulted in 5 distinct implementation strategies to address barriers and improve PrEP uptake: patient education, provider training, PrEP navigation, clinical champions, and electronic medical record optimization. Evidence-based implementation strategies that address individual, provider, and clinic factors are needed to engage women in the PrEP care continuum. Tailoring implementation strategies to address identified barriers increases the probability of successfully improving PrEP uptake. Our results provide an overview of a comprehensive, multilevel implementation strategy (ie, "POWER Up") to improve PrEP uptake among women. RR2-10.1371/journal.pone.0285858.

Mid-transversal hepatectomy: breaking new ground in parenchymal sparing hepatectomies.

We, herein, describe a case of complex parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases (CRLMs). A 61-year-old woman, previously operated for an occlusive adenocarcinoma of the transverse colon and undergoing adjuvant chemotherapy, developed metachronous bilobar CRLMs. After administration of a II line chemotherapy with partial response, she was referred to our hospital. The pre- and post-treatment imaging recognized seven liver lesions, with a bilobar distribution involving segments 3, 4, 5, 8, and 7. After multidisciplinary team evaluation, the surgical strategy was planned by means of three-dimensional reconstruction and simulation software. The planned and executed procedure consisted of a unique transection plane comprising partial resection of segments 3-4-5-8-7, thus removing the central transversal portion of the liver. Accurate preoperative planning and intraoperative ultrasound for resection guidance allowed us to achieve a complex parenchymal sparing procedure in an advanced disease that would be usually candidate for major resection and staged hepatectomy.

Penetrating intraorbital wooden foreign bodies involving the right frontal lobe of the brain: A rare case report

Background: Penetrating orbital trauma from a wooden foreign object is rare and challenging to identify, as it cannot be detected with a computed tomography (CT) scan. This report highlights the clinical presentation, diagnosis, and management of such a case. Case Description: A 19-year-old female experienced penetrating orbital trauma from a wooden object following a traffic accident. She intermittently visited the hospital with eye swelling and headache, without visible penetrating wounds on the palpebra. The swelling persisted for weeks, accompanied by increasing signs of ocular and cerebral infection. The suspicion of a non-metallic foreign body penetrating the brain was confirmed 3 months after the initial visit, delayed by the hidden entry wound between the eyelid and eyeball and orbital edema mimicking non-penetrating trauma. A multidisciplinary team managed the case. Procedures included debridement, retro-orbital exploration, retro-orbital abscess evacuation, and frontal basal trephination exploration, successfully removing the wooden object that had penetrated the medial orbit, frontal bone, and brain, along with cerebral abscess evacuation. Postoperative CT scans showed complete removal of the foreign object and successful abscess evacuation. The patient showed improvement in ocular symptoms, resolution of headaches, and no wound leakage. She was discharged on the 14th day after completing antibiotic treatment and having the dressing removed. Conclusion: This case is notable for its rarity, high risk of misdiagnosis, and potentially fatal consequences if not promptly managed. We emphasize the importance of patient involvement in routine consultations, careful anamnesis, clinical examination, and a multidisciplinary approach for optimal outcomes.

Rehabilitation Management of a Pediatric Patient with Modified Van Nes Prosthesis after Type B-IIIA Hip Rotationplasty: A Case Report

Van Nes rotationplasty has gained popularity as a surgical treatment for malignant bone tumors without resorting to amputation. However, the nature of the surgery poses unique challenges in the rehabilitation management in order to optimize safety and functional mobility. We describe a case of a 6-year-old female with Ewing’s sarcoma of the right femur who underwent Van Nes Type BIIIA rotationplasty. This procedure involved a complete femoral resection, with the tibia and the foot rotated by 180 degrees and the lateral tibial plateau placed into the acetabulum that is expected to remodel to form a neo-hip joint. The patient was referred to rehabilitation medicine and was eventually admitted due to impairment in mobility secondary to the surgery. The goal was to achieve K-1 level of function. This case demonstrates that the rehabilitation management of a child with Type B-IIIA rotationplasty using a modified Van Nes prosthesis requires a comprehensive multidisciplinary approach.

Editorial: Value of a multidisciplinary approach for modern diagnosis of infectious diseases

Editorial: Value of a multidisciplinary approach for modern diagnosis of infectious diseases

Aberrant intrinsic brain activities in functional gastrointestinal disorders revealed by seed-based d mapping with permutation of subject images

Functional gastrointestinal disorders (FGIDs) are characterized by complex interactions between the gut and brain, leading to altered brain function and symptom manifestation. We used neuroimaging meta-analytic techniques in order to analyze the correlation between FGIDs and aberrant brain activity. A systematic review was performed to ascertain resting-state functional magnetic resonance imaging (rs-fMRI) studies examining brain function in FGIDs. Pooled meta-analyses by seed-based d mapping with permutation of subject images (SDM-PSI) were performed to assess variations in regional brain activity, and sensitivity analyses were applied to evaluate the robustness of findings. Meta-regression analyses were then carried out to examine possible links between demographic factors and neuroimaging changes. Our meta-analysis revealed significant changes in regional brain activities among FGIDs patients compared to healthy controls (HC). Increased brain activation was observed in several regions including the postcentral gyrus, calcarine fissure/surrounding cortex, superior frontal gyrus, and insula, while decreased activity was noted in the left posterior cingulate gyrus, right median cingulate/paracingulate gyri, and the left caudate nucleus. Furthermore, meta-regression analyses indicated negative associations between disease duration and alterations in specific brain regions. These findings underscored the intricate interplay between gut dysfunction and aberrant brain activity in FGIDs. Early intervention and multidisciplinary approaches addressing both gastrointestinal symptoms and associated emotional distress are crucial for improving the quality of life of the patients.

Exploring application of neuromarketing in advertising effectiveness: a bibliometric and TCCM-based approach

PurposeThe study was devise to summarizees the underlying theories and concepts in the context of probing effective advertising through neuromarketing.Design/methodology/approachThe given review has applied a bibliometric analysis to conduct performance and science mapping. We adopted Theory, Context, Character and Methodology (TCCM) approach for conducting systematic literature review.FindingsThe study found that emotion theory was mostly implemented for the related research. The researchers used emotion induced stimuli for measuring responses preferably through electroencephalogram (EEG), galvanic skin response (GSR) and eye tracking (ET). Experimental studies provided more insightful results, despite conducting research on few participants.Research limitations/implicationsFuture researchers are advised to perform interdisciplinary research pertaining to the neuroscience and psychology.Originality/valueThe paper provides a thorough understanding of the theories, constructs and methodologies appropriate for conducting experimental neuromarketing research. The existing review papers lack to perform review on TCCM approach in the context of neuromarketing in advertising.

Sensitivity of the Northern Hemisphere Warming Trend to Snowpack Variability

Abstract A marked decrease in land surface snow cover within the Northern Hemisphere under global warming will warm the atmosphere near the land surface. However, minimal information exists regarding the contribution of snowpack variation to interannual surface air temperature variability. The current study investigates the effects caused by snow water equivalent (SWE) change on surface air temperature (SAT). To this end, an SWE pacemaker experiment of land–atmosphere coupling (AMIP-type) is undertaken for the period 1901–2010, during which the Model for Interdisciplinary Research on Climate, version 6 (MIROC6), atmospheric general circulation model’s SWE is continuously nudged toward SWE derived from an land-only (LMIP-type) experiment. Compared to a reference MIROC6 simulation without SWE nudging, the spatial correlation of 1980–2010 interannual SWE trends in our experiment with those in GlobSnow observation data increased by 0.31 over the Northern Hemisphere. Similarly, the linear correlation of interannual SAT with reanalysis data is greater by 0.04, 0.04, 0.08, and 0.07 for autumn, winter, spring, and summer over the region from the reference experiment, respectively. It is shown that due to this SWE nudging, the modeled interannual SAT change in the Northern Hemisphere becomes more accurate. Through a surface energy budget analysis, changes in SAT are attributed to changes in surface albedo, soil evaporation, and soil temperature. Areas of greater contribution of SWE variability to SAT variability appear to shift from south to north areas as snow melts. These results highlight surface albedo, snow hydrological, and land heat storage effects through which the SWE interannual trend on the land surface significantly controls atmospheric air temperature variability near the land surface. Significance Statement This study investigates the contribution of land snowpack to surface air temperature in the Northern Hemisphere using a climate model updated with observation-based estimates of snow water equivalent. A marked decrease in snowpack under global warming is expected to warm the atmosphere near the land surface. Variations in surface albedo, soil evaporation, and soil temperature through the snow–soil–atmosphere processes during the early snow-melting season are crucial for accurately simulating surface air temperature in the Northern Hemisphere. Moreover, terrestrial snowpack is a significant factor in global warming rates.

Depression, stress, and tryptophan metabolism through the kynurenine pathway: treatment strategies from the perspective of Chinese herbal medicine.

The pathogenesis of depression is complex, involving abnormalities in tryptophan (TRP) metabolism through the kynurenine pathway (KP). Moreover, depression is closely related to the hypothalamic-pituitary-adrenal (HPA) axis, the gut-brain axis, neuroinflammation, and stress. These factors collectively influence the multidimensional pathological mechanisms of depression. TRP, a fundamental amino acid, serves as a precursor for neuroactive metabolites vital to physiological functions. Central to TRP metabolism is the KP, and the imbalance between neurotoxic and neuroprotective metabolites is closely related to the onset and progression of depression. Therefore, maintaining the balance of KP metabolites is important. In this review, we have investigated the role of the KP in depression and explored the complexity of KP dysregulation and its therapeutic importance. Here, we highlight how a deeper understanding of the KP and its regulation can pave the way for new treatment strategies. Specifically, we have summarized the latest advances in elucidating the key mechanisms of rate-limiting enzyme inhibitors, providing insights into their potential therapeutic efficacy. In addition, we have explored the emerging field of Chinese herbal medicine, discussing its potential to regulate KP metabolites and alleviate depressive symptoms, thereby expanding the treatment options for depression. Our findings emphasize the multifaceted nature of depression and the necessity of interdisciplinary research to fully utilize KP regulation and Chinese herbal medicine as strategies to advance the treatment of depression.

Staring into a crystall ball: understanding evolution and development of in vivo aquatic organismal transparency

Organismal transparency is an ecologically important trait that can provide camouflage advantages to diverse organisms. Transparent organisms are quite common—especially in oceans. Organismal transparency requires low absorption and scattering of light in the body across multi-scale levels. However, it is still not fully understood how such organisms achieve these requirements. Understanding this process requires multiple approaches from various fields and methods. Here, we offer recent insights on this topic from the viewpoints of evolution, developmental biology, and evaluation methodologies of organismal transparency. We also propose “organismal transparency biology” as a new interdisciplinary field of study. Furthermore, we suggest that tunicates are an ideal model animal for studying in vivo organismal transparency.

Machine Learning Methods to Personalize Persuasive Strategies in mHealth Interventions That Promote Physical Activity: Scoping Review and Categorization Overview.

Although physical activity (PA) has positive effects on health and well-being, physical inactivity is a worldwide problem. Mobile health interventions have been shown to be effective in promoting PA. Personalizing persuasive strategies improves intervention success and can be conducted using machine learning (ML). For PA, several studies have addressed personalized persuasive strategies without ML, whereas others have included personalization using ML without focusing on persuasive strategies. An overview of studies discussing ML to personalize persuasive strategies in PA-promoting interventions and corresponding categorizations could be helpful for such interventions to be designed in the future but is still missing. First, we aimed to provide an overview of implemented ML techniques to personalize persuasive strategies in mobile health interventions promoting PA. Moreover, we aimed to present a categorization overview as a starting point for applying ML techniques in this field. A scoping review was conducted based on the framework by Arksey and O'Malley and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria. Scopus, Web of Science, and PubMed were searched for studies that included ML to personalize persuasive strategies in interventions promoting PA. Papers were screened using the ASReview software. From the included papers, categorized by the research project they belonged to, we extracted data regarding general study information, target group, PA intervention, implemented technology, and study details. On the basis of the analysis of these data, a categorization overview was given. In total, 40 papers belonging to 27 different projects were included. These papers could be categorized in 4 groups based on their dimension of personalization. Then, for each dimension, 1 or 2 persuasive strategy categories were found together with a type of ML. The overview resulted in a categorization consisting of 3 levels: dimension of personalization, persuasive strategy, and type of ML. When personalizing the timing of the messages, most projects implemented reinforcement learning to personalize the timing of reminders and supervised learning (SL) to personalize the timing of feedback, monitoring, and goal-setting messages. Regarding the content of the messages, most projects implemented SL to personalize PA suggestions and feedback or educational messages. For personalizing PA suggestions, SL can be implemented either alone or combined with a recommender system. Finally, reinforcement learning was mostly used to personalize the type of feedback messages. The overview of all implemented persuasive strategies and their corresponding ML methods is insightful for this interdisciplinary field. Moreover, it led to a categorization overview that provides insights into the design and development of personalized persuasive strategies to promote PA. In future papers, the categorization overview might be expanded with additional layers to specify ML methods or additional dimensions of personalization and persuasive strategies.

Earthquake Environmental Effects: The Case of Late Classical-Hellenistic Helike, Gulf of Corinth, Greece

Human habitat is much controlled by the landscape and its ongoing processes overtime. Some of these processes occur instantaneously and are often triggered by seismic events with a major destructive impact on the human-built environment. Helike, on the southwest shore of the Gulf of Corinth, is a characteristic case of an ancient habitation site bearing witness to repetitious natural disasters from the Early Bronze Age to the Late Antiquity. The Late Classical-Hellenistic site, revived in the Helike plain after the 373 BC earthquake, has been systematically investigated thanks to the multidisciplinary research and excavations of the Helike Project in the last 35 years. This work has significantly enriched the historical seismicity of the region and shed light on past human-environment relationships. The study of the architectural remains excavated by the Helike Project, coupled with geological and soil micromorphological analysis on archaeological soils and sediments of the settlement, demonstrates a constant effort of the Helike people to reconcile with the elements of nature. Our results underline the destruction of a flourishing textile dyeworks operated at the settlement, due to a strong earthquake which triggered extensive morphological changes in a broader area. These changes include co-seismic liquefaction and lateral spreading, and post-seismic changes in the gradient of river channels. The former changes attest to an uplift in the headwater area and subsidence in the lowland plain of the ravine flowing near the ancient site.

Enabling biocontained plant virus transmission studies through establishment of an axenic whitefly (Bemisia tabaci) colony on plant tissue culture.

Whiteflies (Bemisia tabaci) and the diseases they transmit are a major detriment to crop yields and a significant contributor to world hunger. The highly evolved interactions of host plant, phloem-feeding insect vector with endosymbionts and persistently transmitted virus represent a tremendous challenge for interdisciplinary study. Presented here is the establishment of a colony of axenic whiteflies on tissue-cultured plants. Efficient colony establishment was achieved by a surface sterilization of eggs laid on axenic phototrophically tissue-cultured plants. The transfer of emerging whiteflies through coupled tissue culture vessels to new axenic plants facilitates robust subculturing and produces hundreds of whitefly adults per month. Whitefly proliferation on more than two dozen plant species is shown as well as in vitro testing of whitefly preference for different plants. This novel multi-organism system provides the high-level of biocontainment required by Federal permitting to conduct virus transmission experiments. Axenic whitefly adults were able to acquire and transmit a begomovirus into tissue-cultured plants, indicating that culturable gut microorganisms are not required for virus transmission. The approach described enables a wide range of hypotheses regarding whitefly phytopathology without the expense, facilities, and contamination ambiguity associated with current approaches.

Initiating Prognostic Talk During Hospice Multidisciplinary Team Meetings: A Conversation Analytic Study.

Objective: Guidelines recommend that patients' prognoses should be discussed by the palliative care multidisciplinary team. However, there is a lack of evidence on how multidisciplinary teams carry out prognostic discussions, and especially how prognostic talk is initiated during team meetings. This study explored how prognostic talk is initiated and responded to during meetings of a hospice multidisciplinary team. Methods: Video-recordings of 24 inpatient multidisciplinary team meetings in a UK hospice were collected from May to December 2021. A total of 65 multidisciplinary team members participated in the meetings. Recordings were transcribed and analysed using Conversation Analysis. Results: Prognostic talk was initiated during multidisciplinary team members' patient case presentations. Case presentations followed a certain template, and prognoses could be initiated as responses to template items such as the patient's Phase of Illness and Karnofsky's Performance Status score and the patient's main diagnosis and issues. Prognoses also occurred as accounts for a lack of template item responses. Beyond the patient case presentation, prognostic talk was initiated in relation to discharge planning. Prognoses appeared with sequences of assessments that accounted for them. When a prognosis was provided, it received confirming minimal responses from other team members. Conclusions: Patients' prognoses were embedded into other care discussions during meetings of a hospice multidisciplinary team. These findings can be used to inform the development of clinical guidelines and interventions aiming at improving multidisciplinary team discussions around prognosis in the future.

Modern approach to bone comorbidity in prolactinoma.

Prolactinomas account for more than half of pituitary adenomas, and besides their clinical impact on fertility and gonadal function, they lead to detrimental effects on bone. Patients with prolactinoma are prone to deterioration of bone structure caused not only by prolactin (PRL) induced hypogonadism but also by its direct actions on bone cells and calcium metabolism. However, clinical studies have shown inconsistent evidence regarding whether PRL could have a deleterious effect independently from gonadal insufficiency on skeletal integrity. Seminal studies from our group reported an increased prevalence of vertebral fractures (VFs) in both female and male patients with prolactinoma. Treatment of prolactinoma with dopamine agonists can restore gonadal function and improve bone mineral density. Since the presence of VFs may be related to more aggressive disease, bone comorbidities in prolactinoma should be managed by a multidisciplinary team in line with the recent concept of 'pituitary tumors centers of excellence'. The review aims to evaluate the mechanism of PRL actions on bone, as well as to provide practical indications for a modern approach to the management of skeletal complications of patients with prolactin-secreting adenoma considering different clinical characteristics and outcomes.

FORESTIER DISEASE

Introduction We present the case of M.E., a 73 year old patient, who presented to his local medical services for progressive dysphagia. Follow-up cervical CT scan revealed ossification of the anterior longitudinal ligament, at C3 - C4, C4 - C5 and C5 - C6 levels, consistent with diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier disease. Material and Methods The patient was operated on by a multidisciplinary team (Neurosurgery and O.M.F. surgery). After a left sided vertical cervical incision and dissection of tissue, the spinal cervical levels were identified radiologically, followed by reduction of bony elevations at C3 - C4, C4 - C5 and C5 - C6 using a regular drill tip. Postoperatively the patient’s dysphagia was completely alleviated. Conclusion Although Forestier disease is usually identified incidentally, patients may present with decreased neck mobility, cervical pain and dysphagia. While the disease is similar to ankylosing spondylitis, it does not have a genetic component and it mainly affects the cervical and thoracic spines. Surgery may be necessary if dysphagia progresses.

GIANT LUMBO-SACRAL TUMORS

Objectives Despite comprising just 8% of all spinal tumors, sacral tumors present a long list of issues that should be taken in consideration when neurosurgical approach is tempted. Their unique anatomic location, close relation with neural structures and pelvic organs and high-vascularity are just a few nuances of these type of conditions. This paper outline the importance of a good preoperative and intraoperative management in order to facilitate the maximum recovery of the patients. Material and Methods This paper analyses retrospectively a series of 2 cases of giant sacral tumors (>100 cm3) that were operated in our clinic in 2024 by a multidisciplinary team (neurosurgeons and general surgeons). Follow-up data were obtained from the charts and medical records. All the lesions were localised under L4 vertebra with invasion of sacrum. Results Our first case was a 47-years old man who accused diffuse mild lumbar pain for more than 2 years, but acutely aggravated in the last months with lumbosacral radicular pain, palsy of the inferior lumbar nerves, urinary incontinence and paraesthesia. MRI showed a giant L5-S2 mass and biopsy diagnostic was myxopapillary ependymoma. Second case was of a young woman with lumbosacral radicular pain debuted a few months ago, whose clinical state worsened rapidly becoming paralytic of lower limbs. MRI showed a giant sacral mass with invasion of the pelvic musculature and surrounding the iliac vessels (intraoperative aspect: sarcoma). Both patients ameliorated postoperatively, and are currently enrolled in a recovery program. Sub-total resection and near-total resection were obtained. Conclusions Sacral tumors exhibit a challenge in the field of spine surgery being clinical silence over a period of months and years, and then followed by gross deficit. We diagnosed sacral tumors based on clinical, radiographic and laboratory aspects. Prognostic factors were preoperative clinical status and gross-total resection.

A strategic approach of the management of sleep-disordered breathing in multiple system atrophy.

Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction associated with a combination of cerebellar, parkinsonian, or pyramidal signs. Sleep-disordered breathing (SDB) such as stridor, obstructive sleep apnea (OSA) and central sleep apnea (CSA) are common in MSA and can impact survival. Several studies have evaluated treatment modalities. However, the optimal strategy often remains unclear in these patients. This review aims to provide an overview of the current evidence on treatment of SDB in MSA. Systematic review of the current literature through combined keyword search in PubMed, Embase, the Cochrane Library and cited references: multiple system atrophy, stridor, sleep apnea syndrome, sleep-disordered breathing, Shy Drager syndrome. Twenty-nine papers were included, with a total of 681 MSA patients with SDB. Treatment modalities are: continuous positive airway pressure (CPAP); tracheostomy; tracheostomy invasive ventilation (TIV); non-invasive positive pressure ventilation (NPPV); adaptive servoventilation (ASV); vocal cord surgery; botulinum toxin injections; oral appliance therapy; cervical spinal cord stimulation; selective serotonin reuptake inhibitors (SSRIs). Conflicting results on survival are found for CPAP therapy. Tracheostomy has a proven survival benefit. Most beneficial outcomes are seen with TIV. CPAP, other types of PAP and tracheostomy can adequately control symptoms of OSA. However, CPAP may exacerbate central sleep apnea. There was a lack of sufficient data regarding ASV or NPPV. Some patients exhibit a floppy epiglottis and require a different approach. In conclusion, due to the complex characteristics of SDB in MSA, an individualized and multidisciplinary approach is mandatory.