Management Of Complex Patients Research Articles

Combined Pediatric Rheumatology/Dermatology Clinics: Benefits and Challenges.

Integrated care models, like combined rheumatology/dermatology clinics (RDCs), facilitate efficient coordination between specialists and provide comprehensive care. Given the limited literature on pediatric RDC logistics, outcomes, benefits and, challenges, we comprehensively characterized our patient cohort at the UCSF Benioff Children's Hospital RDC and surveyed pediatric dermatologists participating in RDCs. We retrospectively reviewed 71 patients new to the UCSF Pediatric RDC between September 2017 and September 2023. A survey was distributed in 2024 to 17 dermatologists in North America, each representing a unique pediatric RDC. 69% of patients (49/71) were female. Seventeen (24%) presented without a known diagnosis; the first RDC visit established a diagnosis for 7 of them (41%). Of patients with a previously established diagnosis, initial RDC evaluation confirmed it in 52 (96%) and revised it for 2 (4%). The most encountered diagnoses were linear morphea (33%), lupus (23%), and psoriasis (13%). New systemic therapy was prescribed for 23% of patients, and additional work-up was recommended via skin biopsy (8%) and imaging (28%). Survey results revealed all pediatric RDCs include trainees, but only 59% (10/17) receive administrative support. All agreed that RDCs are valuable for patient care and most (15/17, 88%) felt that the RDC was a valuable use of their time. Pediatric RDCs are valuable for consensus diagnosis, streamlined evaluation, and management of complex patients. Though clinical and administrative support for RDCs is generally poor, RDCs are valuable to patients, a good use of time for clinicians, and offer educational opportunities for team members.

Psoriasis management tree based on comorbidity.

Psoriasis, a common chronic inflammatory skin disorder, encompasses various subtypes, including guttate, pustular, erythrodermic, and the most common type, plaque psoriasis. Irrespective of the subtype, psoriasis can manifest with multisystemic presentations, including psoriatic arthritis, metabolic disorders, cardiovascular disease, malignancies, chronic kidney disease (CKD), psychiatric illness, and inflammatory bowel disease (IBD). Many comorbidities and concomitant conditions must be considered when selecting the most appropriate therapy for a patient (Kaushik etal., 2019 and Monks etal., 2021) . Ongoing clinical trials and the development of new therapeutic targets contribute to the continuous improvement of available treatment options. Given the dynamic landscape of therapies, particularly when managing complex patients with multiple comorbidities, dermatologists are constantly challenged with the task of adeptly tailoring treatments to each psoriasis patient. This article systematically reviews the current evidence, presenting it as an updated Psoriasis Decision Tree to assist physicians in selecting tailored treatment options.

Development of Interprofessional Competencies Through the Process of Collaborative Clinical Reasoning: A Qualitative Study.

Effective interprofessional (IP) collaboration is essential for managing complex patient cases. Collaborative clinical reasoning (CCR) is an approach where IP teams collectively analyze and address complex clinical cases, facilitating a shared understanding of patient management. While simulation and case-based learning are established methods for fostering IP collaboration, the process by which students develop a shared mental model for patient management after a simulated home visit and how this approach promotes the development of IP competencies is unknown. Understanding this process is critical for advancing IP competences that are fundamental to case management practice. The purpose of this study was to explore students' perceptions of the CCR processes used to develop an integrated care plan following a simulated home visit. Home care and community-based practice settings. A qualitative descriptive approach was employed to explore PT and nursing student teams' perceptions of the CCR processes used to develop an integrated care plan following a simulated home visit. Written responses to five reflection questions were analyzed using conventional content analysis among n =87 physical therapy and nursing students. There were three overarching themes: clarifying roles; developing a mutual approach; embracing shared values. Students' perceptions reflected skills needed to develop IP competencies including CCR. More research is needed to explore how student teams resolve disputes and use interdisciplinary knowledge in the process of CCR. Findings highlight the importance of IP collaboration in clinical case management, emphasizing the need for case managers to facilitate clear role clarification, mutual approaches, and shared values among IP teams to enhance integrated care planning and improve patient outcomes. These insights can inform training and development programs for case managers on IP teams, promoting the adoption of CCR in practice.

Integrative dental management of complex patients: a comprehensive care case report

Integrative dental management of complex patients: a comprehensive care case report

Telemedicine and Remote Management of Patients with Heart Failure: From Theory to Daily Practice.

Background: Heart failure (HF) is responsible for a high number of hospitalizations, caused by a progressive worsening quality of life. Telemedicine allows for better management of patients' complex conditions, improving the care released. However, the risk of remaining at a testing stage often limits the integration of remote care in daily pathways for HF patients. The aim of this study is to outline the steps needed to integrate telemedicine activities into ordinary HF clinic practices. This methodology is applied to observe activities and trend improvements over a 12-month routine phase. Method: Three steps have been defined for an efficient introduction of remote care services in ordinary activities, integrating them with traditional in-person care: (i) introduction of temporary telemedicine projects, (ii) systematization of telemedicine pathways, and (iii) evaluation of monitoring phase. Observational data have been collected from structured interviews to show the rate of telemedicine activities achieved in clinical practice over the last year. Results: The methodology has been proposed in the HF clinic of the Italian hospital ASST Bergamo Est. After an initial testing phase, in which usability and user experience have been tested, four different remote activities were added: (i) telemonitoring for patients with an implantable device, (ii) follow-up televisits, (iii) nursing telephone support, and (iv) high-intensity telesurveillance pathways for patients after an HF acute event. During the last year, 218 telemonitoring pathways, 75 televisits, 500 telephone calls, and nine telesurveillance pathways have been performed. Success rates were high, and patients gave positive feedback. Conclusion: By integrating multiple telemedicine activities, it has been possible to better manage complex patients, keep track of disease progression, and improve their participation in care.

The Singular Therapeutic Project As A Learning And Comprehensive Care Tool: Experience Report On The Management Of Chronic Pain In An Elderly Patient

Background: Chronic pain is a complex condition that affects patients physically, emotionally, and socially. Addressing it effectively in primary care requires a holistic approach that integrates non-pharmacological and pharmacological strategies. The Singular Therapeutic Project (STP) enables personalized, patient-centered care through multidisciplinary collaboration. Aim: This experience report aims to describe the practical learning experience of medical students implementing a STP for a patient with chronic pain, highlighting the impact on care and medical education. Experience Report: During the second semester of 2024, medical students from Bragança, Pará, engaged in home visits through the STP framework under faculty supervision. These visits facilitated an expanded understanding of the patient’s clinical and psychosocial context using tools such as genograms, ecomaps, and functional assessments. Students applied interventions to manage chronic pain and address barriers to medication adherence. Additionally, collaboration with the healthcare team ensured adjustments to care based on the patient’s evolving needs, promoting reintegration into physical activities. Conclusion: The implementation of the STP fostered practical and humanized learning by emphasizing empathy, teamwork, and communication skills. This approach strengthened the students' understanding of primary healthcare, enabling the development of professional competencies essential for managing complex patient cases and contributing to the patient’s improved quality of life.

Catalysts for change: A qualitative study of middle managers' perception of nursing professional competence in primary healthcare.

This study aims to explore middle managers' perception of nursing professional competence within the Norwegian primary healthcare service, a sector vital for managing complex patient needs. Semi-structured interviews were conducted with four middle managers across different municipalities in Norway. Qualitative content analyses, following Graneheim and Lundman, were used for analysing the transcription of the interviews and the data collected. The qualitative content analysis revealed three main themes: the significance of advanced competence, challenges related to competence development and the necessity for defining advanced competence. The findings indicate that middle managers recognise the importance of advanced nursing competence in providing comprehensive patient care, notwithstanding challenges in manpower and competence enhancement. This research underlines the significance of investing in increased competence and improved management in primary healthcare and offers valuable insights for healthcare policy and practice to enhance patient care.

VPExam in Heart Failure Innovating Virtual Cardiac Care

Telehealth and Virtual care are growing fields of importance, but the loss of comprehensive physical exam creates barriers to managing complex patients especially those with heart failure. Disruptive digital tools such as VPExam virtual care combine augmented reality instruction of visuals with bluetooth stethoscopes and ECGs to improve accuracy by assessing volume status, cardiopulmonary auscultation, arrythmia detection, and providing structured data including remote patient monitoring (RPM) data, vitals, medication reconciliation, and labs. VPExam intervention has significantly improved outcomes for high-risk and underserved populations with heart failure discharged to Skilled Nursing Facilities and Home Care. VPExam QI revealed workflows for both routine and urgent cardiology consultation following heart failure hospitalizations resulted in moderate significance modification in clinical management in 84% of encounters, while being associated with a 40% relative risk reduction in 30-day hospital readmission rate and a 56% relative risk reduction in 30-day mortality rate. The review summarizes both challenges to cardiac transitions of care and the evolution of cardiac virtual care with actionable physical exam data to optimize readmissions and mortality that is especially relevant to the underserved populations of skilled nursing facilities and home bound patients served by home care agencies.

ChatGPT vs Expert-Guided Care Pathways for Postesophagectomy Symptom Management

BackgroundThe objective of this study was to compare generative artificial intelligence–initiated care pathways, using ChatGPT, with expert-guided consensus-initiated care pathways from AskMayoExpert (AME) for symptom management of esophageal cancer patients after esophagectomy. MethodsA formal protocol for development of 9 AME care pathways was followed for specific patient-identified domains after esophagectomy for esophageal cancer. Domain scores were measured and assessed through the Upper Digestive Disease tool. These care pathways were developed by experts validated by a consensus-driven methodology. ChatGPT was used to answer specific questions similar to the AME care pathway on April 9, 2023, and March 28, 2024. To compare outcomes, answers were recorded, and algorithms were compared with a survey tool composed of 5 questions. ResultsBoth modalities were able to provide a clear definition with multidirectional management options for all 9 domains: dysphagia, generalized dumping, gastrointestinal dumping, pain, regurgitation, heartburn, nausea, physical health, and mental health. When provided with a simple prompt, ChatGPT 3.5 failed to provide a comprehensive stepwise approach for providers, any testing recommendations, or any form of triage process. However, ChatGPT 4.0 provided plans, similar to AME care pathways, when a sophisticated prompt was used. ConclusionsGenerative artificial intelligence–initiated care pathways can be used by physicians as a supplementary tool to guide provider management of patients with complex symptoms after esophagectomy. This technology will continue to advance but is currently insufficient to solely guide clinical management of complex patients with severe symptoms.

TAKOTSUBO SYNDROME PRECEDING THE INDEX EVENT: A DANGEROUS CLINICAL SETTING

Abstract We describe the case of a 68–year–old patient who presented to the Emergency Department following an unwitnessed syncopal episode with slow recovery of consciousness. On admission, the patient had dyspnoea together with physical signs of pulmonary congestion. Cardiac ultrasound showed severe left ventricular dysfunction with an ejection fraction of 30%, and apical and paraapical akinesis. The admission electrocardiogram showed sinus tachycardia and diffuse repolarization abnormalities, hs TnI was elevated and BNP vl blood gas analysis were unremarkable. During observation in the Emergency Department, the patient experienced epileptic seizure, promptly resolved by intravenous Midazolam. Contrast–enhanced chest CT ruled out aortic dissection disclosing a clinically irrelevant subsegmental pulmonary embolism. A non–contrast CT scan of the brain yielded negative results. In consideration of the atypical clinical presentation and scattered evidence of an acute coronary syndrome, the patient was admitted to our Cardiac Intensive Care Unit (CICU) for additional diagnostic workup delaying coronary angiography in the presence of stable TnI elevation. Three hours after admission the patient continued showing altered consciousness and a subsequent brain CT was performed, demonstrating an intraparenchymal hemorrhagic spreading. Repeat ECGs showed precordial T wave inversion and prolongation of the QT interval. These data, together with LV apical dysfunction, raised the suspicion of Takotsubo syndrome secondary to an acute cerebrovascular event. During the hospital stay, recovery of consciousness, spontaneous absorption of the cerebral hemorrhagic spread and complete recovery of left ventricular function at repeat cardiac ultrasound examinations were observed, confirming the almost unequivocal diagnosis of Takotsubo syndrome. The patient was discharged uneventfully and was scheduled for an outpatient coronary CT scan. This case underscores the crucial importance of a thorough clinical assessment in the management of complex patients in the presence of nonunivocal clinical signs and misleading blood test and imaging data. Moreover, Takotsubo syndrome is a protean clinical entity that can precede the index event as in our patient, i.e. cerebral hemorrhage. Misclassification of these patients as having an acute coronary syndrome could have led to the initiation of antithrombotic therapy, with potential fatal outcomes for the patient.

The importance of collaboration in maternal medicine: A retrospective descriptive study of a maternal multidisciplinary team meeting.

In the present study we aimed to review the evolution and function of the maternal medicine multidisciplinary team (MMMDT) meeting of a maternal medicine service of a tertiary level stand-alone maternity hospital. We conducted a retrospective descriptive study of all minutes of MMMDT meetings from 2014 to 2020, with the aim of evaluating meeting characteristics and patient demographics. There were 575 multidisciplinary team (MDT) discussions of 486 women during 43 meetings in the 7 year period. On average, 13 (range 3-23; SD = 5.28) women were discussed at each meeting, attended by 17 (range: 11-27; SD = 4.26) attendees. There were 18 women discussed during successive pregnancies. When analyzing the 2017-2020 data, preconceptual discussions made up 7.3% (n = 42) of patients discussed, with 5.7% (n = 33) being postnatal. The mean maternal age was 32.5 years (range 15-48 years) and women were most likely to be discussed in the mid-trimester period (21-24 weeks gestation). The top five primary specialities involved were hematology, neurology, rheumatology, neurosurgery and gastroenterology; however, 22 specialities were represented overall when classified by the primary medical condition. When examining the MDT input, hematology input was required in 144 patients (25.0%), radiology in 161 (28.0%) patients, and 117 in anesthesiology (20.3%). When examining the number of teams required to manage the patient, 80 women required the input of three specialities, with 16 women requiring the input of four specialities. We demonstrate the value and role of the MDT in the management of complex patients, providing a forum to discuss care in all phases of the obstetric journey.

Acute coronary syndrome in a patient with gastric cancer treated by immune checkpoint inhibitor: A case report

AbstractObjectiveTo highlight the incidence and management of acute coronary syndrome (ACS) in patients with gastric cancer undergoing immune checkpoint inhibitor (ICI) therapy, emphasizing the need for early detection and intervention in this high‐risk population.Patients and methodsWe presented a case of a 71‐year‐old male patient with poorly differentiated adenocarcinoma of the gastric antrum, clinical stage cT4N2M0, phase III, with no prior history of chronic diseases or cardiovascular risk factors. The patient was treated with a combination of ICI therapy (sintilimab) and chemotherapy using the albumin‐bound paclitaxel combined with S1 regimen. Following therapy, he developed symptoms and diagnostic findings consistent with ACS, which was managed with percutaneous coronary stenting.ResultsThe patient's presentation with ACS during ICI therapy underscored the potential cardiovascular risks associated with cancer treatments, particularly in patients without traditional cardiovascular risk factors. Management involved collaboration between oncologists and cardiologists, leading to successful coronary stenting and continuation of antitumor therapy.ConclusionACS is a significant risk in patients with malignancies undergoing ICI therapy, even in those without prior cardiovascular disease. Early recognition and management of ACS in this context are crucial to enable the continuation of cancer treatment and improve patient outcomes. This case underscores the importance of interdisciplinary collaboration in managing complex patients with concurrent cancer and cardiovascular disease.

Management of the anatomically complex penile implant candidate through an infrapubic incision: a review of surgical techniques and benefits.

This article provides a comprehensive discussion of 3-piece inflatable penile implant surgery when performed through an infrapubic approach in patients presenting with challenging anatomy or corporal fibrosis. The infrapubic approach is one of the primary approaches for inflatable device placement with excellent long-term functional outcomes. While the literature is rich in descriptions of infrapubic placement in the primary, uncomplicated setting, its role in the management of complex patients presenting to centers of excellence is less elucidated. In uncomplicated cases, the infrapubic approach offers several theoretical advantages including shorter operative time and quicker return to sexual function. In addition to describing specific details of our infrapubic technique and perioperative management, I discuss scenarios in which an infrapubic approach may allow for better exposure for correction of dorsal deformity, facilitate secondary surgical maneuvers such as suprapubic lipectomy, or protect existing incontinence prosthetics already in place. Specific technique and surgical pearls from our prosthetic center of excellence are reviewed for each of these challenging scenarios. Ultimately, prosthetic surgeons should be adept at placing, revising, and removing devices through both approaches so that various forms of anatomical deformity and device failures can be addressed proficiently. In addition to my own clinical reflections, a critical review was performed using the Medline database to support our statements.

КЛИНИЧЕСКИЙ СЛУЧАЙ УСПЕШНОЙ РЕАЛИЗАЦИИ РЕПРОДУКТИВНОЙ ФУНКЦИИ У ПАЦИЕНТКИ С ДИСГЕНЕЗИЕЙ ГОНАД

An important problem is the problem of implementing reproductive function in patients with forms of infertility caused by genetic abnormalities. Previously, the prognosis for their reproductive function was considered unfavorable. In modern conditions, by improving IVF techniques using oocyte donation, treatment of infertility in these patients becomes possible. Therefore, studying the features of the tactics of managing such patients at the stage of preconception preparation, the features of IVF protocols, as well as the features of managing pregnancy and labor and delivery is relevant. The purpose of the study is to substantiate the possibility of successful implementation of reproductive function in a patient with gonadal dysgenesis. A clinical case of pregnancy and childbirth in a patient with a typical form of gonadal dysgenesis (karyotype 45 X0) is presented. The diagnosis was made at the age of 15 during a comprehensive examination for primary amenorrhea, and hormone replacement therapy was prescribed. The patient's pregnancy occurred after preparation of the endometrium with estrogens and gestagens as a result of the fourth IVF attempt with the donation of an egg fertilized by her husband's sperm, and was complicated by the threat of termination at 8 and 19 weeks. At 36 weeks, the pregnancy was complicated by severe preeclampsia, which required emergency caesarean section. The course of the postoperative period was uneventful with continuation of therapy for complications of gestation. It is recommended after cessation of lactation - HRT using drugs with an estrogenic component similar in chemical structure to natural ones, gestagenic - metabolically neutral. The study of this clinical case is of undoubted interest, taking into account the peculiarities of management tactics. It is necessary to implement a multidisciplinary approach to the management of such complex patients. Taking into account the peculiarities of the body condition in patients with gonadal dysgenesis and the absence of hormonal ovarian function, it is necessary to ensure optimal preconception preparation, the use of an individual approach to the implementation of the IVF protocol, and the prevention of complications during pregnancy. Fulfillment of these conditions will ensure a positive result of infertility treatment in patients with gonadal dysgenesis who previously did not have the opportunity to realize reproductive function.

A Case Report of Rheumatoid Meningitis – A Rare Condition Presenting with Neurological Deficits

Rheumatoid meningitis (RM) is a rare condition seen in patients with longstanding rheumatoid arthritis (RA). It can present with a variety of neurological symptoms and is often mistaken for other neurological conditions, especially in the setting of immune suppression in these patients. We present a rare case of RM in an elderly woman with RA that presented with focal neurological symptoms and was eventually diagnosed on brain biopsy. Our case serves to highlight the diagnostic dilemmas faced while evaluating and treating patients presenting with such an exceedingly rare condition and the importance of multidisciplinary collaboration in the management of such complex patients.

The Role of Chronic Disease and Multiple Chronic Conditions on the Level and Change in Per Capita Health Care Spending, 2010-2021

Objective: To estimate the key factors accounting for the level and change in inflation-adjusted per capita spending among all adults, privately insured adults aged 18-64 and Medicare beneficiaries. In addition to examining demographic factors, we focus on the role of patients with multiple chronic conditions and in the most recent years the impact that COVID-19 had on per capita spending. Methods: We used generalized linear regression models (GLM) with log-link given the skewness of the data. Our analysis focuses on 2010 to 2021. We report results for 2010, 2016 and 2021. The regressions models control for patient demographics, income, race/ethnicity, region of the country, the number of diagnosed chronic conditions and whether the adult was treated for COVID-19. Results: The number of chronic conditions treated were the strongest predictor of per capita health care spending. Moreover, in each of the populations examined, the impact of patients with 5 or more chronic on per capita spending increased dramatically. Patients diagnosed and treated, even controlling for comorbid chronic conditions, had a significant impact on increasing per capita spending. Conclusions: Adults with multiple chronic conditions are the key drivers of the level and growth in spending. During 2021, the COVID-19 pandemic also independently increased spending. With the prevalence of COVID-19 waning, this trend should take some pressure off the growth in spending. New more effective team-based care coordination models are needed to prevent and manage complex patients with multiple chronic conditions. The system need to continue to integrate the various silos of care into a more comprehensive patient centered focus.

Outcomes and GP perceptions of reviewing patients at risk of harm from opioids

Abstract Introduction The Clinical Commissioning Group (CCG) Medicines Optimisation workplan for 2021-22 had a focus on reducing harm from opioids.1,2 In particular, asking GP practices to identify and review two cohorts of patients: those on a combination of oxycodone and amitriptyline or similar high-risk combinations, and those over the age of 65 prescribed fentanyl transdermal patches. Practices were then expected to consider actions on how to reduce the risk for patients and also to provide feedback to the CCG on how the reviews had progressed. Aim We aimed to understand the outcomes, challenges and learning points experienced by practices in reviewing these patients. Methods Sixty practices were invited to participate. A feedback form was received from each practice that completed either or both reviews (covering anonymised outcomes of each review, challenges encountered, and practice-level learning points / changes made). Quantitative data were collated for each action, and feedback comments were categorised into broad groups. No patient details were collected. As this project was a service evaluation, ethical approval was not required. Results Forty-three practices completed the review of the combination of oxycodone and amitriptyline, though 5 of these had no patients to review. Overall, 185 patients were identified. Of these, 21 (11%) patients had the combination prescribing ceased, 22 (12%) were commenced on a reduction plan, and another 46 (25%) have been made aware of the risk and to report respiratory symptoms. Forty-three practices completed the fentanyl review, though one of these had no patients to review. Overall, 272 patients over 65 years were identified with 64 (24%) invited for a review with their GP or other allied health professional, 39 (14%) patients were put on a fentanyl patch dose reduction plan, and 14 (5%) had prescribing ceased. Practices reported various difficulties encountered with these reviews, including patient engagement in making changes to their pain medication which patients are reluctant to reduce; counselling and raising awareness of long-term effects of opioids to help gain patient understanding; how to manage complex patients who had been stable on their regimen over many years; and that it was time consuming to regularly check in with the patient and plan reduction regimens. Changes made by practices included recording risks discussed with patient in their medical record for easier future review; ensuring regular reviews, including by practice-based pharmacists, of patients prescribed opioids; trying to make time to see patients face to face; raising awareness of the risks of prescribing amitriptyline alongside oxycodone e.g. serotonin syndrome; and recognising that a collaborative process and patient engagement is necessary. Discussion/Conclusion The actions undertaken by practices link into national recommendations,1 with some GP feedback similar to the challenges and opportunities to improve patient safety on opioid use as reported elsewhere.3 Even with this small targeted patient cohort, this work demonstrates difficulties encountered by GPs in refraining from opioid prescribing. Other limitations of this small-scale review include lack of certainty whether reductions in opioid prescribing were always clinically appropriate, and reliance on practice feedback.

EGS P04 Recent ten year experience of Boerhaave’s Syndrome Management in a tertiary Oesophago-gastric Surgery Centre

Abstract Background Oesophageal Perforation (OP) is a low incidence, high complexity gastrointestinal surgical emergency with associated high mortality rates. A consequence of UK centralisation of oesophago-gastric (OG) cancer surgery is passive centralisation of OG surgical emergencies leading to reduced mortality for OP and lower threshold for surgical intervention by high volume OG cancer surgeons. Boerhaave's Syndrome characterised by Mackler’s Triad (vomiting, thoracic pain and subcutaneous emphysema) represents 30% of OP. UCLH has an OG surgery catchment population of 3 million. We present our experience of managing Boerhaave’s syndrome as an OG cancer centre with a dedicated OG Consultant on-call rota. Methods A retrospective review of electronic health records of all adult patients with a radiological diagnosis of OP over a 10 year period from 01/01/2013 to 31/12/2022) at our institution was performed. The inclusion criteria were adult patients with a clinical and radiological diagnosis of Boerhaave’s syndrome. Those with OP due to malignancy, endoscopic, or foreign body perforation were excluded from further analysis. The primary outcome measure was 90-day mortality and the secondary outcome measures were length of stay and reintervention rate. Results 41 patients with Boerhaave’s syndrome were identified (31 male, 10 female) with median age of 62 (46 - 71). 17 (41.5%) patients presented directly to our institution and 24 (58.5%) were transferred from other hospitals. Primary intervention was surgical in 31 (75.6%), endoscopic in 3 (7.3%) and conservative in 7 (17.1%) patients respectively. Overall 90-day mortality was 12.2% but 6.5% in the surgically managed group. Median length of stay was 58 days (22 - 70). 9 patients had reintervention – 7 (17.1%) had a thoracotomy/thoracoscopic surgery for intrathoracic collections and 2 patients (9.8%) had endoscopic intervention. Conclusions This is a report of the experience of managing Boerhaave’s syndrome in a high volume tertiary OG centre. A favourable 90-day mortality rate of 12.2% compares to 38.8% described in a previous UK cohort is likely a result of management in a tertiary centre with appropriate multidisciplinary infrastructure to manage complex patients and provide a consistently high level of perioperative care. The lower mortality rate (6.5%) in the operatively managed group is likely due to patient selection and surgical techniques honed from familiarity with complex cancer and benign oesophageal surgery and working as part of an effective multidisciplinary team.

An updated meta-analysis of effectiveness and safety of mTOR inhibitors in the management of tuberous sclerosis complex patients.

Tuberculous sclerosis complex (TSC) is an autosomal dominant multi-system disease. In TSC patients, the inhibition of mTOR pathway is weakened, which leads to the uncontrolled proliferation of normal resting cells. Therefore, mTOR inhibitors have many therapeutic potentials in the treatment of TSC. However, there is no consensus on the safety and efficacy of mTOR inhibitors so far. This article aimed to present new evidence for the efficacy and safety of mTOR inhibitors in the treatment of TSC by evaluating published clinical trials. A systemic search of online databases, such as Cochrane Library, Embase, PubMed, and the US National Institutes of Health Clinical Trials Registry, was conducted. The researchers selected studies that met the following entry criteria: randomized, double-blinded or single-blinded, placebo-controlled, parallel-group studies with active and control arms receiving rapamycin or everolimus and matched placebo, respectively. The meta-analysis included seven studies. Tumor response or epilepsy seizure frequency response rates were considered efficacy outcomes. In seven studies involving 877 patients, using of mTOR inhibitors therapy showed an improvement in both tumor response and seizure frequency outcomes in TSC. In combination of AML (angiomyolipomas), SEGA (subependymal giant cell astrocytoma), epilepsy, and facial angiofibroma subjects, the RR is 3.01 (95% CI 2.03 to 4.45, p = 0.000) with observed heterogeneity (I-squared = 55.4%). The main side effect of mTOR inhibitors was stomatitis. The updated meta-analysis suggests that the use of mTOR inhibitors is an effective therapy for patients with TSC.

Using Swanson’s theory to improve quality of work life to strengthen the healthcare sector in Ukraine and South Africa

South Africa and Ukraine share similar challenges for staff in the healthcare sector. Health care workers in South Africa have borne the brunt of the COVID-19 pandemic whereas in Ukraine health care workers, amidst the war have had to show valour and a tough spirit in caring for their patients under very trying circumstances. Arising from the above tragedies, health care workers have shown incredible bravery both in Ukraine and in South Africa, however they display extreme burn out. In Ukraine, nurses are working in the conflict zone and have to manage complex patient mental and physical health issues. Some have even been subjected to violence from traumatized patients. This article assesses the healthcare situation both in Ukraine and South Africa and provides a descriptive report utilizing The Swanson's theory of caring. The elements of Swanson’s theory consisting of maintaining belief, knowing, being with, doing for, and enabling can be linked to characteristics such as supporting patients and colleagues, being sensitive, affectionate and empathetic while feeling a sense of responsibility towards the department and patients. The study, based at selected South African public central hospitals in two provinces, adopted a descriptive exploratory paradigm. Qualitative techniques were used to administer an interview schedule to 322 frontline participants. The results revealed that despite high commitment levels, the participants still faced challenges that impact their daily work life. The study conducted in South Africa on Quality of Work life (QWL) experiences of frontline healthcare workers leaves recommendations for the Ukrainian health care sector.