Medical Team Research Articles

Breast neurotization along with breast reconstruction after nipple sparing mastectomy enhances quality of life and reduces denervation symptoms in patient reported outcome: a prospective cohort study.

Persistent postoperative sensory loss significantly limits breast reconstruction following mastectomy. In addition, the absence of sensation profoundly impacts patients' physical well-being and overall quality of life. New surgical techniques involving nerve autograft intercostal nerve elongation have been introduced to neurotize reconstructed breasts. However, patient quality of life after neurotization has not been well evaluated. This study aimed to investigate improvements in patient quality of life in association with breast neurotization. A prospective cohort study of 132 patients treated at (blinded for review) between January 2018 and December 2022 was conducted. Two groups of patients who underwent nipple-sparing mastectomy (NSM) and breast reconstruction were compared: those with (n=67) and without (n=65) breast neurotization. Patient-reported outcomes were assessed via the BREAST-Q reconstruction module questionnaire and an additional questionnaire measuring sensation, nipple satisfaction, and breast symptoms. Objective measurements were conducted via the Semmes-Weinstein monofilaments test. With respect to patient-reported outcomes, the innervated group had significantly higher scores for nipple sensation and on the BREAST-Q domains of psychosocial well-being (71.6±18.1 vs. 62.8±18.6, P=0.006), sexual well-being (56.9±22.1 vs. 47.3±20.7, P=0.015), satisfaction with the medical team, as well as less frequent post-operative breast symptoms. In the subgroup analysis, the innervated group demonstrated higher scores in both autologous flap and implant-based reconstruction. Linear regression revealed a statistically significant relationship between objectively measured monofilament value and subjectively examined patient-reported outcomes: nipple sensation, breast sensation, and BREAST-Q score for the psychosocial well-being domain (coefficient:-4.922, P=0.033). Breast reconstruction with autologous nerve graft neurotization yields improved sensory outcomes and has a statistically significant positive impact on the quality of life of breast reconstruction patients.

Use of mobile health units in natural disasters: a scoping review

Abstract Background Mobile Health Units have become important resources for healthcare delivery to dispersed populations following natural disasters. However, criticism regarding their operational flexibility, health coverage and cost-effectiveness remain unaddressed. There are few studies evaluating their usefulness in natural disasters and deployment reports have never been included in peer-reviewed publications. With an expected rise in weather-related disasters, knowledge about the impact of MHUs on addressing health needs is needed. This study aimed to elucidate the use of mobile health units in natural disasters as described in the literature. Methods A scoping review was conducted, searching twenty-six databases and websites. Documents detailing operational characteristics and practices of mobile health units deployed to natural disasters, published between 2000 and 2022 in English, were included. Findings were analysed using thematic content analysis with the World Health Organization Classification and Minimum Standards for Emergency Medical Teams as a guiding framework. Results Nearly 3000 documents were screened, yielding thirteen documents eligible for inclusion. The literature highlighted seven themes: key characteristics, operational availability, services, benchmark indicator, staff, self-sufficiency and pre-deployment preparations. The reports cover earthquakes, floods, tsunamis, hurricanes, typhoons, cyclones, landslides and mudslides. Mobile health units were described to improve access to outpatient healthcare for populations with limited access to routine services. However, limitations related to mobility, logistics, referral capacity, health coverage and communication posed significant challenges. Conclusions Data on the use of mobile health units in natural disasters is scarce with inconsistent reporting of key aspects, stressing a need for uniform reporting. In response to inaccessible fixed healthcare facilities, mobile health units were described to address the normal burden of disease rather than emergency care. Coordination, transportation, referral systems and data collection were highlighted as the main areas of improvement. Trial registration Not applicable.

Placenta Accreta Spectrum Care in Middle-Resource Settings.

Management of the placenta accreta spectrum (PAS) in resource-limited settings poses significant challenges. Traditional approaches, which often involve hysterectomy and extensive technology in all the patients are being replaced by individualized treatment plans considering each patient's specific clinical situation, available resources, and team expertise. Using ultrasonographic and surgical staging based on PAS topographic classification can help design tailored surgical plans and optimize resource use. This article explores the need for personalized PAS management, safe surgical option selection, and how medical teams can adapt to provide more versatile treatment options in resource-constrained environments.

Resilience is job satisfaction using nephrology as an example

The shortage of specialists in medicine has become an everyday occurrence in both the medical and nursing fields. There is agreat need for young talent in all areas of the healthcare sector. The strain on people working in this field is enormous and is perceived differently in different areas of work, depending on their professional and educational background. If we look at the medical field alone, students' wishes, requirements, objectives and necessities with regard to everyday working life are different from those of postgraduate training assistants or the management level consisting of senior physicians and chief physicians. Various measures are required to counteract the shortage of junior staff on the one hand and to meet all requirements in patient care on the other, while achieving and maintaining ahigh level of job satisfaction. These must be coordinated and adapted to the different needs of the various levels. Working conditions in the interactive, interprofessional, interdisciplinary, financial and social context need to be revised in many areas in order to maintain the attractiveness of the medical profession. Aresilient medical team can defy many adversities, but this requires acontribution from all sides.

When the Inherent Authority of the High Court Trumps Parental Authority in Medical Decision-Making Involving the Withdrawal of Life Support Treatment affecting Minor Children and their Parents

Judges are often up against very grave cases when they have to decide whether to order the withdrawal of life support from children who are seriously ill or in a vegetative state. What’s more medical practitioners attending to the medical care of the child affected believe that clinically, it would be in the best interest of the child that his or her life should be terminated. Any continued medical treatment would be futile. The parent(s) on the other hand, do not agree with the medical team. Because the parties involved cannot reach agreement, the dispute is consequently referred to the High Court. It is then up to the court to make the final decisions. In this triad, some of the fundamental legal issues caused to be decided, include: who should have the final say over the withdrawal of life support treatment for minor patient? What criteria does the court use in resolving the dispute between the parties? This article provides a critical insight into when the High Court’s inherent authority trumps parental authority in medical decision-making involving the withdrawal of life support treatment, affecting a minor child. What will become apparent is that the South African High Court has only sporadically been asked to exercise their inherent authority to interfere with a parent’s decision-making power when, because of religious reasons, the parent refuses to consent to the child being exposed to blood transfusions. Here, the High Court has often come to the rescue of the child by adopting an orthodox approach. The court will firstly, in search of the welfare of the child, exercise its authority as upper guardian of children. Secondly, the court will search for the welfare of the child under the rubric of ‘what is in the best interest of the child’. The South African High Court, unlike its English counter-part, has not been exposed to cases dealing with end-of-life decisions. What is called for is for the South African courts to develop its own jurisprudence. To this end, the South African High Court does not have to look further than adopting the well-developed criteria found in the English cases. But, before the parties engage in litigation, mediation should be attempted.

Pre-rounding in hospital medicine: a narrative review.

Pre-rounding in hospital medicine is the practice of having junior physicians in the medical team come to work early to pre-clerk new and existing patients in advance, in order to formulate preliminary management plans, draft rounding notes and prepare for ward round presentations when the attending consultant and senior members of the team arrive. While pre-rounding is part of a long-standing tradition in the United States hospital-based practice, its adoption has been highly heterogeneous across the world, due to controversy over its purported benefits in patient care and post-graduate training. In this article, we sought to review the relevant literature on pre-rounding in hospital medicine and examine its current role in postgraduate training and practice, specifically evaluating its clinical and pedagogical utility. From our analyses and discussion, we propose a simple "PRE-ROUND" (Prioritise/pre-select patients for physical review, Review of electronic medical record charts/documentations, Escalation of urgent clinical cases, Rounding notes drafting, Organise the sequence of ward rounds, Understand and synthesise pertinent medical issues to practise clinical reasoning, Narrative, structured ward round presentation, Developing a healthy institutional pre-round culture) model that practically encapsulates the key principles required for effective pre-rounds in hospital-based practice that can contribute meaningfully to patient care and post-graduate training, whilst avoiding excessive burden and clinical redundancy on junior physicians.

Oral hygiene, quality of life, and risk of heart failure

PurposeHeart failure (HF) is a debilitating form of cardiovascular disease that is increasing worldwide. Poor oral health is an established risk factor for cardiovascular disease, but there are few studies specific to the development of HF. In particular, there are no known studies on oral hygiene and HF in the United States. This study characterizes the association between oral hygiene, oral health-related quality of life (OHRQoL), and risk of HF in adults.MethodsA case-control sample was assembled from adult patients of the Marshfield Clinic Health System in north-central Wisconsin. HF cases were matched on age and sex to HF-free controls. HF case status, along with clinical covariates, were extracted from electronic health records. Surveys were used to collect oral health exposures (toothbrushing, flossing, dental visits, and OHRQoL) and other sociodemographic covariates. Multivariable regression was used to examine associations with HF.ResultsSurvey response rates were 67% in HF cases and 74% in HF-free controls, yielding an analytical sample of 410 individuals. OHRQoL was not significantly associated with HF, but both oral hygiene and last dental visit were. Specifically, multivariable models revealed that participants with excellent oral hygiene had significantly lower odds of HF as compared to those with fair/poor oral hygiene [aOR = 0.47 (CI: 0.24, 0.95), p = 0.035]. Similarly, participants with a more recent dental visit that occurred less than two years prior had significantly lower odds of HF as compared to participants with a dental visit that occurred more than two years prior [aOR = 0.43 (CI: 0.25, 0.74), p = 0.002].ConclusionGood oral hygiene (i.e., regular toothbrushing/flossing) and a recent dental visit were protective against HF. If poor oral health is established as a causal contributor to HF in future research, it could open up previously unrecognized or underappreciated additional pathways to prevention whereby the risk of HF development could be interrupted by more intense screening/recognition of deteriorating oral health by medical care teams, as well as a more direct focus on cardiovascular disease prevention by dental care teams.

Leadership in sustainment of Individual Placement and Support model: a comparative case study in Finland.

Individual Placement and Support is an evidence-based practice designed to assist individuals with psychiatric disorders in gaining employment. Contextual factors such as policies, funding, and organizational structures are widely acknowledged as barriers and facilitators to the sustainment of evidence-based practices. This study focuses on leadership's role in driving the sustainment process and navigating the dynamic interplay between internal and external contexts following a national development project in Finland. We used qualitative data from semi-structured interviews. Participants included outside experts such as trainers and researchers (n = 4), leaders from the implementing sites, including medical directors, nursing directors, administrators (n = 11), project managers and team leaders (n = 6), and frontline workers (n = 8). We performed an abductive thematic analysis to identify patterns and themes within the data. We identified three Leadership Approaches for IPS Model Sustainability that differentiated agencies with more robust sustainment strategies from those with less robust ones. The Visionary Approach included championing recovery-oriented principles to foster organizational readiness and aligning IPS with organizational goals. The Proactive Approach was characterized by early and deliberate planning to minimize challenges, leveraging IPS fidelity evaluations for quality improvement. Leaders employing the Collaborative Approach emphasized effective facilitation within governance structures, including the integration of IPS into the strategies of administrative units. The study presents three leadership approaches that differentiate implementing agencies with more robust IPS model sustainment strategies from those with less robust ones. It introduces and empirically explores a conceptual model that can be used both in research and practice.

The study of thermal closures for the prevention of hypothermia (experimental study)

Prevention of hypothermia in the wounded and injured remains an urgent problem in providing assistance to the wounded and injured with polytrauma. The purpose of the study was to evaluate the effectiveness and safety of using a thermal cover designed to prevent hypothermia of the victim in an experiment with the participation of volunteers. Materials and methods. The study was carried out with the participation of volunteers who were exposed to cold temperatures with and without the use of a thermal blanket. The subjects were lying motionless on a stretcher in a thermal chamber for 60 minutes at an ambient temperature of 00C, the air humidity was 50%. Temperature sensors were located on the skin, on the upper layer of clothing and on the surface of the thermal cover. Results. The use of thermal seals at negative ambient temperatures contributes to a slower cooling of the body due to the reflection of heat from the inner surface of the product. The subjective feelings of the volunteers showed statistically significant differences in heat perception when using thermal covers. In the experimental group, the volunteers did not note that they were «cold» at any stage, in the control group, after 45 minutes of observation, in 4 cases they were given 1 point («cold»), and one of the volunteers wished to stop the study. At the same time, thermal blankets contribute to a slower cooling of the body. In the group using a thermal blanket, the core temperature (the sensor is installed in the oral cavity) was on average 4,2 °C higher compared to the group of volunteers without a thermal blanket. Thus, thermal blankets can help prevent hypothermia in victims during evacuation by emergency medical teams. Conclusion: the presented samples of thermal coating products are effective means of preventing hypothermia in low ambient temperatures.

Physiological team dynamics explored: physiological synchrony in medical simulation training

IntroductionFor researchers and medical simulation trainers, measuring team dynamics is vital for providing targeted feedback that can lead to improved patient outcomes. It is also valuable for research, such as investigating which dynamics benefit team performance. Traditional assessment methods, such as questionnaires and observations, are often subjective and static, lacking the ability to capture team dynamics. To address these shortcomings, this study explores the use of physiological synchrony (PS) measured through electrocardiogram (ECG) data to evaluate team dynamics automated and in high-resolution.MethodsA multicentre observational field study was conducted involving 214 medical first responders during mixed reality (MR) mass casualty training sessions. Participants were equipped with electrocardiogram (ECG) sensors and MR gear. The study measured dyadic PS using heart rate (HR), root mean square of successive differences (RMSSD), and standard deviation of NN intervals (SDNN). Data were collected at high frequency and analysed using dynamic time warping (dtw) to assess fluctuations in PS.ResultsFindings indicate that PS varies significantly by task nature, with higher synchrony during cooperative tasks compared to baseline. Different ECG metrics offered unique insights into team dynamics. Proximity and scenario conditions influenced PS, with closer teamwork leading to higher PS. Smaller sampling intervals (e.g. 5 s) provided a detailed view of PS fluctuations over time.DiscussionThe results demonstrate the potential of PS as an indicator of team performance and cohesion. High-resolution monitoring provides detailed insights into team dynamics, offering high-resolution feedback that traditional methods cannot provide. The integration of physiological measures into training programmes can enhance team performance by providing objective, high-resolution data.ConclusionThis study shows that PS, measured by ECG data, is sensitive to medical team activities, offering insights into team dynamics. Different ECG metrics highlight various aspects of team performance, and high-resolution monitoring captures detailed dynamics. Further research is needed to validate these findings across diverse scenarios. This approach could improve training methodologies, resulting in better-prepared medical teams and improved patient care outcomes.

Exploring clinical rehabilitation practices for bronchopulmonary dysplasia in neonatal intensive care unit: A qualitative study.

Bronchopulmonary dysplasia (BPD) is a common complication in premature infants, particularly those born extremely preterm, and is a significant risk factor for neurodevelopmental impairment. Rehabilitation therapy has been shown to improve both pulmonary and neurological functions in infants with BPD. However, in China, there is no consensus on the optimal timing, type, frequency or follow-up of rehabilitation exercises for these infants. Understanding the current clinical practices, challenges and areas for improvement is essential to enhancing outcomes. To investigate current clinical rehabilitation practices for BPD in the Neonatal Intensive Care Unit (NICU). Qualitative descriptive study. A total of 12 informants participated in this study. Four major themes were identified: (1) Non-standardized rehabilitation practices: Inconsistent frequency and intensity of rehabilitation therapy, delayed initiation and lack of follow-up. (2) Lack of consensus and collaboration: Absence of expert consensus on rehabilitation practices and insufficient interdisciplinary communication. (3) Limited parental involvement in rehabilitation: Minimal kangaroo care, low engagement in caregiver training and limited support for family participation in rehabilitation. (4) Nurses' involvement in rehabilitation therapy is limited, with issues including unstandardized positioning management, minimal participation in rehabilitation coordination and a lack of proactive feedback on BPD infants' rehabilitation tolerance. (5) Inadequate rehabilitation environment: Constraints such as limited space, lack of family-centred wards, insufficient equipment and environmental issues with noise and lighting. Rehabilitation practices for BPD in the NICU are inconsistent, with limited interdisciplinary collaboration and suboptimal parental involvement. The study underscores the need for establishing a multidisciplinary team and developing evidence-based, culturally tailored rehabilitation protocols. Improving parental participation, creating appropriate rehabilitation spaces, managing environmental factors like noise and lighting, nurses should participate in training on positioning management and assist with rehabilitation therapy, actively providing feedback to the medical team on the tolerance of BPD infants and enhancing equipment availability will contribute to the early recovery of infants with BPD. This study highlights critical gaps in current rehabilitation practices for BPD in NICUs, suggesting that a standardized, evidence-based approach is needed to optimize care. Clinicians should focus on fostering multidisciplinary collaboration, enhancing parental involvement and improving the physical environment of NICUs to support the rehabilitation process for premature infants with BPD. Nurses in the NICU play a pivotal role in the rehabilitation of children with BPD. Their key responsibilities include assessing the infants' condition to determine their ability to tolerate rehabilitation and providing hands-on support throughout the treatment process.

Incidental Findings on MRI Brain Imaging in Pilots from the Canadian White Matter Hyperintensity Study.

Incidental neuroanatomical findings are commonly identified during brain MRI completed clinically, for research, or for other purposes, including aircrew screening. Such findings range from benign to pathological and some may be disqualifying for flight duties. We present a series of cases with incidental neuroanatomical findings identified in Royal Canadian Armed Forces (RCAF) aircrew during the Canadian White Matter Hyperintensity research study, and the subsequent aeromedical evaluation undertaken to manage them. Our study group performed 48 brain MRI scans on 42 RCAF pilots and 6 aviation physiology technicians and parajumpers. Participants were men ages 25-70 with a mean age of 39. Incidental neuroanatomical findings were detected in four pilots, with six distinct findings (four vascular abnormalities, one arachnoid cyst, and one nonspecific nodule). All cases were asymptomatic. After evaluation of the findings of each case by a medical consortium, including an aeromedical neurologist, all pilots were cleared for ongoing duties with no restrictions. The rate and nature of incidental findings in RCAF members in the White Matter Hyperintensity Study is consistent with that found in both the general population and in other military pilot populations. There is no international standard for screening or management of incidental findings; therefore, we recommend an approach that involves a case-by-case evaluation of the findings by a multidisciplinary medical team, with careful identification and consideration for high-risk features. Danho S, Saary J. Incidental findings on MRI brain imaging in pilots from the Canadian White Matter Hyperintensity Study. Aerosp Med Hum Perform. 2025; 96(3):255-259.

Psychological support for people with hemophilia and HIV who suffer from cancer: A first national survey

Psychological support is necessary for people with hemophilia and HIV (PHH) who suffer from cancers. Most PHH are infected with not only HIV but also hepatitis C virus due to non-heat-treated blood coagulation factor products. PHH have a high risk of carcinogenesis, including liver cancer. Furthermore, many PHH present psychological problems, due to the great stress resulting from carcinogenesis and which impedes their cancer treatment. This study aimed to assess the psychological support system through a nationwide survey of healthcare workers caring for PHH at HIV care hospitals in Japan. The response rate was 49.1% (194/395), with a coverage rate of 74% (516/697) for PHH. Our findings indicated that psychologists were the most likely to be "coordinated" or "expected to coordinate" when PHH suffered from cancer (74%, multiple responses allowed). The most common reason for rating the adequacy of psychological support as "very good" or "good" was "easy collaboration with various professionals and medical teams". The number of HIV coordinator nurses and clinical psychologists per facility was 1.06 and 2.56, respectively. Our findings indicated more psychological support systems should be established in Japan, including reimbursement for psychological support for PHH.

A Case of Placenta Percreta Presented with Frank Hematuria and Managed Conservatively

A serious risk of potentially fatal hemorrhage is associated with adherent placenta percreta, an uncommon variation of Placenta Accreta Spectrum (PAS) illnesses. An even rarer occurrence is bladder involvement, which can occasionally manifest as extensive hematuria alone. Therefore, hematuria during pregnancy, whether microscopic or macroscopic, should be regarded as concerning symptoms that need to be addressed right once. In situations of placenta percreta that are suspected or confirmed, early urologist and multidisciplinary medical team involvement is particularly crucial because prompt surgical intervention may be required to guarantee patient safety. We describe the case of a 33-year-old lady who had three cesarean procedures in the past and who complained of lightheadedness and bloody urine at 28 weeks.

Oral appliance therapy for snoring and obstructive sleep apnoea: a Practical Guide for Clinical Care.

Obstructive sleep apnoea (OSA) is a disorder associated with multiple cardiovascular, metabolic and neurocognitive comorbidities which impact the health and quality of life of patients. Dentists trained in dental sleep medicine have a significant role as part of a collaborative multidisciplinary team led by specialist sleep physicians in the overall management of OSA. Based on the recommendations of the medical team and the patient's preference, dentists have a pertinent role in the provision of oral appliance (OA) therapy for OSA. This narrative review provides a practical guide for OA therapy for snoring and OSA.

Caregiver Satisfaction During the Transition From Inpatient Cancer Care to Home-Based End-of-Life Care

Background: People with advanced cancer often cite home as their preferred place of death, yet a preponderance of deaths occurs in hospitals. Hospice care improves outcomes at end of life (EOL). Hospital-to-home transitional care is a critical area of care delivery, but the caregiver’s experience during this transition is a gap in the literature. Objective: This mixed-methods study explored informal caregiver perceptions of the transition from inpatient cancer care to home-based EOL care. Methods: A cross-sectional survey measured caregiver satisfaction with advanced cancer and palliative care. A qualitative content analysis of additional free-text comments from respondents was also conducted. Results: A total of 53 (27%) of caregivers completed the survey. Responses were positive overall, with higher satisfaction noted for Hispanic/Latino caregivers (P = .033) and caregivers with greater self-reported support at home (P = .006), and trending toward higher satisfaction for caregivers aged 65 years and older (P = .075). Qualitative findings indicate effective communication and care coordination are critical components of positive experiences. Conclusions: Results suggest that early identification and support for caregivers with lower self-reported outside support at EOL may increase satisfaction. Implications for Practice: Previous work demonstrated a gap in the understanding of caregiver experience in the transition from hospital-based to home hospice care. Assessment of outside caregiver support should be performed before discharge. What Is Foundational: As institutions consider satisfaction of care as an important metric of quality, caregivers need to be included, particularly within transitions of care. Clear communication between the medical team and the primary caregiver is an essential component of care.

Therapeutic trajectories of families with rare diseases in Chile from the perspectives of patients, carers, and healthcare workers: a qualitative study

BackgroundRare diseases are conditions that have a low prevalence in the population and a high disease burden and are often chronic and progressive. International evidence concerning the experience of people and families living with rare diseases is scarce, leading to late and erroneous diagnoses, as well as non-specific treatments. This study explored the therapeutic trajectories of people and families living with rare diseases within Chile’s public and private healthcare systems from the perspective of patients, caregivers, and medical teams, including the initial symptoms, first consultation, testing, diagnosis, treatment, and follow-up.MethodsA qualitative exploratory study was conducted through multiple case studies. Sixty participants were interviewed in person and/or virtually: patients (n = 16), caregivers (n = 22), healthcare workers (n = 20), and two patient organisation leaders. The material was analysed using thematic analysis. The project was approved by the Scientific Ethics Committee of Facultad de Medicina Clínica Alemana, Universidad del Desarrollo.ResultsAfter similar initial symptoms and first consultation, three main types of trajectories were identified: (i) the path taken by those who reach a diagnosis for a disease that has specific treatment available; (ii) the journey of those who reach a diagnosis for their health condition, but their disease does not have a specific treatment available; and (iii) the trajectory of those who have not reached a diagnosis and receive symptomatic treatments for symptoms.ConclusionsThe therapeutic trajectories of patients with rare symptoms are similar in terms of initial symptoms and first consultation. However, their paths diverge at the diagnostic stage, with diverse experiences related to these journeys, largely based on having a diagnosis and whether there is a specific treatment. Rare conditions in Chile requires further attention and urgent action that considers those who live with them and their families.

Barriers and facilitators to implementing a first managed alcohol program in Montreal, Canada

Background Indigenous people experiencing homelessness, are disproportionately affected by the health risks associated with alcohol use. Managed alcohol programs (MAPs) are interventions that address alcohol use and homelessness by providing housing and regulated doses of alcohol. While research has shown MAPs to be beneficial, little is known about their implementation. Our paper addresses this gap by exploring the barriers and facilitators to implementing a MAP for Indigenous men in Montreal, Canada. Methods The study follows a qualitative approach. Semi-structured and informal interviews along with questionnaires were conducted with the program’s residents, staff and medical team members. The collected data were thematically analyzed. Results Participants identified barriers including resistance to adhering to the individualized alcohol plan, hostile behaviours and conflicts, loss of purpose and boredom, and staff workload and turnover. The facilitators reported were teamwork, flexibility, cultural safety, and trusting relationships. Conclusion Our findings about certain barriers, particularly hostile behaviours and conflicts, and staff workload and turnover, remain undocumented in the literature. Certain facilitators including flexibility, trusting relationships, and cultural safety merit further exploration. In offering a detailed description of the implementation of a MAP, we hope to inform policies supporting the dissemination of similar programs in other contexts.

Care of tracheostomized children

Tracheotomy is an emergency surgical procedure that first appeared and was developed in ancient times. Surgical techniques for tracheotomy have been perfected in modern times, and in adults it is one of the most common surgical procedures performed in emergency departments and intensive care units worldwide. In children, however, tracheotomies present far greater challenges to the medical teams involved. A number of related issues - indications and contraindications, time to perform, and protocols for decannulation, among others - still need to be clarified. In recent years, the development of medical science, the introduction of vaccination programs, the use of many improved medical materials and technologies, and the achievements in neonatal and pediatric intensive care have changed the focus of pediatric tracheostomy from its emergency performance to solve acute asphyxiation problem to its implementation in children, who represent a complex group of patients with permanent dependence on tracheostomy and related medical technologies for long-term survival. There is a growing number of children who have had complex therapy and for whom tracheostomy care and mechanical ventilation are part of their care, including in the home environment. This in turn raises new questions: Who will care for the child in the early post-operative period and after hospitalization? Who will train people to care for the tracheostomized child at home? What precautions should be taken with these children during their daily activities, including eating, bathing, and playing inside and outside the home?

45 Anastomotic leakage and peritonitis secondary to cocaine consumption after elective colorectal surgery

Abstract Introduction Many well-known factors contribute to the success or failure of an intestinal anastomosis. Cocaine is a sympathomimetic drug, with an important effect on the cardiovascular system, more precisely a peripheral vasoconstriction. In patients who have recently undergone surgery with an intestinal anastomosis, the vascular supply of that union is a crucial aspect to bear in mind, and any situation favouring vasoconstriction can have an effect on adequate healing. Case report We present the case of a 54-year-old male, with medical history of a gastrointestinal bleeding due to a gastric ulcer. He was admitted to our tertiary care university hospital for an acute decompensation of heart failure with severe aortic insufficiency, caused by bacterial endocarditis, which ended up needing cardiac surgery and implantation of a prosthetic biological valve. During the work-up study of the endocarditis, an abdominal CT-scan incidentally diagnosed a tumour in the right colon. Colonoscopy was performed and the biopsy confirmed an adenocarcinoma, without metastasis. The patient underwent an elective intervention: laparoscopic right colectomy, with a hand-sewn ileo-colic anastomosis, uneventful. There were no complications during the immediate postoperative period. The patient was able to eat orally within 3 days, the stool was normal in consistency, and the lab-results were normal in the second and fourth day including WBC and C-reactive protein. The patient was discharged on the 6th postoperative day. Six days after (twelve after the surgery) the patient came to the Emergency Department (ED) referring intense abdominal pain, with increasing tenderness in a time-lapse of 12 hours approximately. New lab tests showed elevated WBC, and CRP of 250 mg/l. A CT scan was performed showing pneumoperitoneum in the proximity of the anastomosis, free fluid inside the abdominal cavity and signs of low perfusion in the small bowel. He was taken to the OR and a mid-line laparotomy was performed. A localized peritonitis was found, due to anastomotic leakage with ischemia of the terminal ileum. A resection of the affected colon was performed, and it was decided to make a new ileo-colic anastomosis. The postoperative period was, again, uneventful and the patient completed antibiotic treatment and was discharged after 12 days. That same day, before going home, he confessed to the medical team that since the first day he arrived home after surgery, he consumed ‘excessive amounts’ of cocaine. So he had been consuming cocaine daily for 6 days until he returned to the ED with the leak. Conclusions The patient described had many cardiovascular risk factors, which could have affected the blood supply of the primary anastomosis like the aortic valve endocarditis, or the cardiac surgery just 2 months before. However, he had surgery with those conditions and everything went well without complications. The only new variable in those 6 days while the patient was at home was the consumption of cocaine. The importance of this clinical case is that as General Surgeons, we should know the factors that affect the success or not of an intestinal anastomosis: good technique, tension-free segments and an adequate blood supply. In this last aspect, cocaine consumption is not usually mentioned by patients when taking their medical history, but it can have an important impact, generating peripheral vasoconstriction with ischemia and resulting in anastomotic leakage and peritonitis.