Multidisciplinary Care Team Research Articles

Impact of Multidisciplinary Team Management on Survival and Recurrence in Stage I–III Colorectal Cancer: A Population-Based Study in Northern Italy

This study aimed to assess whether multidisciplinary team (MDT) management improves outcomes in patients with stage I–III colorectal cancer (CRC) compared to non-MDT care. This study included 460 CRC patients diagnosed from 2017 to 2018 in a northern Italian province, of whom 300 (65%) were managed by MDT. MDT patients were younger, more frequently had rectal cancers, were diagnosed at earlier stages, and were more likely to undergo surgery and chemotherapy. Disease-free survival (DFS) and overall survival (OS) were significantly better in the MDT group. The recurrence rate was 8.5%, with no significant differences between MDT and non-MDT patients, although MDT patients exhibited lower recurrence rates for early-stage tumors. A multivariable analysis showed that DFS and OS were adversely affected by older age, advanced stage, and lack of MDT management. Kaplan–Meier estimates demonstrated a 3-year DFS of 78% in the MDT group versus 65% in the non-MDT group, as well as an OS of 83% versus 69%, respectively. The MDT approach was associated with improved treatment adherence and better management of recurrences. While limited by a small sample size, this population-based study highlights the beneficial impact of MDT care on CRC outcomes. Further research with extended follow-up is warranted to confirm these findings.

Letter to the Editor: Exploring the integration of dentistry within a multidisciplinary palliative care team: does bedside dental care improve quality of life and symptom burden in inpatient palliative care patients?

Letter to the Editor: Exploring the integration of dentistry within a multidisciplinary palliative care team: does bedside dental care improve quality of life and symptom burden in inpatient palliative care patients?

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.

Harmonizing high-risk pregnancies: A comprehensive investigation into maternal and fetal well-being

High-risk pregnancies are a global concern, with maternal and fetal well-being at the forefront of clinical care. Pregnancy’s three trimesters bring distinct changes to mothers and fetal development, impacting maternal health through hormonal, physical, and emotional shifts. Fetal well-being is influenced by organ development, nutrition, oxygenation, and environmental exposures. Effective management of high-risk pregnancies necessitates a specialized, multidisciplinary approach. To comprehend this integrated approach, a comparative literature analysis using Atlas.ti software is essential. Findings reveal key aspects vital to high-risk pregnancy care, including intervention effectiveness, case characteristics, regional variations, economic implications, psychosocial impacts, holistic care, longitudinal studies, cultural factors, technological influences, and educational strategies. These findings inform current clinical practices and drive further research. Integration of knowledge across multidisciplinary care teams is pivotal for enhancing care for high-risk pregnancies, promoting maternal and fetal well-being worldwide.

Patient Experiences of Long-term Pain and Pain Management Following Pelvic Exenteration for Locally Recurrent Rectal Cancer: A Qualitative Study.

Although pain may persist for patients who undergo pelvic exenteration for treatment of locally recurrent rectal cancer, studies exploring patient experience of postoperative pain and its management remains limited. This study aimed to explore patient experiences of postoperative chronic pain and management following pelvic exenteration. Qualitative cohort study of patients who have undergone pelvic exenteration for locally recurrent rectal cancer. The study was conducted through one-on-one semi-structured telephone interviews. Seventeen patients with locally recurrent rectal cancer who underwent pelvic exenteration between January 2018 and December 2020 were included. Semi-structured interviews explored participants' experiences of pain including its impact on life and management strategies at six and twelve months following exenteration. Interview transcripts were analyzed by two researchers using inductive thematic analysis. Participant experiences of pain following exenteration are reflected by three themes identified: 1) adapting to long-term consequences of pelvic exenteration including pain, 2) reluctance to take pain medications, 3) engaging multidisciplinary care team is essential to post-pelvic exenteration chronic pain management. Several participants reported ongoing intermittent pain following surgery that significantly affected various aspects of their lives. This prompted participants to adapt their lifestyle and explore alternative pain relief methods as some were hesitant to rely on analgesics. The small sample size from a single center whereby all patients underwent curative pelvic exenteration for lower recurrent rectal cancer with none undergoing the procedure for palliation limits the generalizability of the results of this study. While chronic pain following pelvic exenteration for locally recurrent rectal cancer interferes with patient's postoperative quality of life, analgesia use was influenced by pain habituation and fear of dependence on pain medications. Our findings emphasize the further need to investigate a multidisciplinary approach, including non-pharmacological methods, for optimization of pain outcomes following pelvic exenteration. See Video Abstract.

Clinical impact of multidisciplinary team management on postoperative short-term outcomes in colorectral cancer surgery.

The multidisciplinary team (MDT) approach has become the standard for perioperative patient care. At our institution, a multidisciplinary perioperative care team called "Surgical, Nutrition and Rehabilitation Integrated Services for Excellence Team (SUNRISE)" was established for all patients with gastrointestinal cancer undergoing surgery. This study aimed to elucidate the significance of SUNRISE as a perioperative MDT by comparing short-term postoperative outcomes before and after the introduction of SUNRISE in patients with colorectal cancer. We included 181 patients diagnosed with colorectal who underwent radical surgical resection with regional lymphadenectomy. The patients were divided into two groups: the pre-SUNRISE group, consisting of 105 patients who underwent radical colorectal surgery before the introduction of the SUNRISE, and the SUNRISE group, consisting of 76 patients who underwent radical colorectal surgery after the introduction of the SUNRISE. We compared the short-term postoperative outcomes between these two groups and analyzed the risk factors affecting postoperative complications using logistic regression models. The incidence of postoperative complications in the SUNRISE group was significantly lower than that in the pre-SUNRISE group (22.4% vs. 41.0%, p = 0.011). Multivariate analysis identified the presence of SUNRISE (odds ratio, 0.33, 95% confidence interval, 0.15-0.73, p < 0.006) as an independent risk factor for postoperative complications. The median postoperative hospital stay in the SUNRISE group was significantly shorter than that in the pre-SUNRISE group (9 vs. 11days, p < 0.01). The MDT approach is useful for optimizing preoperative patient care and improving short-term postoperative outcomes in patients with colorectal cancer.

Psychosocial Needs of People Living With Pleural Mesothelioma and Family Carers: A Mixed Methods Study.

Mesothelioma is a cancer of growing global incidence, especially in developing countries, with unique complex psychosocial impacts on patients and their carers. To provide a comprehensive understanding of the psychosocial needs of people living with pleural mesothelioma and family carers. A mixed methods design with 61 semi-structured interviews and psychometrically validated questionnaires to assess pleural mesothelioma patients' (n=36) quality of life and frailty and carers' (n=25) caregiving experiences, quality of life, and pre-loss prolonged grief symptoms. People with mesothelioma (29 men, 7 women, aged 46-89years) indicated moderate quality of life; 18 (50%) met criteria for frailty. Current carers (21 women, 4 men; aged 41-79years) generally reported positive caregiving experiences and high quality of life; 5 (20%) scored in the range indicative of risk for prolonged grief disorder. Four themes were generated: a desire for tailored information with bespoke detail, assistance to coordinate tasks of treatment, improved social and peer support, and effective psychological services. Needs varied, with main concerns being about breaking the news to spouses/children, the impact of the disease and death on family, loss of personal future, managing psychological symptoms, and avoiding burden. These specific and unmet psychosocial needs provide a strong basis for individualised care pathways to address these needs via the integration of psychology into the multidisciplinary care team and the development and evaluation of mental health and wellbeing interventions for mesothelioma patients and carers. Doing so will reduce psychosocial distress and improve residual vitality.

Simulation-based training to improve provider-preparedness for amniotic fluid embolism: A lived experience

BackgroundAmniotic fluid embolism (AFE) is a rare, yet deadly obstetric (OB) crisis. Simulation-based training (SBT) can promote provider self-confidence and protocol adherence for multidisciplinary OB care teams during AFE. MethodsTwo multidisciplinary samples of participants were included in this quality improvement project. Sample 1 engaged in SBT for which they were assessed for confidence and protocol adherence at three timepoints: baseline, immediate post-simulation and four months post-simulation. During the implementation phase of this project, an inpatient experienced AFE, leading to increased staff interest in AFE education and training and the need for a second sample. ResultsSample 1: Significant improvement was shown for all confidence items between baseline and initial post-simulation assessments (p < .05) which was sustained at four months post-simulation. Significant improvement in protocol adherence scores were shown between the baseline and repeat simulations (p = .004) which were sustained at four months. Sample 2: Significant improvement was noted for 4 out of 5 confidence items between pre- and post-simulation confidence assessments (p < .001). ConclusionThis project demonstrated that SBT contributed to increased confidence in management of AFE.

Primary clinics achieving regular follow-up of patients: Teamwork aspects among healthcare staff

Abstract Backgrounds Studies have shown that more temporally regular primary care visits, or visits more evenly spaced in time, are associated with improved patient outcomes. However, no study has examined what clinic staff can do to encourage greater temporal regularity (TR). We aimed to understand factors related to healthcare staff dynamics that contribute to higher TR for adults with chronic conditions. Methods The study is part of a two-stage mixed methods project. In the first stage, we ranked clinics according to their TR level. In this qualitative stage, we interviewed staff at 6 clinics with extremely high TR (regular follow-up with primary care physician, or PCP), and 6 clinics with extremely low TR. Interviews were conducted with 15 PCPs, 12 nurses, 15 administrative staff, and 4 pharmacists between July 2022- September 2023. Interviews were audiotaped, transcribed, and analyzed using Atlas qualitative analysis software. Findings Themes emerged regarding best ways to promote regular follow-up of patients with chronic conditions. Strategies included having a defined system to reach out to no-show patients, having routine staff meetings to discuss no-shows, adapting workflow to meet the needs of challenging patients, dealing with bureaucracy on patients’ behalf, informal channels of communication with patients, and consulting social workers more often. Relational aspects among staff members at high TR clinics emphasized flat as opposed to hierarchical relationships, as well as high levels of teamwork. Conclusions Teamwork between staff members in primary care settings can contribute to more proactive care delivery, with greater potential to prevent long-term complications. The findings suggest that a high-functioning multidisciplinary care team that focuses on creating the right sorts of interactions and teamwork among staff members, and uses proactive strategies to help engage patients, can contribute to more temporally regular care and thus improved outcomes. Key messages • Stronger teamwork and flat relationships between staff members in primary care settings can result in proactive medicine and developing strategies that improve patients’ regular follow-ups. • Programs focusing on how medical staff utilize their dynamics/relations to improve health outcomes and how doctors’ role align with the staff, can facilitate regular follow-ups of challenging patients.

The Effect of Multidisciplinary Care on Polypharmacy in Advanced Cancer Patients near the End of Life

Abstract Objectives Multidisciplinary Team (MDT) aims to integrate cancer patient care plans and provide holistic care to improve clinical outcomes and quality of life. However, there is a lack of empirical evidence regarding the effect of MDT on polypharmacy in advanced cancer patients near the end of life, which warrants further investigation. Methods This retrospective cohort study utilizes the National Health Insurance Research Database (NHIRD), Taiwan Cancer Registry, and Cause of Death Statistics, provided by the Health and Welfare Data Science Center (HWDC), Ministry of Health and Welfare (MOHW). The study subjects were patients who were diagnosed with stage III or IV cancer, aged 65 or above, experienced recurrence or metastasis, and who died between 2014 and 2020. Propensity score matching (PSM) was employed, followed by analysis using the Generalized Estimating Equation (GEE) to examine the differences in the risk of polypharmacy in the last 30 days before death. In addition, to confirm the robustness of the results, we conducted two different sensitivity tests: the first way is to use different ages as sample selection criteria and only include people who died over 75 years old as study subjects; the second way is to use conditional logistic regression models as a multivariate statistical method. Results There were 35537 samples before matching, including 4942 who received MDT care and 30595 who did not. After 1:1 matching, 9884 patients were finally included in the analysis. The prevalence of polypharmacy significantly decreased during the study period from 59.90% to 58.80% (p = 0.03; trend test). When examined through different PIM criteria, patients who received care from MDT exhibited a lower risk of polypharmacy (OR = 0.91, 95% CI = 0.84-0.98). Conclusions Advanced cancer patients who received care from MDT during the end-of-life period had a significantly lower risk of polypharmacy. Key messages • The prevalence of polypharmacy significantly decreased during the study period from 2014 to 2020 among advanced cancer patients. • Advanced cancer patients who received care from MDT during the end-of-life period had a significantly lower risk of polypharmacy.

Nursing Roles in Extracorporeal Membrane Oxygenation

ABSTRACT Extracorporeal membrane oxygenation (ECMO) is a type of mechanical circulatory support that is increasingly utilized in the United States for severe respiratory and/or cardiac failure refractory to conventional therapies. It is an expensive and complex life support modality. Moreover, patients on ECMO are critically ill and require a strong multidisciplinary care team. A successful ECMO program involves a trained team consisting of physicians, perfusionists, nurses, and respiratory therapists. This article discusses the multiple roles of ECMO nurses, the various ECMO delivery care models, and the potential cost savings of an RN ECMO specialist staffing model—and introduces the novel role of the ECMO lead.

Expanding the primary care workforce by integrating genetic counselors in multidisciplinary care teams.

Collectively, rare diseases are common, affecting approximately 8% of the population in Canada and the USA. Therefore, the majority of primary care (PC) clinicians will care for patients who are affected or at risk for a genetic disease. Considering the increasing ways in which genetics is being implemented into all areas of healthcare, one way to address these needs and expand the capacity of the PC workforce is through the integration of genetic counselors (GCs) into PC multidisciplinary teams. GCs are Masters-educated allied health professionals with specialized training in molecular genetics, communication, and short-term psychotherapeutic counseling. The current models of GCs in PC mimic other multidisciplinary models. Complex tasks related to genetics, such as pre- and post-test counseling, genetic test selection, and results interpretation, are conducted by GCs, which, in turn, allows physicians, nurse practitioners, and other PC providers to work at the top of their scope of practice. Quality genetics services provided by GCs improve clinical outcomes for patients and their families; the simultaneous provision of genetic education and psychological support by a GC is associated with an increase in patient knowledge, perceived personal control, decrease in distress, and can lead to positive health behavior changes, all of which are aligned with the goals of primary healthcare. With their extensive training in clinical care, medical communication, and psychotherapeutic counseling, integrating GCs into PC care teams will improve the care patients receive and allow PC clinicians to ensure their patients are at the forefront of the personalized medicine revolution.

18 Past and current care practices for neonates with complex medical needs: A scoping review to support clinical program evaluation

Abstract Background Neonates with complex medical needs (NCMN) are a rapidly growing patient population internationally. Although NCMN are a relatively small proportion of all Neonatal Intensive Care Unit (NICU) admissions, they are high healthcare utilizers. Since 2018, a dedicated Neonatal Complex Care Team (NCCT) has cared for NCMN at a large quaternary care center. The NCCT cares for NCMN in a dedicated, single-family room, patient area within the NICU. This model of care has yet to be evaluated for its potential impact on healthcare outcomes. Objectives The objective of the scoping review is to determine the breadth of available literature on the care practices for the management of NCMN and to collate the available evidence to define outcome measures to be used in a formal program evaluation. Design/Methods The review followed the PRISMA extension for scoping reviews and utilized resources from the Joanna Briggs Institute. The two databases that were utilized include Medline via OVID and CINAHL. The dates for included publications are January 1st 1993, until July 15th 2023. Only studies published in English and primary research were included. Two independent reviewers performed the initial title and abstract screening, and the full text review. The data extraction was completed by one independent reviewer. Results 102 articles were included in the title and abstract screen, and 12 were considered for full text review. Four articles were included. Interventions discussed in the included articles ranged from discharge conferences with patient’s caregivers, to the implementation of an entirely new model of care. Multidisciplinary health care teams appear to be integral to the in-hospital care and smooth discharge of NCMN. We identified that caregiver involvement and satisfaction are important to the discharge process as they are primarily responsible for their infant’s care after discharge, and so it is important that the specifics of care are communicated and taught effectively. The outcomes of interest identified as most useful for clinical program evaluation were length of stay and readmission rate. Additionally there was limited data reported on long-term health outcomes of this patient population. Conclusion This scoping review identified few articles that reported new models of care, a lack of consistent outcomes used in evaluating existing care models and overall a gap in research in this rapidly growing patient population. There is more work to be done to improve care of NCMN and our findings will be used in designing future studies that evaluate care models.

Knowledge, Awareness, And Practice Of Multidisciplinary Team (MDT) Involved In The Rehabilitation Of Head And Neck Cancer Patients Regarding Post-Radiotherapy Prosthetic Options.

BACKGROUND: Head and neck cancer (HNC) patients require specialized multidisciplinary team care throughout the diagnosis, treatment, and survival. To achieve rehabilitation goals, a multidisciplinary team (MDT) should have adequate information regarding post-radiotherapy prosthetic options. This enables optimal rehabilitation and improves their quality of life. AIM: To assess the Knowledge, awareness, and practice of a multidisciplinary team involved in the rehabilitation of Head and Neck cancer patients regarding post-radiotherapy prosthetic options. SETTINGS AND DESIGN: Descriptive survey. MATERIALS AND METHODS: The URLs of the questionnaire consisting of fifteen closed-ended questions were shared via the web to the MDT team practicing in Tamilnadu and Pondicherry, to obtain a response of 119 which was the predetermined sample size. STATISTICAL ANALYSIS: Frequency and percentages and the results were further analysed statistically by the Chi square test. RESULT: Majority of the members in the multidisciplinary team were aware of few information on the impact of common treatment side effects on prosthetic rehabilitation and prosthetic options available, but were not practicing. CONCLUSION: Prosthetic options in postradiotherapy patients provides better results in terms of retention, stability, masticatory efficiency, comfort, and psychological well-being of the patient. Hence, the awareness of MDT should be increased regarding various available options of the prosthetic rehabilitation, advantages and disadvantages of prosthesis, and possibilities for retreatment in the case of failure for a successful treatment outcome.

Prevalence and exploratory factor analysis of long COVID-19 symptoms among experienced infected population in Bangkok, Thailand

BackgroundPatients with long COVID may experience various concomitant symptoms caused by inflammation, which affect their lives and well-being. In this study, we aimed to (1) investigate the prevalence of long COVID; (2) explore the levels of symptom severity and functional disability owing to long COVID, overall health, and their relationship; and (3) conduct exploratory factor analysis of long COVID-19 symptoms among experienced infected population in the capital of Thailand.MethodsA cross-sectional research design was used and a sample of 337 community members with previously COVID-19 infection in Bangkok, Thailand was recruited for this study. Purposive sampling was used. Data collection was performed using an online and a paper-based questionnaire. Descriptive statistics (number, percentage), odds ratio, exploratory factor analysis, and Spearman’s rank correlation coefficient were used for the data analysis.ResultsThe prevalence of long COVID was 32.9%. The main reported symptoms included anxiety (28.5%), fatigue (26.1%), and dyspnea (13.4%). There was a significant relationship between symptom severity and functional disability (rs=0.385, p value < 0.01). Overall health was negatively correlated with symptom severity (rs = − 0.291, p < .01) and functional disability (rs = − 0.108, p < .05). Using principal component analysis with Promax rotation, three clusters were identified, explaining 71.44% of the total variance. The Clusters comprised (1) common symptoms of long COVID and communication, (2) fatigue, functioning, and nutritional concerns, and (3) psychosocial impacts.ConclusionsThe present results might help multidisciplinary care teams understand the concurrent symptoms of patients with long COVID and develop rehabilitation care programs to ease all symptoms simultaneously and improve patients’ quality of life.

Cause of death for heart transplant patients, an autopsy study

IntroductionHeart transplantations are lifesaving for patients with end-stage heart failure. It is pertinent for the multidisciplinary care team to understand how heart transplant patients succumbed to death and the complications that occurred. In this study, we performed a comprehensive retrospective review of all the autopsies performed in our institute for heart transplant patients and report the trend of demographic data, cause of death, and autopsy findings. Materials and methodsReports, photos, and slides of autopsies performed at our institute from 1990 to 2023 for heart transplant patients were reviewed. Pertinent demographic data (age, gender, pretransplant diagnosis), clinical data (clinical history of rejection, complication, time interval from transplant to death, clinical cause of death) and pathological findings (allograft pathology, infectious etiology, other findings related to cause of death) were reviewed, documented, and analyzed. ResultsWe identified 88 cases, consisting of 53 male and 35 female patients. The median age at transplant was 26 years, while 28.5 years was the median age at death. The median interval from transplant to death was 10 months. The cases were classified in three categories based on length of survival post-transplant: Superacute (<1 month, 21%), Early (1 month-12 months, 30%), and Late (> 12 months, 49%). Slides were unavailable for review in 15 cases, which were excluded from cause of death (COD) evaluation. We categorized 41.1% of cases as allograft-related COD and 58.9% as non-allograft-related COD. Six of the CODs were not perceived premortem. These unexpected CODs included moderate/severe acute cellular rejection in a patient with a recently negative biopsy, dehiscent suture caused by a fungal abscess, an aorto-bronchial fistula, CMV myocarditis, acute abdominal bleeding, and ruptured atherosclerotic plaques with acute myocardial infarction. ConclusionWe systematically reviewed 33 years of heart transplant autopsies. We found that 41.1% of deaths were allograft related, with infection being the most frequent COD. While the rate of unexpected findings was low, the findings demonstrate the continued utility of autopsy in patient evaluation.

Impact of a PD-L1 Learning Collaborative: outcomes from a mixed-methods evaluation

Abstract Introduction/Objective PD-L1 Immunohistochemistry testing is often required to determine eligibility for immune checkpoint inhibitor therapy. An ASCP PD-L1 Learning Collaborative (LC) was formed aiming to: 1) identify ways to streamline PD-L1 testing; 2) encourage members to locally implement changes; and 3) develop a resource guide for the community. Methods/Case Report The PD-L1 LC (n=38 pathologists and laboratory professionals) participated in 3 activities: 1) 4 meetings in which LC members discussed current literature and practice; 2) 3 30-minute on-demand, credit-bearing panel videos, in which selected LC members summarized the LC outputs and shared their experiences; and 3) a guide summarizing resources relevant to streamlining PD-L1 testing. The mixed-methods evaluation included: 1) five- minute surveys before (n=24), immediately after (n=11) and 7-months post-LC (n=17); 2) polling questions (2-4 per meeting); 3) semi-structured interviews (n=5). Quantitative data was analysed using descriptive and inferential analysis, qualitative data using a thematic analysis / inductive reasoning approach. Results (if a Case Study enter NA) Baseline data confirmed delays in testing caused by unstandardized PD-L1 testing processes and suboptimal confidence in PD-L1 validation and methodologies. Post-LC, members self-reported perceived increased knowledge and higher confidence levels regarding discussion of PD-L1 scientific evidence and best practices. At the 7-month follow-up, 59% of respondents reported at least one PD-L1-related practice change, with 29% of participants selecting:1) Improving protocols for specimen acquisition, handling, or processing; 2) Improving communication with multidisciplinary care team; 3) Optimizing biomarker testing workflows. Remaining suboptimal knowledge post-LC suggests need for further educational efforts. Participants identified “Tumor-specific considerations” as the main resource missing for PD-L1 testing. Conclusion A learning collaborative has shown impact in improving PD-L1 testing processes and related practices among a group of pathology professionals. The group successfully made available three panel videos and a resource guide, and PD-L1-related practice changes were reported. Future initiatives should address remaining gaps and develop tumor-specific PD-L1 testing considerations.

A rare case of IgG4-related aortitis in the thoracic aorta mimicking an intramural hematoma: navigating the diagnostic labyrinth

A 54-year-old female presented with recurrent abdominal pain and new onset chest pain. Chest computed-tomography angiogram detected a thoracic aortic aneurysm with suspected Type A intramural hematoma (IMH) versus aortitis. Initially, conservative management was pursued while awaiting a definitive diagnosis. Differential workup was negative, while additional imaging modalities favored IMH, prompting expedited surgical intervention. During ascending aortic and hemiarch replacement, severe aortitis was unexpectedly discovered without evidence of IMH. Histopathological examination of the aortic specimens identified transmural aortic inflammation with lymphoplasmacytic infiltrate and irregular fibrosis. Numerous IgG4-positive plasma cells were present with IgG4/IgG ratio of 40–50% suggesting IgG4-related disease (IgG4-RD). Subsequent analysis revealed B cells positive for clonal IgH gene rearrangement, and bone marrow biopsy then revealed the same clonal B cells. She was ultimately diagnosed with CLL, the most common phenotype of monoclonal B-cell lymphocytosis, thought to account for the IgG4-predominant plasma cells causing aortitis. Although rare, this case highlights the importance of considering IgG4-related disease (IgG4-RD) as a cause of aortitis when assessing symptomatic patients with aortic pathologies, emphasizing the complexities involved in diagnosing due to a variety of imaging presentation, differentiating, and managing large-vessel vasculitides. Moreover, it underscores the importance of Multidisciplinary Aortic Team care and the use of multiple diagnostic modalities in evaluating ambiguous aortic pathologies.

Roles of pediatric surgeons in palliative pediatric oncology.

Pediatric surgeons engaged in oncology will inevitably treat patients receiving palliative care, but their role in this context is poorly described. This article identifies some of the challenges and opportunities of surgical involvement in pediatric oncology palliative care, underscoring how the surgeon's expertise can be exploited to significantly benefit children with cancer. Specific examples of skills (procedural, communication, and coordination) that surgeons can provide to the multidisciplinary palliative care teams are described and the importance of collaboration is highlighted.

Ambulation in patients with peripheral veno-arterial extracorporeal membrane oxygenation and concomitant femoral intra-aortic balloon pump support.

The mobilization and ambulation of patients with severe cardiogenic shock supported with peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) and concomitant femoral intra-aortic balloon pump (IABP) support is not well-described. This technical paper describes an ambulation protocol to prevent deconditioning in this critically ill patient population. A protocol for the ambulation of patients with pVA-ECMO and concomitant IABP support was created in December 2022 and implemented at a single center. To initiate ambulation, patients were initially placed in a vertical position utilizing the VitalGo Total Lift Bed (VitalGo Systems, Miramar, FL) with mechanical circulatory support device monitoring performed by a critical care multidisciplinary team. Retrospective analysis of successfully ambulated patients was performed from December 2022 to January 2024. A total of 35 patients out of 112 patients with ECMO support were ambulated in the study period. Four of these patients had pVA-ECMO with concomitant IABP support with this cohort completing a total of 11 sessions during the study period. Patients ambulated an average of 200 feet per session without any adverse events, including cannula and balloon pump migration or displacement. Three of the four patients studied were either bridged to an advanced therapy including orthotopic heart transplant or durable left ventricular assist device or were discharged. A protocol for ambulation of CS patients with pVA-ECMO support and concomitant femoral IABP support is feasible and can safely be implemented in this critically ill patient population. Further multicenter studies are necessary to determine the overall impact of ambulation on patient outcomes.