Patient Blood Management: a systematic review of current international guidelines.

Thrombocytopenia, characterized by a platelet count less than 150 × 10^9/L, is a frequently encountered hematologic abnormality in pregnancy, observed in approximately 7-12% of all pregnant individuals. While gestational thrombocytopenia is the most common cause and is often benign, other underlying causes, such as immune thrombocytopenia (ITP), pre-eclampsia-related conditions like HELLP syndrome, and thrombotic microangiopathies (e.g., TTP, HUS, AFLP), may carry significant maternal and fetal risks. The current review aims to provide a comprehensive overview of thrombocytopenia during pregnancy, with emphasis on its differential diagnosis, clinical presentation, diagnostic workup, and management strategies. Particular focus is placed on conditions requiring urgent intervention, including thrombotic microangiopathies. We conducted a narrative review of published literature, consensus guidelines, and registry data. Emphasis was placed on clinical applicability, trimester-wise drug safety, and proposed diagnostic algorithms. Tables summarize platelet thresholds for delivery, transfusion indications, and drug safety profiles. The review reiterates that the causes of thrombocytopenia during pregnancy range from benign to potentially life-threatening. Gestational thrombocytopenia remains the most common etiology, typically requiring no intervention. In contrast, ITP and thrombotic microangiopathies often necessitate immunosuppressive therapy or plasma exchange. Differentiation is aided by clinical history, timing of onset, and accompanying systemic features. This review helps conclude that early recognition, appropriate triaging, and multidisciplinary coordination are essential to improve maternal and neonatal outcomes. Wherever feasible, therapeutic decisions must be individualized, balancing maternal benefit with fetal safety. Tables and figures should guide the clinician in applying evidence-based decisions across diverse clinical scenarios.

Over the past decade, metabolic dysfunction-associated steatotic liver disease (MASLD) has become a leading cause of chronic liver disease in Japan, with estimated prevalence rising from 33.7% (2020) to 44.8% (2040), owing to an aging population and lean individuals. In this narrative review, we summarize the epidemiology, pathogenesis, diagnostic strategies, and emerging treatments for MASLD and metabolic dysfunction-associated steatohepatitis (MASH) in Japan, culminating in a proposed ideal patient care pathway tailored to local needs. MASLD pathogenesis involves complex interactions between metabolic dysfunction, inflammation, insulin resistance, and genetic susceptibility. In Japan, a stepwise diagnostic algorithm is endorsed, starting with non-invasive liver disease assessments (NILDA) such as fibrosis-4, followed by imaging-based fibrosis evaluation and selective biopsy. We propose a two-tiered diagnosis combining first-line NILDA (fibrosis-4) with second-line NILDA (e.g., enhanced liver fibrosis, Mac-2 binding protein glycosylation isomer, cytokeratin-18 fragment, andserum type IV collagen 7S) to refine risk stratification, reduce unnecessary referrals, and optimize healthcare resources, with qualifying patients referred to a hepatologist and treatment plans based on imaging-based NILDA or liver biopsy. The management of MASLD/MASH relies on lifestyle modification and pharmacological agents targeting metabolic comorbidities. However, novel anti-fibrotic, anti-inflammatory, and metabolism-targeted therapies are advancing, with future treatment decisions expected to integrate genomic and metabolomic profiling alongside NILDA. The proposed care model is multidisciplinary, engaging physicians, hepatologists, dietitians, psychologists, pharmacists, and hepatitis medical care coordinators to address both hepatic and systemic metabolic care. This evolving paradigm emphasizes proactive, personalized care informed by real-world data and long-term monitoring to improve outcomes and quality of life for patients with MASLD/MASH in Japan.

Implementation of a Prenatal Hemorrhage Risk Screening Tool: A Quality Improvement Initiative.

The exponential growth of cancer survivors represents a major healthcare challenge, with more than 23 million people in Europe and 2.2 million in Spain requiring long-term specialized follow-up. Five-year survival has reached 60% in our country, creatinga growing population of long-term survivors who need comprehensive care beyond the stage of active oncological treatment. This consensus document between oncology and primary care professionals establishes a care framework based on shared management for the follow-up of cancer survivors. The proposed model is based on the principles of continuity and ongoing communication, equity in access, and efficiency in resource use, recognizing that the needs of these patients go beyond purely medical aspects to encompass physical, psychological, social, and functional dimensions. This proposal defines a dynamic risk stratification that enables the identification of high-risk patients, who will continue to receive preferential hospital follow-up, and low-risk patients, whose care can be led by primary care with the support of other specialists. Specific roles are established for each level of care, along with bidirectional communication pathways and multidisciplinary coordination tools that include shared medical records, agreed protocols, and rapid referral channels.

Ten Guiding Principles for the Management of Postcardiotomy Cardiogenic Shock: Salvaging the Unsalvageable.

Brachytherapy for rectal cancer: An overview of clinical competency development in contemporary practice.

ABSTRACT Introduction Secure text messaging systems (STMS) have largely replaced pagers in inpatient care, yet their operational, workflow, and safety implications in hospital medicine remain poorly understood. We evaluated perceived benefits, challenges, and improvement opportunities related to STMS use among hospitalist physicians and advanced practice providers (APPs) at a large academic medical center. Methods We conducted a cross-sectional, anonymous survey of 133 hospitalist physicians and APPs using Likert-scale items addressing message volume, urgency, platform preference, teamwork, workflow, safety, and well-being, along with open-ended questions. Quantitative data were summarized descriptively, and qualitative responses were analyzed using inductive thematic analysis. Results Sixty-four clinicians responded (48.1% response rate), with 59 complete surveys analyzed. Over half (57.6%) reported using STMS more than pagers, and more than 80% received ≤50 messages daily. Nearly all respondents rated message urgency as low to moderate. While most reported improved multidisciplinary coordination (93.2%) and teamwork (79.7%), 50.9% experienced alarm fatigue or cognitive overload, and 49.2% reported negative effects on well-being. Physicians were more likely than APPs to perceive adverse effects on teamwork (mean 2.71 vs. 3.50, p = 0.006). Qualitative themes included message overload, workflow disruption, and safety risks related to missed or delayed responses. Suggested improvements included urgency labeling, role-based routing, and clearer communication protocols. Conclusion STMS are valued for care coordination but may simultaneously contribute to communication burden, workflow fragmentation, and safety concerns. Hospital systems should adopt governance strategies, including triage tools, training, and role-specific expectations, to optimize digital communication while protecting clinician well-being and patient safety.

Aortoesophageal fistula (AEF) after thoracic aortic repair is a rare and devastating complication with an extremely high mortality (33-100%). Although emergency thoracic endovascular aortic repair (TEVAR) can provide immediate hemostasis, it does not address the underlying infection and therefore is insufficient for long-term survival. A staged multidisciplinary strategy may improve outcomes in selected patients: initial hemodynamic stabilization, early source eradication (esophagectomy), and delayed reconstruction. A 78-year-old woman, who had undergone total arch replacement 6 years prior, presented with sudden haematemesis. Endoscopy and CT confirmed secondary AEF. Emergency TEVAR successfully stabilized bleeding. Two days later, the patient underwent thoracoscopic oesophagectomy, cervical oesophagostomy, jejunostomy, and omental flap coverage. Parvimonas micra was isolated intraoperatively, and targeted antimicrobial therapy was continued for eight weeks. After achieving infection control and nutritional optimization, presternal ileocolonic reconstruction was performed on postoperative day 69. She was discharged home 94 days after the initial intervention and remains well, free of recurrence, at 7 months post-TEVAR. This case highlights the critical role of a well-executed staged strategy in contributing to favorable clinical outcomes from secondary AEF. Immediate TEVAR served effectively as a life-saving bridge. Crucially, the early multidisciplinary coordination allowed for the prompt removal of the oesophageal source within 48h, an intervention essential to prevent uncontrolled mediastinal sepsis. This sequence-haemostasis, early source control, and delayed extra-anatomical reconstruction-may provide a reasonable strategy for survival in selected high-risk patients.

Contained rupture of a mycotic abdominal aortic aneurysm (AAA) is rare and potentially fatal. While most cases involve Salmonella or Staphylococcus aureus, Escherichia coli is an uncommon cause.A man in his early 60s presented with acute E. coli prostatitis and a prostatic abscess. Abdominal ultrasound incidentally revealed a 3.8 cm infrarenal saccular AAA suspicious for contained rupture. Contrast-enhanced CT confirmed focal aortic wall disruption without active extravasation. Intravenous ceftriaxone and vancomycin were initiated, and serial imaging demonstrated stability. After infection control, endovascular aneurysm repair (EVAR) with an Endurant II stent graft was successfully performed. Recovery was uneventful and the patient completed targeted antibiotic therapy.This case illustrates an unusual presentation of E. coli-associated mycotic aneurysm detected before frank rupture. Early imaging, infection control and multidisciplinary coordination enabled a staged strategy with a favourable outcome.

Gastrostomy decision-making for people living with motor neurone disease (MND) is complex. While international studies report healthcare professionals' (HCPs) beliefs and practices in this area, little is known about the Australian context. To examine Australian HCPs' beliefs, clinical practices, and support needs regarding gastrostomy decision-making in MND. A national cross-sectional online survey of Australian HCPs involved in gastrostomy discussions (n = 123) was conducted, exploring five domains: 1) initiating discussions and timing; 2) patient education; 3) multidisciplinary coordination; 4) guideline use; 5) and professional development needs. Descriptive statistics were applied. Most HCPs initiated discussions about gastrostomy (74%), commonly prompted by swallowing difficulty, weight loss, or patient request. Although 72% believed discussions should occur before clinical indications, only 40% reported doing so. Earlier placement was favored in the context of respiratory decline compared with swallowing impairment, and 56% considered gastrostomy to be performed too late. Almost 40% used no formal guidelines, and 74% wanted further professional development. Australian HCPs valued person-centered practice, but belief-practice gaps highlight opportunities to improve consistency, timing, and quality of gastrostomy decision-making support. Enhanced national guidelines, improved multidisciplinary communication, and targeted professional development may help reduce delays and better align practice with evidence-based recommendations.

Comprehensive Cancer Centre Accreditation: Experience and Achievements of a Head Neck Cancer Unit.

Primary Amoebic Meningoencephalitis (PAM), caused by Naegleria fowleri, is a rare but highly devastating infection with a mortality rate exceeding 98%. Although historically sporadic, recent emerging cases and localized outbreaks have raised global concern. The disease's rapid progression and diagnostic complexity demand immediate and precise therapeutic intervention, as even minor medication errors can critically impact patient survival. Such medication errors, ranging from incorrect dosing to delayed administration,Primary Amoebic Meningoencephalitis (PAM), caused by Naegleria fowleri, is a rare but devastating infection with a mortality rate exceeding 98%. Although historically sporadic, recent emerging cases and localized outbreaks have heightened global concern. The disease's rapid progression and diagnostic complexity necessitate immediate, precise therapeutic intervention, where even minor medication discrepancies can critically affect survival outcomes. Medication errors ranging from incorrect dosing to delayed administration pose significant clinical and economic challenges, underscoring the need for robust strategic safeguards. Within this context, clinical pharmacists emerge as pivotal agents of patient safety. Their expertise in pharmacotherapy, drug interactions, and adherence to treatment protocols enables them to implement strategic solutions such as: Standardized treatment algorithms for anti-amoebic therapy to minimize dosing errors. Real-time medication reconciliation systems to prevent delays and ensure timely administration. Multidisciplinary coordination frameworks integrating pharmacists with physicians, microbiologists, and intensivists for rapid decision-making. Continuous training and simulation exercises to prepare healthcare teams for rare but high-stakes infections. Digital monitoring and AI-driven alerts to detect potential drug interactions or deviations from protocol. This article synthesizes case reports from the United States, Pakistan, and India, highlighting both historical and recent PAM instances. These narratives emphasize the evolving role of clinical pharmacists in identifying, preventing, and correcting medication-related issues. By bridging clinical insight with pharmaceutical precision, pharmacists not only enhance therapeutic accuracy but also strengthen institutional preparedness against rare infections. As global awareness grows, embedding clinical pharmacy into multidisciplinary care models represents a strategic solution essential not only for PAM but also for other emerging infectious threats where survival hinges on therapeutic precision.

Gynecologic Concerns for Children and Adolescents with Vascular Anomalies.

Blueprints of Care: A Two-Decade Global Bibliometric Atlas of Neurosurgical Nursing (2006-2025).

Uterine fibroids are a prevalent gynecologic condition traditionally associated with heavy menstrual bleeding and pelvic pressure. However, emerging evidence suggests that large uterine fibroids may also contribute to venous thromboembolism (VTE) by causing mechanical compression of pelvic veins and the inferior vena cava, leading to venous stasis and subsequent thrombosis. This narrative review aims to consolidate current knowledge, discuss diagnostic strategies and management approaches for fibroid-associated VTE, and raise clinical awareness about this often-overlooked complication. A comprehensive literature search was conducted across PubMed, PubMed Central, Embase, Scopus, and Google Scholar from January 2000 to April 2024. Studies examining the relationship between uterine fibroids and VTE, including case reports, observational studies, reviews, and management guidelines, were included. A descriptive synthesis of findings was performed. Twenty-four studies were included, demonstrating a consistent association between large uterine fibroids and increased VTE risk. Key mechanisms included venous compression, hormonal influences, and a fibroid-associated hypercoagulable state. Clinical presentations ranged from isolated deep vein thrombosis (DVT) to life-threatening pulmonary embolism (PE). Early diagnosis often relied on pelvic imaging such as ultrasound and MRI. Management strategies involved prompt anticoagulation, individualized surgical planning (primarily hysterectomy), and multidisciplinary coordination. In select cases, prophylactic anticoagulation was suggested for high-risk patients pending surgery. Uterine fibroids should be recognized as a potential etiology for unexplained VTE, particularly in women without classic risk factors. Early imaging, anticoagulation, and surgical intervention, when appropriate, can optimize outcomes. Further research is needed to establish standardized screening and management guidelines for this underrecognized cause of thromboembolic disease.

Introduction: Anterior mediastinal masses in pediatric patients represent a significant anesthetic challenge due to the high risk of respiratory and cardiovascular collapse, particularly during anesthetic induction and major thoracic procedures. Available evidence is limited and is based mainly on case reports, highlighting the importance of documenting clinical experiences that contribute to the understanding and management of these conditions. Case Presentation: We present the case of an 11-year-old female patient diagnosed with a large anterior mediastinal mass occupying the left hemithorax, with extension to the pulmonary vessels, associated with respiratory failure and recurrent pleural effusions. She underwent anterior sternotomy, left upper lobectomy, and tumor resection under balanced general anesthesia. The intraoperative period was complicated by massive hemorrhage, requiring activation of the massive transfusion protocol, advanced hemodynamic support, and prolonged invasive mechanical ventilation. In the immediate postoperative period, she developed severe hypoxemia and was admitted to the Pediatric Intensive Care Unit. Intervention and Results: Anesthetic management was performed using balanced general anesthesia, preserving spontaneous ventilation during induction and delaying neuromuscular blockade until the start of surgery. Management included invasive monitoring, vasopressor support, lung-protective ventilation strategies, and activation of the massive transfusion protocol. The patient developed postoperative respiratory failure requiring admission to the Intensive Care Unit. No complications attributable to the anesthetic technique were documented. Conclusion: This case highlights the need for an individualized and dynamic anesthetic approach in pediatric patients with mediastinal masses. It also underscores the additional challenges posed by emergency scenarios, in which a complete preoperative evaluation and access to advanced resources recommended in the literature are not always feasible. In this context, decision-making based on pathophysiology, adaptation to available resources, and multidisciplinary coordination are essential to optimize perioperative outcomes in high-risk patients. Article Details

Genitourinary (GU) trauma occurs in ~10% of polytrauma patients and ranges from immediately life-threatening injuries to delayed complications with significant morbidity. Effective management requires multidisciplinary coordination among trauma surgery, urology, radiology, orthopedics, and critical care teams. Management of renal injury has continued to evolve, and up-to-date application of adjunctive therapy is essential to optimize outcomes. Bladder injury is often associated with pelvic fractures; diagnosis, categorization, and management of urine flow reduces infection and complications. Knowledge of ureteral and urethral injury management principles, strategy, and timing has been shown to reduce long-term complications and morbidity. Genital injuries, while less common and less severe, may be managed using systematic evaluation and intervention to improve functional outcome. Long-term follow-up is critical across all GU injuries to monitor for complications, including hypertension, fistula, stricture, incontinence, sexual dysfunction, and impaired renal function. Early recognition and adherence to structured management principles are essential to optimize outcomes and preserve genitourinary function.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide, requiring a multidisciplinary approach for effective management. The MDT Project aimed to define and pilot a structured care model for HCC management in Italy, supported by the implementation of integrated care pathways (ICPs), to standardize organizational processes and ensure the organizational requirements needed for appropriate patient management. A multi-phase approach included a narrative review, semi-structured interviews with national experts, and the development of an optimal care model operationalized through a maturity model with 15 organizational elements. A total of 13 hospitals, selected to reflect national heterogeneity, participated in a pilot phase involving tailored action plans and hospital-specific ICPs. In total, ten hospitals proceeded to ICP implementation, and eight achieved certification by an external accreditation body. An expert consensus meeting subsequently validated the care model, key performance indicator (KPI) panel, and assessment tools. Organizational changes were assessed pre- and post intervention through the maturity model evaluation and a survey capturing clinicians' perceptions. Organizational improvements were observed primarily in areas directly targeted by the action plans, including the formalization of care-flow processes, multidisciplinary team structuring, case management, and coordination processes. More limited progress was seen in information systems and KPI monitoring, which require structural investments. Clinicians perceived the certification process as helpful in consolidating procedural standardization and documentation quality. The MDT Project piloted an organizational model for HCC management in Italy, focusing on care-pathway governance, multidisciplinary coordination, and center readiness. These findings represent an initial step toward broader implementation; future phases should incorporate clinical outcomes and patient-reported measures to evaluate the model's long-term impact.

Submental intubation is an alternative to tracheostomy when oral and nasal intubation are contraindicated in maxillofacial surgery. We report two cases of self-inflicted facial gunshot injuries in which pre-existing traumatic tracts were used to externalize reinforced endotracheal tubes, avoiding tracheostomy and additional incisions. Multidisciplinary coordination between anesthesia and surgical teams enabled safe airway management and unobstructed surgical access. Both patients remained intubated postoperatively for airway protection without airway-related complications. These cases suggest that, in selected trauma patients, existing tracts may provide a safe and efficient alternative to traditional submental intubation.