Multidisciplinary Involvement Research Articles

P40 A challenging case of new systemic lupus erythematosus

Abstract Introduction The diagnosis of systemic lupus erythematosus (SLE) and its distinction from systemic infection can be challenging. We present a case of new systemic lupus alongside endocarditis, which illustrates this problem. Case description A previously well, 35-year-old male tarmacer of mixed ethnicity, presented with a three months’ history of general malaise, arthralgia and weight loss of 20kg. Two weeks prior to admission he developed progressive confusion, headaches and imbalance. Clinical assessment revealed a pyrexial patient in delirium without focal neurological signs, a faint maculopapular facial rash, symmetrical synovitis, very few nailfold infarcts, a systolic and diastolic murmur and sterile haemato-proteinuria. No history of IV drug abuse. Investigations showed elevated ESR 61, CRP 217, WBC 11.70 and procalcitonin 7.0. He had AKI stage 2 (eGFR 35 with a urinary protein/creat ratio 162; homogenous ANA (1:1280) with positive dsDNA and crithidia-luciliae binding. C3 and C4 suppressed (0.59 and 0.13, respectively); One blood culture prior to broad spectrum antibiotics was negative. Assuming the possibility of Libman-Sacks endocarditis, the attending acute stroke physician initially also treated with pulsed IV steroids, as well as antibiotics. Due to the delirium, key diagnostic tests were technically difficult, although a transthoracic ECHO showed moderately severe aortic and mitral regurgitation that were not felt to be typical for infective endocarditis by the attending cardiologist. The ITU team offered sedation and controlled ventilation to enable all necessary investigations: trans-oesophageal ECHO showed vegetations of aortic and mitral valve leaflets with perforations of single leaflets, resulting in severe acute aortic and mitral regurgitation; a renal biopsy showed class 3 lupus nephritis and an MRI/A Brain showed widespread cerebral foci of restricted diffusion imaging. Consultation with the regional cardiothoracic centre advised urgent transfer for double metal valve replacement, performed on Day 8 post admission. Surgical inspection confirmed an aortic root abscess, and enrichment culture of the native valve subsequently grew Staph. aureus. In addition to IV antibiotics for infective endocarditis, he was continued on steroid taper and commenced on MMF for lupus nephritis. Discussion It can be difficult to differentiate between infective endocarditis and Libman-Sacks endocarditis, especially when there are no existing risk factors. In cases like these antibiotics and steroids can be started at the same time. In our case, we had a young gentleman with no prior medical history who had multiple compounding factors and barriers to fully investigate. Because of his agitation, he required sedation and that allowed the team to perform life saving investigations (renal biopsy and TOE). He ended up having a double metal valve replacement within 8 days post-admission. Multidisciplinary team involvement and close collaboration was of crucial importance in this case to ensure a safe patient outcome. Key learning points • This case illustrates the need to vigorously chase the possibility of concurrent infection in severe new SLE. Close collaboration between multiple specialities to achieve this is key, especially when a patient lacks agency due to their illness.

Anesthetic Management of a Child with Frontonasal Encephalocele and Hemifacial Microstomia Syndrome for Repair of Encephalocele and Microstomia Correction

AbstractAnesthetic management of a child with hemifacial microstomia and frontonasal encephalocele can be challenging due to factors such as a difficult airway, associated systemic conditions, young age, and prolonged operating time. Hereby, we outline the intraoperative management of a 3-year-old child undergoing repair of multiple defects requiring multidisciplinary involvement of neurosurgery, plastic surgery, and anesthesia team. In our case, a size 0 mask and hyper-angulated D-blade video laryngoscopy were used to prevent sac compression and facilitate intubation. Blood conservation strategies included tranexamic acid, precise fluid management, and maintenance of normothermia. Extubation was carefully planned, considering blood loss and airway edema, and performed when the child was fully awake, ensuring a stable postoperative period and successful recovery. This report emphasizes the importance of meticulous preoperative assessment, readiness for a challenging airway, efficient management of intraoperative blood loss, and the value of teamwork.

Admitting clinical department effect on outcomes for acute pulmonary embolism

Abstract Background Pulmonary embolism (PE) is the third most fatal cardiovascular disease and its management is often complex requiring multidisciplinary involvement. Aims To investigate whether there are differences between patient populations with acute PE and associated outcomes admitted to different clinical departments based on a German nationwide inpatient population. Methods We used the German nationwide inpatient sample to identify hospitalizations of patients with acute PE within the period 2005-2020. Patients were classified according to the department were they spent the longest duration of hospitalization (cardiology, general internal medicine, or pulmonology/critical care medicine). Patients admitted and treated to other departments were excluded from the analysis. Temporal trends of hospitalizations, as well as the impact of admitting departments on case-fatality were investigated with the cardiology department used as reference and after multivariable adjustment for age, sex, and comorbidities (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2020, own calculations). Results During the investigated period a total of 759,115 patients with acute PE were identified; of those 117,501 (15.5%) were admitted to cardiology, 37,726 (5.0%) were admitted to pulmonology/critical care, while the majority of 603,888 (79.5%) were admitted to internal medicine (Table 1). A trend towards increasing number of patients admitted to cardiology in recent years was observed as opposed to being admitted to internal medicine. The number of patients admitted to pulmonology/critical care appeared stable (Figure 1A). Patients admitted to cardiology were more likely to be younger (Figure 1B) and had less risk factors for acute PE, such as cancer and recent surgery. The PE severity indices were higher in patients admitted to cardiology with a higher prevalence of tachycardia, syncope, signs of right ventricular dysfunction and shock (Table 1). There was an overall trend towards decrease in systemic thrombolysis and increase in catheter-directed thrombolysis independent of the admitting department. Catheter-directed thrombectomy has increased when patients were admitted to cardiology and internal medicine, but not when patients were admitted to pulmonology/critical care. Trends for in-hospital mortality were decreasing linearly over time independent of the admitting clinical service. In the multivariable adjustment, admission to cardiology was associated with significantly reduced rates of in-hospital mortality (OR 0.73, 95% CI 0.71-0.74). Conclusion In this nationwide analysis, the majority of patients with PE were hospitalized in an internal medicine ward, while notably, cardiology admissions demonstrated unique patient characteristics compared to other departments and were associated with decreased in-hospital mortality, suggesting specialized care's potential benefits in PE management.Table 1Figure 1

4.C. Scientific session: Navigating through complex challenges of responding to outbreaks of multidrug-resistant organisms

Abstract Antimicrobial resistance is one of the top ten global public health threats according to the WHO, contributing to millions of deaths each year. While outbreaks of multidrug-resistant organisms (MDROs) are well studied in hospital and nursing home settings, knowledge gaps exist concerning the complex challenges of outbreaks of MDROs among vulnerable patient populations, such as patients with intellectual disabilities or elderly patients living longer at home with multiple comorbidities. The coordination of such outbreaks requires a multidisciplinary approach as these patients often receive care throughout different healthcare settings, including long-term care and home-based nursing care. We delve into the complexities of coordinating an MDRO outbreak response involving healthcare professionals from various healthcare settings. The challenges inherent to the coordination of multidisciplinary involvement and the use of innovative strategies for outbreak preparedness and surveillance, will be thoroughly examined based on scientific evidence and practice based experiences. Workshop objectives • To exchange experiences on managing cross-institutional outbreaks of MDROs • To foster deeper understanding of the complexities of multidisciplinary involvement during MDRO outbreaks among vulnerable patient populations The workshop structure: - A brief introduction will be provided on the generic challenges in providing long-term care to vulnerable patient populations carrying MDROs. We will subsequently illustrate potential challenges faced during a cross-institutional MDRO outbreak among these patients through a realistic scenario (5 min): A patient with severe intellectual and physical disabilities living in both a long-term care facility as well as with family at home, unexpectedly turns out to be carrying an MDRO after recent hospital admission. As the patient receives nursing care from both from family members and nursing staff in different healthcare settings, a cross-institutional MDRO outbreak has occurred requiring a coordinated response. - Hereafter, individual presenters will address evidence- and experience-based challenges faced in MDRO outbreak responses within the specific healthcare settings covered in the previously presented scenario. We will navigate through the scenario together with the participants, discussing practical and ethical dilemmas, and explore ways for containing the MDRO outbreak while maintaining effective and compassionate healthcare delivery. In addition, we will discuss the use of public health innovations, such as social network analysis as a basis for the development of a stress test exercise to improve preparedness for MDRO outbreaks, and the role of wastewater surveillance in MDRO outbreaks. Discussions will be facilitated by (online) voting tools to invite participants to exchange experiences (40 min). We conclude with an exciting quiz to summarize the key messages of this workshop (10 min). Key messages • Healthcare setting, knowledge, proportionality and well-being of vulnerable patients populations are important to acknowledge during cross-institutional MDRO outbreaks. • Novel stress test exercise and wastewater surveillance are potential methods to improve preparedness and surveillance, respectively, during cross-institutional MDRO outbreak responses.

7756 Gonadectomy in Individuals with Differences of Sex Development - A Prospective I-DSD Registry Study

Abstract Disclosure: M.A. O'Connell: None. A.K. Lucas-Herald: None. J. Bryce: None. M. Chen: None. J.H. Davies: None. M. Shnorhavorian: None. N. Atapattu: None. I. Bachynska: None. N. Birkebaek: None. M. Cools: None. K. Demir: None. L. de Vries: None. H. Elsedfy: None. M.A. Fahmy: None. E. Globa: None. R. Grinspon: None. G. Guaragna-Filho: None. G. Guerra-Junior: None. D. Janus: None. Z. Kolesinska: None. I. Mazen: None. S.M. O'Connell: None. S.N. Seneviratne: None. M. Stancampiano: None. G. Verkauskas: None. S.F. Ahmed: None. O. i-DSD gonadectomy surveillance consortium: None. Introduction: Gonadectomy may be indicated in people with differences of sex development (DSD), but variation in practice is reported. This study aims to determine, through prospective surveillance, the frequency of gonadectomy and associated care pathways in individuals with DSD internationally. Methods: All I-DSD centres were invited to participate; the study commenced in December 2022. Participating centres receive a monthly email asking whether a gonadectomy has been performed in an individual with DSD. Where informed consent for inclusion in the I-DSD Registry has been obtained in a reported case, a secondary survey captures additional clinical information. Results: Of 208 centres invited, 74 have responded to monthly email surveys. Over the first 12 months of surveillance, gonadectomies were reported in 71 individuals from 34 centres in 19 countries (median [range]: 1[1, 5]); 40 centres reported no gonadectomy. Secondary survey data are available for 30/65 (46%) of reported cases to date. Twenty-four (80%) individuals are female; median (range) age at gonadectomy was 9.2 (2.1,20.0) years. All had specialist multidisciplinary team involvement prior to gonadectomy: endocrinology (97%), genetics (77%) and psychology (67%) were most frequently involved. Gonads were intra-abdominal in 25/30 (83%). Differences of gonadal development (13/30 [43%]) and Turner syndrome (8/30 [27%]) were the most frequent underlying DSD. Pre-gonadectomy investigations included: hormonal testing (28/30 [93%]), imaging (23/30 [77%] - US alone n=14; US + MRI n=7; MRI alone n=2), direct visualisation at laparoscopy (7/30 [23%]) and gonadal biopsy (2/30 [7%]). Bilateral gonadectomy was undertaken in 25/30 (83%). Mitigation of future malignancy risk in the context of gonadal insufficiency was the most common primary indication for gonadectomy (19/30, [63%]); additional indications were concerning changes on biopsy/imaging (3/30 [10%]), hormone production incongruent with sex assigned (4/30 [13%]) or gender identity (2/30 [7%]) and parental choice (2/30 [7%]). Histopathology confirmed neoplastic change in 7 individuals (23%). Gonadectomy was intentionally deferred in 8/30 (27%) individuals, most commonly to allow their involvement in decision making. Twelve individuals (40%) were 12yrs or older at gonadectomy; all were involved in the pre-operative decision-making process. Conclusions: This study offers important contemporary insights into the practice of gonadectomy in individuals with DSD internationally. Multidisciplinary care provision prior to gonadectomy is standard; however, management pathways vary, likely reflecting diversity of clinical presentations and lack of consensus regarding optimal approach. The I-DSD platform shows clear utility for performing prospective surveillance of rare procedures; such studies are essential for care quality improvement. Presentation: 6/2/2024

Characteristics of Severe Asthma Clinic Patients With Eosinophilic Granulomatosis With Polyangiitis

BackgroundEosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis associated with varying clinical presentations and overlapping multiorgan involvement. Asthma is a predominant feature of EGPA, typically in its prodromal phase, often severe and precedes vasculitic complications. However, there is paucity of studies describing the prevalence and characteristics of EGPA in the asthma population. ObjectiveWe aim to describe the clinical and serological characteristics and longitudinal therapeutic outcomes of patients with EGPA in the severe asthma (SA) cohort. MethodsRetrospective study of patients with EGPA attending the multidisciplinary SA clinic in a tertiary hospital from 2011 to 2023 was conducted. Baseline demographics, organ manifestations, biological markers, lung function and therapeutic outcomes were assessed. Results23 out of 596 patients in the SA registry were identified to have EGPA. Median time interval between asthma and EGPA diagnosis was 10 years (range 2.5 to 32 years). Almost all patients (95.7%) had peak blood eosinophil count of >1.0 x 109/L (range 0.47 – 14.08 x 109/L). Upper airway involvement was the most detected manifestation in addition to asthma, followed by neuropathy and renal involvement. Patients who were treated with biologic therapy were significantly younger, had more upper airway, renal, pulmonary involvement and lower five factor score (FFS). ConclusionThe prevalence of EGPA in the SA population was 3.9% in our cohort. Its diagnosis requires high clinical suspicion in patients with SA and blood eosinophilia, prompting stringent evaluation for extrapulmonary manifestations and multidisciplinary involvement.

Quality Of Care In Parkinson's Disease: Lessons From A National Audit

Abstract Background It is recommended that people with Parkinson’s disease (PD) are treated within specialised services. As part of a research project mapping and evaluating PD services nationally, the first audit of PD services in the Republic of Ireland was conducted. Methods A de novo audit tool was developed by an expert group, based on a rigorous review of existing international standards, guidelines and audit tools, with extensive stakeholder input (including people with PD). All 14 specialist PD services in the Republic of Ireland were eligible; up to 30 case-notes were randomly selected per service in 2022/2023, looking at the most recent 2 visits (new patient) or 3 visits (established patient). Results In total, 261 case-notes were included, from 11 specialist PD services, led by a geriatrician (n=5) or neurologist (n=6). Overall, 16.8% of patients were seen less often than annually. Motor and mobility assessments were well performed (>75%); but cognition (70%) and pain assessments (64%), saliva management (50%), and bone density determination (18%) were inadequate. Access to PD nurses (65%), physiotherapy (69%), speech and language therapy (53%), and occupational therapy (50%) was inadequate; PD nurses were mainly in Dublin. However, specialist nurse and MDT access was better than reported by people attending generic services for PD care (1). Providing written information following diagnosis (24%), and communication with the carer were infrequently documented (financial support discussion: 12%; availability of support locally: 26%). Gerontology-led services more often screened for malnutrition (99% v 78%) or orthostatic hypotension (94% v 52%). Conclusion PD care relating to assessment, multidisciplinary involvement, and information sharing was sub-optimal in some areas, with the caveat that documentation may not reflect actual practice. Reference 1. O’Shea E, et al. Experiences of Health Service Access and Use for People Living with Parkinson’s Disease in Ireland: A National Survey. Health & Social Care in the Community. 2023 Aug 9;2023.

Establishing a national linked database for Fetal Alcohol Spectrum Disorder (FASD) in the UK: multi-method public and professional involvement to determine acceptability and feasibility

IntroductionFetal Alcohol Spectrum Disorder (FASD) is one of the leading non-genetic causes of developmental disability worldwide and is thought to be particularly common in the UK. Despite this, there is a lack of data on FASD in the UK. ObjectiveTo conduct public and professional involvement work to establish stakeholder views on the feasibility, acceptability, key purposes, and design of a national linked longitudinal research database for FASD in the UK. MethodsWe consulted with stakeholders using online workshops (one for adults with FASD [and their supporters] N\,$=$\,5; one for caregivers of people with FASD (N=7), 1:1/small-team video calls/email communication with clinicians, policymakers, data-governance experts, third-sector representatives, and researchers [N=35]), and one hybrid clinical workshop (N\,$=$\,17). Discussions covered data availability, benefits, challenges, and design preferences for a national pseudonymised linked database for FASD. We derived key themes from the notes and recordings collected across all involvement activities. ResultsOur tailored, multi-method approach generated high levels of stakeholder engagement. Stakeholders expressed support for a pseudonymised national linked database for FASD. Key anticipated benefits were the potential for: increased awareness and understanding of FASD leading to better support; new insights into clinical profiles leading to greater diagnostic efficiency; facilitating international collaboration; and increased knowledge of the long-term impacts of FASD on health, social care, education, economic and criminal justice outcomes. Given the rich data infrastructure established in the UK, stakeholders expressed that a national linked FASD database could be world-leading. Common stakeholder concerns were around privacy and data-sharing and the importance of retaining space for clinical judgement alongside insights gained from quantitative analyses. ConclusionsMulti-method and multidisciplinary public and professional involvement activities demonstrated support for a national linked database for FASD in the UK. Flexible, diverse, embedded stakeholder collaboration will be essential as we establish this database.

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees-Part 1: Anatomy and Physiology.

The velopharyngeal (VP) port separates the nasopharynx from the oropharynx and is bordered by the velum, lateral pharyngeal walls, and posterior pharyngeal wall. Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the VP port, affecting speech and swallowing. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism; (2) fundamental speech terminology and principles of perceptual speech assessment for VPD; and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 1, the authors focus on the anatomy and physiology of the velopharyngeal port, the anatomy of cleft palate, and the causes of VPD. There are 3 types of VPD: velopharyngeal insufficiency, involving structural deficits; velopharyngeal incompetence, resulting from neuromuscular issues; and velopharyngeal mislearning, due to maladaptive speech habits. VPD is commonly associated with cleft palate due to anatomic disruptions that impair velopharyngeal function. However, there are numerous causes of noncleft VPD, including congenital or acquired structural defects, neuromuscular conditions, and developmental/behavioral factors. Diagnosis and management of VPD require a multidisciplinary approach involving, at a minimum, surgeons and speech-language pathologists. Plastic surgery trainees often receive education on the surgical treatment of VPD, but without a foundational knowledge of the disease spectrum and speech pathology, the complex terminology can impede a thorough understanding of its diagnosis and management. This series serves as an accessible resource, providing the foundational knowledge required for surgical trainees new to this topic.

Aggressive Surgical Management of Bilateral Metachronous Lung Metastases in Fibrolamellar Hepatocellular Carcinoma, a Case Report

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a malignant primary hepatic cancer that affects mainly adolescents and young adults without underlying liver disease. Its biology remains unknown, but it is pathologically distinct from traditional HCC. Therapeutic strategies are not well defined and, as chemotherapies seem to have limited efficacy, surgical resection remains the only effective treatment. Here we report on a case of a metastatic FL-HCC in an 18-year-old man successfully treated with aggressive intra-thoracic bilateral lung metastasectomy following primary tumour resection and adjuvant chemotherapy. Survival time after initial hepatectomy is 39 months, with no recurrence of disease to date. Aggressive surgical resection and redo surgery should be considered until more effective multimodality therapies are identified. Multidisciplinary team discussion and involvement of medical and surgical specialties are essential in managing these rare entities.

Rehabilitation for Functioning and Quality of Life in Patients with Malignant Pleural Mesothelioma: A Scoping Review.

Malignant pleural mesothelioma (MPM) represents a significant clinical challenge due to limited therapeutic options and poor prognosis. Beyond mere survivorship, setting up an effective framework to improve functioning and quality of life is an urgent need in the comprehensive management of MPM patients. Therefore, this study aims to review the current understanding of MPM sequelae and the effectiveness of rehabilitative interventions in the holistic approach to MPM. A narrative review was conducted to summarize MPM sequelae and their impact on functioning, disability, and quality of life, focusing on rehabilitation interventions in MPM management and highlighting gaps in knowledge and areas for further investigation. Our findings showed that MPM patients experience debilitating symptoms, including fatigue, dyspnea, pain, and reduced exercise tolerance, decreasing quality of life. Supportive and rehabilitative interventions, including pulmonary rehabilitation, physical exercise improvement, psychological support, pain management, and nutritional supplementation, seem promising approaches in relieving symptoms and improving quality of life but require further research. These programs emphasize the pivotal synergy among patient-tailored plans, multidisciplinary team involvement, and disease-specific focus. Despite advancements in therapeutic management, MPM remains a challenging disease with limited effective interventions that should be adapted to disease progressions. Rehabilitative strategies are essential to mitigate symptoms and improve the quality of life in MPM patients. Further research is needed to establish evidence-based guidelines for rehabilitative interventions tailored to the unique needs of MPM patients.

Routine Postclinical Event Debriefings on Inpatient Pediatric Units.

Debriefings are an underutilized opportunity to enhance team performance and safety culture. Little is known about the impact of postclinical event debriefing programs in Pediatric Hospital Medicine (PHM). We sought to develop a standardized debriefing process with multidisciplinary involvement after all clinical events on PHM service lines. Our primary aim was to achieve 75% debriefing completion rate over 12 months with debriefing duration less than 10 minutes. A standardized postclinical event debriefing process was created at a large tertiary children's hospital. We aimed to debrief after clinical events on PHM services. The debriefing process was developed with key stakeholders and used a key driver diagram and Plan-Do-Study-Act cycles to refine the process. The project team reviewed the data monthly. During our 20-month study period, debriefing completion rate sustained a median of 66% with a median debriefing time of 7 minutes. Most debriefings (61%) had all core team members present with attending physicians (pediatric hospitalists) being absent most often. Barriers to debriefing with all core members present included service type, time of day, and shift change. Process changes were implemented based on concerns addressed in the debriefings. Multidisciplinary, postclinical event debriefings were successfully implemented on inpatient pediatric wards. Future steps include process implementation on non-PHM units in our hospital based on expressed interest and to further assess how debriefings optimize team performance and improve clinical outcomes.

Chronic shoulder pain due to spinal accessory nerve palsies present opportunities for improved care integration.

Aim: Chronic shoulder pain due to iatrogenic spinal accessory nerve (SAN) injury continues to be under-recognized, resulting in delayed time-to-diagnosis and poorer outcomes. Solutions are needed to improve the management of this condition, which can be challenging as care needs to be coordinated across pain management, neurophysiology, rehabilitationand reconstructive surgery.Cases: We present a series of sixpatients with shoulder pain refractory to conservative pain treatments to highlight how SAN injuries continued to be missed and treatment delayed, even at advanced care centers. The time to diagnosis of SAN palsy took an average of 21months and treatment was inconsistent for all patients.Discussion: None of the sixcases had initial suspicion of SAN palsy and only onepatient received targeted SAN injury care. SAN treatment should be started as early as possible so that patients can be referred for prompt surgical evaluation if they fail conservative management. Integrated care pathways may be a solution for formalizing multidisciplinary team involvement and improving SAN injury outcomes.Conclusion: Systemic processes, such as integrated care pathways, are needed to optimize early recognition and targeted treatment of SAN injury and may be beneficial for other underdiagnosed and undertreated neuropathic pain conditions.

Postoperative Care and Outcomes in Solid-Organ Transplant Patients Undergoing Lower Extremity Fracture Treatment.

To determine the postoperative outcomes in solid-organ transplant (SOT) patients undergoing operative treatment of lower extremity fractures. Retrospective comparative study. Academic Level 1 trauma center. Patients who underwent SOT and operative treatment of lower extremity fracture from 2013 to 2021 were identified, excluding pathologic fractures. Postoperative complications, length of stay, time to death, 90-day and 1-year readmission rates, readmission causes, discharge location, and immunosuppressive regiments. Sixty-one patients with an average age of 67 years (range 29-88) were included. The mortality rate was 37.7%. The average follow-up was 15.2 months (range of 2 weeks-10 years). The majority of patients (32.8%) had received a liver transplant, and femoral neck fractures constituted the largest fracture group. The average length of stay was 10 days, with the shortest being 1 day and the longest being 126 days (SD 18). The majority of patients (57.3%) were not discharged home. Only 2 suffered from a postoperative complication requiring another procedure: hardware removal and liner exchange for periprosthetic joint infection, respectively. There was a 27.9% 90-day readmission rate with 2 deaths within that period with the most common being altered mental status (29.4%), genitourinary infections (17.6%), repeat falls (11.8%), and low hemoglobin requiring transfusion (11.8%). The longest average time to death analyzed by transplant type was found among lung transplant patients (1076 days, 62.5% mortality), followed by liver transplant patients (949 days, 35.0% mortality), and then kidney transplant patients (834 days, 38.9% mortality). The shortest time to death was 71 days from index procedure. Family members of SOT patients undergoing operative treatment of lower extremity fractures should be made aware of the high risk for 90-day readmission postoperatively (27.9%) and overall mortality (12.5%). Providers should be aware of the need for multidisciplinary involvement for inpatient care, monitoring postoperative complications, and facilitating discharge planning. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Challenges and Elements Hindering the Adoption of Enhanced Recovery After Surgery (ERAS) Protocols in Colorectal Surgery and Their Resolutions: A Systematic Review.

This systematic review focuses on the various aspects of Enhanced Recovery After Surgery (ERAS) implementations, such as the various barriers, facilitators, and the role of teamwork. A systematic search was performed in PubMed, PubMed Central (PMC), and the Cochrane Library for studies published between the years 2018 and 2023. Inclusion criteria encompassed studies assessing the various factors hindering the implementation of ERAS protocols on patients undergoing colorectal surgery.It collectively highlights the importance of a multidisciplinary approach, continuing education, supervision, and patient involvement in achieving a successful implementation. Important findings include the positive impact of a performance improvement team, audits and feedback, and patient-centered approaches in reducing hospital length of stay, reducing inflammation, and improving patient outcomes. In addition, the study emphasizes the challenges of complete adherence to all ERAS components and suggests a simplified protocol to improve implementation. This paper also seeks to understudy the hurdles encountered during the adoption of the ERAS protocol and studies the various fundamental components of the protocol.

Premature ovarian insufficiency

Key content: Premature ovarian insufficiency (POI) is a clinical syndrome involving ovarian follicle depletion and defined by loss of ovarian function before 40 years of age. The diagnostic workup in women with suspected POI is in two steps: confirming the diagnosis and establishing its cause; it is important to understand the rationale for performing each diagnostic test, how to interpret results and appropriate multidisciplinary team involvement. Treatment options include various regimens and preparations of hormone replacement therapy (HRT), monitoring and surveillance, induction of puberty in those with very early POI, complimentary treatment and fertility treatment. Management of POI requires a comprehensive and personalised strategy that addresses not only the physical symptoms and disease risks, but also the psychosocial and reproductive health aspects, and it is important that women receive adequate counselling. Learning objectives: To raise awareness of early diagnosis of POI. To be able to discuss the implications of POI for the health of women affected and their families, as well as for different hormonal and non‐hormonal treatment options. To understand various fertility treatment options for POI. Ethical issues: It is important to consider the reproductive and diagnostic implications for women with chromosomal or genetic problems (e.g. Turner syndrome, Fragile X mutation carriers) and for their family members. A diagnosis of POI may have differing implications based on social and cultural factors, and healthcare providers should consider a patient's values, beliefs, cultural background and preferences.

MULTIDISCIPLINARY APPROACHES TO THE DIAGNOSIS AND TREATMENT OF CENTRAL NERVOUS SYSTEM TUMORS

The symptoms of CNS tumors vary according to the location and tumor neurobiology, the mass effect of the neoplasm increases intracranial pressure (ICP), favoring seizures, headaches, projectile vomiting, optic nerve edema, compression of cranial nerves pairs, among other manifestations, which can be confused with numerous differential diagnoses. The objective of this article is to review therapeutic, multidisciplinary approaches performed with patients diagnosed with CNS tumors on different continents over the last decades, contributing to more precise therapeutic decisions on the subject, whether through clinical or surgical approaches. This study is an integrative literature review, which searched through the DeCS/MeSH descriptors “Neurology,” “Neurosurgery,” “Central Nervous System Tumors,” “Treatment,” and “Diagnosis” on PubMed, ScienceDirect, and BVS databases. Multidisciplinary involvement is essential to improve surveillance and decision-making for patients with CNS tumors. Interactions between different healthcare areas are crucial for enhancing the diagnostic process and the treatment of patients with these tumors. Imaging technology proved to be extremely useful for the diagnosis and assessment of the patient’s preoperative course. In terms of tumor incidence analyzed, it is predominantly female, and the main age group ranges from 41 to 50 years, varying according to each patient’s individual situation. Meningioma was the most frequently observed diagnosis, encompassing neurosurgery as one of the widely used treatments for various types of CNS tumors. The average hospitalization period for patients varied from 8 to 25 days, depending on the needs and personal issues of each patient.

Mediastinal Nontuberculous Mycobacterial Infection in Children: A Multidisciplinary Approach.

Mediastinal infections due to nontuberculous mycobacteria remain an exceedingly rare entity. Most cases in the published literature do not include pediatric patients. Due to their clinical infrequency, poor response to antimicrobial therapy and often precarious anatomical location, the optimal management of these lesions can be challenging. Retrospective medical record review of 4 pediatric cases of mediastinal nontuberculous mycobacteria infection was undertaken. Each child presented with nonspecific respiratory symptoms, including significant acute airway obstruction and required a range of investigations to confirm the diagnosis. Nonresponsiveness to conservative measures and antimycobacterial therapy ultimately resulted in surgical intervention to obtain clinical improvement. All 4 children had extensive evaluation and multidisciplinary involvement in otolaryngology, respiratory medicine, pediatric surgery, infectious diseases and cardiothoracic surgery. They all eventually had their disease debulked via thoracotomy in addition to prolonged antimycobacterial therapy, with successful clinical outcomes. Mediastinal nontuberculous mycobacteria infections in the pediatric population are rare and diagnostically challenging. A high clinical suspicion should be maintained, and multidisciplinary input sought. Targeted surgery with adjuvant medical therapy can reduce disease burden with minimal long-term morbidity.

Navigating the future of Alzheimer’s care in Ireland - a service model for disease-modifying therapies in small and medium-sized healthcare systems

BackgroundA new class of antibody-based drug therapy with the potential for disease modification is now available for Alzheimer’s disease (AD). However, the complexity of drug eligibility, administration, cost, and safety of such disease modifying therapies (DMTs) necessitates adopting new treatment and care pathways. A working group was convened in Ireland to consider the implications of, and health system readiness for, DMTs for AD, and to describe a service model for the detection, diagnosis, and management of early AD in the Irish context, providing a template for similar small-medium sized healthcare systems.MethodsA series of facilitated workshops with a multidisciplinary working group, including Patient and Public Involvement (PPI) members, were undertaken. This informed a series of recommendations for the implementation of new DMTs using an evidence-based conceptual framework for health system readiness based on [1] material resources and structures and [2] human and institutional relationships, values, and norms.ResultsWe describe a hub-and-spoke model, which utilises the existing dementia care ecosystem as outlined in Ireland’s Model of Care for Dementia, with Regional Specialist Memory Services (RSMS) acting as central hubs and Memory Assessment and Support Services (MASS) functioning as spokes for less central areas. We provide criteria for DMT referral, eligibility, administration, and ongoing monitoring.ConclusionsHealthcare systems worldwide are acknowledging the need for advanced clinical pathways for AD, driven by better diagnostics and the emergence of DMTs. Despite facing significant challenges in integrating DMTs into existing care models, the potential for overcoming challenges exists through increased funding, resources, and the development of a structured national treatment network, as proposed in Ireland’s Model of Care for Dementia. This approach offers a replicable blueprint for other healthcare systems with similar scale and complexity.

Pathophysiological aspects of morphological changes in the structure of atrioventricular valves leafl ets in diabetes mellitus

The increasing number of patients with diabetes in the structure of comorbid cardiothoracic patients necessitates a more detailed study of the pathophysiological mechanisms of the modifying infl uence of diabetes, taking into account new scientific data. This allows for a more systematic view of processes that were previously the prerogative of specialists. Content. A modern perspective on the pathophysiological mechanisms of diabetes on cardiac structures is presented, with a description of the two most signifi cant pathological syndromes — diabetic cardiomyopathy and changes in the morphological structure of the atrioventricular valve leafl ets. The expansion of the endocrinologist’s role in the examination and treatment of cardiothoracic patients is justifi ed. Conclusion. A systemic approach to the problem of diabetes in cardiothoracic surgery, incorporating a multidisciplinary approach and active involvement of endocrinologists at all stages of the treatment process, will improve treatment outcomes for cardiothoracic patients and reduce their postoperative recovery times.