Multidisciplinary Management Plan Research Articles

Multidisciplinary team approach in management of anterior spinal dysraphism with unusual presentation: case series and surgical approach

ObjectivesTo report our experience with three cases of anterior lumbosacral meningocele with our multidisciplinary team plan and perioperative management and surgical approach for each case.BackgroundAnterior meningocele is a rare congenital form of spinal dysraphism that involves protrusion of the theca anteriorly into the retroperitoneal and presacral space through an anterior defect.MethodThree cases with anterior meningocele at different spinal levels (lumbar and sacral) were operated at Neurosurgery Department at Assiut University hospital from June to November 2020 with multidisciplinary management plans that were tailored separately for each case.ConclusionAnterior meningocele is a rare form of spinal dysraphism and a challenging congenital anomaly that requires proper diagnosis and selection of surgical approach. Our case series outlines the importance of multidisciplinary team approach for tailoring perioperative management and surgical approach with intraoperative important steps.

Perceptions of Farmers Regarding the Opportunities and Obstacles in Utilizing Indigenous Fish Species within Assam's Aquaculture Industry

Background: Assam is blessed with over 200 fish species. The perceptions of fish farmers in Nalbari and Barpeta districts of central Assam regarding the opportunities and challenges of utilizing indigenous fish species (IFS) for aquaculture have been discussed. Methodology: Utilizing a combination of purposive and random sampling techniques, data was collected from 120 fish farmers across Barpeta and Nalbari districts. Pertinent information was gathered from fish farmers (n=240) combined in the districts of Barpeta and Nalbari. To rank the causal factors based on the responses from the respondents, subsequently calculate the Rank Based Quotient (RBQ). Results and Discussion: High demand, market value, and potential returns as key prospects driving farmer preferences for indigenous fish species cultivation. However, high capital investment, inadequate technical support, flood, quality seed etc. were found as significant challenges in the study areas. These factors are negatively impacting farmers, hindering their ability to achieve anticipated fish yields and income. The study focused on addressing these challenges through integrated, multidisciplinary management plan on resource conservation together with geo-environmental, eco-biological and socio-cultural integrity.

Do sociodemographic and clinical characteristics affect mortality rates in people with intellectual disability and dysphagia who have a percutaneous endoscopic gastrostomy? A cohort study between 2000 and 2022

AbstractBackgroundPeople with intellectual disability frequently have eating, drinking and swallowing difficulties (dysphagia) and are at greater risk of premature mortality, particularly from aspiration and respiratory infections. The insertion of a percutaneous endoscopic gastrostomy (PEG), as part of a multidisciplinary management plan, may help to maintain and improve nutrition. This study included people with intellectual disability who had ever had a PEG inserted and who presented to the specialist Speech and Language Therapy team in one Greater Manchester borough between 2000 and 2022 and assessed the risk of death and sociodemographic and clinical factors associated with this.MethodsThis was a cohort study using secondary data. Kaplan–Meier estimates were used to construct the probability of mortality curves. Cox proportional hazards were used to compare death rates in the different sociodemographic and clinical characteristic groups and were presented as hazard ratios and 95% confidence intervals.FindingsOf 42 people included in the study, 18 (43%) died from the point of PEG insertion to the end of the study (December 2022). The median (interquartile range) time to death from PEG insertion was 5 (2–10) years, with four people (10%) dying in the first year. Aspiration pneumonia and unspecified pneumonia were responsible for seven (39%) deaths. No significant associations were found between sociodemographic and clinical factors and risk of death.ConclusionIn persons with intellectual disability and a PEG who were followed up between 2000 and 2022, the mortality was around 40% with deaths occurring in the first year and respiratory conditions being an important cause. The lack of association with sociodemographic and clinical characteristics may have been due to a limited sample size. Further research is needed with larger samples and more variables, including quality of life data, to help understand and improve clinical practice in this area.

Developing precision-based multidisciplinary pharmacotherapy management plans in the critically ill.

Developing precision-based multidisciplinary pharmacotherapy management plans in the critically ill.

Cardiac problems in the fetus: a review for pediatric providers.

The aim of this study was to provide pediatric providers with a review of the diagnosis and management of fetal cardiac disease in the current era. Prenatal detection of congenital heart disease (CHD) has improved but is still imperfect. In experienced hands, fetal echocardiography can detect severe CHD as early as the first trimester and a majority of more subtle conditions in the second and third trimesters. Beyond detection, a prenatal diagnosis allows for lesion-specific counseling for families as well as for development of a multidisciplinary perinatal management plan, which may involve in-utero treatment. Given the diversity of cardiac diagnoses and the rarity of some, collaborative multicenter fetal cardiac research has gained momentum in recent years. Accurate diagnosis of fetal cardiac disease allows for appropriate counseling, pregnancy and delivery planning, and optimization of immediate neonatal care. There is potential for improving fetal CHD detection rates. Fetal interventions are available for certain conditions, and fetal and pediatric cardiac centers have developed management plans specific to the expected postnatal physiology.

Патологічне прикріплення плаценти: діагностика, тактика ведення та розродження

The incidence of placenta previa is 0.2-0.9% but continues to be one of the most serious factors in the development of obstetric’s bleeding and perinatal losses. The situation is aggravated by the fact that placenta previa is combined with various variations of abnormal (deep) attachment of the placenta to the uterus (placenta adhaerens, accreta, increta, percreta). Placenta previa, placenta accreta, and vasa previa cause significant maternal and perinatal morbidity and mortality. With the increasing incidence of both cesarean delivery and pregnancies using assisted reproductive technology, these 3 conditions are becoming more common. Placental accretion remains the main cause of maternal hemorrhage and obstetric hysterectomy, resulting in significantly high maternal morbidity and mortality. Risk factors for placenta previa include prior cesarean delivery, pregnancy termination, intrauterine surgery, smoking, multifetal gestation, increasing parity, and maternal age. Advances in ultrasound have facilitated prenatal diagnosis of abnormal placentation allowing the development of multidisciplinary management plans to achieve the best outcomes for mother and baby. Purpose - to review the literature on abnormal placentation, including an evidence-based approach to diagnosis, management and treatment; to follow the evolution of this obstetric pathology in recent years and the complications that may arise. Identification of risk factors, correct antenatal and preoperative diagnosis, multidisciplinary treatment and counseling will help in the overall management of women with placenta accreta and reduce maternal morbidity. According to the literature, it can be concluded that true placenta previa or placenta percreta, as well as suspected placenta previa (for example, in cases with a history of caesarean section in anamnesis), should be managed and delivered by caesarean section in a tertiary health facility. In no case should the placenta be separated if edematous blood vessels with visible placental blood flow after laparotomy are found in the area of attachment of the placenta to the anterior wall of the uterus, as well as when the diagnosis is placenta percreta or placenta increta. As a tactic, not only primary hysterectomy should be considered, but also conservative therapy or delayed hysterectomy (two-stage hysterectomy). In a situation where placenta accreta or partial placenta accreta cannot be accurately diagnosed, a good understanding of hemostasis with balloon catheter occlusion, various methods of suture hemostasis, and total hysterectomy procedures should be considered. No conflict of interests was declared by the author.

Development of a specialist ileoanal pouch surgery pathway: a multidisciplinary patient-centred approach

BackgroundRestorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch...

Predictors of stress in patients with Lupus.

BackgroundStress is common in patients with Systemic Lupus Erythematosus (SLE), and is associated with depression, fatigue, and disease flares. Stress may be modifiable and identifying those at high risk allows clinicians and allied health care professionals to develop a multidisciplinary management plan to direct appropriate resources. This study is aimed at identifying predictors of high stress over time among patients with SLE.MethodsLongitudinal data from two interviews of the Lupus Outcomes Study 2 years apart from 726 patients with SLE were analyzed for stress, measured using the Perceived Stress Scale (PSS; high-stress PSS ≥6). T-test and Chi-square analyses compared patient characteristics by high-stress status. Logistic regressions were conducted with high stress as the dependent variable. Covariates included demographics, disease features, quality of life (QOL), health care utilization (HCU), and comorbidities. QoL was measured using the SF-36 form (Physical Component Score, PCS; Mental Component Score, MCS) and MOS Cognitive Functioning Scale (CFS). HCU indicated having established care with a rheumatologist, use of an emergency room or hospitalization, and quality of care. P ≤ 0.05 were considered significant.ResultsThe mean age of the cohort was 50.6 (12.5) years, 92% were women and 68% were Caucasian. The mean (SD) PSS was 5.3 (3.6), and high stress (PSS >6) was noted in 253 participants. Those with high stress were more frequently below the poverty line and less commonly employed. They had a greater prevalence of comorbidities and HCU; and worse disease severity (activity, flare, damage) and QOL. In regression analyses, high stress (baseline) was associated with younger age, married status, worse QOL, and presence of diabetes. Better QOL (PCS, MCS) independently predicted decreased odds of high stress, while high stress (baseline) predicted high stress (OR 3.16, 95% CI 1.85, 5.37, p < 0.0001) at follow-up, after adjusting for demographics, disease features, HCU, and comorbidities.ConclusionPatients with SLE should be routinely screened for QOL and stress during their clinical care, to identify those at risk for poor health outcomes. This information can facilitate multidisciplinary management for those at risk for worse health outcomes.

Multiple anthropogenic stressors in the Galápagos Islands' complex social-ecological system: Interactions of marine pollution, fishing pressure, and climate change with management recommendations.

For decades, multiple anthropogenic stressors have threatened the Galápagos Islands. Widespread marine pollution such as oil spills, persistent organic pollutants, metals, and ocean plastic pollution has been linked to concerning changes in the ecophysiology and health of Galápagos species. Simultaneously, illegal, unreported, and unregulated fishing are reshaping the composition and structure of endemic and native Galápagos pelagic communities. In this novel review, we discuss the impact of anthropogenic pollutants and their associated ecotoxicological implications for Galápagos species in the face of climate change stressors. We emphasize the importance of considering fishing pressure and marine pollution, in combination with climate-change impacts, when assessing the evolutionary fitness of species inhabiting the Galápagos. For example, the survival of endemic marine iguanas has been negatively affected by organic hydrocarbons introduced via oil spills, and endangered Galápagos sea lions exhibit detectable concentrations of DDT, triggering potential feminization effects and compromising the species' survival. During periods of ocean warming (El Niño events) when endemic species undergo nutritional stress, climate change may increase the vulnerability of these species to the impacts of pollutants, resulting in the species reaching its population tipping point. Marine plastics are emerging as a deleterious and widespread threat to endemic species. The Galápagos is treasured for its historical significance and its unparalleled living laboratory and display of evolutionary processes; however, this unique and iconic paradise will remain in jeopardy until multidisciplinary and comprehensive preventative management plans are put in place to mitigate and eliminate the effects of anthropogenic stressors facing the islands today. We present a critical analysis and synthesis of anthropogenic stressors with some progress from local and international institutional efforts and call to action more precautionary measures along with new management philosophies focused on understanding the processes of change through research to champion the conservation of the Galápagos. Integr Environ Assess Manag 2023;19:870-895. © 2022 SETAC.

Domestic dog-wildlife interactions and support for pet regulations in protected areas

Effective management of non-native species in protected areas is fundamental for biodiversity conservation on a global level. In recent years, the extent of protected areas has increased along with the human population, and this has led to negative anthropic impacts within and along the edges of these areas. In particular, a non-native species, the domestic dog (Canis lupus familiaris), has become one of the main threats to wildlife in anthropized areas and their surroundings. Through an online survey we evaluated the relationship between four aspects that link society with dogs, wildlife and protected areas: i) awareness of dog-wildlife interaction, ii) appreciation of protected areas and wildlife, iii) level of concern about aggressive events on the part of dogs towards wildlife and people, and iv) level of agreement with measures to regulate dog access to protected areas. We also sought to map the potential threat of dogs to wildlife. We found that free-roaming dogs are widespread throughout Argentina: they are present in at least 78.5 % of the protected areas visited by respondents. The greater respondents' awareness of dog-wildlife interaction, the more concerned they were about dog attacks and the less they agreed with allowing dogs access to protected areas. Respondents' concerns about the threats from dogs depended on how often they had witnessed dog attacks on wildlife and their appreciation of protected areas and wildlife. A multidisciplinary management plan for free-roaming dogs is urgently needed. This should include controlling populations in sensitive areas, and conducting outreach campaigns on responsible pet ownership.

In Vitro Fertilization as an Independent Risk Factor for Placenta Accreta Spectrum

(Am J Obstet Gynecol. 2020;223:568.e1–568.e5) Placental accreta spectrum (PAS) is an increasingly prevalent and possibly life-threatening condition. While major risk factors for the condition are well-recognized (placenta previa and history of cesarean delivery), identifying additional risk factors will also facilitate the focus on at-risk populations. Antenatal diagnosis, in turn, allows for development of multidisciplinary management plans before labor onset or bleeding with PAS, thus improving outcomes and limiting morbidity. Prior studies have suggested a possible association between in vitro fertilization (IVF) and PAS. The primary goal of this study was to investigate if there was an independent association between IVF and PAS, with the hypothesis that patients undergoing IVF are at increased risk for PAS. The primary outcome variable was PAS.

Outcomes of orbital exenteration for craniofacial lesions.

Orbital exenteration (OE) is an ablative procedure used in the management of malignancies of the orbit of either primary or secondary origin. Publications evaluating this procedure have suffered from small patient numbers, heterogeneity of pathologies, and poor patient follow-up. The purpose of this study was to assess patient outcomes in a large cohort of patients undergoing OE at a tertiary cancer center. A retrospective review was conducted of 180 consecutive patients who underwent OE at the authors' institution. Overall survival (OS) was the primary end point measured in the study. Time to locoregional recurrence (progression-free survival [PFS]) and disease-free survival were secondary end points. Between the years 1993 and 2011, 180 consecutive patients received OE for craniofacial malignancy at the authors' institution. The median follow-up for the cohort was 9.7 years (116 months). The median OS was 73 months, and the median PFS was 96 months. The presence of perineural invasion was associated with shorter OS (P = .01) and PFS (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter PFS than negative margins (P < .01) but with no change in OS (P = .15). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5), and there was 1 death observed (0.6%). Used judiciously in the setting of a multidisciplinary management plan, OE for tumor control is a safe therapy. Between the years 1993 and 2011, 180 consecutive patients received orbital exenteration for craniofacial malignancy at the MD Anderson Cancer Center. The median follow-up for the cohort was 9.7 years. The presence of perineural invasion was associated with shorter overall survival (P = .01) and progression-free survival (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter progression-free survival than negative margins (P < .01). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5).

Prognostic factor for recurrence in esophagus cancer patients who underwent surgery for curative intent: A single-institution analysis

The purpose of this study is to analyze predisposing factors for a higher risk of recurrence in esophageal cancer patient who underwent surgery for curative intent and to do survival analysis of prognostic factors. Between February 2018 and March 2020, we retrospectively identified 28 cases staged T1b to T4a managed electively at our institute as per multidisciplinary management plan. Demographic, clinical, radiological, operative, histopathological parameters, upfront surgery done or not, type of preoperative, and adjuvant treatment used and whether neoadjuvant or adjuvant therapy was planned along with waiting time for surgery, were assessed as potential risk factors. End point of study was to find potential risk factors for recurrence and to do their subgroup survival analysis. The recurrence rate in our study was 25% with a mean follow-up of 24 months. The median time of recurrence was 8.5 months, all recurrence occurred within 1 year. Overall DFS at 2 years was 72%. On univariate analysis, following prognostic factors were associated with high risk of recurrence, male sex X2 (1) =4.42, p = 0.035; histology subtype of adenocarcinoma X2 (1) = 7.07, p = 0.008; margin positive X2 (1) =3.76, p = 0.05; presence of lymph vascular invasion (LVI) X2 (1) =7.88, p = 0.005; presence of perineural invasion (PNI) X2 (1) =5.97, p = 0.015; postoperative T size >4 cm X2 (1) =3.86, p = 0.049; and nodal positivity X2 (3) =13.47, p = 0.004. Male sex, adenocarcinoma histological subtype, positive resected margin, presence of LVI and PNI, postoperative T size >4 cm, and high postoperative nodal positivity and whether neoadjuvant versus adjuvant therapy given (on K. M analysis) were the identified predictors of recurrence which compromised DFS.

Autoimmune Dry Eye without Significant Ocular Surface Co-Morbidities and Mental Health.

Dry eye symptoms can negatively affect the psychological, physical, and social functioning, which can potentially impair the health-related quality of life. This review evaluated the association between autoimmune related dry eye in the absence of significant ocular surface co-morbidities and mental health. This review found a significantly higher prevalence of mental health disorders (such as depression and anxiety) in systemic lupus erythematous, rheumatoid arthritis, systemic sclerosis, Behcet’s disease, and primary Sjogren’s syndrome patients when compared to the general population. Moreover, patients with depression and anxiety interpret ocular sensations differently than healthy controls and the perception of dry eye symptoms can be influenced by their mood. Somatization is common in depression, and this could influence the perception of ocular discomfort. Anti-depressants and anxiolytics with their potential side effects on the tear film status may also contribute or aggravate the dry eye symptoms in these patients. Although ophthalmologists manage the dry eye disease, as per standardized algorithms, they should be mindful of different ocular sensation interpretation and coexistent mental health issues in a large number of this patient group and initiate a multidisciplinary management plan in certain cases. While rheumatologists look after their autoimmune condition, it may be worth liaising with GP and/or psychiatrist colleagues in order to address their neuropathic type pain and mental health co-morbidities.

Reengineering the Discharge Management of Heart Failure Patients Discharged to Skilled Nursing Facilities Utilizing a Multidisciplinary Team Approach Reduces 30-day Readmission Rate

Introduction Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge is the large volume of hospitalized Heart Failure (HF) patients (4,000/year) with a historically high 30-day readmission rate (27%). HF patients discharged to Skilled Nursing Facilities (SNF) (23%) were at higher risk of readmission, p-value Hypothesis Development of a designated multidisciplinary HF Team (NP, PharmD, Case manager and SNF leadership) approach that integrates a standardized comprehensive pre/post discharge multidisciplinary management plan will decrease 30-Day readmission rates. Methods January 15 - April 1, 2019 was the implementation phase of the SNF Heart Failure Readmission Reduction Initiative (SNF -HFRRI) Pilot Project which included generation of a daily patient list with Primary HF (ICD-10) and HF anticipated discharge list from case management. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients identified to be discharged to a SNF were flagged for further in-depth pre-discharge HF NP consult/PharmD counsel and to develop a warm handoff to SNF leadership. Post discharge HF weekly telephone assessment with SNF senior RN leadership and attendings were conducted. Retrospective review of prospectively collected data was analyzed based on age, gender, NYHA, ACC stage, LOS, Unit of discharge and 30-Day Readmission and included Pre-SNF-HFRRI (June 1, 2018 - January 15, 2019); Implementation Phase (January 15, 2019 -March 31, 2019); Post SNF-HFRRI (April 1, 2019 November 15, 2019). Results We identified 182 HF patients (88-Pre-SNF-HFRRI and 94 Post SNF-HFRRI). Continuous variables (age, LOS) and categorical variables (gender, NYHA, LVEF, ACC stage, reason for readmission, hospital unit discharged and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank, chi square and Fisher's exact test. The groups were comparable to age, LOS, LVEF, ACC class, units discharged. A structured weekly post discharge phone assessment incorporating Guideline-Directed Medical Therapy was statistically significant, p Conclusion Our newly integrated multidisciplinary HF team approach that incorporates a structured post-discharge collaborative approach can prevent avoidable 30-day readmissions and improve discharge preparedness.

A National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence in Greece.

Obesity in childhood and adolescence represents one of the most challenging public health problems of the 21st century owing to its epidemic proportions worldwide and the associated significant morbidity, mortality and public health costs. In Greece, the prevalence of overweight and obesity in childhood and adolescence exceeds 30–35%. To address the increasing prevalence of overweight and obesity in children and adolescents in our country, we developed the ‘National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence’, which provides specific and detailed guidance to all primary health care physicians about the personalized management of children and adolescents with overweight or obesity. In the present study we evaluated 2400 children and adolescents [mean age ± SEM: 10.10 ± 0.09 years.; Males: 1088, Females: 1312; Obesity (n = 1370, 57.1%), Overweight (n = 674, 28.1%), normal BMI (n = 356, 14.8%)], who followed the personalized multi-disciplinary management plan specified by the ‘National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence’, and were studied prospectively for 1 year. We demonstrated that at the end of the first year, the prevalence of obesity decreased by 32.1%, the prevalence of overweight decreased by 26.7%, and the cardiometabolic risk factors improved significantly. These findings indicate that our National e-Health Program is effective at reducing the prevalence of overweight and obesity in childhood and adolescence after one year of intervention in the largest sample size reported to date.

An exploration of the reliability and usability of two delirium screening tools in an Australian intensive care unit: A pilot study

ObjectiveTo compare the inter-rater reliability and usability of two delirium screening tools designed for use in ICU; the Confusion Assessment Method for ICU and the Intensive Care Delirium Screening Checklist. Research methodology/designA multiple methods design was used. The intra and inter rater reliability of the tools were evaluated using Kappa statistics and intra class correlation coefficients. Focus groups were conducted to explore ICU staff perceptions of the usability of the tools and feasibility of delirium screening. SettingPrivate hospital ICU, Melbourne Australia. Results66 patients were assessed for delirium; median age of 71 (IQR 62–75) years. Seventeen patients (26%) scored positive for delirium using the screening tools and 11 (17%) had delirium confirmed on the medical ICU discharge summary. Ten nurse assessors performed 99 paired assessments using the two tools sequentially, demonstrating the intra and inter-rater agreement and reliability of the tools was moderate to high.Four focus groups were conducted with 16 participants. Content analysis identified three themes: (i) current recognition of delirium, (ii) benefits of delirium screening, and (iii) future directions for delirium management. Time and medical staff indifference were identified as barriers to screening, facilitators were education and having a follow-up plan. ConclusionThis study found that the reliability and usability of the CAM-ICU and ICDSC were acceptable and that using structured delirium screening was feasible as part of a wider, multi-disciplinary delirium management plan.

A Comprehensive Multidisciplinary Management Plan Is Effective in Reducing the Prevalence of Overweight and Obesity in Childhood and Adolescence

Background: Obesity in childhood and adolescence represents a major health problem of our century. In Greece, 30–35% of children and adolescents are overweight or obese. Objective and Hypotheses: To investigate the effectiveness of a comprehensive multidisciplinary personalized management plan at reducing the prevalence of overweight and obesity in childhood and adolescence. Patients and Methods: One thousand (n = 1,000) children and adolescents aged 2–18 years (mean age ± SD: 10.09 ± 2.86 years; 520 females, 480 males) were studied prospectively. Subjects were classified as obese (n = 579, 57.9%), overweight (n = 295, 29.5%) or having a normal body mass index (BMI) (n = 126, 12.6%) according to the International Obesity Task Force cutoff points. All subjects were evaluated by a multidisciplinary team at frequent intervals, received personalized advice on diet and exercise and were studied prospectively for 1 year. Detailed clinical evaluation and laboratory investigations were performed at the beginning and at the end of the study. Results: At initial evaluation, 57.9% of subjects were obese, 29.5% overweight and 12.6% of normal BMI. Indices of cardiometabolic disease were higher in obese than in overweight and normal-BMI subjects. Following 1 year of multidisciplinary management interventions, the prevalence of obesity decreased by 16.8%, the prevalence of normal BMI increased by 8.2%, and all cardiometabolic indices improved significantly. Conclusions: A personalized multidisciplinary management plan is effective at reducing the prevalence of obesity in childhood and adolescence.

Warfarin-associated intracranial haemorrhage in pregnant woman with double mechanical valve replacement: a case presentation

BackgroundManagement of warfarin-associated major haemorrhage in prosthetic valve diseases is difficult as there is a fine line between haemorrhage and thrombosis. An individual’s propensity towards thrombosis, such as pregnancy, makes this situation even more complicated. Cases like these are very rare in the literature.Case presentationA 26 weeks pregnant, gravida two, para one, 35-year-old patient with prosthetic aortic and mitral valves presented to an external emergency clinic with clouding of consciousness. Her international normalised ratio(INR) was 8.9 at presentation. Brain MRI revealed a left subdural haematoma with no significant mass effect. Warfarin treatment was discontinued. On the second day of follow-up, she was referred to our centre for further evaluation of her clinical deterioration. She was haemodynamically stable on admission to the intensive care unit and followed up with a stable condition until the fourth day when she developed right eye drop and subsequent loss of consciousness. Her haematoma was surgically evacuated, and her condition improved. Eventually, she and a healthy newborn were discharged.ConclusionIntracranial haemorrhage during pregnancy is a relatively rare complication that requires a multidisciplinary management plan. Although the thrombogenic risk is high, it is vital to complete a reversal of warfarin anticoagulation in pregnant women with major bleeding.

A multidisciplinary approach for managing the infraglottic difficult airway in the setting of the Coronavirus pandemic

Management of a difficult airway caused by pathology below the glottis is high-risk and requires a shared approach to airway planning and surgical treatment. Access to the trachea requires a careful assessment of the airway since the end-point of laryngoscopy for infraglottic airway management is not visualization of the larynx for tube placement, but access to the laryngotracheal complex in cases where intubation may not be feasible or may preclude surgical access.This work provides a common framework for creating multidisciplinary shared-airway management plans and presents devices and strategies that have in recent years improved airway management safety in this difficult patient group and may prove useful in the setting of the novel Coronavirus Disease 2019 (COVID-19).