Multidisciplinary Management Strategy Research Articles

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

CLINICAL CHARACTERISTICS OF PATIENTS WITH RARE DOUBLE PRIMARY CANCERS INVOLVING THE LUNG AND ESOPHAGUS: A SYSTEMATIC REVIEW

SESSION TITLE: Late-breaking Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Investigate the available published data on the clinical characteristics, treatment, and outcomes of patients diagnosed with double primary cancers (DPCs) of the lung and esophagus. METHODS: PubMed, Medline, ScienceDirect, and Scopus literature search, from database inception through June 30, 2020, for “lung cancer” and “esophageal cancer,” pooled with a case from our institution. RESULTS: We included 15 patients. The male: female ratio (14:1). The mean age at first primary cancer diagnosis (FPCd) was 60 (range:38-78 years), with ten patients (75%) being 60 years of age or younger. Of those, 85.7% and 42.8% had tobacco smoking and alcohol abuse history, respectively. The most common symptoms were dysphagia and weight loss in 50% and 20% of patients at the time of FPCd, respectively, and 64% and 22% of patients at the time of second primary cancer diagnosis (SPCd), respectively. DPCs were metachronous in 60% of patients (9/15) with a mean interval between FPCd and SPCd of 46.6 (range 0-192 months). Twelve patients (80%) had lung FPC, who later developed esophageal SPC. The most common locations were the left lung, right lung, and middle thoracic esophagus (MTE) in 46.1%, 38.5, and 15.4% of FPCd patients, respectively, compared to the distal esophagus, right lung, and MTE in 57.0%, 21.5%, 21.5% of SPCd patients, respectively. At the time of FPCd, cancer was at stage I, II, and III in 62.5%, 25%, and 12.5% of patients, respectively; with no distant metastasis in 100% of patients, whereas SPC was at stage III, I, II, and IV in 38.5%, 30.7%, 23.1%, and 7.7%, respectively. Treatment modality for FPC was surgery, surgery plus chemotherapy, chemotherapy, chemoradiation, and surgery plus chemoradiation in 60.0%, 13.3%, 13.3%, 6.7%, and 6.7%, respectively. In contrast, SPC was treated with surgery, surgery plus chemotherapy, chemoradiation, and surgery plus chemoradiation in 71.5%, 14.3%, 7.1%, and 7.1%, respectively. The mean duration of follow-up was 18.9 (range 0.5-108 months). In terms of outcomes, six (50%) were alive and disease-free, two (16.7%) were alive with disease, one (8.3%) was alive with recurrence, and three (25%) died of the disease. CONCLUSIONS: In our cohort, several findings are noteworthy. First, three-fourths of the patients were 60 years of age or younger at the time of FPCd; all had no distant metastasis. Second, Lung cancer was the most common FPCd in 80% of patients. Third, the most common overall treatment modality was surgery in both FPC and SPC. Here we highlight the unique characteristics of DPCs of the lung and esophagus. Their entwined perplexed management makes them even more challenging. A high index of clinical suspicion for a SPC would improve early detection, management, and outcomes. CLINICAL IMPLICATIONS: This study's findings would expand our knowledge, enhance accurate evaluation, and promote multidisciplinary management strategies, that will eventually reshape outcomes. DISCLOSURES: No relevant relationships by Dawood Findakly, source=Web Response

Surgical outcomes and multidisciplinary management strategy of Cushing's disease: a single-center experience in China.

The primary aim of this study was to investigate the value of multidisciplinary team (MDT) management in treating patients with Cushing's disease (CD). The secondary aim was to assess the concordance of bilateral inferior petrosal sinus sampling (BIPSS) lateralization with intraoperative observations. The authors recruited 124 consecutive patients (128 procedures) who had undergone endoscopic endonasal resection of adrenocorticotropic hormone-secreting pituitary adenomas from May 2014 to April 2018 and assessed their clinical characteristics, surgical outcomes, and adjuvant therapies. The criteria for surgical remission were normalized serum and urinary cortisol levels, which could be suppressed by a low-dose dexamethasone suppression test at 3-months' follow-up without adjuvant treatment. The remission rates of the 113 patients with long-term follow-up (20.3 ± 12.2 months) were 83.2% after surgery alone and 91.2% after adjuvant therapy. The surgical remission rates of macroadenomas, MRI-visible microadenomas, and MRI-negative tumors were 66.7% (12/18), 89.3% (67/75), and 75% (15/20), respectively (p = 0.039). The surgical remission rates had a trend of improvement during the study period (87.5% in 2017-2018 vs 76.5% in 2014, p = 0.517). Multivariate regression analysis showed that a history of previous pituitary surgery (OR 0.300, 95% CI 0.100-0.903; p = 0.032) and MRI-visible microadenoma (OR 3.048, 95% CI 1.030-9.019; p = 0.044) were independent factors influencing surgical remission. The recurrence rate was 3.2% after a mean of 18 months after surgery. The remission rate of postoperative MDT management in patients with persistent disease was higher than non-MDT management (66.7% vs 0%, p = 0.033). In cases with preoperative BIPSS lateralization, 84.6% (44/52) were concordant with intraoperative findings. MRI-visible microadenoma and primary surgery were independent predictors of surgical remission in CD. The MDT management strategy helps to achieve a better overall outcome. BIPSS may help to lateralize the tumor in MRI-negative/equivocal microadenomas.

Clinical features and outcomes of neuroblastomas in adults.

e14546 Background: Neuroblastomas (NBs) are a spectrum of primitive tumors that include Esthesioneuroblastoma (ENB), and both neuroblastoma (NB) and ganglioneuroblastoma (GNB). NB and GNB are prevalent in children and rare in adults with a paucity of data on their therapy and outcomes. This review is to investigate the clinicopathologic features, treatment, and outcomes of NBs in adults. In addition, we highlight genomic findings of a 63-year-old man treated at our institution and discuss ALK-inhibition as a novel treatment strategy for ALK-driven adult-onset NB. Methods: PubMed literature search for NB adults (19+ years) for the period 2000 – 2020 pooled with a case from our institution. Results: Of the 163 included cases, 105 were ENB, 40 were NB, and 18 were GNB. Male:female ratio (1.50:1, 1.29:1, and 1.83:1 respectively). Mean age at diagnosis (49.8, 39.3, and 38.8 respectively). Most common primary site was sinonasal (60%) in ENB, retroperitoneal (20%) in NB, and adrenal (22%) in GNB. Metastasis found in 31.4%, 42.0%, and 16.7% with a mortality rate of 45%, 53%, and 33% respectively. Most common treatment modality overall was surgery with radiation in ENB (35%), Surgery with chemotherapy in NB (28%) and surgery alone in GNB (50%). Most common treatment modality in metastatic cases was surgery with chemoradiation in ENB (50%), surgery with chemotherapy in NB (36%), and surgery alone in GNB (33%). In our patient, ALK gene (R1275Q) gain of function mutation found both in molecular profiling and genomic circulating DNA analysis. Conclusions: Metastatic NB in adults is associated with very high mortality. Their rarity, heterogeneity of clinical behaviors, diverse treatment regimens, and variable outcomes make them even more challenging. The findings of this study would improve our understanding and develop multidisciplinary management strategies for this rare malignancy in adults. Moreover, further research focusing on the potential novel treatment with ALK-targeted inhibitors may hold promise to improve survival outcomes in adult-onset ALK-positive NB. [Table: see text]

The Landmark Series: Neoadjuvant Systemic Therapy (NAST) for Stage 3 Melanoma Patients - A Potential Paradigm Shift in Management.

Since the advent of effective systemic therapy, quantum changes have occurred in the multidisciplinary management strategies used for patients with American Joint Committee on Cancer stages 3 and 4 melanoma. For high-risk stage 3 patients, neoadjuvant immune checkpoint blockade (ICB) and targeted therapies present a promising novel approach to improving survival outcomes. In particular, patients who respond to ICB have an excellent prognosis, and clinical trials are ongoing to investigate whether those with a pathologic complete response (pCR) or near-pCR in a single node may avoid therapeutic lymph node dissection and adjuvant therapy. Toxicities currently are acceptably low, but when toxic events occur, they can have an enduring impact on a patient's quality of life. To date, nearly all patients evaluated after treatment with neoadjuvant dabrafenib plus trametinib have some clinical and pathologic response. Patients who achieve pCR have improved prognosis, but pCR is not as reliable a predictor of improved outcome as pCR or near-pCR after neoadjuvant ICB. Ongoing studies should ideally be coordinated through the International Neoadjuvant Melanoma Consortium to ensure maximal efficiency at improving outcomes for melanoma patients.

Perioperative management of patients receiving non-vitamin K antagonist oral anticoagulants: up-to-date recommendations.

Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.

Rhizosphere immunity: targeting the underground for sustainable plant health management

Managing plant health is a great challenge for modern food production and is further complicated by the lack of common ground between the many disciplines involved in disease control. Here we present the concept of rhizosphere immunity, in which plant health is considered as an ecosystem level property emerging from networks of interactions between plants, microbiota and the surrounding soil matrix. These interactions can potentially extend the innate plant immune system to a point where the rhizosphere immunity can fulfil all four core functions of a full immune system: pathogen prevention, recognition, response and homeostasis. We suggest that considering plant health from a meta-organism perspective will help in developing multidisciplinary pathogen management strategies that focus on steering the whole plant-microbe-soil networks instead of individual components. This might be achieved by bringing together the latest discoveries in phytopathology, microbiome research, soil science and agronomy to pave the way toward more sustainable and productive agriculture.

1744 Not an Ordinary Ulcer: A Case of an Aorto-Esophageal Fistula

INTRODUCTION: Hematemesis is a common manifestation of variceal and non-variceal upper gastrointestinal (GI) bleed with a broad differential. Aortoesophageal fistula (AEF) is a life-threatening and catastrophic cause of gastrointestinal bleeding, which is caused by the abnormal communication between the aorta and the esophagus. We are presenting a rare case aorto-esophageal fistula in a young patient who was found to have a benign appearing esophageal ulcer on endocscopy that subsequently was found to be an (AEF). CASE DESCRIPTION/METHODS: A 33-year-old Caucasian male presented to the hospital for fatigue, non-blood emesis and progressively worsening leg swelling. His history is significant for hypertension, seizure disorder, chronic kidney disease (due to pauci-immune glomerulonephritis), heart failure and a descending aortic transection due to an accident 12 years ago which was repair endovascularly. The patient reported usage of NSAIDs prior to admission for pain control but otherwise denied alcohol or other substance abuse. The patient was admitted for his progressive renal failure and was started on hemodialysis complicated with a DVT for which was started on warfarin. During his hospitalization, the patient had an episode of hematemesis with hemodynamic instability which prompted cessation of anticoagulation. An EGD revealed a 2-3 cm non-bleeding ulcer in the proximal esophagus. The patient had stabilized hematocrit and hemodynamics and was restarted on anticoagulation. A week later, the patient had another episode of massive hematemesis with hypotension. A chest x-ray showed widening of the aortic knob, suggested change in location of the thoracic stent. CT angiogram showed aortoesophageal fistula with a leaking pseudoaneurysm at the proximal aspect of the thoracic aortic endovascular stent. Surgery proceeded with endovascular aortic repair of thoracic pseudoaneurysm. Patient had multi-disciplinary management strategy for staged repair. DISCUSSION: AEF are classified as primary i.e. spontaneous erosion of the aortic wall into the esophagus or secondary caused by either esophageal malignancy, surgeries or foreign body. Exact incidence of the AEF is unknown. Early recognition is important to decrease mortality. Chiari et al described the triad of midthoracic pain, herald hemorrhage, and fatal hematemesis as usual presenting features. Endoscopy plays a significant role in the evaluation however it has a poor rate of detection for AEFs prompting the need of CT imaging with high clinical suspicion.

Male Breast Cancer: Surgical and Genetic Features and a Multidisciplinary Management Strategy

Background: Male breast cancer (MBC) is a rare disease with a rising incidence trend. The major risk factors related to MBC are a positive family history of breast cancer (BC) and BRCA1/2 mutations, which indicate a relevant genetic role. Methods: In this retrospective series, we enrolled 69 male patients presenting with male breast cancer (MBC) between 01/01/1992 and 31/12/2018, and 26 high-risk not-affected men presenting between 01/01/2016 and 31/12/2018. Participants’ electronic clinical records were reviewed. Patients’ data reported age at diagnosis, tumor characteristics, therapeutic management, and BRCA1/2 status as well as a family history of breast, ovarian, or prostate cancer (PCa) in first-degree relatives. Results: We analyzed 69 MBC patients. Median age was 64 years. The majority of tumors diagnosed were of an early TNM stage. The most frequent histological subtype was invasive ductal carcinoma (76.7%). Hormone receptors were positive in >90% of MBC cases. Nearly all patients underwent modified radical mastectomy or total mastectomy. Adjuvant endocrine therapy was delivered in 59.4%. Among MBC-affected patients, we recorded a high percentage of a positive family history of BC. Mutational analysis for the BRCA1/2 genes was performed in 17 MBC patients; 11.8% were carriers of BRCA2 pathogenic mutations. Among 26 healthy high-risk subjects included in this case series, 4 were BRCA1 mutation carriers and 9 were BRCA2 mutation carriers. Discussion: We evaluated the distribution of clinicopathological characteristics in MBC subjects and assessed the frequency of mutations in the BRCA genes in affected patients and healthy high-risk subjects, with the aim of proposing a surveillance program for BC and PCa.

PB2318 DOUBLE HETEROZYGOSITY S/C AT HEMATOLOGY DEPARTMENT ANNABA HOSPITAL ‐ALGERIA

Background:Major sickle cell disorders account for 95% of the hemoglobinopathies supported at our service; double S/C heterozygosity is infrequent and represents only 6,4%.Aims:The objective of our work is to determine the prevalence and characteristics of acute and chronic complications that occurred in our patients during their follow‐up.Methods:This is a retrospective, descriptive study of 99 patients with double S / C heterozygosity and followed regularly since recruitment until December 2017.The patients benefit from a regular follow‐up, every 04 months with an annual report aimed at detecting the chronic complications.Results:The average age of patients at the time of diagnosis is 21 years, with extremes of [02‐49 years].The current average age of the cohort is 33 years, with extremes of [13‐66 years]The majority of our patients come from Algerian‐Tunisian border area (79%).During this monitoring, several variously associated complications were collected:The acute complications are dominated by vaso‐occlusive crises in various locations, with exceptionnellent‐required hospitalization;During follow‐up, 32.09% of our patients developed various chronic complications:Summary/Conclusion:Despite of an acute symptomatology low noise from the S/C, chronic complications are frequent, imposing the implementation of a multidisciplinary management strategy at our level.image

Factors influencing disability in patients with chronic low back pain attending a tertiary hospital in sub-Saharan Africa

BackgroundVery little is known about the burden of chronic low back pain in Africa. This study aimed at assessing disability and associated factors in chronic low back patients in Cameroon.MethodsWe carried a hospital-based cross-sectional study including patients suffering from low back pain (LBP) of at least 12 weeks’ duration. Disability was assessed using the Roland Morris Disability Questionnaire (RMDQ). RMDQ > 4 described persons with dysfunctional levels of disability.Multivariable linear regression was used to investigate factors associated with higher RMDQ scores hence greater disability. Variables investigated included; gender, age, marital status, employment status and type, smoking history, alcohol consumption, income, pain intensity, LBP duration, psychological wellbeing, sleep satisfaction, leg pain, numbness/paresthesia, bowel/bladder dysfunction symptoms (BBDS), body mass index (BMI), and days of work absence.ResultsA sample of 136 adults (64% female) with a mean age of 50.6 ± 12.2 years participated in the study. Median duration of LBP was 33 (25th – 75th percentile: 12–81) months. Mean RMDQ score was 12.8 ± 6. In multivariable linear regression, pain intensity (β = 0.07, p = 0.002), longer days of work absence (β = 0.15, p = 0.003) and BBDS (β =2.33, p = 0.029) were associated with greater disability. Factors such as consumption of alcohol (β = − 3.55, p = 0.005) and higher psychological wellbeing scores (β = − 0.10, p = 0.004) significantly contributed to less disability (lower RMDQ scores). Dysfunctional levels of disability were present in 88.1% of patients.ConclusionCLBP is associated with significant disability and this relationship is driven by several factors. Multidisciplinary management strategies especially those targeted to improve pain control, manage BBDS and improve psychological wellbeing could reduce disability and improve quality of life.

Obstructive Sleep Apnea in Cardiovascular Disease: A Review of the Literature and Proposed Multidisciplinary Clinical Management Strategy.

Cardiovascular disease (CVD) remains a highly prevalent cause of morbidity and mortality, both in the United States and worldwide. In parallel with the development of new and improved therapies for established CVD such as coronary artery disease or heart failure (HF), there has been an increased focus on modification of cardiovascular risk factors for both primary and secondary prevention, reflecting an evolving understanding of CVD as a systemic process with numerous determinants. Obstructive sleep apnea (OSA) has been associated with many different forms of CVD including hypertension, stroke, HF, coronary artery disease, and atrial fibrillation (AF).1 Adults with OSA not only have an increased risk of developing comorbid CVD but also have worse outcomes related to CVD. OSA is highly prevalent, estimated to affect 34% of men and 17% of women in the general population2 and 40% to 60% of patients with CVD.3, 4 Furthermore, the prevalence is increasing, with these figures representing a 30% increase over the previous 2 decades,2 likely related to the obesity epidemic as well as an aging population. Despite the clear association between CVD and OSA, randomized trials have failed to demonstrate that treatment of sleep apnea improves hard cardiovascular outcomes in patients with established CVD.5 Nevertheless, this area remains controversial, as randomized trials performed to date remain limited in number as well as design, highlighting the need for further study.6 Furthermore, the current literature suggests that the impact of diagnosing and treating OSA varies between specific CVD processes, implying the need for a more sophisticated understanding and nuanced clinical approach to this issue. In this article we review the literature pertaining to OSA in patients with CVD. Additionally, we offer a practical clinical approach to the evaluation and management of known or suspected OSA in patients with CVD consisting of recommendations integrated from several separate societal practice guidelines combined with several of our own suggestions on issues not addressed by current guidelines, based on our own clinical experience and best available literature.

Survival of Patients with Oligometastatic Pancreatic Ductal Adenocarcinoma Treated with Combined Modality Treatment Including Surgical Resection: A Pilot Study.

Purpose: To evaluate the overall survival of patients with oligometastatic pancreatic ductal adenocarcinoma (PDAC; metastatic tumor <4 cm, ≤2 metastatic tumors total) receiving neoadjuvant therapy, metastasectomy and/or ablation, and primary tumor resection.Methods: We performed a case–control study from January 2005 to December 2015. Patients who underwent curative-intent surgery combined modality therapy (M1 surgery group; 6 [14%], tumor [T]3, node [N]1, and oligo-metastases [M]1) were matched 1 to 3 based on TN stage with two control groups (M0 surgery and M1 no surgery). The M0 surgery group (18 [43%], T3, N1, and M0) included patients without metastases who underwent resection. The M1 no surgery group (18 [43%], T3, N1, and M1) included patients with metastatic PDAC who received palliative chemotherapy without surgical resection.Results: Median overall survival in the M1 surgery, M0 surgery, and M1 no surgery groups was 2.7 years (95% confidence interval [CI], 0.71–3.69), 2.02 years (95% CI, 0.98–3.05), and 0.98 years (95% CI, 0.55–1.25), respectively. Eastern Cooperative Oncology Group (ECOG) status was associated with survival (p = 0.01) after univariate analysis. After adjusting for ECOG status, multivariate analysis showed M1 surgery patients had improved survival compared with M1 no surgery patients and similar survival to M0 surgery patients.Conclusion: Multimodal therapy benefitted our M1 surgery patients. A larger, prospective study of this multidisciplinary management strategy is currently under way.

Mode of death and predictors of mortality in adult Fontan survivors: A Japanese multicenter observational study

BackgroundMortality rates may be high in adult Fontan patients; however, the clinical determinants remain unclear. PurposeWe conducted a prospective multicenter study of adult Fontan survivors to determine the 5-year mortality rate and clarify the determinants. Method and resultsWe followed 600 adult Fontan survivors from 40 Japanese institutions (307 men, 28 ± 7 years old, follow-up: 18 ± 6 years). The New York Heart Association (NYHA) functional class I and II was 51% and 42%, respectively. During the follow-up period of 4.1 ± 1.6 years, 33 patients died, and the 5-year survival rate was 93.5%. The mode of death was heart failure in 11 patients (34%), arrhythmia or sudden death in 8 (24%), cancer in 5 (15%), perioperative problems and hemostatic problems in 4 each (12% for each), and infection in 1 (3%). Left isomerism, prior hospitalization, protein losing enteropathy (PLE), pulmonary arteriovenous fistulae, NYHA functional class, impaired hemodynamics, hyponatremia, hepatorenal dysfunction, and use of diuretics were associated with a high mortality rate (p < 0.05–0.0001). Further, PLE (hazard ratio [HR]: 14.4), left isomerism (HR: 3.5), and NYHA (HR: 2.4) independently predicted a high 5-year high mortality (p < 0.05 for all). The incidence of cancer-related mortality increased markedly with age >40 years. ConclusionsMajority of the Japanese adult Fontan survivors had good functional status, with an acceptable 5-year survival rate. However, the significant prevalence of non-cardiac mortality highlights Fontan pathophysiology as a multi-organ disease that requires a multidisciplinary management strategy to improve the long-term outcome.

Perioperative Management of Pregnant Women With Idiopathic Pulmonary Arterial Hypertension: An Observational Case Series Study From China

The mortality of pregnant women with idiopathic pulmonary arterial hypertension (PAH) is very high. There are limited data on the management of idiopathic PAH during pregnancy. The authors aimed to examine systematically the characteristics of parturient women with idiopathic PAH, to explore the adverse effects of idiopathic PAH on pregnancy outcomes, and to report the multidisciplinary perioperative management strategy from the largest comprehensive cardiac hospital in China. Observational case series study. Tertiary referral acute care hospital in Beijing, China. The cases of 17 consecutive pregnant idiopathic PAH patients undergoing abortion or parturition at Anzhen Hospital were reviewed retrospectively. Preoperative characteristics, anesthesia method, intensive care management, PAH-specific therapy, and maternal and neonatal outcomes were analyzed in this case series study. Maternal and neonatal outcomes were the main measures. The mean ages of the 17 parturient women with idiopathic PAH were 28.3 ± 5.4 years, and the mean systolic pulmonary arterial pressure was 97.9 ± 18.6 mmHg. Fifteen patients (88.2%) received PAH-specific therapy before delivery, including sildenafil, iloprost, and treprostinil. All except 1 parturient received epidural anesthesia for surgery due to an emergency Caesarean section. Three patients experienced pulmonary hypertension crisis that necessitated conversion to general anesthesia. Ten parturients underwent Caesarean delivery at a median gestational age of 31 weeks. Three patients developed acute pulmonary hypertensive crisis intraoperatively. Two patients underwent cardiopulmonary resuscitation and extracorporeal membrane oxygenation support. The maternal mortality was 17.6% (3/17). Of the 10 delivered neonates, 9 (90.0%) survived. The maternal mortality of the idiopathic PAH parturient was high in this case series from China. The authors applied epidural anesthesia, early management with multidisciplinary approaches, PAH-specific therapy, avoidance of oxytocin, and timely delivery or pregnancy termination to improve maternal and neonatal outcomes.

Effect of Prophylactic Placement of Internal Iliac Artery Balloon Catheters on Outcomes of Women With Placenta Accreta: An Impact Study

(Anaesthesia. 2017;72:853–858) Effective prenatal diagnosis of placenta accreta using ultrasound and magnetic resonance imaging has aided in the development of multidisciplinary management strategies for these patients, with the goal of obtaining the best outcomes for both the mother and neonate. Although cesarean hysterectomy is the predominant management technique chosen by obstetricians for abnormal placentation, massive hemorrhage is still relatively common and can lead to increased maternal morbidity and mortality. The goal of this study was to determine the efficacy of prophylactic placement of internal iliac artery balloon catheters for reducing hemorrhage and transfusion requirements in women with placenta accreta undergoing cesarean section.

Giant adenoid basal cell carcinoma of the scalp with intracranial involvement—successful management strategies for a rare entity

Adenoid basal cell carcinoma (BCC) is a rare but aggressive histologic subtype of BCC. The aim of this report is to present our multidisciplinary management strategy and a literature review on this seldom reported entity. A 72-year-old female with fungating giant BCC of the scalp, ear, and bone underwent preoperative biopsy revealing adenoid histology with infiltrating and nodular components. The patient underwent radical resection of the biparietal and occipital scalp, auriculectomy and craniectomy with dural resection. Immediate reconstruction of the intracranial and bony defect was performed with dural substitute and a titanium cranioplasty. The soft tissue defect was reconstructed with a latissimus dorsi free flap and split thickness skin graft using the right superficial temporal artery and vein as recipient vessels. Adjuvant external beam radiation was initiated postoperatively. Nearly 2 years postoperatively, she presented mesh exposure necessitating secondary reconstruction with debridement, hardware removal, and an anterolateral thigh (ALT) free flap, followed by flap debulking. Four years following initial presentation, she remains disease-free. To our knowledge, this is the only reported case of a giant, locally invasive scalp BCC with the adenoid subtype treated with composite resection and single stage reconstruction. Using an aggressive multimodal management paradigm, treatment and surveillance of the rarely reported, giant, locally invasive scalp BCC with adenoid subtype can result in a durable disease-free response and a functional, esthetic reconstruction. Evidence-based medicine level.

Health implications and management of women with opioid use disorder

Opioid use disorder has risen to epidemic proportions in the United States at an alarming rate in the past decade and is considered a leading public health concern. Women have a higher rate of acute and chronic pain conditions and are more likely to be prescribed opioids for pain management. The disproportionate incidence of opioid use, misuse, and progression to heroin and injectable drug use among reproductive age women is associated with increased morbidity and mortality. Of particular concern are the unique health risks opioid-dependent women face including immune system alterations, endocrinopathies, diminished fertility, psychosocial isolation, interpersonal violence, and unintentional overdose. Opioid use in pregnancy is associated with negative maternal and neonatal consequences and requires comprehensive, multidisciplinary services for the co-occurring medical, mental health, infectious disease, social stressors, and legal issues. Neonatal abstinence syndrome is linked to a cluster of physiological withdrawal symptoms and considered the primary adverse outcome of opioid exposure in newborns. Maternal medication-assisted treatment with methadone or buprenorphine to decrease the negative effects of neonatal withdrawal is the standard of care for opioid use disorders in pregnancy. The complexity of services required for maternal opioid use disorders requires collaborative and multidisciplinary management strategies to optimize maternal and neonatal outcomes.

Pediatric multiple sclerosis: Perspectives from adolescents and their families.

Supporting young people with pediatric multiple sclerosis can be challenging for families and health care providers. Adolescents may be more resilient than adults in reaction to the diagnosis but can have more difficulty planning for their futures. Appropriate, sensitive, and focused health provision should include consideration of the perspective of both the patient and parents. Multidisciplinary management strategies are often effective, as are referrals to programs that enhance individual and family coping and strengthen a sense of community.

Invasive placental disease: the impact of a multi-disciplinary team approach to management

Purpose: To determine the impact of a structured multi-disciplinary management strategy on clinical outcomes in women with invasive placental disease (IPD).Materials and methods: This was a retrospective cohort study of consecutive women having peripartum hysterectomies with IPD over seven years. For the most recent three years, a structured multidisciplinary team (MDT) reviewed each suspected case, created a management plan, and implemented that plan. Outcomes were compared between cases delivered prior to and after the MDT process was started.Results: There were 47 pregnancies with IPD, of which 31 (66.0%) were suspected antenatally and 40 (85.1%) had a prior uterine surgery. An MDT approach was performed in 19 (40.4%) cases. In the MDT group, there were longer operative times (260 min versus 181 min, p = 0.0001), less blood loss (1200 mL versus 2500 mL, p = 0.009), less administration of blood products (47.4% versus 85.7%, p = 0.005), and higher intraoperative lowest mean arterial pressures (MAPs) (57 mmHg versus 48 mmHg, p = 0.002, when compared to the No-MDT (n = 28) approach. No differences were found for other outcomes.Conclusion: Clinically meaningful improvements of less blood loss, fewer transfusions, and higher intraoperative MAPs suggest that MDT cases were more stable intraoperatively, which over a larger number of patients, should translate into improved outcomes.