Multidisciplinary Medical Care Research Articles

Early diagnosis, effective treatment: modern approaches to the management of ectopic pregnancies

Purpose of research: The aim of this article is to provide an overview of the diagnosis and management of atypical ectopic pregnancy, with particular reference to pregnancy in the cesarean scar. The importance of early detection and medical intervention will be described, as well as the impact of advanced diagnostic techniques and modern treatments on the curability of patients.This article aims to provide valuable insights into the development of effective strategies for the diagnosis, treatment and prognosis of ectopic pregnancy. State of knowledge: Ectopic pregnancies account for 1-2% of all pregnancies, with the majority (90%) occurring in the fallopian tube. Less commonly, they present as ovarian, cervical or abdominal pregnancies. Advances in diagnosis and treatment have made it possible to identify rare forms such as cesarean scar pregnancy (0.15% of all pregnancies), interstitial pregnancy and recurrent ectopic pregnancy on tubal remnants. Techniques such as transvaginal ultrasound (TVS), MRI and laparoscopy have the potential to improve diagnostic accuracy and treatment outcomes. Modern interventions such as transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and methotrexate have shown promise in terms of safety and efficacy. Conclusions: Ectopic pregnancy and its complications have a significant impact on the psycho-physical health of patients, requiring ongoing research to improve diagnostic and therapeutic methods. Future studies should focus on long-term outcomes and the coordination of multidisciplinary medical care to further improve diagnosis and treatment.

The role of reconstructive plastic surgery in the treatment of victims of the 2023 Kahramanmaraş earthquake

Objective: As a result of the 2023 Kahramanmaraş earthquake, medical institutions experienced a large influx of patients requiring acute multidisciplinary surgical and medical care. This study aimed to evaluate the patient demographics and treatment management of survivors admitted to our reconstructive plastic surgery department. Materials and Methods: We retrospectively analyzed the age, sex, time under the wreckage, time of admission, types and locations of injuries, treatment modalities, receipt of hyperbaric oxygen therapy, and receipt of vacuum-assisted closure therapy of the earthquake victims referred to our department. Results: The definitive management of all 42 earthquake survivors admitted to our department was reviewed. This included five free flaps, four regional flaps, 18 split-thickness skin grafts, and one maxillofacial fracture repair. Eight patients were treated conservatively including two with non-displaced maxillofacial fractures. Of the 26 patients treated for lower extremity injuries, four were already amputees. Among the remaining 22 patients with such injuries, one underwent Charcot amputation plus free flap reconstruction to preserve extremity length and one underwent below-the-knee amputation. Of the 16 upper extremity injuries, two patients referred with extensive forearm necrosis underwent forearm amputation. To preserve extremity length and ensure the limbs were suitable for biomechanical orthoses, free transverse upper gracilis musculocutaneous flaps and free chimeric Anterolateral- Vastus Lateralis musculocutaneous flaps were performed. Conclusion: This study illustrates the value of multi-modal reconstructive plastic surgery in the treatment of disaster survivors, particularly in the management of multi-trauma.

The acceptability of hospital-at-home for persons living with cancer and their caregivers.

1548 Background: Hospital at Home (HaH) is part of a comprehensive patient-centered model that delivers multidisciplinary acute medical care in the home. While HaH has mainly been tested in general medical patients, uncertainties persist regarding the feasibility and acceptability of this model within oncology populations. This study assessed patient and caregiver characteristics associated with acceptability of a hypothetical HaH program in persons hospitalized with cancer and described patient medical needs. Methods: A cross-sectional survey assessing acceptability of a hypothetical HaH program, home characteristics, and demographics was completed by 250 patients and 33 caregivers. Eligible patients were English-speaking adults (18+ years) admitted to the medicine service at a cancer hospital. Acceptability was measured on a 5-point Likert scale and defined as responses of “strongly agree” or “agree” to the statement, “I would consent to the use of my home for my hospital care” if such a program were available. Surveys were conducted in person or via telephone during the index hospitalization. Unpaid adult caregivers were surveyed in person and acceptability of the hypothetical HaH program was similarly assessed. Characteristics of the hospitalization were assessed via the electronic health record. Continuous variables were compared between acceptability groups using Wilcoxon rank sum test; categorical variables were compared using Fisher’s exact test and Pearson’s chi-squared test. Results: Median patient age was 63, 134 (54%) were female, 38 (16%) identified as Black and 21 (8.8%) as Hispanic, and 171 (72%) completed some college education or more. 208 patients (83%) rated participation in HaH as acceptable, as did 28 (85%) caregivers. Patients living with metastatic disease were more likely to accept HaH (p<0.05). Acceptability differed by race (p<.05) and was lowest among Black patients (74%) and those who preferred not to provide their race (70%). Of those who rated HaH acceptable, 137 (66%) had advanced imaging or a surgical procedure after the first day of admission and 21 (10%) had an absolute contraindication to being hospitalized at home such as a home member using illicit drugs at home (15, 7%). Conclusions: Over 80% of persons hospitalized with cancer and their caregivers would agree to HaH. Those with advanced disease were more likely to agree to home hospitalization compared to curative-intent patients, but Black patients were less likely to agree to be hospitalized at home compared to white patients. Many patients had hospitalization characteristics (e.g., imaging) that may be challenging to coordinate from home, but few patients had safety-related contraindications to HaH. These findings will inform future efforts to evaluate and target HaH programs in oncology to patients most likely to agree to and benefit from them, and address barriers to uptake in certain racially minoritized populations.

SEVERE COURSE OF PARAGANGLIOMAS IN CHILDREN WITH SUCCINATE DEHYDROGENASE MUTATIONS – A REPORT OF TWO CASES

Objective: Paragangliomas and pheochromocytoma (PPGL) are rare causes of arterial hypertension (AH) in children. This study aimed to present the clinical course in two adolescents with PPGL tumors due to succinate dehydrogenase mutations. Design and method: We analyzed age, gender, clinical manifestations, laboratory findings, including plasma methoxycatecholamines, genetic and imaging findings, pharmacological and surgical treatment, and outcome. Results: Case 1: A 14-year-old boy presented with tinnitus, dizziness, and balance disorders. A computed tomography (CT) revealed a paraganglioma in the area of the left internal jugular vein bulb, causing ear and bone destruction. The boy was diagnosed with AH; his plasma normetanephrine was 343pg/mL (normal range: 18-138), metanephrine and 3-methoxytramine were normal. The patient was started on doxazosin, and the tumor was removed. A genetic study showed a pathogenic variant in the SDHD gene (c.33C>A). PET/CT showed another tumor between the inferior vena cava and diaphragm. A successful tumor resection was performed. Currently, the boy is 17 years old, methoxycatecholamine levels are normal. The patient has AH (primary hypertension) and is treated with rampiril and amlodipine. Case 2: A 17.5-year-old girl was admitted to the hospital due to headaches and AH lasting about six months. Laboratory tests revealed a markedly elevated plasma normetanephrine - 8734.59pg/mL (normal range: 16-142) and a slightly elevated 3-methoxytramine - 25.52pg/mL (normal range < 14). CT showed a large tumor (11x7x7cm) at the level of the diaphragm, modeling the heart, liver, and inferior vena cava. Whole-body PET/CT and MIBG scintigraphy did not detect other tumors. A genetic test showed a pathogenic variant in the SDHB gene (c.181dupT). The girl was treated with doxazosin. Surgical treatment included two transarterial embolizations, followed by surgical removal of the tumor. Currently, the patient is 18 years and 2 months old, has normal methoxycatecholamines, and does not require antihypertensive drugs. The same variant of the SDHB gene was found in the patient's father and older brother. Conclusions: 1.PPGL can have an unusual clinical course in children, and patients may present with a variety of symptoms 2.Pediatric patients with PPGL require genetic tests and individualized, multidisciplinary medical care.

Preparation for implantation of mechanical circulatory support: psychological adjustment and treatment of mental disorders in the pre- and postoperative period.

Treatment of patients with advanced heart failure (HF) with the use of left ventricular assist devices (LVADs) improves the quality of life and the length of survival. Despite the undeniable benefits associated with improved physical performance, as a result of the decrease of the underlying disease symptoms, it carries the risk of complications in the area of the patient's somatic and psychological status. Long-term circulatory failure can contribute to a weakening of the adaptative mechanism and consequently lead to a variety of emotional disruptions. Patients must face the fear of imminent physical, family, and social changes that LVAD requires. They may experience sleep disorders, mood disorders, anxiety disorders, and in the early postoperative period also disorders of consciousness with a pattern of delirium. For this reason, it is advisable to provide multidisciplinary medical care for the patient at all stages of treatment, including regular monitoring of general health and mental health. This article presents risk factors for psychiatric disorders in patients with LVADs and ways of pharmacological and non-pharmacological management when these factors are identified and disorders are diagnosed.

Neuropsychiatric Aspects of Sotos Syndrome: Explorative Review Building Multidisciplinary Bridges in Clinical Practice.

Background: Sotos syndrome is a genetic disorder caused by NSD1 gene (nuclear receptor binding SET domain containing protein 1) variants and characterized by overgrowth, macrocephaly, learning disabilities, and co-occurring neuropsychiatric symptoms. Methods: Literature sources published in 2002-2023 were selected and analyzed from PubMed and Google Scholar databases. Results: Neuropsychiatric symptoms are observed among children and adolescents with Sotos syndrome. The majority have intellectual disabilities or borderline intellect. Verbal IQ is higher than performance IQ. Individuals display difficulties in expressing language. Aggression is reported by parents. Children express autistic behavior, ADHD, anxiety based on phobias, and early bedtime-wake times. Conclusions: Sotos syndrome is associated with neuropsychiatric disorders in children. Slow intellectual and language development, aggressive outbursts, anxiety, autism spectrum disorder, and hyperactivity are present in the newest studies. Comprehensive assistance is needed for Sotos syndrome patients in responding to areas of difficulty. There is still a lack of research on the developmental characteristics of these children and the possibilities of improving psychosocial adaptation by providing multidisciplinary long-term medical, educational, and social care.

The Potential Coexistence of Autoimmune Thyroid Diseases and Pediatric Vulvar Lichen sclerosus.

Vulvar lichen sclerosus (VLS), a chronic inflammatory skin disorder, often coexists with autoimmune thyroid disease (AITD). VLS presents with subtle symptoms including vulvar itching and discomfort. Clinically, a "Figure 8" pattern involving the labia minora, clitoral hood, and perianal region is often observed. It is prevalent both in pre-pubertal girls and women aged 40-60, and the link between VLS and AITD remains unclear, with proposed causes including autoimmune, hormonal or genetic factors, and environmental triggers. This study addresses the lack of research on the association in children, aiming to investigate the largest group of underage girls to date. This study aimed to investigate the coexistence of thyroid autoimmune diseases in girls diagnosed with vulvar lichen sclerosus (VLS) and to assess the presence of antibodies for specific thyroid autoimmune diseases. Our study was conducted from July 2020 to February 2021, involving a sample of 55 girls aged 2-18 years old, all free from systemic diseases. The study group comprised 20 girls previously diagnosed with vulvar lichen sclerosus (VLS), while the control group included 35 girls without VLS. Legal guardians completed questionnaires detailing the medical history of their children. Blood samples were collected from all participants and subjected to biochemical analysis. The presence of human IgG antibodies against thyroid peroxidase and IgG antibodies against thyroglobulin was assessed using the immunoenzymatic method with commercially available ELISA kits. In the study group, common symptoms included itching, soreness, burning sensation, excoriation, and erythema or pallor of the skin and perineal mucosa. An evaluation of anti-thyroglobulin and anti-thyroid peroxidase antibodies revealed no statistical significance between the study and control groups (anti-TG p = 0.379, anti-TPO p = 0.96). Family history of autoimmune diseases showed no significant correlation with anti-thyroid antibodies in girls. Although no significant relation between VLS occurrence and antibody levels was found, it emphasizes the need for multidisciplinary medical care. Further research with larger patient groups is necessary.

Prenatal Ultrasound Imaging of Orofacial Clefts: A Pictorial Essay.

Orofacial clefts (OFCs), including cleft lip (CL), cleft palate (CP), and CL with palate (CL/P), are relatively common congenital birth defects occurring in approximately 1 in 500 to 1 in 2500 live births. Detecting OFCs during prenatal ultrasound screening is crucial for informed decision-making and multidisciplinary medical care. This review provides a practical guide for routine and advanced screening for OFCs during mid-pregnancy. The Maarse classification system facilitates effective communication among the multidisciplinary team, categorizing OFCs into five types. Basic ultrasound views encompass coronal, sagittal, and axial imaging of the face and hard palate. Additional visualization techniques are employed in case of suspected anomalies during the initial screening. Advanced ultrasound views provided by the expert in prenatal OFC diagnosis include imaging of the posterior edge of the hard palate and the posterior part of the soft palate. Detected OFCs exhibit a range of severity and affect different structures, underscoring the importance of accurate detection and classification for appropriate treatment planning. Implementing a standardized screening protocol for OFCs is essential. By enhancing detection rates and enabling early diagnosis, prenatal ultrasound screening contributes to improved patient outcomes and facilitates timely intervention by the multidisciplinary team. In conclusion, this review emphasizes the significance of standardized protocols and specialized techniques for prenatal ultrasound screening of OFCs. Early detection and classification of these malformations play a vital role in comprehensive management, ensuring that affected individuals and their families receive the appropriate care and support they need.

Socioeconomic determinants of the biology and outcomes of acute lymphoblastic leukemia in adults

AbstractVarious socioeconomic and biologic factors affect cancer health disparities and differences in health outcomes. To better characterize the socioeconomic vs biologic determinants of acute lymphoblastic leukemia (ALL) outcomes, we conducted a single-institution, retrospective analysis of adult patients with ALL treated at the University of Chicago (UChicago) from 2010 to 2022 and compared our outcomes with the US national data (the Surveillance, Epidemiology, and End Results [SEER] database). Among 221 adult patients with ALL treated at UChicago, BCR::ABL1 was more frequent in patients with higher body mass index (BMI; odds ratio [OR], 7.64; 95% confidence interval [CI], 1.17-49.9) and non-Hispanic Black (NHB) ancestry (59% vs 24% in non-Hispanic White (NHW) and 20% in Hispanic patients; P = .001). In a multivariable analysis, age (hazard ratio [HR], 6.93; 95% CI, 2.27-21.1) and higher BMI at diagnosis (HR, 10.3; 95% CI, 2.56-41.5) were independent predictors of poor overall survival (OS). In contrast, race or income were not predictors of OS in the UChicago cohort. Analysis of the national SEER database (2010-2020) demonstrated worse survival outcomes in Hispanic and NHB patients than in NHW patients among adolescent and young adults (AYAs) but not in older adults (aged >40 years). Both AYA and older adult patients with higher median household income had better OS than those with lower income. Therefore, multidisciplinary medical care coupled with essential supportive care services offered at centers experienced in ALL care may alleviate the socioeconomic disparities in ALL outcomes in the United States.

QOL-10. MULTIDISCIPLINARY MEDICAL CARE SYSTEM FOR BRAIN TUMOR SURVIVORS IN JAPAN

Abstract INTRODUCTION: Brain tumor patients suffer from psychological distress and various aftereffects. Although the number of "brain tumor survivors" has been increasing due to improved outcomes of brain tumor treatment, the support system for them is inadequate in Japan. Therefore, we are examining issues affecting the QOL faced by brain tumor patients and their families, with the aim of establishing a fulfilling medical care system with a multidisciplinary approach. Here, we report on the current status of the multidisciplinary medical care system. METHODS: The EORTC QLQ-C30, 14-item resilience scale, PHQ-9, and Pittsburgh Sleep Quality Index are used to assess QOL. Based on these, an optimal care plan for brain tumor patients was developed through multidisciplinary team of professionals among physicians, nurses, clinical neuropsychologists, speech-language pathologists, occupational therapists, pharmacists, and nutritionists. A brain tumor survivorship program designed to support brain tumor patients, survivors, and care givers was developed, and this program was launched in December 2021. RESULTS AND DISCUSSION: Quality of life assessment of brain tumor patients revealed their problems and unmet needs, which enabled the development of optimal care plans in collaboration with multiple disciplines. In addition, neuropsychological approaches and cognitive behavioral therapy have been utilized as interventions for cognitive dysfunction. The Brain Tumor Survivorship Program has 18 participants as of May 31, 2023. In addition to providing online resources, patient support meetings were held virtually, providing an opportunity for participants to communicate directly with each other. CONCLUSION: We believe it is essential to establish a long-term follow-up system specifically for brain tumor patients. Through the multidisciplinary medical care system, we plan to continue to scientifically investigate and develop a support system for the various survivorship issues that brain tumor patients and their families experience across the trajectory of the illness.

Diabetic severity and oncological outcomes of colorectal cancer following curative resection: A population-based cohort study in Taiwan.

Although diabetes is a poor prognostic factor for colorectal cancer (CRC), whether diabetes severity provides an additional predictive value for CRC prognosis remains unclear. The study aimed to investigate the prognostic differences after curative CRC resection among patients with different diabetic severities. This population-based retrospective cohort study analyzed data registered between 2007 and 2015 in the Cancer Registry Database, which is linked to the National Health Insurance Research Database and National Death Registry. Patients with CRC who underwent curative radical resection for stage I-III disease were evaluated, with their diabetic status subdivided into no diabetes, diabetes without complication, and diabetes with complications. Cox regressions were applied to determine the association between diabetes severity and CRC survival, including overall survival (OS), disease-free survival (DFS), time to recurrence, and cancer-specific survival (CSS). A total of 59,202 patients with CRC were included. Compared with the no diabetes group, the diabetes without complication group has insignificantly worse OS (hazard ratio [HR],1.05; 95% confidence interval [CI],1.01-1.09), DFS (HR,1.08; 95% CI,1.04-1.12), and CSS (HR,0.98; 95% CI,0.93-1.03), whereas those with complicated diabetes had a significantly higher risk of poor survival (OS: HR,1.85; 95% CI,1.78-1.92; DFS: HR,1.75; 95% CI,1.69-1.82; CSS: HR,1.41; 95% CI,1.33-1.49). Patients with CRC and diabetes also had a higher risk of recurrence than did those without diabetes. Sex and TNM staging were important effect modifiers. Among patients with CRC who undergo curative resection, the severity of the diabetes is inversely correlated with long-term outcomes, especially in women and patients in the earlier stages of CRC. The prognostic impact of diabetes severity in colorectal cancer (CRC) is yet to be clarified. In this cohort study of 59,202 patients with CRC, compared with patients with CRC and without diabetes, those with uncomplicated diabetes had an insignificantly worse CRC survival, whereas those with complicated diabetes had a significantly higher risk of poor survival. Multidisciplinary medical care to prevent progression into diabetes with complications is needed to improve survival among patients with CRC and diabetes.

A Study of Oral Health Parameters and the Properties and Composition of Saliva in Oncological Patients with and without Medication-Related Osteonecrosis of the Jaw Who Take Bisphosphonates.

Background and Objectives: The aim of this study was to examine how the status of the oral cavity, composition and properties of saliva change in oncological patients with and without Medication-Related Osteonecrosis of the Jaw (MRONJ) undergoing bisphosphonate therapy. Materials and Methods: A retrospective case-control study of 49 oncological patients using bisphosphonates (BPs) was conducted. The study population was divided into two groups-Group I consisted of 29 patients with MRONJ and Group II of 20 patients without MRONJ. The control group consisted of 32 persons without oncological history and without antiresorptive therapy. Standard dental examination included the assessment of the number of teeth remaining, teeth with caries and fillings, Approximal Plaque Index (API) and Bleeding on Probing (BOP). In terms of MRONJ, localization and stage were assessed. Laboratory tests of saliva included determination of pH and concentrations of Ca and PO4 ions, total protein, lactoferrin, lysozyme, sIgA, IgA, cortisol, neopterin, activity of amylase at rest, and stimulated saliva. The buffering capacity and microbiological tests (Streptococcus mutans, Lactobacillus spp. load) of stimulated saliva were also determined. Results: There were no statistically significant differences between the selected oral parameters and saliva of Group I and Group II. Significant differences were found between Group I and the control group. BOP, lysozyme and cortisol concentration were higher, while the number of teeth with fillings, Ca and neopterin concentrations were lower in comparison to the control group. In Group I, a significantly higher percentage of patients with a high colony count (>105) of Streptococcus mutans and Lactobacillus spp. was also found. The significant differences between Group II and the control group concerned the concentrations of lysozyme, Ca ions, sIgA, neopterin and the colony count of Lactobacillus spp. In the Group I patients who received a significantly higher cumulative dose of BP compared to the Group II, a significant positive correlation was found between the received BP dose and the BOP. Most MRONJ foci were stage 2 and were mainly located in the mandible. Conclusions: Among oncological patients with and without MRONJ undergoing BP therapy compared to the control group, there are statistically significant differences in the dental, periodontal and microbiological status and in the composition of the saliva. Particularly noteworthy are the statistically significant differences in the decreased level of Ca ions, the increased level of cortisol and the elements of saliva related to the immune response (lysozyme, sIgA, neopterin). Additionally, a higher cumulative dose of BPs may affect the susceptibility to the development of osteonecrosis of the jaws. Patients undergoing antiresorptive therapy should receive multidisciplinary medical care, including dental care.

Economic Impact of a Multidisciplinary Neurofibromatosis Clinic in a Canadian Tertiary Care Hospital (P8-13.001)

<h3>Objective:</h3> The objective of this research protocol is to measure the economic impact of implementing a multidisciplinary neurofibromatosis clinic in a Canadian tertiary care hospital. <h3>Background:</h3> Neurofibromatosis type 1 (NF1) is associated with a wide range of complications, such as psychological and physical pain due to neurofibromas and other tumors, increased risk of malignancy, neuropsychiatric comorbidities, unemployment, impaired quality of life, and reduced life expectancy. Consequently, NF1 patients require close monitoring from a number of specialists including neuro-oncologists, neurosurgeons, geneticists, and endocrinologists. Multidisciplinary clinics provide numerous advantages, such as increased access to care and reductions in no-show rates, and have been proven cost-effective in multiple clinical contexts. However, there have been no studies on the economic impact of multidisciplinary neurofibromatosis clinics. <h3>Design/Methods:</h3> We will perform a cost-effectiveness analysis of the Centre Hospitaliser de l’Université de Montréal (CHUM) multidisciplinary neurofibromatosis clinic, Quebec, Canada during a five-year period since its implementation in 2021. We will determine the cost of illness linked with NF1 in our province using a bottom-up cost estimation approach. We will then estimate the clinic-associated costs using administrative databases. Patients visiting the clinic will periodically answer a battery of questionnaires measuring the impact of their disease on quality of life, which will allow us to determine the quality-adjusted life-years (QALYs) gained from the intervention. We will determine the economic benefit of our clinic by combining total costs and QALY gains and comparing them to the estimated cost of illness. We will perform a sensitivity analysis to assess the validity of our results. <h3>Results:</h3> Not applicable <h3>Conclusions:</h3> This is the first study protocol assessing the economic impact of multidisciplinary medical care for NF1 patients. We hypothesize that this intervention is cost-effective and will positively impact the overall wellbeing of the NF1 population in our region. <b>Disclosure:</b> Dr. Rousseau has nothing to disclose. Dr. Lapointe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion.

Thalassemia care in Nepal: In dire need of improvement.

Thalassemia care in Nepal: In dire need of improvement.

Morbidity and Mortality Trends in Preterm Infants of

Owing to advances in critical care treatment, the overall survival rate of preterm infants born at a gestational age (GA) <32 weeks has consistently improved. However, the incidence of severe intraventricular hemorrhage (IVH) has persisted, and there are few reports on in-hospital morbidity and mortality. Therefore, the aim of the present study was to investigate trends surrounding in-hospital morbidity and mortality of preterm infants with severe IVH over a 14-year period. This single-center retrospective study included 620 infants born at a GA <32 weeks, admitted between January 2007 and December 2020. After applying exclusion criteria, 596 patients were included in this study. Infants were grouped based on the most severe IVH grade documented on brain ultrasonography during their admission, with grades 3 and 4 defined as severe. We compared in-hospital mortality and clinical outcomes of preterm infants with severe IVH for two time periods : 2007-2013 (phase I) and 2014-2020 (phase II). Baseline characteristics of infants who died and survived during hospitalization were analyzed. A total of 54 infants (9.0%) were diagnosed with severe IVH over a 14-year period; overall in-hospital mortality rate was 29.6%. Late in-hospital mortality rate (>7 days after birth) for infants with severe IVH significantly improved over time, decreasing from 39.1% in phase I to 14.3% in phase II (p=0.043). A history of hypotension treated with vasoactive medication within 1 week after birth (adjusted odds ratio, 7.39; p=0.025) was found to be an independent risk factor for mortality. When comparing major morbidities of surviving infants, those in phase II were significantly more likely to have undergone surgery for necrotizing enterocolitis (NEC) (29.2% vs. 0.0%; p=0.027). Additionally, rates of late-onset sepsis (45.8% vs. 14.3%; p=0.049) and central nervous system infection (25.0% vs. 0.0%; p=0.049) were significantly higher in phase II survivors than in phase I survivors. In-hospital mortality in preterm infants with severe IVH decreased over the last decade, whereas major neonatal morbidities increased, particularly surgical NEC and sepsis. This study suggests the importance of multidisciplinary specialized medical and surgical neonatal intensive care in preterm infants with severe IVH.

Respiratory phenotypes of neuromuscular diseases: A challenging issue for pediatricians.

Neuromuscular disease (NMDs) encompass a heterogeneous group of genetic disorders, with respiratory problems of variable intensity and progression described at any pediatric age, from infancy to adolescence, and they are largely associated with significant lifelong morbidity and high mortality. Restriction of breathing, impaired gas exchange, decline of lung function and sleep disordered breathing progressively develop because of muscular weakness and culminate in respiratory failure. Depending on the disease progression, airways manifestations can take weeks to months or even years to evolve, thus depicting two major respiratory phenotypes, characterized by rapid or slow progression to respiratory failure. Assessing type and age at onset of airways problems and their evolution over time can support pediatricians in the diagnostic assessment of NMD. In addition, knowing the characteristics of patients' respiratory phenotype can increase the level of awareness among neonatologists, geneticists, neurologists, pulmonologists, nutritionists, and chest therapists, supporting them in the challenging task of the multidisciplinary medical care of patients. In this review we examine the issues related to the pediatric respiratory phenotypes of NMD and present a novel algorithm that can act as a guide for the diagnostic agenda and the key preventive or therapeutic interventions of airways manifestations. With prolonged survival of children with NMD, the advent of neuromuscular respiratory medicine, including accurate assessment of the respiratory phenotype, will help physicians to determine patients' prognoses and to design studies for the evaluation of new therapies.

IMPLEMENTATION OF THE HOSPITAL DISTRICT FOR THE MEDICAL INSTITUTIONS: MEDICAL AND SOCIAL JUSTIFICATION OF THE FINANCIAL AND ECONOMIC STATE OF KALUSH CENTRAL DISTRICT HOSPITAL BEFORE AND AFTER IMPLEMENTATION

The aim: To determine the financial and economic condition before and after the implementation of the hospital district in the Kalush Central District Hospital and to show the medical and social justification of the changes in the institution's finances. Materials and methods: The object of this study was the activity of the Kalush Central District Hospital, which is a multidisciplinary medical and preventive health care facility, in which medical assistance is provided to patients in surgical, neurosurgical, traumatological, cardiological, gastroenterological, endocrinological, urological departments, in the department of miniinvasive surgery. In order to see how the implementation of hospital districts a"ected the financial condition of medical institutions, the financial statements of the institution for 2017-2018 were used to study the financial condition of the organization. During this period medical assistance was provided to more than 92,000 patients. Results: The reform of the health care system in 2017 took place in accordance with the developed concept of the development of medicine, which is based on the creation of hospital districts. On average, the hospital district covers about 60 kilometers of territory. Such a distance allows us to deploy a powerful network of various hospitals that are able to provide almost the entire range of medical services, starting from diagnostics and ending with urgent treatment. The hospital district is headed by an institution that coordinates the work of all institutions and recommends building such organizational and financial structures that allow the medical institution to develop and create a quality medical product. Kalush Central District Hospital coped with the reforms of medicine, the implementation of hospital districts became a significant event that changed not only the organization of the provision of medical services, but also changes in the financial and economic condition of medical institutions. In general, the financial condition of the enterprise shows that the hospital is autonomic, it is financed from its own sources of financing. Conclussions: The financial condition of the enterprise shows that the Kalush Central District Hospital is autonomous, that is, to a greater extent, it is financed from its own sources of financing. However, liquidity indicators are negative, which require more e"ective management of cash #ows so that the organization can timely repay salary arrears and pay mandatory payments for the use of material resources and energy. At the same time, a large number of patients are coming to the hospital because the income level has increased, which is definitely a positive factor. However, when planning activities for the following periods, it is necessary to take into account the need to update material and technical support, as well as to find sources of increasing sta" wages.

JS-CME-2: REDUCTION IN CARDIOVASCULAR MORBIDITY AND MORTALITY BY CARDIAC REHABILITATION: WHAT'S THE EVIDENCE?

The Japanese Society of Cardiac Rehabilitation defines cardiac rehabilitation (CR) as follows. Cardiac rehabilitation refers to a long-term, multifaceted, comprehensive program designed to optimize a cardiac patients physical, psychological, social, and vocational status, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic or heart failure processes, thereby reducing recurrence, rehospitalization and mortality and enabling patients to live comfortably and actively. CR programs include medical assessment, prescribed exercise training, coronary risk factor modification, patient education, counseling and optimal medical therapy for individual patients, which are provided by a multi-disciplinary team in a coordinated manner. Comprehensive CR consists of continuous multidisciplinary team medical care centered on exercise therapy and disease management. Comprehensive CR improves exercise tolerance and physical function in most heart diseases. Improvements in subjective symptoms and QOL are also observed in many heart diseases. Concerning long-term prognostic improvement effect, it is observed in coronary artery disease and heart failure. Reduced readmissions are also observed in heart failure patients. Mechanisms for improving the long-term prognosis of patients with coronary artery disease and heart failure include: 1) improvement of coronary risk factors, 2) improvement of vascular endothelial function and systemic anti-arteriosclerosis/anti-inflammatory effects via suppression of oxidative stress, 3) improvement of autonomic nerve function, 4) increase in skeletal muscle mass and associated various myokine actions. Based on the above-mentioned evidence, all clinical guidelines of the Japanese Circulation Society, AHA, and ESC strongly recommend participation in CR as class I (evidence and/or general agreement that a given procedure or treatment is effective and useful) for patients after acute myocardial infarction. In post-CABG patients, American and European guidelines recommend CR as Class I. As for chronic heart failure, exercise therapy is strongly recommended as class I in all heart failure clinical guidelines in Japan, Europe, and the United States. However, a clinical problem is the low rate of CR participation in patients with heart disease. This tendency is particularly conspicuous in Japan. Furthermore, an increase in the number of elderly heart failure patients with frailty is also a major issue. There is a need to create a system that supports patients through a community network throughout the acute, recovery, and maintenance phases.

COMMUNICATIONS OF DOCTORS AND NURSES. TEAMWORK

The article deals with the issues of communication between doctors and nurses. Attention is paid to the obstacles which affect effective communication between doctors and nurses, which include the increase of the workload, the constant change of staff, the use of high-tech terminology, the previous negative experience of communication between nurses and doctors, etc. Recommendations for improving communication in a medical team are given. It is emphasized that the factors contributing to effective communication between hospitals and organizations providing primary health care are multidisciplinary medical care plans drawn up in cooperation with patients and caregivers.

Japanese herbal kampo medicine individually contributes to alleviating side effects of cancer patients

Cancer patients suffer from physical pain due to cancer itself and side effects by anticancer drugs, as well as social pain such as employment problems, psychological and spiritual pain. It is important to overcome these total pains with multidisciplinary medical care. Regarding drug treatment, if there is no drug effective in alleviating the patients' symptoms, it is necessary to develop a novel drug or drug repositioning to apply existing drugs. Among them, "Japanese herbal kampo medicine", introduced from China and developed in Japan, has come to occupy an important position as a complementary and alternative medicine to Western drugs.