Multidisciplinary Protocol Research Articles

Implementation of Clinical Pathways for CAR-T Cell Therapy in a Brazilian Private Healthcare Organization

Introduction: the treatment with CAR-T cells in Brazil is challenging because it requires a highly qualified multidisciplinary team trained in new clinical pathways to take care of these patients. Objective: to describe the implementation of the clinical pathways for CAR-T cell therapy, ensuring safety and quality. Method: this is an experience report study, performed in four private general hospitals of the Americas from São Paulo, Rio de Janeiro and Ceará states, during the year of 2022. The process of implementing the CAR-T Cell clinical pathway included: creation of a medical committee with the main medical references and specialist nurses from each center, for the elaboration of the main clinical protocols and operational procedures, in addition to the discussion of eligibility cases for therapy with CAR-T Cells. Identification of the multidisciplinary reference team in all phases of treatment, training the team involved in the clinical care of the patient, and finally, establishment of patient clinical pathway before, during and after the CAR-T cell therapy. The implementation process lasted seven months between the qualification of centers by the Therapy provider, internal qualification each center and the first cell infusion with CAR-T Cell performed. Results: In all hospitals, professionals from the multidisciplinary team (pharmacy, nursing, physicians - hematologists, pediatric hematology-oncologists involved in hematopoietic stem cell transplantation, neurologists, pediatric and adult intensive care physicians) were trained. The Multidisciplinary Care Protocol was elaborated including indications, early and late complications. The Standard Operating Procedures addressed the pre and post infusion care, daily screening, criteria to transfer the patients to the intensive care unit, recognition and management of cytokine release syndrome and neurological toxicities. The main challenges of this process were to create the routines for evaluation and systematic monitoring and to identify and involve the multidisciplinary professionals directly involved in patient care. Conclusions: the implementation of the program brought improvements to the clinical pathway, positively impacting professional satisfaction, the quality and safety of the patients. The CAR-T cell therapy was performed in a safe and integrated environment, uneventful and successful.

Whole-Body Cryostimulation in Post-COVID Rehabilitation for Patients with Obesity: A Multidisciplinary Feasibility Study.

A post-COVID condition can reduce activity and quality of life, resulting in a significant socioeconomic and health burden. Understanding its impact on patients' health is important for the development of personalized rehabilitation interventions. An independent association between obesity and post-COVID condition was found because of complications and comorbidities. Sixteen patients with obesity and post-COVID symptoms (i.e., dyspnea, pain, poor sleep quality, muscle fatigue), admitted to the Istituto Auxologico Italiano, Piancavallo (VB), Italy, were recruited for a four-week rehabilitation program including conventional exercise therapy, nutritional intervention, psychological support and whole-body cryostimulation (WBC). All participants attended all sessions of the program. Anthropometric data showed statistically significant changes in weight, waist circumference and body mass index. Biochemical analyses showed significant reductions in lipid and inflammatory profiles. There was a significant improvement in physical performance, reduction in pain and improvement in psychological well-being. A multidisciplinary rehabilitation protocol including WBC, designed for patients with obesity and a post-COVID condition, is safe and feasible. The overall improvements demonstrate that multidisciplinary rehabilitation was effective on post COVID patients and suggest that the use of WBC is safe and could play a role as a booster in rehabilitation programs.

Diagnosis, Management and Outcomes in Children with Paget Schroetter Syndrome: A Retrospective Cohort Study

Introduction Venous thoracic outlet syndrome occurs secondary to the extrinsic compression and impingement of the subclavian vein as it passes through the thoracic outlet, eventually resulting in upper extremity effort thrombosis, or Paget-Schroetter syndrome (PSS). This rare condition typically affects the dominant arm of athletic young adults with a history of repeated overhead activities. At Boston Children's Hospital (BCH), a multidisciplinary team of hematologists, interventional radiologists, and vascular surgeons manage these patients according to a standardized protocol including anticoagulation, pharmaco-mechanical thrombolysis, venoplasty, and decompressive rib-resection surgery. Herein we report the clinical and radiological outcomes of a cohort of patients with PSS managed at BCH. Objective The principle objective of this retrospective cohort study was to review the diagnosis, pharmacological, interventional radiology and surgical management, complications, and long-term outcomes of sequential pediatric patients (≤21 years) treated for PSS at BCH over a 3.5-year period of time (January 1, 2020 to July 31, 2023). Methods This study was performed as a part of an ongoing quality improvement initiative and was deemed exempt by the Institutional Review Board. Eligible patients were defined as children (≤21 years) with PSS per criteria established by the Society for Vascular Surgery. Clinical and demographic data, including post-thrombotic syndrome (PTS) scores of eligible patients were abstracted from their medical records. PTS evaluation at BCH is typically performed 6-12 months after DVT diagnosis using both the modified Villalta and Manco-Johnson instruments. Major bleeding, and recurrent/progressive thromboses were defined per published guidelines by the International Society on Thrombosis and Haemostasis. Standard statistical methods were used - median (range) for continuous variables and frequency with 95% CI for categorical data. Results The study cohort consisted of 20 patients (9 female). PSS was confirmed based on dynamic imaging with provocative maneuvers for all patients. Median (range) age at DVT diagnosis was 17 (15-21) years. Thirteen patients were diagnosed at an outside hospital and referred to BCH for further management. Fourteen patients received upfront anticoagulation with low molecular weight heparin of whom 13 patients were transitioned to a DOAC. Six patients were started on DOACs upfront. Fifteen subjects (75%) received upfront endovascular intervention at diagnosis. Median interval between DVT diagnoses to endovascular intervention was 5 (1-118) days. All patients underwent decompressive rib-resection surgery. Median interval between DVT diagnosis and surgery was 12 (7-39) weeks. Three patients (15%) developed major bleeding and 3 (15%) patients developed recurrent/progressive thrombosis after surgery. Two of the 3 patients who developed major bleeding were anticoagulated with a DOAC pre-operatively, which had been held for 48 hours before surgery. All subjects had a planned post-operative venogram, 14 (70%) of whom underwent completion venoplasty. Anticoagulation was discontinued in 18/20 (90%) patients with a median duration of therapy of 19.5 (14-60) weeks. Four patients (20%) were noted to have an underlying thrombophilia (Factor 5 R506Q [2]; Factor 2 G20210A [1]; Protein S deficiency [1]). End-of-therapy imaging was obtained for all patients - 17 (85%) had complete thrombus resolution, while two (10%) had partial thrombus resolution. Seventeen (85%) patients have undergone evaluation for PTS, of whom 12 (71%) were noted to have mild PTS and 2 (12%) have moderate-severe PTS as defined by the modified Villata instrument. Discussion Greater than 90% of pediatric patients with PSS who were treated per our institutional multi-disciplinary protocol had complete or partial thrombus resolution. Additionally, only 12% of patients reported moderate to severe PTS on follow-up and were prescribed sequential compression sleeves. Lastly, DOACs appear to be safe and efficacious in this cohort, though based on our internal data, we now interrupt DOACs for 72 hours before decompressive surgery.

DPYD variant testing in candidates for fluoropyrimidine treatment: A study protocol

ObjectiveThe main purpose of this study is to evaluate the potential clinical impact of pharmacogenetic testing on the reduction of the toxicity in patients treated with fluoropyrimidines. This will be achieved by comparing the frequency of adverse events and the incidence of toxicity of two groups of patients that will differ from each other only in that one will receive pharmacogenetic counseling. The hypothesis is that availability of a pharmacogenetic report prior to treatment initiation has a positive effect. One of the main secondary goals is to analyze allele frequencies and the association of polymorphisms rs895819 (miR27A) and rs1801160 (DPYD*6) with toxicity by conducting an observational study to determine their clinical relevance and standardize a dose adjustment recommendation. MethodThe study has an single-center ambispective, quasi-experimental design and is based on a multidisciplinary protocol involving implementation and standardization of DPYD*2A; DPYD*13; c.2846A>T; and HapB3 measurements. Following these measurements, pharmacogenetic counseling will be carried out and its clinical impact will be evaluated. The primary endpoint of the study is severe toxicity and/or mortality. The toxicity observed in two groups with similar epidemiological characteristics will be compared: the intervention group (candidates for treatment with fluoropyrimidines who will be subjected to the protocol) and the control group (retrospective cohort). Additionally, rs895819 (MIR27A) and rs1801160 (DPYD*6) will be determined. Testing for these variants is not part of the hospital's daily practice, nor are they included in clinical guidelines. However, according to recently published studies, the activity of dihydropyrimidine dehydrogenase might be affected by these variants, as they may be associated with toxicity. The results of the measurements of these two variants will not be incorporated to pharmacogenetics counseling until their association with toxicity is determined by means of the observational study to be conducted. The project, as well as the patient information sheet and the informed consent form, were approved by the Ethics Committee of the participating center (code 20/006).

Enhanced Recovery After Surgery: Exploring the Advances and Strategies.

Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.

THU088 Perioperative Management Of Patients With Pituitary Tumors Undergoing Surgery: A Retrospective Review

Abstract Disclosure: J.T. Batch: None. H. Belal: None. G.Y. Gandhi: None. Background: Pituitary tumors account for 10% of brain neoplasms with transsphenoidal resection of these tumors responsible for 20% of all intracranial operations performed for primary brain tumors. Hypothesis: We suspected significant heterogeneity and lack of standardized protocols in the perioperative endocrine evaluation and management of patients undergoing resection of sellar masses. Methods: From June 2016 through November 2022, we identified 46 adult patients (23 females, mean age 52 years, age range 25 to 84 years) who underwent pituitary mass resection (44 transsphenoidal and two transcranial approaches) at our institution. We abstracted information about perioperative endocrine evaluation from their medical records. Results: The vast majority (32 patients) had nonfunctioning pituitary macroadenomas. Other indications for surgery included Cushing’s disease (3), prolactinomas (2), acromegaly (3), pituitary metastasis (1), gonadotroph adenomas (2), Rathke cleft cyst (2), and epidermoid cyst (1). Preoperative cortisol level was not measured in 8 patients. The decision to administer intraoperative corticosteroids was not consistently based on preoperative cortisol levels. 24 patients had cortisol levels <11 mcg/dL; 22 received intraoperative corticosteroids at anesthesia induction. 13 patients had cortisol levels ≥11 mcg/dL, and 11 received intraoperative steroids. Two patients had very large pituitary masses (over 4 cm), and one received intraoperative corticosteroids. Of the two patients with Cushing’s disease, one received intraoperative corticosteroids. Cortisol level was checked in 27 patients in the first four weeks after surgery; in the rest, it was measured between 2 months and three years after surgery. All five patients with confirmed adrenal insufficiency with cortisol levels <3 mcg/dL were treated with corticosteroids. 22 patients had cortisol levels in the equivocal zone (3 to 15 mcg/dL), and 16 were treated with corticosteroids. Nine patients ultimately did not have a follow-up in endocrinology. The long-term permanence of the diagnosis of diabetes insipidus could not be established due to a lack of uniform follow-up testing. Conclusions: Patients with pituitary gland tumors represent a heterogeneous yet commonly encountered neurosurgical population. Successful surgical management is critically dependent on the quality of perioperative care. Understanding preoperative evaluation, intraoperative management, potential complications, their management, and strategies for avoidance are fundamental to reduce morbidity and mortality. High-quality evidence guiding perioperative practices in this population is needed. We have used the information gathered in this study to create a multidisciplinary perioperative protocol with expertise from endocrinologists, neurosurgeons, neuro-ophthalmologists, and neuroradiologists. Presentation: Thursday, June 15, 2023

Exploring elderly patients’ experiences and concerns about early mobilization implemented in postoperative care following lumbar spinal surgery: a qualitative study

BackgroundGiven its apparent benefits, early mobilization is becoming increasingly important in spinal surgery. However, the time point at which patients first get out of bed for mobilization after spinal surgery varies widely. Beginning in January 2022, we conducted a study of early mobilization (mobilization within 4 h postoperatively) following multi-segment lumbar decompression and fusion surgery in elderly patients. The study goal was to better understand elderly patients’ perceptions of early mobilization and ultimately contribute to the improvement of elderly patients’ perioperative experiences and quality of life.MethodsWe employed a qualitative descriptive study design involving face-to-face semi-structured interviews. Forty-five consecutive patients were invited, among whom 24 were enrolled and completed the qualitative investigation from February to June 2022. Of these 24 patients, 10 underwent early mobilization (mobilization within 4 h postoperatively) and 14 underwent mobilization at ≥ 24 h postoperatively. Three researchers conducted a 15-question interview the day before each patient’s discharge. The interviews were audio-recorded, and content analysis was used to assess the data.ResultsSix themes regarding the patients’ experiences and concerns about early mobilization were identified: worries, benefits, daily routines, pain, education, and support. The study results revealed the obstacles in early mobilization practice and highlighted the importance of perioperative education on early mobilization.ConclusionsClear and explicit guidance on early mobilization and a multidisciplinary mobilization protocol that incorporates a comprehensive pain management plan are essential for effective patient education. These measures may have positive effects on reducing patients’ stress and anxiety regarding postoperative early mobilization.

122.2: Development of a multidisciplinary protocol for thoracic organ donation process.

122.2: Development of a multidisciplinary protocol for thoracic organ donation process.

Radiation Therapy for Gestational Trophoblastic Neoplasia: Forward-Looking Lessons Learnt.

Gestational trophoblastic neoplasia (GTN) includes several rare malignant diseases occurring after pregnancy: invasive moles, choriocarcinoma, placental site trophoblastic tumours, and epithelioid trophoblastic tumours. Multidisciplinary protocols including multi-agent chemotherapy, surgery, and occasionally radiotherapy achieve good outcomes for some high-risk metastatic patients. In this narrative review of the published studies on the topic, we have tried to identify the role of radiotherapy. The available studies are mainly small, old, and retrospective, with incomplete data regarding radiotherapy protocols delivering low doses (which can make this disease appear radioresistant in some cases despite high response rates with palliative doses) to wide fields (whole-brain, whole-liver, etc.), which can increase toxicity. Studies considering modern techniques are needed to overcome these limitations and determine the full potential of radiotherapy beyond its antihemorrhagic and palliative roles.

The role of enhanced recovery after surgery (ERAS) in promoting quality improvement and patient safety in pediatric urology

Enhanced Recovery After Surgery (ERAS) is a set of evidence-based, multidisciplinary protocols that aim to improve the perioperative experience for patients by optimizing factors before, during, and after surgery. Originally developed for adult colorectal surgery, these protocols have expanded and been adopted into the pediatric surgical realm, including pediatric urology. Preoperative interventions are directed toward reducing physiologic and emotional stress prior to surgery, including preoperative education and decreased duration of fasting. Intraoperative interventions are designed to support physiologic homeostasis through maintenance of normothermia and euvolemia, use of regional anesthesia, and minimizing placement of drains. Postoperative interventions seek to reduce the physiologic burden of surgery and restore patients to their functional baseline through early oral intake, early mobilization, and opioid-sparing, multimodal analgesia. ERAS has demonstrated efficacy and safety across a wide variety of surgical subspecialties. In pediatric urology, ERAS has led to earlier return of bowel function, decreased opioid utilization, and shorter hospital length of stay, without an increase in complications compared to prior standard of care. ERAS can thus be seen as a system through which quality improvement (QI) initiatives can be designed and tailored to particular settings and patient populations. This review aims to summarize current data in pediatric urology regarding ERAS elements in the context of QI and patient safety. It will discuss the barriers and future directions of this field, including collaboration with implementation science to facilitate adoption of these protocolized measures more widely.

Pituitary tumor registry: a multidisciplinary program protocol.

This registry aims to collect information to create an appropriate platform for the development of a basis for clinical research and basic sciences to carefully study pituitary adenomas. Demographic data, diagnosis, treatment, and outcome information of the patients with a confirmed diagnosis of pituitary adenomas will be collected by investigators of the registry. Analysis of registry data generates aggregate reports summarizingpituitary tumor epidemiology, treatment, and outcome. These reports include annualpublic datareports.In the future, the registry program may provide a wider network in Iran and ultimately support the expansion of international studies. For a long time, patients with pituitary adenomas should be observed. Implementing a registration system would greatly reduce the challenges of patients' follow-up so that their monitoring can be improved.

Synoptic results on the potential impacts of the Lake Maggiore water management strategy on freshwater littoral ecosystems and invertebrate biocoenosis (NW, Italy)

The first results of the application of the integrated multidisciplinary protocol to study the effects of water level management on the Lake Maggiore littoral habitats and biocoenosis are presented. The "Parchi Verbano Ticino" project (2019-2021, ID: 481668) was the driving force to fine-tune the monitoring and management system of multidisciplinary information (chemistry, hydro-morphology, macro- and meio-fauna monitoring). The study reveals that water level fluctuations in Lake Maggiore, sometimes characterized by measurable changes in water levels, have remarkable effects on littoral habitats and on the structure and function of macro- and meiofaunal assemblages living there. Overall, this study provides insights into the potential impacts of Lake Maggiore water management strategy on freshwater littoral ecosystems during late spring-early summer, and emphasizes the need for a comprehensive understanding of the lake ecosystem dynamics. Thanks to the results achieved, publicly endorsed water management rules will be stated, for the late spring-early summer period, considering frequency and amplitude of water level fluctuations as crucial factors in management plans to mitigate their impacts. The endorsed rules turn out to be a negotiated compromise between the maintenance of ecosystem services and the protection of littoral life below water.

Adrenal Gland Necrosis in Pregnancy: How to Manage? Case Series at Nantes University Hospital and Literature Review.

Adrenal necrosis is a rare but serious cause of abdominal pain of thrombotic origin during pregnancy. There is often a delay in diagnosis and treatment. The objective was to specify the clinical and paraclinical signs suggestive of adrenal necrosis, making it possible to improve the delay in diagnostic. The secondary objective was to establish a multidisciplinary protocol regarding management. This is a case report of pregnant women with a radiological diagnosis of adrenal gland necrosis. In parallel, we carried out a systematic review in the same period. We studied these patients' clinical, biological and radiological data. We included eight patients with a computed tomography scan diagnosis of adrenal necrosis and fifteen articles in the literature describing twenty-four cases. All the patients presented with the same symptoms. The treatment was based on curative anticoagulation. The diagnosis of adrenal gland necrosis is worth suggesting in view of the array of sudden morphine-resistant abdominal pain associated with a biological inflammatory syndrome. The diagnosis is based on the computed tomography scan. Three to six months of curative anticoagulation is recommended as well as a thrombophilia and endocrinological assessment to rule out adrenal insufficiency.

Implementation of a Multidisciplinary Medication Refill Protocol.

Primary care clinicians spend significant time managing nonvisit activities, including processing of requests for prescription renewal. Delays in processing refills may lead to patient dissatisfaction and impact provider productivity. Having nonclinicians process refills can be more efficient and time-saving. We aimed to evaluate the use of a multidisciplinary medication refill protocol to decrease the time to complete refill requests. We implemented nursing-driven management of refill requests within two family medicine residency clinics in Milwaukee, Wisconsin (Phase 1: single clinic implementation [March 2017-June 2019]; Phase 2: added second clinic prepandemic [June 2019-March 2020] and postpandemic [April 2020-December 2020]). The multidisciplinary refill protocol was created by faculty, residents, pharmacy, and nursing. Data were collected using electronic health record time stamps to determine when refill requests were initiated and filled by faculty, residents, and nurses. We used Mood's median test to compare the median time for medication refill completion. We used Levene's test to test for equal variance surrounding the median of each caregiver group. We used Fisher's exact test or χ2 test with Yates' correction for 2×2 contingency tables. In both phases, we identified a significant reduction in median time to refill completion ( P<.001) and variability of time to refill completion ( P<.001). Notably, in Phase 1, reduction in median refill time was most apparent among residents (383 vs 79 min postimplementation); and in Phase 2, the percentage of refills completed within 48 hours significantly increased between the pre-COVID-19 and COVID-19 pandemic among faculty and nursing in Clinic 1 and residents and faculty in Clinic 2 (all P's<.001). Implementation of a multidisciplinary refill protocol significantly improved time and predictability of refill completion in both phases.

Work resumption after invasive heart procedures, rehabilitation and ergonomic evaluation: from the hospital to the workplace.

Our Institute adopts a multidisciplinary protocol named "CardioWork" for work resumption after invasive cardiac procedures and subsequent rehabilitation: after evaluation of the cardiac functional profile, the occupational physician analyzes the work activity prior to the cardiopathological event, identifies the presumed task energy requirement (from specific, published tables), and compares it with the exercise test results. Indications regarding the timing and modality of returning to work are formulated accordingly. To verify the reliability of the indications thus provided, we carried out a clinical-functional follow-up study in the workplace with Holter electrocardiography (ECG) and armband measurement of actual energy expenditure. Over the course of 2 years, we enrolled 36 patients (mostly males, aged between 30 and 70 years) who were hospitalized after coronary revascularization, valve replacement, or cardiac defibrillator implant. After rehabilitation, instrumental diagnostics (Holter ECG, echocardiography, exercise test) showed discrete functional conditions, with better values with regard to cardiac function than exercise capacity and effort tolerance. All subjects were judged fit for the job, in most cases with limitations concerning ergonomic factors, working timetable, and/or stress. They returned to work quickly, with good adherence to the indications provided. The workplace Holter ECG did not show appreciable differences compared to the hospital evaluation. In one case, the average energy expenditure measured while working was higher than that inferred from the tables; in the remaining subjects, the actual expenditure coincided with what was expected or was lower. In a minority of cases (39%), the measured average expenditure slightly exceeded the optimal value (35% of the maximal value at the exercise test) recommended at the time of hospital discharge. At the end of the workplace evaluation, it was not necessary to formulate new indications. The study provides further evidence of the effectiveness of the CardioWork protocol in promoting a return to work after invasive heart procedures. Although they need continuous updating, the published estimates of presumed task energy requirements remain reliable. In particularly complex cases, however, it is advisable to carry out a field check of the ergometric assessments performed at the end of rehabilitation.

Single-Center Experience in Vaccination of Children in Special Risk Groups: A Multidisciplinary Institutional Consensus Protocol.

Despite marked improvements in the accessibility of childhood vaccines, knowledge gaps remain about the vaccination of children in special risk groups (SRG). This study aimed to analyze the clinical data of children vaccinated in SRG in a single-center unit to contribute to the clinical evidence for the specific planning of immunization of children in SRG. The second- ary aim is to present institutional consensus on the vaccination of children in SRG. This retrospective study was conducted at a single-center pediatric vaccination clinic. Patient charts between 2018 and 2021 were retrospectively reviewed, and clinical and laboratory data were extracted. Serial joint meetings with multiple healthcare pro- fessionals were performed to develop an institutional protocol for vaccination. There were 479 children vaccinated between 2018 and 2021 for reasons such as post- chemotherapy, after hematopoietic stem cell transplantation, before/after solid organ trans- plantation, allergies, and chronic diseases. Of these, 298 (62.2%) children vaccinated in the unit due to a history of food or vaccine allergies were excluded. One hundred eighty-one children were vaccinated at a median age of 11 [7-15] years. Most children were vaccinated after treat- ment for malignancies. Solid tumors were the most frequent malignancy (67%), followed by acute lymphoblastic leukemia (29.0%) and acute myeloid leukemia (4.0%). Institutional vacci- nation protocols for cancer survivors, hematopoietic stem cells, and solid organ recipient chil- dren were developed and presented. There is a need to prepare national guidelines for vaccinating children with altered immunocompetence. Sharing vaccination practices by multidisciplinary vaccination units might increase and provide knowledge to develop national policies.

Implementation of a nurse-led multidisciplinary huddle meeting for improvement of early rehabilitation in ICU: a healthcare quality improvement project

The physical decline of critically ill patients affects their discharge from the intensive care unit (ICU) and their subsequent lives. Therefore, it is essential to actively provide rehabilitation at an...

Mohs surgery for female genital Paget’s disease: a prospective observational trial

Extramammary Paget's disease recurs often after traditional surgical excision. Margin-controlled surgery improves the recurrence rate for male genital disease but is less studied for female anatomy. This study aimed to compare surgical and oncologic outcomes of margin-controlled surgery vs traditional surgical excision for female genital Paget's disease. We conducted a prospective observational trial of patients with vulvar or perianal Paget's disease treated with surgical excision guided by Mohs micrographic surgery between 2018 and 2022. The multidisciplinary protocol consisted of office-based scouting biopsies and modified Mohs surgery followed by surgical excision with wound closure under general anesthesia. Modified Mohs surgery cleared peripheral disease margins using a moat technique with cytokeratin 7 staining. Medial disease margins (the clitoris, urethra, vagina, and anus) were assessed using a hybrid of Mohs surgery and intraoperative frozen sections. Surgical and oncologic outcomes were compared with the outcomes of a retrospective cohort of patients who underwent traditional surgical excision. The primary outcome was 3-year recurrence-free survival. Three-year recurrence-free survival was 93.3% for Mohs-guided excision (n=24; 95% confidence interval, 81.5%-100.0%) compared to 65.9% for traditional excision (n=63; 95% confidence interval, 54.2%-80.0%) (P=.04). The maximum diameter of the excisional specimen was similar between groups (median, 11.3 vs 9.5 cm; P=.17), but complex reconstructive procedures were more common with the Mohs-guided approach (66.7% vs 30.2%; P<.01). Peripheral margin clearance was universally achieved with modified Mohs surgery, but positive medial margins were noted in 9 patients. Reasons included intentional organ sparing and poor performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Grade 3 or higher postoperative complications were rare (0.0% for Mohs-guided excision vs 2.4% for traditional excision; P=.99). Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival after surgical excision for female genital Paget's disease. Use on medial anatomic structures (the clitoris, urethra, vagina, and anus) is challenging, and further optimization is needed for margin control in these areas. Mohs-guided surgical excision requires specialized, collaborative care and may be best accomplished at designated referral centers.

Mammary analogue secretory carcinoma (MASC) of parotid gland- A case report

Mammary analogue secretory carcinoma is a rare salivary gland carcinoma which shares morphologic and immunohistochemical features with the secretory carcinoma of breast and was first proposed by Skalova in 2010 with translocation of (q13; q25), t (12; 15), subsequently giving ETV6-NTRK3 gene rearrangement. Usually, it is a benign tumor that affects the parotid gland, with slight predilection for males. The present article report a case of secretory carcinoma of right parotid gland with special emphasis on histological feature and immunohistochemistry for diagnostic purpose and its management. Differential diagnosis includes AciCC, ADC-NOS and MEC. In a review by Chiosa et al (2012) in 337 cases of salivary gland malignancy included AciCC, ADC-NOS, MEC, LGCC, non-ITAC, signet ring adenocarcinoma, PLGA and most common malignancy reclassified as MASC were AciCC (11/89), ADC-NOS (14/37), MEC (1/165). Management for MASC includes surgical excision of the lesion (either superficial or total parotidectomy) for local, less aggressive disease like for low-grade malignant salivary gland neoplasms. For more invasive, metastatic disease and positive margins- neck dissection, radiotherapy and chemotherapy are reserved. There is no standard multidisciplinary treatment protocol established due to scarcity of this disease.

Rapid-Response Electroencephalography in Seizure Diagnosis and Patient Care: Lessons From a Community Hospital.

BACKGROUND: Nonconvulsive seizures are a major source of in-hospital morbidity and a cause of unexplained encephalopathy in critically ill patients. Electroencephalography (EEG) is essential to confirm nonconvulsive seizures and can guide patient-specific workup, treatment, and prognostication. In a 208-bed community hospital, EEG services were limited to 1 part-time EEG technician and 1 EEG machine shared between inpatient and outpatient settings. Its use was restricted to typical business hours. A nursing-led quality improvement (QI) project endeavored to enhance access to EEG by introducing a point-of-care rapid-response EEG program. METHODS: For this project, a multidisciplinary protocol was developed to deploy a Food and Drug Administration-cleared, point-of-care rapid-response EEG platform (Ceribell Inc) in a community hospital's emergency department and inpatient units to streamline neurodiagnostic workups. This QI project compared EEG volume, study location, time-to-EEG, number of cases with seizures captured on EEG, and hospital-level financial metrics of diagnosis-related group reimbursements and length of stay for the 6 months before (pre-QI, using conventional EEG) and 6 months after implementing the rapid-response protocol (post-QI). RESULTS: Electroencephalography volume increased from 35 studies pre-QI to 115 post-QI (3.29-fold increase), whereas the median time from EEG order to EEG start decreased 7.6-fold (74 [34-187] minutes post-QI vs 562 [321-1034] minutes pre-QI). Point-of-care EEG was also associated with more confirmed seizure diagnoses compared with conventional EEG (27/115 post-QI vs 0/35 pre-QI). This resulted in additional diagnosis-related group reimbursements and hospital revenue. Availability of point-of-care EEG was also associated with a shorter median length of stay. CONCLUSION: A nurse-led, rapid-response EEG protocol at a community hospital resulted in significant improvements in EEG accessibility and seizure diagnosis with hospital-level financial benefits. By expanding access to EEG, confirming nonconvulsive seizures, and increasing care efficiency, rapid-response EEG protocols can enhance patient care.