Multidisciplinary Specialty Research Articles

Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers.

The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.

Assessing the impact of COVID-19 on healthcare staff at a combined elderly care and specialist palliative care facility: A cross-sectional study

Background: In the pre-COVID-19 era, healthcare professionals experienced stress and burnout. The international literature confirms that COVID-19 placed significant additional burdens on healthcare workers. Aim: To describe and characterise the magnitude and variety of ways in which the COVID-19 pandemic affected the personal, social and professional lives of healthcare workers representing several multidisciplinary specialties in a fully-integrated palliative and elderly care service. Design: All staff were invited to complete an anonymised standardised questionnaire evaluating the impact of COVID-19 across a diverse range of domains. The study was conducted over a 6-week period commencing 11 September 2020. Setting: The setting incorporates two distinct but integrated services operating under a single management structure in Ireland: (i) Specialist palliative care across hospice (44 beds), community and hospitals and (ii) Elderly Care Service (long-term and respite care) delivered in a 63-bed inpatient unit. Results: 250 respondents (69.8%) completed the questionnaire. Nurses and healthcare assistants comprised the majority of respondents (60%) and other disciplines were represented proportionately. 230 participants (92%) agreed that their personal workload had changed significantly in response to COVID-19 and 182 (72.8%) agreed that their responsibilities had increased. 196 (78.4%) reported greater work-related stress. Highest-rated sources of stress included fear of contracting COVID-19 or transmitting it to friends/family, interacting with isolated frail/dying patients, changes to workplace protocols and reduced social interaction with colleagues. Conclusions: This study demonstrates the profound impact of COVID-19 on personal and professional wellbeing of staff. The greatest burden was carried by those providing prolonged, direct and intimate patient care.

Distance learning: the “Extension for Community Healthcare Outcomes: ECHO” project: a case study

This article reports a case conference that was part of the Extension for Community Healthcare Outcomes (ECHO®) project, which is a model of monthly telemedicine conferences on chronic disease and behavioral health, important topics for primary care teams in rural areas and for university-based specialists. The ECHO® project has proved to be a successful learning model in health care. The main goal of the project is moving knowledge not the patients, so this tele-mentoring builds capacity and creates access to high-quality specialty care serving local communities. A secondary goal is shared learning between community providers and specialists about best practices that are practical, achievable, and sustainable for the community. We present the case of a critical care patient who was brought to the emergency department with left-side weakness and dysarthria. Computed tomography of the head and electrocardiograms established the diagnosis during the admission. Discussion points from a multidisciplinary team and specialty consultants via telemedicine are listed in this article.
 Key words: telemedicine, teleconsulting, primary care, developing countries, rural area

The best today for a better tomorrow: a standard of practice to both recognise and develop infectious diseases pharmacy

Infectious disease is a multidisciplinary specialty involving infectious diseases physicians, clinical microbiologists, nurses and pharmacists among other specialities. Given that so much of infectious diseases involves antimicrobial drugs, it is obvious that pharmacists are an integral part of the care of patients with infections. Infectious diseases pharmacy has developed as its own specialty over the last 10–15 years with the development of antimicrobial stewardship programs, which are now a requirement of hospital accreditation. For those of us that have the privilege of working with specialist ID pharmacists, there are few days that we would not call upon their expertise for difficult areas – HIV drug interactions, dosing in organ failure and critically ill patients, the more unusual antibiotic interactions, and hospital in the home programs, for example. Australian pharmacists have also contributed immensely to areas outside of direct clinical care. In research, The Australian newspaper named Prof Jason Roberts as the leading national researcher in the fields of both critical care and communicable diseases in 2019.1 Many other examples of the impact of pharmacists are provided in this document. Pharmacists have led the ongoing development of Australian national treatment guidelines, Therapeutic Guidelines, while providing key insights into quality and safety programs at state and national levels, as well as contributing to the National COVID-19 Evidence Task Force, among many other contributions. The SHPA Standard of Practice in Infectious Diseases for Pharmacy Services, published in this issue, crystallises the skills and scope that pharmacists have in the management of infectious diseases, particularly in providing clinical care but also into broader governance systems. These include ensuring the quality use of antimicrobials (through education, antimicrobial stewardship programs, developing and reviewing policies and procedures) and ensuring access through formulary policies. The immediate impact of the Standard is to form the basis for a curriculum for junior pharmacists intending to specialise in this area, or for general pharmacists who may require skills in this area in other settings, such as rural hospitals or community settings. Advanced training for physicians has evolved from an “apprenticeship” model to a more structured educational model. While most currently available post-graduate courses are international, a standardised curriculum should facilitate local training and education initiatives, analogous to accreditation developed for infection prevention and control nurses by the Australasian College of Infection Prevention and Control. Collaborative guidance such as this Standard will help future ID pharmacists to build on existing roles and extend into emerging areas of practice. It should be noted that like the scope of practice of pharmacists more generally, this will continue to evolve and expand over time. The infectious diseases community welcomes this major step in recognising the expertise of infectious diseases pharmacists and their contribution to clinical care and the systems that support healthcare. The author has no conflicts of interest to declare.

Beyond Statistics: Uncovering the Roots of Racial Disparities in Breastfeeding.

* Abbreviations: BFHI — : Baby-Friendly Hospital Initiative CDC — : Centers for Disease Control and Prevention IHS — : Indian Health Service Breastfeeding is for white women. This sentiment was expressed by several Black women featured in Chocolate Milk , an eye-opening documentary series that was shown during a 2-week virtual breastfeeding elective created for medical students and implemented amid the coronavirus disease 2019 pandemic.1 In addition to learning about proper latch techniques, effective positions, and the breastfeeding challenges that women face, our learning also revealed racial disparities in breastfeeding. As 2 medical students who identify as Black and Native American, we desired to dig deeper to better understand the roots of these disparities and the systemic changes we can advocate for within medicine. Racial disparities in breastfeeding are similar to those that persist in other facets of health, including infant mortality. According to the Centers for Disease Control and Prevention (CDC), only 25.6% of all US infants born in 2017 were exclusively breastfed through 6 months of age. Whereas the 6-month exclusive breastfeeding rate among white infants born in 2017 was above the national average at 28.7%, only 21.2% of Black infants born in the same year and 19.6% of Native American infants born in 2015 (there is a lack of reporting after 2015) were exclusively breastfed for the first 6 months of life.2 Given the known benefits of breastfeeding for both mother and infant and the increased risks of comorbid health conditions for these communities, there is much to learn about how … Address correspondence to Suet Kam Lam, MD, MPH, MS, Department of Pediatric Hospital Medicine, Cleveland Clinic, 9500 Euclid Ave, S1-20, Cleveland, OH 44195. E-mail: skl48{at}case.edu

Delayed Referral for Adult Traumatic Brachial Plexus Injuries

The treatment of traumatic brachial plexus injury (BPI) is time-sensitive, and early nerve reconstruction is associated with superior nerve recovery. The objective of this study was to determine the rate of delayed referral to our centers for traumatic BPI, identifiable causes of delayed referral, and factors associated with delayed referral to a brachial plexus surgeon. We identified 84 patients with traumatic BPI referred to and evaluated by brachial plexus surgeons at 2 tertiary care referral centers from 2015 to 2019. Delayed referral was defined as more than 3 months from the date of injury to the date of initial evaluation by a brachial plexus surgeon. Causes of delayed referral were identified by review of the medical record. Bivariate analysis and multivariable logistic regression were used to identify factors associated with delayed referral. Mean age of the 84 patients in the study was 45 years; 69% were male. The most common pattern of BPI was global palsy (39%), followed by upper-trunk palsy (23%) and infraclavicular palsy (15%). Median time from injury to surgical evaluation was 2 months (interquartile range, 2-4 months). Thirty-seven patients had a delayed referral (44%). Multivariable logistic regression analysis showed that the hospital to which the patient was referred, Medicare insurance, and motorcycle accident as the mechanism of injury were associated with a delayed referral. Nearly half of traumatic BPI patients evaluated at 2 tertiary referral centers in a large metropolitan area in the United States presented in a delayed time frame. Both modifiable and nonmodifiable associations with delayed referral were identified. Patients with Medicare insurance had increased odds of delayed referral. Establishment of multidisciplinary BPI specialty centers, outreach to local and regional hospitals, and development of referral algorithms and pathways may improve timeliness of referrals.

Urgent Need of Continuing Medical Education: The Key for Patient Awareness of Labor Epidural Analgesia – A Survey of Chinese Perinatal Care Providers

Abstract Objective: This survey was designed to understand the misconceptions about labor epidurals. Methods: This voluntary and anonymous online survey on wenjuan.com was conducted from September 1st, 2015 to January 1st, 2016 via mainly WeChat groups dedicated to perinatal healthcare providers in China. The questionnaire included items inquiring the knowledge and opinions about labor epidural analgesia related to maternal complications, baby safety, and effect on laboring. Incomplete surveys were excluded from the data analysis. The data was presented as percentages and a Chi-square test or Fisher's exact test, as appreciate, was used to quantitatively compare the results. Results: A total of 1412 respondents completed surveys with 42.9% (606/1412) of them being anesthesiologists, 35.1% (495/1412) being obstetricians, 11.8% (167/1412) being midwives, 3.7% (52/1412) being labor and delivery nurses, and 6.5% (92/1412) being hospital administrators and unspecified. The study revealed a lack of knowledge in labor pain control. Although 82.4% (1164/1412) of respondents were familiar with labor epidural analgesia, 8.9% (126/1412) did not know how it works, and 1.1% (15/1412) never heard it in a multiple-choice question. The three main groups (anesthesiologists, obstetricians, and midwives/labor and delivery nurses) were chosen for comparisons. Opinions among these three groups concerning five questions in the three main concerns were evaluated using a statistical significance of P < 0.05. Conclusion: The results in our survey indicated an urgent need of continuing medical education to multidisciplinary specialties to improve evidence-based medical practices as these misconceptions have existed for over 10 years in the medical professionals. Lack of public awareness fueled by misconceptions related to labor epidural analgesia may be associated with a lack of professional knowledge. Correct knowledge in professionals needs to be disseminated to the public in order to dispel possible misconceptions and rumors about labor epidural analgesia. This would not only enhance patient understanding of their care but also improve maternal, fetal, and neonatal outcomes.

An Integrated Approach to the Management of Meningoencephalocoeles.

Meningoencephalocoeles are congenital herniations of meningeal and cerebral tissues through a cranial defect. They occur most commonly in South-East Asia, and are relatively rare amongst European ancestry populations, with an estimated prevalence of 1/40,000 live births. The treatment of congenital meningoencephalocoeles is primarily surgical and are best managed by dedicated multi-disciplinary craniofacial teams. The authors performed a retrospective case review of all primary meningoencephalocoeles managed in the Oxford University Hospitals NHS Foundation Trust between 1986 and 2012. Twenty-nine cases (13 frontal, 9 occipital, 2 parietal, and 5 basal) were included in this study. The median age at presentation was 11 months (range 0-60 years). Twenty-five cases presented with an external mass; 3 with recurrent meningitis and 1 with otorrhoea. Twenty-six cases underwent surgery, and 17 of these were managed by an integrated approach between 2 or more surgical specialties. Twenty out of 26 operations were performed via a transcranial approach. The authors describe a particularly complex case in order to highlight the challenges associated with management of meningoencephalocoeles, the surgical technique employed, and the importance of a multidisciplinary surgical approach. This is the largest reported case series of meningoencephalocoeles managed in a single hospital in the United Kingdom. Designated craniofacial units with access to multidisciplinary surgical specialties provide a safe and optimal setting for the management of meningoencephalocoeles.

Fetal surgery.

Fetal medicine is a super-specialty enterprise and a technology-driven field. The growth and interest in fetal surgery can be largely attributed to advances in fetal imaging and bespoke instruments for in utero intervention. Previously fatal fetal conditions are now being treated using open surgery, minimally invasive procedures, and percutaneous fetal technologies. Several fetal conditions, including myelomeningocele and twin-to-twin transfusion syndrome, have been tested rigorously in RCTs. However, as the specialty of fetal surgery grows, a robust evidence base with long-term follow-up is obligatory for every procedure. This article offers an overview of fetal surgery and antenatal intervention. As more cutting edge therapies come into clinical practice, growing public opinion and medical ethics will play a significant role in the future of this multidisciplinary specialty.

Conceptual Models of Nursing in Critical Care.

Introduction Intensive care units are systems organized for the provision of care to patients in critical situations. In general, it is suggested that intensive care consists of a multidisciplinary and interprofessional specialty. Nevertheless, the predominance, relative to the professions that incorporate these units, falls on nurses. A conceptual model of nursing provides a framework for reflection, observation, and interpretation of phenomena and, specifically, it provides guidelines and guidance for aspects of clinical practice. Objective To understand the applicability of conceptual models of nursing in intensive care units. Method Review of the literature following the Scoping Review protocol of the Joanna Briggs Institute. The research was performed in CINAHL, Cochrane, Pubmed, Scopus, and Web of Science to identify studies published prior to 2021. Fourteen studies were selected. Results There is no conceptual model of nursing universally accepted as ideal for intensive care units. However, there is unanimity in the identification of several benefits associated with the application of a conceptual model of nursing in the care of critically ill patients. Conclusion For the selection of a conceptual model of nursing for these contexts, the focus should be on the person and the choice should fall on the model that is most appropriate to the patient, and not on the philosophy that supports the model. Considering the nature of care, the nursing team can select a model or a combination of models.

Modern tendences in high education: the experience of the new specialty introduction at Odessa National Economic University

Today, university institutions face the question of relevance, modernity and innovation of the educational content and specialties they offer. Multidisciplinary specialties replace singleprofile specialties. The ability of the university administration to respond to these changes in time, to offer the potential students and teachers new directions of development and new learning trajectories and to meet the challenges of today’s real business environment is a guarantee of success of any higher education institution. With Ukraine’s entry into the global educational environment, migration and interest in education in Ukraine from the potential foreign student’s, the demand for teaching in English is growing. At the same time, the number of teachers who could do it well, unfortunately, is insufficient to meet such demand. Secondly, we can see that many potential students, even immediately before submitting application for the enrollment into the universities, have not finally decided on their priorities, and until the last moment often choose between philology, business education and pedagogical education. We decided that we can offer them a great decision and to work in all those areas at the same time. And most importantly, the modern young generation has another ideas about success and the strategy to achieve it, in which education is perceived not as a social elevator and a tool for career building, but as element of their uniqueness, means of realizing their creative potential. Multidisciplinary specialties replace single-profile specialties. The author of the article considers thirteen main trends in modern education, describes ONEU’s innovative approach to the filling of the educational content and the experience of implementing a three-component educational program “English in Economics and Business Education” into the modern educational process. The article also focuses on current challenges that contribute to the transformation of the educational process and the formation of new educational trends.

Abstract PO-185: Physical activity and nutrition behaviors in Hispanic patients with non- alcoholic fatty liver disease

Abstract Background. Non-alcoholic fatty liver disease (NAFLD) is a growing problem in the U.S. and has become an important risk factor for hepatocellular carcinoma (HCC). Hispanics experience the highest burden of both NAFLD and HCC. Increasing physical activity and making dietary changes to achieve weight loss are the mainstay for NAFLD treatment and potentially for HCC prevention. While newly diagnosed NAFLD patients usually get brief information on the etiology and management of their disease, it is unclear exactly what patients actually think about their current health behaviors and their need to be more active or eat healthier. The purpose of this study was to describe Hispanic NAFLD patients’ current physical activity and dietary behaviors, perceptions of those behaviors, and any barriers they perceive to be hindering them from making a change. Methods. We conducted a cross-sectional study among 414 Hispanic patients participating in the Harris County NAFLD Cohort, a prospective cohort study that recruits consecutive adult patients with NAFLD referred to a multidisciplinary specialty clinic within a safety-net healthcare system in Texas. NAFLD was diagnosed based on liver imaging, excluding other known causes. Height and weight were measured at baseline to obtain Body Mass Index (BMI); diabetes was classified based on pre-existing diagnosis reported by the patients and verified in the medical records. Self-administered questionnaire measured demographic factors, physical activity (Rapid Assessment of Physical Activity Scale), diet (NCI FLASHE questionnaire), and perceptions of and barriers to doing physical activity or eating healthy. We used descriptive statistics to explore demographics, behaviors, perceptions, and barriers. Results. Average age was 46 years, 84% spoke primarily Spanish, and 59% were born in Mexico. More than half of the sample were insufficiently active (55%), but encouragingly 90.1% reported wanting to be more active. Most of the sample (79%) did not meet fruit and vegetable intake guidelines. While 92% of the sample reported that they could eat healthier, only 61% of the total sample thought that they should eat more fruits and vegetables, 70% thought that they should eat less fat and 65% thought that they should eat less sugar. The top 5 barriers to eating healthier were cost, perceptions that healthier food doesn’t taste good, lack of time to cook, difficulty of cooking and difficulty of going to the grocery store. Top barriers to doing more physical activity were Lack of time, feelings of laziness, pain, nowhere to exercise, and feeling that is it too difficult to exercise. Discussion. Interventions will be necessary to encourage physical activity and health dietary behaviors, as well as correct certain perceptions among Hispanic patients diagnosed with NAFLD. Multi-level interventions may be needed to help patients address barriers to these two behaviors. Citation Format: Aaron Thrift, Maya Balakrishnan, Natalia I. Heredia, Yan Liu. Physical activity and nutrition behaviors in Hispanic patients with non- alcoholic fatty liver disease [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-185.

Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance.

Hepatic hydrothorax is the formation of transudative pleural effusion as a consequence of portal hypertension. Only a minority of cases resolve after sodium restriction and diuretics. Despite the relatively low incidence of 5-15% among patients with cirrhotic portal hypertension, the high morbidity and serious clinical implications associated with hepatic hydrothorax necessitate a well-defined treatment strategy to guide patient care. Management is typically multidisciplinary, involving hepatologists, interventional pulmonologists, interventional radiologists, surgeons, and other specialties. In this manuscript, we assemble a multidisciplinary team to critically review the available literature and provide an evidence-based guidance for management of hepatic hydrothorax.

Fourteen-year follow-up of a child with acroscyphodysplasia with emphasis on the need for multidisciplinary management: a case report

BackgroundAcroscyphodysplasia has been described as a phenotypic variant of acrodysostosis type 2 and pseudohypoparathyroidism. In acrodysostosis, skeletal features can include brachydactyly, facial hypoplasia, cone-shaped epiphyses, short stature, and advanced bone age. To date, reports on this disorder have focused on phenotypic findings, endocrine changes, and genetic variation. We present a 14-year overview of a patient, from birth to skeletal maturity, with acroscyphodysplasia, noting the significant orthopaedic challenges and the need for a multidisciplinary team, including specialists in genetics, orthopaedics, endocrinology, and otolaryngology, to optimize long-term outcomes.Case presentationThe patient presented as a newborn with dysmorphic facial features, including severe midface hypoplasia, malar flattening, nasal stenosis, and feeding difficulties. Radiologic findings were initially subtle, and a skeletal survey performed at age 7 months was initially considered normal. Genetic evaluation revealed a variant in PDE4D and subsequent pseudohypoparathyroidism. The patient presented to the department of orthopaedics, at age 2 years 9 months with a leg length discrepancy, right knee contracture, and severely crouched gait. Radiographs demonstrated cone-shaped epiphyses of the right distal femur and proximal tibia, but no evidence of growth plate changes in the left leg. The child developed early posterior epiphyseal arrest on the right side and required multiple surgical interventions to achieve neutral extension. Her left distal femur developed late posterior physeal arrest and secondary contracture without evidence of schypho deformity, which improved with anterior screw epiphysiodesis. The child required numerous orthopaedic surgical interventions to achieve full knee extension bilaterally. At age 13 years 11 months, she was an independent ambulator with erect posture. The child underwent numerous otolaryngology procedures and will require significant ongoing care. She has moderate intellectual disability.Discussion and conclusionsKey challenges in the management of this case included the subtle changes on initial skeletal survey and the marked asymmetry of her deformity. While cone-shaped epiphyses are a hallmark of acrodysostosis, posterior tethering/growth arrest of the posterior distal femur has not been previously reported. Correction of the secondary knee contracture was essential to improve ambulation. Children with acroscyphodysplasia require a multidisciplinary approach, including radiology, genetics, orthopaedics, otolaryngology, and endocrinology specialties.

Establishment of a multidisciplinary fetal center streamlines approach for congenital lung malformations

Purpose Fetuses with a diagnosis of congenital lung malformations (CLM) on prenatal imaging are commonly referred to a multi-disciplinary specialty team for prenatal assessment and postnatal management. The net effect of such services is broadly stated to improve the outcomes of affected newborns. However, these claims are relatively unsubstantiated. Methods After IRB approval, a retrospective review of children diagnosed with CLM from 2008 to 2018 and referred to a large urban children’s hospital was performed. A comparison was performed between prenatally diagnosed patients having a multi-disciplinary fetal center evaluation (FC) and prenatally diagnosed patients who did not receive a referral or were seen prior to the establishment of the center (NON-FC). Results Eighty-eight live-born patients with a prenatal diagnosis of CLM were identified, with 49 in the FC group and 39 NON-FC. Thirty-four (63%) and 23 (59%) patients underwent operative resection of CLM, respectively. FC patients presented earlier at first postnatal follow-up (42 vs. 145 days, p = .03), had fewer preoperative office visits (2.1 vs. 3.4, p = .0003), received fewer preoperative chest radiographs (0.5 vs. 1.3; p = .002) and chest computed tomography (0.9 vs. 1.4; p = .001), and had fewer preoperative pneumonias (0 vs. 17.4%; p = .02) compared to their NON-FC counterparts. FC patients were also more likely to undergo resection at an earlier age (217 vs. 481 days, p = .003) and were more likely to undergo a minimally invasive resection (75% vs. 39.1%, p = .015). There were no differences in post-operative outcomes between the two groups. Conclusion Children with a prenatal diagnosis of CLM appear to benefit from an organized multi-specialty team approach in several impactful parameters. Hospital systems and providers that invest in similar strategies are likely to achieve improved outcomes in the care of newborns prenatally diagnosed with a CLM.

Interventional Neuroradiology: A Review

Interventional neuroradiology (INR) has evolved from a hybrid mixture of daring radiologists and iconoclastic neurosurgeons into a multidisciplinary specialty, which has become indispensable for cerebrovascular and neurological centers worldwide. This manuscript traces the origins of INR and describes its evolution to the present day. The focus will be on cerebrovascular disorders including aneurysms, stroke, brain arteriovenous malformations, dural arteriovenous fistulae, and atherosclerotic disease, both intra- and extracranial. Also discussed are cerebral vasospasm, venolymphatic malformations of the head and neck, tumor embolization, idiopathic intracranial hypertension, inferior petrosal venous sinus sampling for Cushing's disease, and spinal interventions. Pediatric INR has not been included and deserves a separate, dedicated review.

Complicated sinusitis in developing countries: an African perspective.

Complicated rhinosinusitis continues to be a diagnosis not to be missed because of the potential life-threatening and life-changing outcomes. This is true for clinicians in both developed and developing countries. Advances in diagnostic imaging, appropriate antibiotic use and timely surgical intervention have resulted in better outcomes particularly in the developed world. This review focuses on the current management of complicated sinusitis in resource-limited settings. Recent publications indicate leaning toward endoscopic sinus surgery as a standalone procedure or in combination with traditional external approaches in the management of complicated rhinosinusitis with less morbidity and shorter recovery time. It is becoming increasingly evident that multidisciplinary specialties should be involved in the effective management of patients with complicated sinusitis. Early recognition, prompt surgical intervention and antibiotic therapy remain keys in the management of complicated rhinosinusitis. In many African countries and other developing countries, the absence of specialized imaging and endoscopic diagnostic equipment and endoscopic surgical facilities and expertise means that reliance must be placed on clinical acumen both for diagnosis and monitoring of treatment response of complicated sinus infections.

Influence of endurance training-induced weight loss on the levels of ghrelin and obestatin of obese women with polycystic ovary syndrome

Polycystic ovary syndrome is an observed plurimetabolic syndrome associated with central obesity and insulin resistance. The purpose of the present study was to investigate the effects of 12-week training program on weight loss, serum ghrelin, acylated ghrelin, des-acylated ghrelin, and obestatin levels in obese sedentary women with polycystic ovary syndrome (PCOS). To this end, thirty sedentary obese women with PCOS (mean age 31.07 ± 2.49 years, height 162.23 ± 2.39 cm, weight: 87.23 ± 4.48 kg, BMI 33.12 ± 0.92) were recruited from a multidisciplinary PCOS specialty clinic in Tabriz city in 2017 and evaluated before and after a 12-week training program, including 45 min per session of aerobic training at an intensity of 60–75% of age-predicted maximum heart rate (300 kcal/day). After the exercise program, body weight, waist circumference, and percentage body fat mass were decreased. Also, fasting glucose, insulin, and serum acylated ghrelin levels were significantly decreased (P 0.05). The moderate aerobic exercise training is associated with improvements in obestatin and health profiles of obese women with PCOS without associated structured energy restriction.

SUN-597 Healthcare Utilization Patterns Among Commercially Insured Patients with Prader-Willi Syndrome: A Retrospective Analysis of Administrative Claims

Prader-Willi syndrome (PWS) is a complex orphan endocrine disease characterized by hyperphagia and abnormal food-related behaviors that contribute to severe morbidity and early mortality along with a significant burden on patients and caregivers. Life-long medical care is required but the consistency of services rendered to this population has not been evaluated. This study characterized use of US hospital care, specialty physician care, and growth hormone (GH) therapy for PWS patients at different life stages. Methods: PWS ICD-9 codes in the IQVIA™ Health Plan Claims Data from 1/2006 to 9/2015 were used to identify PWS patients. Inclusion criteria considered patients <65 years of age with ≥12 months of continuous enrollment who received ≥2 PWS diagnostic codes. Observation time was segmented into 12-month patient-years for analysis. Standardized billing code conventions were used to identify and categorize services of interest from 1/2006 to 11/2018. Results: A total of 5,060 PWS patient years representing 1,461 unique patients were eligible. Mean annual visits to inpatient, emergency department, and physician office settings ranged by age-cohort in years from 0.2-1.6, 0.5-1.3, and 9.2-26.0, respectively. Younger (0-17) and older (50-64) age-cohorts utilized more services than early-mid adulthood age-cohorts. Use of pediatricians or endocrinologists ranged from 76% to 88% among patients under 18 years of age. Utilization of cardiologists, orthopedists, physical therapists, and otolaryngologists ranged by age-cohort from 8-44%, 7-21%, 3-21%, and 7-38%, respectively, with highest utilization among younger patients. GH use increased from 37% to 46% of PWS patients between 2007 and 2018. GH users <18 years of age were 3.0, 0.6, 1.9, 1.7, and 1.4 times as likely to utilize endocrinologists, cardiologists, orthopedists, physical therapists, and otolaryngologists, respectively, compared with non-GH users. Conclusions: Use of hospital services for PWS patients was bimodal with higher use among the youngest and oldest age-cohorts. Change in the utilization level of select specialists reflects the complexity of care for age-related clinical sequelae, such as orthopedic concerns in infancy and early-onset cardiovascular disease due to hyperphagia and obesity in adolescents, as well as syndrome-specific treatment protocols (e.g., specialty consults needed for GH treatment). That less than half of PWS patients <18 years of age received GH therapy despite growing clinical evidence on the benefits and tolerability of GH suggests a potential gap in provider knowledge of the standard of care for PWS. Our analysis suggests that GH use may be a surrogate for better access to a multidisciplinary care team and specialty services. Considerable variation of services indicates that more effort is required to optimize care in PWS.

Transplantation Principles

Transplantation is a truly multidisciplinary specialty where a surgical procedure requires inputs from both, the specialists of the specific organ e.g. nephrologist for kidney transplant or hepatologist for liver transplant, as well as from experts of other specialties such as immunology, infectious diseases etc. It is also a rapidly grooving field with the advances in surgical techniques, immunological knowledge and pharmacology. A recent, major advance in the field of transplantation is the emergence of new procedure of vascularized composite allotransplantation, which includes transplantation of non-lifesaving organs such as face, hands, abdominal wall or uterus. Additionally, organ shortage in transplantation yielded a new area of research such as xenotransplantation and regenerative medicine. The specialty of transplantation may be difficult to comprehend for those entering the field; thus, the goal of this chapter is to provide a comprehensive overview of the most important aspects of transplantation. This review contains 2 figures, 3 tables, and 67 references. Keywords: transplantation, solid organ transplantation (SOT), vascularized composite allotransplantation (VCA), transplant immunology, allorecognition, acute rejection, chronic transplant rejection, principles of transplantation, transplantation terminology, immunosuppressive drugs