Multidisciplinary Team Of Specialists Research Articles

Клинические проявления постковидного синдрома

Aim: to assess the prevalence of various clinical manifestations in COVID-19 survivors, depending on the time interval after the disease, clinical severity, and the presence of polymorbidity. Patients and Methods: the study included 253 patients (187 females and 66 males), 18–85 years old, who survived COVID-19. The patients were split into two groups based on the disease severity during the acute phase: group 1 consisted of patients with mild COVID-19 illness (n=133); group 2 consisted of patients with moderate and severe COVID-19 illness (n=120). In addition, patients of each of the groups were divided into two subgroups, depending on the time elapsed from the acute phase of COVID-19 illness: in subgroups A the health assessment of patients was performed within 3 months (12 weeks) after the acute phase of the diseases and in subgroups B — 3 months (12 weeks) after the disease, i.e. the time interval ranged from 3 months to one year after COVID-19 illness. A multi-stage phone interview of the patients was used to reveal the presence of symptoms. Also, outpatient medical records of those patients who addressed therapists or narrow specialists, were reviewed. Results: symptoms were revealed both in patients of subgroup 1A (45/52 (86.5%)) and subgroup 2А (42/45 (93.3%)), or, in other words, the symptoms were absent in 7 (13.5%) and 3 (6.7%) patients, respectively. Three months after COVID-19 illness, the symptoms were absent in 34 (42%) patients of subgroup 1B and in 13 (17.3%) patients of subgroup 2B (p<0.001), while at least one symptom persisted in 47/81 (58%) patients of subgroup 1B and 62/75 (82%) patients of subgroup 2B. In both patient groups the most common symptoms comprised fatigue, shortness of breath, and cough. In group 2 patients central nervous and cardiovascular system consequences and arthralgia were frequently reported. The prevalence of comorbidities was higher in group 2 patients than that in group 1 patients, and the difference was statistically significant (p < 0.01). Conclusions: the development of post-COVID-19 syndrome does not depend on the illness severity during the acute phase, and it may occur both in mild and moderate or severe cases. However, in the latter category the patients will have more symptoms. In patients recovered from COVID-19, most of the disease sequela were revealed in central nervous, bronchopulmonary, and cardiovascular systems. Comorbidities are associated with the severity of the novel coronavirus disease during the acute phase. COVID-19 survivors need follow-up care during the first three months after the acute phase and in the later period which should be provided by multidisciplinary team of specialists for achieving complete recovery of the patients’ health and improving the quality of life. KEYWORDS: coronavirus infection, COVID-19, post-COVID-19 syndrome, comorbidities, central nervous system disorders, bronchopul - monary system disorders, cardiovascular system disorders. FOR CITATION: Asfandiyarova N.S., Filippov E.V., Demikhov V.G. et al. Clinical manifestations of post-COVID-19 syndrome. Russian Medical Inquiry. 2022;6(11):612–617 (in Russ.). DOI: 10.32364/2587-6821-2022-6-11-612-617.

A CLINICAL CASE OF ARTERIAL THROMBOSIS IN A PREMATURE BOY WITH NEONATAL SEPSIS AND HIGH RECTAL ATRESIA

Occlusion of the venous or arterial vessels in childhood is rather rare but dangerous complication. Occurrence of neonatal thrombosis is 0.5 per 10 000 of live newborns. Promoting factors include congenital defects of coagulation, maternal diabetes, neonatal sepsis, necrotic enterocolitis, asphyxia, and metabolic diseases. More than 90 % cases of neonatal thrombosis are associated with catheterization (umbilical arterial or venous, other central venous lines). Acute arterial thrombosis caused by a peripheral venous catheter is very rare complication, but it can result in severe consequences. The article contains a clinical case of right brachial artery thrombosis in a premature boy with extremely low body weight complicated by development of dry gangrene and amputation of the limb. Complex risk factors promoting development of neonatal arterial thrombosis were found: preterm birth, neonatal sepsis, possible incorrect insertion of a peripheral venous catheter. Associative factors were congenital developmental defects of the intestine (high rectal atresia) and heart (bicuspid aortal valve, open oval foramen), and maternal factors. The authors emphasize their attention on the necessity to continuous education of the medical staff concerning the technique of catheter insertion and care of them, absolute implementation of safety policy concerning nosocomial infection, adequate provision of ultrasound examination devices with high rarefaction sensors, involvement of a multi-disciplinary team of specialists to manage complicated clinical cases.

Комплексная реабилитация пациентов после ларингэктомии: основные вехи развития

Laryngectomy is a common treatment of locoregionally advanced (stage III and IV) laryngeal and hypopharyngeal cancer. Surgical treatment causes both vital (breathing, swallowing) and communicative (voice, smell) functions disorder. The degree of recovery of these functions affects the patient’s quality of life, the return to work, and the ability to be an active member of society. The most important role for psychosocial adaptation is played by the restoration of voice function. However, it is not the only direction in the rehabilitation of laryngectomized patients. Correction of the respiratory, swallowing, and olfactory disorders is also important and requires a multidisciplinary team of specialists. The article provides an overview of main methods of restoring lost functions after laryngectomy in historical retrospective.

TEleRehabilitation Nepal (TERN) for People With Spinal Cord Injury and Acquired Brain Injury: A Feasibility Study.

BACKGROUND:Spinal Cord Injury (SCI) or Acquired Brain Injury (ABI) leads to disability, unemployment, loss of income, decreased quality of life and increased mortality. The impact is worse in Low-and Middle-Income Countries (LMICs) due to a lack of efficient long-term rehabilitative care. This study aims to explore the feasibility and acceptability of a telerehabilitation programme in Nepal.METHODS:Prospective cohort feasibility study in a community setting following discharge from a specialist rehabilitation centre in Nepal. Patients with SCI or ABI who had previously accessed specialist rehabilitation were connected to a specialist Multidisciplinary Team (MDT) in the centre through a video conference system for comprehensive remote assessments and virtual individualised interventions. Data were captured on recruitment, non-participation rates, retention, acceptability (via end-of-study in-depth interviews with a subset of participants) and outcome measures including the Modified Barthel Index (MBI), Depression Anxiety Stress Scale (DASS) and EuroQol-5D (EQ-5D), completed pre- and post-programme.RESULTS:97 participants with SCI (n = 82) or ABI (n = 15) discharged from the centre during an 18-month period were approached and enrolled on the study. The telerehabilitation programme facilitated the delivery of support around multiple aspects of rehabilitation care, such as spasticity treatments and pain management. Outcome measures indicated a significant improvement in functional independence (P < .001), depression, anxiety and stress (P < .001) and quality of life (P < .001). Qualitative interviews (n = 18) revealed participants found the programme acceptable, valuing regular contact and input from MDT professionals and avoiding expensive and lengthy travel.CONCLUSION:This is the first study in Nepal to identify telerehabilitation as a feasible and acceptable approach to augment the provision of specialist rehabilitation. Future research is needed to assess the suitability of the programme for other conditions requiring specialist rehabilitation and determine the mechanisms underpinning improved outcomes for people with SCI or ABI.TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04914650

Temporal Bone Rhabdomyosarcoma Mimicking Chronic Suppurative Otitis Media

Rhabdomyosarcoma (RMS) is one of the most commonly encountered soft-tissue sarcomas in childhood. The most common location is in the head-and-neck region, followed by the urogenital system, extremities, and torso. Head and neck is a common site though the temporal bone is an extremely rare site with only a few reported cases in the literature till now. Herein, we report a case of a sclerosing type of temporal bone RMS in an 8-year-old young girl. We discuss clinical, pathological, radiological findings and management of temporal bone RMS. Misdiagnosis is common because of this aggressive temporal bone lesion's similarity to more common benign diseases. Clinicians should maintain suspicion for RMS in patients with chronic otitis media not responsive to medical therapy and should refer a specialist multidisciplinary team in a timely manner as an early diagnosis will optimize the chance of survival. Clinical features, radiologic findings, and histopathological examination using immunohistochemistry are all important for the correct diagnosis of temporal bone RMS. It is important to be aware of and to know how to deal with such rare cases.

FEATURES OF THE TEACHER'S ASSISTANT WORK IN INSTITUTIONS OF GENERAL SECONDARY EDUCATION WITH INCLUSIVE EDUCATION

Summary. The article considers the peculiarities of the work of an assistant teacher in general secondary education institutions with inclusive education. It is proved that inclusive education is not just the inclusion of a child with special educational needs in a regular school, but also the creation of a special approach to learning in the common space, which provides additional elements of the educational process – specially equipped place, appropriate conditions, individual child development plan and mandatory presence of a teacher's assistant in an inclusive classroom. On the basis of scientific and pedagogical literature, normative and legal sources the concept of «teacher's assistant» is revealed and its activity is defined. The functions of the teacher's assistant are singled out, which include: organizational, educational and developmental, diagnostic, prognostic, consultative. It is noted that the main function of a teacher's assistant as a teacher is to work with an inclusive class teacher to help pay attention to each student during the educational process. The task of the teacher's assistant to establish his cooperation with teachers, specialists of the team of psychological and pedagogical support and parents is theoretically substantiated. It is noted that one of the conditions for successful inclusive education is a team approach, which is provided by members of the team of psychological and pedagogical support of a child with special educational needs. This is a mutually agreed complex activity of a multidisciplinary team of specialists and parents of the child, which aims to create the necessary conditions conducive to the development of the child's personality, learning, skills, successful adaptation, rehabilitation, self-realization and integration into society. The role of the teacher's assistant in providing children with a full social life, articipation in the educational process is determined. The organizational aspect of the work is analyzed and the ways of successful cooperation of the teacher's assistant with parents are suggested.

Surgical Treatment of Patients with Full Tracheal Rings: Our Experience.

Introduction: Complete tracheal rings are a rare pathology occurring in 1 out of 100,000 live births. It is rare isolated tracheal or tracheobronchial anomaly resulting from abnormal cartilage growth, forming a complete ring, and leading to airway stenosis. A sliding tracheoplasty, primarily described by Tsang et al. and later widely presented by Grillo et al., overlaps the tracheal stenosing segments and shortens the trachea itself, and thus increases the diameter and circumference of the stenosing area double up. Materials and Methods: We have performed four slide tracheoplasties in the period between February 2019 and December 2020 in children who underwent medical treatment in the department of thoracic surgery in our center. Median age was 10 ± 5.5 months (2 months-1 year 6 months). Median weight was 6.9 ± 1.9 kg (4.5-9 kg). Slide tracheoplasty was performed using central venoarterial extracorporeal membrane oxygenation in 3 cases and using cardiopulmonary bypass in 1 case. Results: Patients were on artificial lung ventilation for 2-6 days in the postoperative period. Patients were discharged 14-18 days after the surgery. There were no lethal outcomes in our study. Discussion: Long segment congenital tracheal stenosis is an often and serious life-threatening anatomical malformation that bounded the length of trachea >50%. There is no unique treatment strategy for patients with such pathology. Sliding tracheoplasty can be recommended for all, but not for the shortest segments of stenosis, as it creates permissible voltage fluctuations during tracheal anastomosis. Excellent results in management of such severe patients can be achieved only through the collaboration of multidisciplinary team of specialists sharing organized and consistent patient-oriented approach.

Pitfalls and progress in adrenocortical carcinoma diagnosis: the utility of a multidisciplinary approach, immunohistochemistry and genomics.

SummaryAdrenocortical carcinoma is a rare disease with poor prognosis whose clinical heterogeneity can at times present a challenge to accurate and timely diagnosis. We present the case of a patient who presented with extensive pulmonary lesions, mediastinal and hilar lymphadenopathy and an adrenal mass in whom the oncological diagnosis was initially uncertain. Through the use of immunohistochemistry, biochemistry and genomic testing, an accurate diagnosis of adrenocortical carcinoma was ultimately made which resulted in more directed treatment being administered. The use of multidisciplinary input and genomics to aid in diagnosis and prognosis of adrenocortical carcinoma is discussed.Learning pointsAdrenocortical carcinomas can present a diagnostic challenge to clinicians given it is a rare malignancy with significant clinical heterogeneity.Specialist multidisciplinary team input is vital in the diagnosis and management of adrenocortical carcinomas.Hormonal testing is recommended in the diagnostic workup of adrenal masses, even in the absence of overt clinical signs/symptoms of hormone excess.Immunostaining for the highly sensitive and specific steroidogenic factor-1 is vital for accurate diagnosis.Genomics can provide prognostic utility in management of adrenocortical carcinoma.

INNV-41. MY STORI – A SYMPTOM TRACKING AND REPORTING INSTRUMENT MOBILE APPLICATION FOR BRAIN TUMOR PATIENTS

Abstract INTRODUCTION Managing symptom burden is an integral part of brain tumor patient care, but tools to facilitate tracking symptoms and self-management for this population are lacking. Reporting is often limited to self-report as part of clinical follow-up care, or episodic between visits if symptoms are severe. While general-purpose and cancer-specific mobile applications that track medical symptoms are becoming more prevalent, they may not cover the entire range of symptoms experienced by patients with brain tumors or allow tracking of self-management strategies. METHODS We developed an iOS operating system mobile application using Apple’s UIKit, Foundation, WebKit, and Core Graphics frameworks. Core Data and iCloud were used to implement local and cloud-based data storage for personal use. Findings from our Outcomes Surveys informed selection of core symptoms to track. A multidisciplinary team of neuro-oncology scientists, providers, and communication specialists developed self-care content from evidence-based sources. RESULTS We developed My STORI, a free mobile application to capture the experiences of brain tumor patients. Patients and their family members can track daily symptoms and their impact on function and record any actions that were taken to mitigate them. Evidence-based self-care information on how to recognize, manage, and report symptoms is provided. Graphical summaries of how these symptoms evolve over time, and how they are impacted by clinical appointments, treatment, and self-care activities can be displayed and compiled into reports that can be shared with their care team, family, or health care record. CONCLUSIONS Mobile applications have the potential to promote self-care, facilitate symptom management, and enable intuitive, frequent, and convenient reporting of clinically relevant data to the health-care team. The My STORI application is an innovation in patient care guided by evidence-based research and can be used to track symptom management, promote self-care, and enhance communication to improve clinical care and research.

Anesthesiological provision of open fetal surgery

Fetal surgery is a rapidly growing feld of medicine. Anesthetic provision of fetal operations is developing together with progressing surgical techniques. The fundamentals of the physiology of a pregnant woman and a fetus are considered. The features of transplacental drug transfer are described. The mechanisms of uteroplacental and fetoplacental interactions have been analyzed. The contemporary data are presented that allow judging about the method of choice and approach to anesthesia in open fetal surgery. Reviewed scientifc information, including reviews of recent years and randomized trials The perspective of an anesthesiologist is shown, involved in open fetal surgery, including perioperative and intraoperative management of two high-risk patients, i.e. a pregnant woman and fetus undergoing surgical intervention at the same time. Postoperative management of patient data. The impossibility of carrying out such operations without the well-coordinated work of a large multidisciplinary team of specialists is noted.

Blood Conservation Strategies in Adult Sickle Cell Patients on Chronic Transfusion Therapy: A Single Center Experience

▪Background: Adult sickle cell patients on chronic transfusion therapy (CTT) garnered special concern during the COVID-19 pandemic, when mass cancellation of blood drives threatened the national blood supply. In response, the American Society of Hematology proposed several strategies to decrease blood utilization, while maintaining adequate disease control for sickle cell patients on CTT. These included targeting a higher end hemoglobin S%, switching patients to simple transfusions when appropriate, and transitioning to alternative disease modifying therapies. There is little evidence to support the safety of altering exchange therapy regimens. Accordingly, at the Johns Hopkins Sickle Cell Center for Adults, a multidisciplinary team of clinicians and transfusion medicine specialists evaluated patients on a case by case basis to determine how their exchanges could be modified to accommodate for anticipated blood supply shortages. We describe our blood conservation efforts during the COVID-19 pandemic and resulting clinical outcomes for adult patients with sickle cell anemia (SCA).Methods: For inclusion in this IRB-approved retrospective study, patients received at least 7 monthly exchange transfusions between March 2019 and February 2020 and continued care through March 2021. Decisions regarding CTT were made prior to data collection. Modifications to chronic exchanges included increasing the fraction of cells remaining (FCR), decreasing the end hematocrit, or switching to a hemodilution method. Additionally, select patients transitioned to monthly simple transfusions if they were clinically stable, had a hemoglobin ≤ 7 g/dL, and had a persistently suppressed hemoglobin S% (≤ 30).We collected basic demographics, pre-exchange laboratory studies, and exchange parameters before and after each transfusion encounter in the year before (March 2019 - February 2020) and during (March 2020 - February 2021) the COVID-19 pandemic. Lastly, we recorded presentations to urgent care and the emergency department; and hospital admissions during each time period. We reported descriptive statistics for the cohort and compared outcomes using the Wilcoxon signed-rank test and Mann Whitney U test. We analyzed data using Stata/SE Version 16.1.Results: We identified 58 patients with SCA who qualified for inclusion (Table 1). Fifty-three patients remained on chronic exchange transfusions during the pandemic, and five were switched to simple transfusions. For patients who remained on chronic exchanges, most received conventional automated red cell exchange (RCE) prior to (85%) and during the pandemic (77%). Use of hemodilution increased (15% to 23% of patients). Forty-three patients experienced an increase in mean FCR (33.6 (SD 11.6) vs 37.7 (4.7), p = .00). Of those, 22 patients saw a concomitant decrease in mean end hematocrit (30.8 (1.7) vs 29.6 (1.1), p = .00). These changes resulted in a decline in the average number of units per procedure (8.6 (1.9) vs 7.3 (1.7), p = .00), which corresponded to 890 units conserved. Mean pre-transfusion hemoglobin values declined (9.4 (1.3) vs 9.2 (1.3), p = 0.01), but hemoglobin S%, reticulocyte count, and ferritin values were unchanged (p > 0.05). Acute care presentations and hospital admissions declined, which were likely spurred by concerns about COVID-19 infection (Table 2, p < 0.05).During the pandemic, three patients died, one of whom had been switched to simple transfusions. This patient experienced a consistent rise in hemoglobin S% until death. Two of the remaining patients on simple transfusions were switched back to automated RCE due to an increase in hemoglobin S% above goal (Figure 1).Conclusions: During the COVID-19 pandemic, we conserved red blood cell units through expanded use of hemodilution, higher FCR values, and switching some patients to simple transfusions. Patients who remained on exchanges maintained hemoglobin S% values near a goal of 30% without increasing iron burden. In contrast, the majority of patients who were switched to simple transfusions were unable to maintain goal hematologic parameters, and one patient died. Our data suggest that in a blood shortage crisis, changing the exchange procedure itself may be the safest means of conserving blood in a population of adult sickle cell patients; however longer follow-up is needed to ensure that these changes are safe. [Display omitted] DisclosuresLanzkron: GBT: Research Funding; Shire: Research Funding; Novo Nordisk: Consultancy; CSL Behring: Research Funding; Pfizer: Current holder of individual stocks in a privately-held company; Teva: Current holder of individual stocks in a privately-held company; Novartis: Research Funding; Imara: Research Funding; Bluebird Bio: Consultancy.

An experience of the treatment of a patient with chronic pancreatitis with pancreatic pleural fistula complicated by lung abscesses

Pancreatic pleural fistula is one of the rare and difficulty verifying complication of chronic pancreatitis. We present a rare medical case of a patient with chronic pancreatitis complicated by pancreatic pleural fistula with the formationof multiple lung abscesses. At the same time, the success of the treatment of the patient was due to the staged treatment and the participation of a multidisciplinary team of specialists.

Міждисциплінарний підхід до удосконалення організації хірургічної допомоги пацієнтам з патологією щитоподібної залози

The interdisciplinary approach is recognized as the gold standard for organizing medical care for patients with oncological pathology. It is declared at the normative level in Ukraine, but the forms and methods of work, channels and methods of communication of specialists are not detailed. This requires further research, in particular, when providing surgical care to patients with thyroid pathology. The purpose of the study was to investigate the state of activity organization of multidisciplinary teams in the provision of surgical care to patients with thyroid pathology and to propose approaches for its improvement. Materials and methods: accounting forms No. 003 for 2019 (1208 units), constituent and administrative documents for the institution, department regulations, job descriptions, clinical pathway of patients (15 units in total). The base of research was communal non-profit enterprise "Kiev City Clinical Endocrinological Center". The methods, which were used, are systematic approach, medical and statistical, medical and geographical methods, content analysis, graphic. Results and discussion. Patients of the Department of Endocrine Surgery were from almost all regions of Ukraine. 3.5% of patients were referred by a general practitioner, 55.7% - by an endocrinologist, 40.1% - independently applied. Malignant neoplasm of the thyroid gland was detected in 33.9% of patients, non-toxic multinodular goiter – in 25.2%, benign neoplasm – in 16.3%. In 448 (37.1%) patients, 687 concomitant diseases and complications were identified. Their structure consisted of diseases of the heart and circulatory system – 40.0%, eye diseases – 3.1%, diseases of the nervous system – 2.0%. In order to meet the needs of patients, instrumental and laboratory studies, consultative examinations, consultations and surgical interventions were carried out. The low level of communication between inpatient doctors and outpatient doctors has been shown. This was the reason for the excessive length of stay in bed – 12.6 ± 2.7 days. There is a separate participation of specialist doctors in accompanying patients in the hospital. It was proposed to formalize the official status and develop a typical provision for a multidisciplinary team of specialists; joint discussion, debate, data exchange within the team and with outpatient doctors; afford access to corporate information for the team and coordinate the work of authorized employees. Conclusion. Improving the efficiency of multidisciplinary teams is possible by strengthening collaboration within the team and communication with outpatient doctors

THE CLINICAL CASE OF HEMIFACIAL MICROSOMIA IN THE NEWBORN BOY FROM MOTHER WITH Z-21

Hemifacial Microsomia (HFM) is a term used to identify facial deformities associated with the development ofthe first and second pairs of branchial arches, characterized by underdevelopment of one half of the face. One typeof hemifacial microsomia is oculo-auriculo-vertebral dysplasia or Goldenhar syndrome.The incidence of HFM is 1:3500-1:7000 of live births and occurs in 1 case per 1000 children with congenitaldeafness. The ratio of boys to girls is 3:2. The etiology and type of inheritance is studied insufficiently. There are threepossible pathogenetic models: vascular abnormalities and hemorrhages in the craniofacial region, damage of Meckel'scartilage, and abnormal cell development of the cranial nerve crest. Environmental factors, maternal internal factors,and genetic factors (OTX2, PLCD3, and MYT1 mutations) may also cause the development of hemifacial microsomia.The article demonstrates a clinical case of hemifacial microsomia in a newborn boy from a mother with Z-21 inthe form of deformation of the left auricle with atresia of the auditory canal and "false" ears on the right, combinedwith congenital anomaly of heart (atrial septal defect) and brain (hypoplasia of the corpus callosum).Emphasis is placed on the need of involving a multidisciplinary team of specialists in the management of thispatient both in the neonatal period and in the system of subsequent follow-up.

P09 Uncommon cause of back pain

P09 Uncommon cause of back pain

ПСИХОТЕРАПЕВТИЧНІ МЕТОДИ ЛІКУВАННЯ ТРИВОЖНО-ФОБІЧНИХ РОЗЛАДІВ: КОРОТКИЙ ОГЛЯД

Nowadays, the problem of diagnosis, interpretation and selection of treatment options for phobic anxiety disorders is becoming more acute taking into account the multidimensionality of a human being. The data obtained on psychopharmacotherapy show its moderate effectiveness for phobic anxiety disorders. The combination of psychopharmacotherapy and psychotherapy, which often plays a leading role in the treatment process, works much better. The paper aims at analyzing psychotherapeutic treatment options for phobic anxiety disorders, such as exposure therapy, cognitive-behavioral therapy, group therapy and self-help groups, hypnotherapy, mindfulness, meditation, deep breathing, progressive muscle relaxation method. There are pros and cons for both psychopharmacological and psychotherapeutic treatment options. Therefore, the choice of the most effective treatment options should be determined after an in-depth examination of a patient and carried out by a multidisciplinary team of specialists.

MANUBRIOSTERNAL JOINT SEPTIC ARTHRITIS IN A MAN WITH A HISTORY OF IV DRUG USE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Septic arthritis is a well-documented disease, much of which contains specific guidelines and recommendations for management. Manubriosternal joint septic arthritis is a rare entity described in literature that lacks consistently successful treatment options. (1) We present the case of a patient found to have a tender chest wall mass and imaging concerns for manubriosternal septic arthritis. CASE PRESENTATION: A 47-year-old male with history of heart failure with reduced ejection fraction, drug-induced non-ischemic cardiomyopathy, cirrhosis, and history of intravenous drug use was admitted to the hospital from heart failure clinic for acute on chronic heart failure exacerbation and mild encephalopathy. He was afebrile but tachycardic with a leukocytosis (13 k/ul) upon presentation. During examination a tender, fluctuant mass was discovered over the sternum. He reported pain in this area began three weeks prior with a mass developing over the previous one week. Chest roentgenogram showed an enlarged cardiac silhouette. Follow-up chest computed tomography revealed a 5 cm x 6 cm mass containing gas surrounding the manubriosternal joint anteriorly and posteriorly. He underwent incision and drainage by cardiothoracic surgery where purulent material was found and appeared to connected to the posterior sternal fluid collection. Wound culture grew Streptococcus agalactiae. Sternal bone biopsy was negative for osteomyelitis. He was placed on IV penicillin G for four weeks of therapy. DISCUSSION: Primary manubriosternal joint infections have been rarely documented in literature with approximately 20 (adult and pediatric) cases noted in a PubMed literature search. (1) Cases appear to be more common in men approaching middle-age. Predisposing risk factors are often present and similar to those for septic arthritis of more typical joint locations including intravenous drug use, immunosuppression, and secondary sources of infection. (1,2,3) Specific treatment guidelines are not clearly defined in literature, likely due to the rarity of this disease process. (1) Various treatment methods have been reported which include various combinations of IV antibiotics, incision and drainage, and aggressive manubriosternal joint resection. (1,2,3) The most common treatment noted during the literature review was conservative management with IV antibiotics. CONCLUSIONS: Manubriosternal joint infections are infrequently seen. A majority of cases reported have presented with typical risk factors for septic arthritis. Consistent treatment guidelines are not available due to the rarity of this disease process though many are treated conservatively with IV antibiotics. Patients should be evaluated by a multidisciplinary team of cardiothoracic surgeons and infectious disease specialists for patient-centered decision making efforts. REFERENCE #1: Ali B, Shetty A, Borah G, Demas C, Schwartz JD. Successful management of sternomanubrial joint septic arthritis with pectoralis muscle flap closure: a case series. J Surg Case Rep. 2020;2020(4):rjaa035. Published 2020 Apr 29. REFERENCE #2: Peng EW, McKillop G, Prasad S, Walker WS. Septic arthritis of the manubriosternal joint. Ann Thorac Surg. 2007;83(3):1190-1194. REFERENCE #3: Carnevale A, Righi R, Maniscalco P, et al. Primary septic arthritis of the manubriosternal joint in an immunocompetent young patient: A case report. Radiol Case Rep. 2017;12(4):682-685. Published 2017 Sep 11. DISCLOSURES: No relevant relationships by Joseph Frederickson, source=Web Response No relevant relationships by Bryton Perman, source=Web Response no disclosure on file for Akshat Sood; No relevant relationships by David Wessling, source=Web Response

Return to Sport Following Anterior Cruciate Ligament Reconstruction: Women's Lacrosse

Participation in women’s lacrosse has increased in popularity over the last 20 years with a subsequent rise in sports-related injuries. Despite this increase, there is a paucity of research examining this population, particularly regarding guidelines for safe return to lacrosse after anterior cruciate ligament (ACL) reconstruction. A lacrosse-specific functional rehabilitation program is critical to the success of the athlete. The athlete must be prepared and demonstrate the ability to cut, pivot, jump, pass, and shoot with the incidental contact required for sport clearance. A criterion-based program delineating a progression of range of motion, mobility, strength, neuromuscular control, agility, and cardiovascular training is an essential part of ACL rehabilitation. Early incorporation of lacrosse-specific skills emphasizing multiplanar neuromuscular control should gradually progress to more challenging field-based tasks as the athlete transitions through their rehabilitation program. A multidisciplinary team of physicians, physical therapists, athletic trainers, strength and conditioning specialists, coaches, and parents must collaborate effectively to reduce the athlete’s risk for reinjury, meet the demands of the sport, and facilitate returning to the field without complications. Associated video content

Cost effectiveness of a specialist wound care service.

The Burden of Wounds Study estimated the cost of wound care across the UK to be £5.3 billion, with £3 billion associated with hard-to-heal wounds. This article looks at potential cost savings of managing hard-to-heal leg ulcers in a specialist wound care service using a multidisciplinary team (MDT) approach. This unique approach includes: a consultant dermatologist; a podiatrist specialising in mobility and gait; a clinical psychologist; clinical nurse specialists; and allied health professionals from tissue viability and lymphoedema services. Bringing together specialists from supporting disciplines provides a one-stop service for the patient. We conducted a retrospective analysis (over 365 days) of wound healing in patients attending the service for management of leg ulcers with differing aetiologies, including venous and atypical leg ulceration. Many of the patients referred to the service had a long wound history, between two and nine years, with a duration up to 25 years in the most complex cases. Within this complex cohort of patients, higher levels of focused compression was required (Accelerate Strapping, Accelerate, UK) for retromalleolar ulceration and management of foot oedema needing toe bandaging or garments. Wound healing was achieved in 72% of patients across all wound aetiologies, demonstrating the impact that a specialist MDT team can have on positive healing outcomes, and which can result in cost savings to the health economy and an improved quality of life for the patient.

Diagnostic Errors of Spinal Cord Injuries in Children with Combined Trauma on the example of Clinical Cases

Diagnostic errors of spinal cord injuries with combined trauma in children are facilitated by the patient’s age, which does not allow foran adequate neurological assessment of motor and sensitive disorders, a reduced state of consciousness in severe traumatic brain injury,the lack of modern methods of neuroimaging in primary hospitals, insufficient qualifications and experience of medical personnel. Aim. To demonstrate outcomes of diagnostic errors in traumatic spinal cord injury in children on clinical examples of two patients. Material and methods. The object of observation was children with severe combined trauma, whose post-traumatic spinal cord injurywas missed in the primary hospital. To diagnose the current condition, the following were used: clinical examination with a neurologicalassessment on the ASIA scale, assessment of motor functioning, laboratory monitoring, instrumental examination, ultrasoundmonitoring, X-ray, MRI, CT, CT densitometry, ECG, echocardiography, USDG. In addition, neuropsychological assessment was made so to evaluate cortical functions and to reveal consequences of traumatic brain injury. Results. The cause of errors in the diagnostics of spinal cord injury in children is the underestimation of state severity due to the combinedtype of injury or small age of the child. Conclusion. The experience of the multidisciplinary team of specialists in the diagnosis and medical rehabilitation of children withspinal cord injury missed in the primary hospital indicates the need to conduct a full-fledged neurological examination, CT accordingto the “head to toe” program and MRI, even if there is a slight suspicion of the spinal cord damage.Underestimation of the severity of the child’s condition with concomitant trauma, including spinal cord injury, leads to the deprivationnot only in the motor function restoration, but also to deterioration in the quality of life of the family and to the problems associatedwith patient’s integration into society.