Multidisciplinary Treatment Strategy Research Articles

Addressing olanzapine-induced diabetic ketoacidosis in a major depressive disorder case

This case study highlights a critical incidence of olanzapine-induced diabetic ketoacidosis (DKA) in a 36-year-old female patient treated for major depressive disorder with psychotic features. The patient developed severe DKA after the initiation of olanzapine, despite initially normal metabolic parameters and a low starting dose. This report underscores the acute metabolic derangement facilitated by olanza- pine, necessitating a comprehensive and urgent medical approach. The clinical intervention involved discontinuing olanzapine and initiating a multidisciplinary treatment strategy, which included medical management of DKA and psychiatric adjustments using alternatives with a lower metabolic risk. This case emphasizes the necessity for regular metabolic monitoring and the potential need for tailored psychiatric medication strategies to prevent severe side effects, highlighting the unpredictability of antipsychotic- induced metabolic disturbances and advocating for a holistic, patient-centered approach in psychiatric care.

Prognostic significance of MRI features in patients with solitary large hepatocellular carcinoma following surgical resection.

To assess the prognostic impact of preoperative MRI features on outcomes for single large hepatocellular carcinoma (HCC) (≥ 8 cm) after surgical resection. This retrospective study included 151 patients (mean age: 59.2 years; 126 men) with a single large HCC who underwent gadoxetic acid-enhanced MRI and surgical resection between 2008 and 2020. Clinical variables, including tumor markers and MRI features (tumor size, tumor margin, and the proportion of hypovascular component on hepatic arterial phase (AP) (≥ 50% vs. < 50% tumor volume) were evaluated. Cox proportional hazards model analyzed overall survival (OS), recurrence-free survival (RFS), and associated factors. Among 151 HCCs, 37.8% and 62.2% HCCs were classified as ≥ 50% and < 50% AP hypovascular groups, respectively. The 5- and 10-year OS and RFS rates in all patients were 62.0%, 52.6% and 41.4%, 38.5%, respectively. Multivariable analysis revealed that ≥ 50% AP hypovascular group (hazard ratio [HR] 1.7, p = 0.048), tumor size (HR 1.1, p = 0.006), and alpha-fetoprotein ≥ 400 ng/mL (HR 2.6, p = 0.001) correlated with poorer OS. ≥ 50% AP hypovascular group (HR 1.9, p = 0.003), tumor size (HR 1.1, p = 0.023), and non-smooth tumor margin (HR 2.1, p = 0.009) were linked to poorer RFS. One-year RFS rates were lower in the ≥ 50% AP hypovascular group than in the < 50% AP hypovascular group (47.4% vs 66.9%, p = 0.019). MRI with ≥ 50% AP hypovascular component and larger tumor size were significant factors associated with poorer OS and RFS after resection of single large HCC (≥ 8 cm). These patients require careful multidisciplinary management to determine optimal treatment strategies. Preoperative MRI showing a ≥ 50% arterial phase hypovascular component and larger tumor size can predict worse outcomes after resection of single large hepatocellular carcinomas (≥ 8 cm), underscoring the need for tailored, multidisciplinary treatment strategies. MRI features offer insights into the postoperative prognosis for large hepatocellular carcinoma. Hypovascular component on arterial phase ≥ 50% and tumor size predicted poorer overall survival and recurrence-free survival. These findings can assist in prioritizing aggressive and multidisciplinary approaches for patients at risk for poor outcomes.

Complete Blood Count-Derived Inflammation Indexes Are Useful in Predicting Metabolic Syndrome in Children and Adolescents with Severe Obesity.

Background: Childhood obesity is a globally increasing pathological condition leading to long-term health issues such as cardiovascular diseases and metabolic syndrome (MetS). This study aimed to determine the clinical value of the Complete Blood Count-derived inflammation indexes Monocyte/HDL-C ratio (MHR), Lymphocyte/HDL-C ratio (LHR), Neutrophil/HDL-C ratio (NHR), and System Inflammation Response Index (SIRI) to predict the presence of metabolic syndrome and its association with cardiovascular risk markers (HOMA-IR, TG/HDL-C, and non-HDL-C) in children and adolescents with obesity. Methods: The study included a total of 552 children/adolescents with severe obesity (BMI: 36.4 [32.7-40.7] kg/m2; 219 males, 333 females; age: 14.8 [12.9-16.3] years), who were further subdivided based on the presence or absence of metabolic syndrome (MetS+ and MetS respectively). Results: The MHR, LHR, and NHR indexes (p < 0.0001), but not SIRI (p = 0.524), were significantly higher in the MetS+ compared to the MetS- subgroup, showing a positive correlation with the degree of MetS severity (p < 0.0001). Furthermore, MHR, LHR, and NHR were positively associated with cardiometabolic risk biomarkers (HOMA-IR: MHR p = 0.000, LHR p = 0.001, NHR p < 0.0001; TG/HDL-C: MHR, LHR, NHR p < 0.000; non-HDL-C: MHR, LHR p < 0.0001, NHR p = 0.000). Finally, the ROC curve analysis demonstrated that among the analyzed indexes, only MHR, LHR, and NHR had diagnostic value in distinguishing MetS patients among children and adolescents with obesity (MHR: AUC = 0.7045; LHR: AUC = 0.7205; NHR: AUC = 0.6934; p < 0.0001). Conclusions: In conclusion, the MHR, LHR, and NHR indexes, but not the SIRI index, can be considered useful tools for pediatricians to assess the risk of MetS and cardiometabolic diseases in children and adolescents with obesity and to develop multidisciplinary intervention strategies to counteract the widespread disease.

Perioperative and oncological outcomes following robotic en bloc multivisceral resection for colorectal cancer.

As multidisciplinary treatment strategies for colorectal cancer have improved, aggressive surgical resection has become commonplace. Multivisceral and extended resections offer curative-intent resection with significant survival benefit. However, limited data exist regarding the feasibility and oncological efficacy of performing extended resection via a minimally invasive approach. The aim of this study was to determine the perioperative and long-term outcomes following robotic extended resection for colorectal cancer. We describe the population of patients undergoing robotic multivisceral resection for colorectal cancer at our single institution. We evaluated perioperative details and investigated short- and long-term outcomes, using the Kaplan-Meier method to analyse overall and recurrence-free survival. Among the 86 patients most tumours were T3 (47%) or T4 (47%) lesions in the rectum (78%). Most resections involved the anterior compartment (72%): bladder (n = 13), seminal vesicle/vas deferens (n = 27), ureter (n = 6), prostate (n = 15) and uterus/vagina/adnexa (n = 27). Three cases required conversion to open surgery; 10 patients had grade 3 complications. The median hospital stay was 4 days. Resections were R0 (>1 mm) in 78 and R1 (0 to ≤1 mm) in 8, with none being R2. The average nodal yield was 26 and 48 (55.8%) were pN0. Three-year overall survival was 88% and median progression-free survival was 19.4 months. Local recurrence was 6.1% and distant recurrence was 26.1% at 3 years. Performance of multivisceral and extended resection on the robotic platform allows patients the benefit of minimally invasive surgery while achieving oncologically sound resection of colorectal cancer.

Global Lake Health in the Anthropocene: Societal Implications and Treatment Strategies

AbstractThe world's 1.4 million lakes (≥10 ha) provide many ecosystem services that are essential for human well‐being; however, only if their health status is good. Here, we reviewed common lake health issues and classified them using a simple human health‐based approach to outline that lakes are living systems that are in need of oxygen, clean water and a balanced energy and nutrient supply. The main reason for adopting some of the human health terminology for the lake health classification is to increase the awareness and understanding of global lake health issues. We show that lakes are exposed to various anthropogenic stressors which can result in many lake health issues, ranging from thermal, circulatory, respiratory, nutritional and metabolic issues to infections and poisoning. Of particular concern for human well‐being is the widespread lake drying, which is a severe circulatory issue with many cascading effects on lake health. We estimated that ∼115,000 lakes evaporate twice as much water as they gain from direct precipitation, making them vulnerable to potential drying if inflowing waters follow the drying trend, putting more than 153 million people at risk who live in close vicinity to those lakes. Where lake health issues remain untreated, essential ecosystem services will decline or even vanish, posing a threat to the well‐being of millions of people. We recommend coordinated multisectoral and multidisciplinary prevention and treatment strategies, which need to include a follow‐up of the progress and an assessment of the resilience of lakes to intensifying threats. Priority should be given to implementing sewage water treatment, mitigating climate change, counteracting introductions of non‐native species to lakes and decreasing uncontrolled anthropogenic releases of chemicals into the hydro‐, bio‐, and atmosphere.

Treatment strategies for borderline resectable pancreatic neuroendocrine tumors: a narrative review.

Well-differentiated pancreatic neuroendocrine tumors (pNETs) are a group of rare, heterogeneous tumors that originate in the endocrine tissue of the pancreas and account for 1-2% of all pancreatic neoplasms. The majority of pNETs are non-functional and typically follow a more indolent course. Especially at early stages, the primary management of pNETs is surgical resection which is associated with relatively low rates of recurrence and excellent long-term prognosis. On the other hand, some patients will present with locally advanced primary tumors or low volume metastatic disease in which complete surgical resection may be more difficult to achieve and recurrence rates are significant. Unlike treatment of borderline resectable (BR) pancreatic adenocarcinoma, in which neoadjuvant treatment strategies are becoming standardized, borderline resectability is not a currently established terminology for pNETs and the optimal multidisciplinary treatment approach is poorly understood. We performed a literature search on PubMed, Google Scholar, and ClinicalTrials.gov using keywords, including 'pancreatic neuroendocrine tumor' and 'borderline resectable'. All studies and review articles in English with full text were considered. Each publication was independently reviewed. We introduce the concept of BR-pNETs, focusing on important criteria that should be included in their definition by balancing the feasibility of resection and the clinical utility of surgery. We suggest that extended resection, involving vascular reconstruction, adjacent organ resection, and/or liver metastasis, should be considered at experienced, high volume centers. Furthermore, we outline multidisciplinary treatment strategies, including systemic and locoregional treatment options, for optimizing outcomes for this growing patient population. Formalizing the definition of resectability in pNETs through multidisciplinary collaborative research will be important for standardizing the indications for multimodality treatment and aggressive surgical approaches for patients.

Abstract 5959: Targeting TRIM11 is a potential therapeutic strategy for malignant gliomas

Abstract Background: TRIM11 (tripartite motif-containing protein 11) belongs to the TRIM/RBCC (the RING B-box coiled-coil) family of E3 ubiquitin ligases. Emerging evidence has demonstrated that TRIM11 is a novel target against cancer and neurodegenerative diseases as it plays vital role in cellular proliferation, differentiation, tumor progression, and apoptosis. Our previous work demonstrated that TRIM11 is over-expressed in high-grade gliomas and promotes proliferation, invasion, migration and tumor growth, suggesting that TRIM11 may be used as a target for malignant glioma treatment. The tumor suppressor p53 plays critical roles in tumor prevention, and deregulated p53 pathway has been found in a majority of glioblastomas (GBMs). Recent studies have shown that TRIM proteins are involved in the regulation of p53, and TRIM proteins are also regulated by p53. Methods: To evaluate the effect of TRIM11 on GBM progression in vivo, we intracranially implanted GBM cells over-expressing TRIM11 in immunocompromised mice, and the animal survival was monitored. We have synthesized a series of TRIM11 inhibitors and evaluated their anti-GBM potential in vitro. Furthermore, we tested the crosstalk between TRIM11 and p53 by knocking down TP53 through RNA interference. Results: Our in vivo data showed that the control group mice (GL261 parent line) survived longer than the mice bearing TRIM11 over-expressing GL261 tumors (p&amp;lt;0.05), suggesting TRIM11 enhances tumor progression in vivo. In vitro data showed that the oncogenic effect of TRIM11 may be related to its influence on the apoptosis pathway since a robust induction of poly (ADP-ribose) polymerase (PARP) was observed in TRIM11 over-expressing GBM cells. When treated with Temozolomide (TMZ), TRIM11 over-expressing cells were more resistant and showed a higher survival rate compared to parental cells. We screened a small library of TRIM11 inhibitors (~ 25 compounds), and identified several compounds which significantly inhibited the growth of both established and primary GBM cells in a dose-dependent manner, implicating that TRIM11 inhibitors may serve as novel agents for GBM treatment. We found that inactivation of p53 by siRNA increased the expression of TRIM11 and modulated the sensitivities of GBM cells to chemotherapy drugs. Conclusion: Despite remarkable advances in the prognosis and multidisciplinary treatment strategies, GBM is still the most lethal primary brain tumor, and there is a pressing need for newer anti-GBM agents with novel targets and mode of action. Our preclinical studies demonstrate a significant anti-tumor effect of TRIM11 inhibitors on malignant glioma cells. Our finding that TRIM11 may be modulated by p53 adds a new layer of regulation to this complicated signaling pathway. A better understanding of the crosstalk between p53 and TRIM11 will benefit the clinical application of targeting p53 and TRIM11 signaling pathways for therapeutical indications in GBM. Citation Format: Kaijun Di, Bhaskar C. Das, Daniela Alexandru Abrams, Daniela A. Bota. Targeting TRIM11 is a potential therapeutic strategy for malignant gliomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5959.

The Fundamental Role of Multidisciplinary Approach in Complex Head and Neck Pathology: A Case Report of Maxillary Adenoid Cystic Carcinoma.

Adenoid cystic carcinoma (ACC) is a rare tumor, with a documented annual incidence ranging from 3 to 4.5 cases per million. It constitutes approximately 1% of all head and neck malignancies and around 10% of salivary gland tumors. It is imperative to adopt a multidisciplinary approach to ensure the most appropriate therapeutic outcome. Treatment strategies usually involve a multidisciplinary approach and may include surgery, radiotherapy, chemotherapy, or various combinations of these. In this context, we present a clinical case of ACC originating in the palate of a woman. Throughout this article, we will detail the diagnostic challenges and multidisciplinary treatment strategies implemented, emphasizing the importance of a comprehensive approach in cases of palatal ACC. In addition, we will discuss the rehabilitation process and the outcomes observed during the follow-up of this case.

Recent advances in the treatment of attention deficit hyperactivity disorder in children: A narrative review

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by age inappropriate levels of inattention, and or impulsivity and hyperactivity. Often arising in childhood, ADHD can also be chronic in nature, frequently continuing through adolescence and beyond, at least at the level of impairment. The early accurate diagnosis of the condition is possible based on clinic settings, clinicians’ expertise; and the context at which screening and evaluation of this population for ADHD is done. ADHD is an etiologically complex neurodevelopmental disorder that begins early in life and has heterogeneous clinical manifestations encompassing a broader spectrum of psychopathology. This underscores the importance of early accurate diagnosis so that effective treatments can be started that significantly reduces immediate and long-term psychosocial burdens. Effective ADHDtreatments are available and cognitive neuroscience is rapidly expanding, however there is a significant gap between empirical evidence and clinical practice. Multimodal and multidisciplinary treatment strategies are the best approach in the treatment, but there is a significant gap between the knowledge and practice, such that evidence-based treatments are often not implemented in the community settings. How we implement such in our clinical practice helps us to advocate and advance towards more effective ADHD treatments. There is growing scientific progress in understanding the causes and treatment of ADHD. Knowledge about the evidence-based recent advances in the treatment helps mental health professionals to advocate for the effective approaches to treat ADHD, with minimal unwanted side effects.

Rare solitary pituitary metastasis of maxillary ameloblastic carcinoma: illustrative case.

Ameloblastic carcinoma (AC) is a rare odontogenic carcinoma with histological features resembling ameloblastoma. Metastasis to distant organs and direct expansion into the skull base structures are associated with a poor clinical outcome. This rare case of AC metastasis to the pituitary gland presented without local recurrence at the primary focus of the maxilla. A 47-year-old man had a 2-year history of AC in the right maxilla. Computed tomography for his regular checkup incidentally demonstrated pituitary tumor, rapidly growing over 2 months. He presented with the recent onset of panhypopituitarism and visual field defect. Magnetic resonance imaging showed a large, irregularly shaped intrasellar and suprasellar lesion with chiasmal compression. Endoscopic endonasal transsphenoidal surgery was performed for decompression of the optic apparatus to avoid intracranial spread. Histopathology confirmed metastatic AC, and a genetic panel test confirmed BRAF V600E mutation. Stereotactic radiotherapy (SRT) with the CyberKnife system was administered to the residual tumor. Remarkable tumor shrinkage was obtained, and panhypopituitarism was resolved 12 months later. A multidisciplinary treatment strategy including maximal safe resection to avoid dissemination in combination with SRT may be crucial for local control with the preservation of pituitary and visual functions in patients with solitary pituitary metastatic AC.

Perioperative management of patients with drug addiction

Background. Patients undergoing surgical or diagnostic procedures, as well as critically ill patients, often suffer from psychoactive substance use disorders. The term “psychoactive substances” here includes both narcotics and psychotropic substances (or their analogs) as well as their precursors. They are strongly associated with drug addiction and such behavioral disorders as addictive behavior and delinquency. People with drug addiction is a high-risk group due to a variety of physical and mental factors. Common comorbidities in this population include human immunodeficiency virus, viral hepatitis, and infections caused by resistant strains of microorganisms. Clinical practice shows that medical professionals often underestimate the likelihood of disorders that occur in such patients before surgery. Generally, disorders related to the abuse of psychoactive substances are treatable, and most pathophysiological changes in organ functions are reversible. Early detection of such disorders and the risks associated with them is crucial for the timely use of the appropriate preventive measures in order to reduce the frequency and severity of these complications. Despite the increased perioperative risk, these patients can be treated safely if multidisciplinary treatment strategies are implemented. Psychoactive substance abuse leads to a wide spectrum of disorders, regardless of whether it is occasional cannabis usage or severe dependence on stimulants or narco­tics. This explains the need for a personalized approach from an anesthesiologist to avoid complications associated with the use of cannabinoids, cocaine, amphetamines, or opioids. Therefore, the need for an individual approach to perioperative anesthesiological management with mandatory monitoring and personalized selection of anesthesia techniques and methods is justified. Conclusions. Drug addiction can be successfully managed if it is detected in time by an anesthesiologist during the preoperative period. Knowledge of the main pharmacological effects and clinical signs of prolonged psychoactive substance use in patients allows anesthesiologists to proactively outline the optimal strategy for anesthetic management of such patients during surgical interventions.

Experience of surgical treatments for abdominal inferior vena cava injuries in a regional trauma center in Korea

Purpose: Inferior vena cava (IVC) injuries are a rare type of traumatic abdominal injuries that are challenging to treat and have a very high mortality rate. This study described our experience with the surgical treatment of traumatic IVC injuries, and we investigated the demographics, clinical profiles, and surgical outcomes of cases at a regional trauma center.Methods: Among the 16 patients who were treated for a traumatic IVC injury between January 2014 and March 2022, 14 underwent surgery. The surgical outcomes included overall mortality and 24-hour mortality, and we investigated the factors associated with these surgical outcomes. The 14 patients were divided into two groups according to the location of the IVC injury (retrohepatic IVC or higher vs. subhepatic IVC), and differences between the two groups were analyzed. Results: A body mass index (BMI) &gt;23.0 kg/m2 (P=0.046), an elevated serum lactate level (P=0.043), and a shorter operation time (P=0.016) were associated with overall mortality. A higher BMI (P=0.050), high serum lactate level (P=0.004), shorter operation time (P=0.005), and an injury at the retrohepatic IVC or higher level (P=0.031) were associated with 24-hour mortality. Younger age (P=0.028), higher BMI (P=0.005), an acidic pH (P=0.028), high lactatemia (P=0.012), a higher hemoglobin level (P=0.012), and shorter door-to-operating room time (P=0.028) were associated with injury at the retrohepatic IVC or higher level. Patients with subhepatic IVC injuries had a high rate of direct repair (75.0%) and a significantly lower 24-hour mortality rate (37.5%, P=0.031).Conclusions: Subhepatic IVC injuries are easy to access and are usually treated with a direct repair method. Injuries at the retrohepatic IVC or higher level are difficult to treat surgically and require a systematic and multidisciplinary treatment strategy.

The Adaptive, Pain Sensitive, and Global Symptoms Clusters: Evidence from a Patient-Based Study.

The largest epidemiologic study conducted about painful temporomandibular disorders (pTMDs) to date identified 3 clusters of individuals with similar symptoms-adaptive, pain sensitive, and global symptoms-which hold promise as a means of personalizing pain care. Our goal was to compare the clinical and psychological characteristics that are consistent with a pTMD clinical examination among patients who are seeking care and assigned to the different clusters. This cross-sectional study used data from the medical records of patients attending Duke Innovative Pain Therapies between August 2017 and April 2021 who received a pTMD diagnosis (i.e., myalgia) and consented to have their data used for research. Data included orofacial and pain-related measures, dental features, and psychological measures. We used the Rapid OPPERA Algorithm to assign clusters to patients and multinomial regression to determine the likelihood (odds ratios [OR] and 95% confidence intervals [CI]) of being assigned to the pain sensitive or global symptoms cluster attributed to each measure. In total, 131 patients were included in this study and assigned a cluster: adaptive (n = 54, 41.2%), pain sensitive (n = 49, 37.4%), and global symptoms (n = 28, 21.4%). The PS cluster displayed greater numbers of temporomandibular joint sites (OR, 1.29; 95% CI, 1.01 to 1.65) and masticatory (1.48; 1.19 to 1.83) and cervical (1.23; 1.09 to 1.39) muscles with pain evoked by palpation. The GS cluster displayed greater scores of pain catastrophizing (1.04; 1.01 to 1.06) and perceived stress (1.23; 1.03 to 1.46) and was more likely to report persistent pain (16.23; 1.92 to 137.1) of higher impact (1.43; 1.14 to 1.80). Our findings support that care-seeking patients with pTMDs who are assigned to the GS cluster display a poorer psychological profile, even though those assigned to the PS cluster display more measures consistent with orofacial pain. Findings also establish the PS cluster as a group that does not display psychological comorbidities despite being hypersensitive. This study informs clinicians that patients seeking care for painful temporomandibular disorders, in specific cases of myalgia, can be classified into 1 of 3 groups that display unique profiles of symptoms. Most importantly, it emphasizes the importance of examining patients with painful temporomandibular disorders in a holistic manner that includes assessing symptoms of psychological distress. Patients with greater psychological distress will likely benefit from multidisciplinary treatment strategies that may include psychological treatments.

Chest wall reconstruction reduces hospital mortality following major chest wall trauma: a retrospective cohort study.

Chest wall reconstruction was introduced for the management of patients with severe chest wall injuries. We undertook a retrospective cohort study to investigate whether the treatment was associated with improved survival compared with conservative treatment. A retrospective single institutional cohort study compared mortality following treatment of major chest wall trauma (Abbreviated Injury Scale ≥3) by chest wall reconstruction (CWR) to conservative management (Non-CWR) between September 2014 and December 2019. Univariable and multivariable associations between demographic and comorbid characteristics and mortality were estimated using Cox proportional hazard analysis and expressed as hazard ratios (HR) and corresponding confidence intervals (CI). Of a cohort of 947, CWR (n=157, 16.6%) had a lower prevalence of polytrauma (35.7 vs 56.3%, p<0.001) and head injury (11.5% vs 26.7%, p<0.001). CWR-treated patients experienced a greater number of fractured ribs, (8.3 vs 5.8, p<0.001), higher incidence of flail chest (84.9% vs 48.9%, p<0.001), higher admission to Critical Care (64.3% vs 44.1%, p<0.001), greater demand for ventilation (36.9% vs 25.6%, p=0.004) and a higher New Injury Severity Scale value (36.9 vs 34.6, p=0.003). Mortality of CWR patients was significantly lower (3.8% vs 8.6%, p=0.04), with adjusted HR 0.30 (95% CI 0.12, 0.72, p=0.008). Chest wall reconstructive surgery, provided as a part of multidisciplinary treatment strategy for major thoracic trauma, reduces risk of mortality. The results validate the UK Government strategy, designed to reduce mortality, by centralising management of serious trauma in Major Trauma Centres.

Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review

Narrative review. With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review's purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.

Ускоренное выздоровление. предоперационная подготовка и преабилитация.

Fast Track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery after surgery programs) or ERP (enhanced recovery program, in russian) is a multimodal and multidisciplinary treatment strategy designed to reduce the duration of disability and improve the quality of medical care. This program includes preparation at the preoperative stage, the use of minimally invasive techniques for performing surgical intervention and active management of the postoperative period to reduce the duration of inpatient treatment, rehabilitation time and the fastest possible return of patients to normal life. In the context of this review, the features of preparation and prehabilitation at the preoperative stage of the enhanced recovery program are considered. The main elements of the strategy are reviewed: correction of eating disorders, carbohydrate loading, preoperative education and problems of multidisciplinary interaction, sarcopenia, lifestyle changes, pharmacogenomics, correction of anemia and preoperative bowels preparation. Prehabilitation and preoperative preparation together help make the patient for surgery and subsequent recovery. The main elements of training are patient and staff training, multidisciplinary interaction, correction of concomitant somatic disorders and diseases, nutrition optimization and lifestyle changes.

MULTIDISCIPLINARY MANAGEMENT, ANTI-TNF THERAPY, AND CLINICAL OUTCOMES OF INTERNALLY PENETRATING CROHN’S DISEASE COMPLICATION IN PEDIATRICS: INTERIM ANALYSES OF A MULTICENTER RETROSPECTIVE COHORT

Abstract BACKGROUND Internally penetrating Crohn’s disease (CD) complications (IPCDC; i.e. abscess and/or inflammatory mass) confer significant morbidity to pediatric patients with CD. Management strategies are heterogenous. Anti-tumor-necrosis-factor-a biologics (anti-TNF) are the mainstay of penetrating CD therapy and are most effective early in the treatment course. However, anti-TNF use among patients with IPCDC is limited by hesitancy concerning infectious risk. Recent studies show that this risk may be overstated. We hypothesized that early anti-TNF following IPCDC diagnosis, in the context of infection control, is 1) safe and 2) effective in pediatric patients. Here, we present interim results of an observational multi-center study. METHODS We performed a retrospective cohort study of pediatric patients with IPCDC, across 12 tertiary children’s hospitals. Patients (age 6+ years) were identified via radiology, ICD-coding, and ImproveCareNow searches. Patients admitted for an IPCDC diagnosed via MRI or CT from 2007-2021, with 1+ year of follow-up were included. Patients were excluded if complications were due to a non-CD-related process, solely perianal, if admission followed outpatient or outside institution treatment failure, or if surgery was required within 7 days of IPCDC (n=7). First, we measured the safety effect of anti-TNF following IPCDC diagnosis, prior to IPCDC resolution, on infectious serious adverse events (SAE) (i.e. new or enlarging IPCDC, or infection, requiring hospitalization or surgery), within 30 days. Next, we measured the effectiveness of anti-TNF within 30 days of IPCDC diagnosis on CD-related SAEs (i.e. non-infectious CD-related hospitalization or surgery), within one year. Kaplan-Meier curves were generated to describe outcomes over time. RESULTS 95 patients were included. Cohort characteristics, multidisciplinary treatment strategies, and outcomes are presented in Table 1. Kaplan-Meier curves are presented in Figure 1. 80% of patients received anti-TNF within one year of IPCDC (median 37 days [IQR 7-68]). Infectious SAEs within 90 days of IPCDC occurred in 37% (median 20 days [IQR 10-26]). Among patients initiating anti-TNF prior to IPCDC resolution, 27% had an infectious SAE within 90 days, compared to 49% of those not initiating anti-TNF prior to IPCDC resolution. Non-infectious CD-related SAEs within one year occurred in 44% (median 51 days [IQR 27, 89]). Among patients initiating anti-TNF within 30 days of IPCDC, 47% had a CD-related SAE, compared to 43% in those not receiving anti-TNF within 30 days. CONCLUSION Among a large multicenter pediatric cohort, IPCDC are associated with high rates of both infectious and CD-related SAE. Further data collection, implementation of causal inference methods, and subgroup analyses will be critical in isolating the relationship between timing of anti-TNF post-IPCDC and SAEs. Values represent Number (Percent) for categorical variables and Median (Interquartile Range) for continuous variables. Kaplan-Meier Survival Analyses for A) Infectious Serious Adverse Events and B) Crohn's Disease-Related Serious Adverse Events, stratified by exposure status. No censoring for lost-to-followup occured, as all patients had at least 1 year of follow-up avaialble.

Immune evasion in esophageal squamous cell cancer: From the perspective of tumor microenvironment.

Esophageal cancer (EC) is one of the most life-threatening malignancies worldwide. Esophageal squamous cell carcinoma (ESCC) is the dominant subtype, accounting for approximately 90% of new incident EC each year. Although multidisciplinary treatment strategies have advanced rapidly, patients with ESCC are often diagnosed at advanced stage and the long-term prognosis remains unsatisfactory. In recent decades, immunotherapy, such as immune checkpoint inhibitors (ICIs), tumor vaccines, and chimeric antigen receptor T-cell (CAR-T) therapy, has been successfully used in clinical practice as a novel therapy for treating tumors, bringing new hope to ESCC patients. However, only a small fraction of patients achieved clinical benefits due to primary or acquired resistance. Immune evasion plays a pivotal role in the initiation and progression of ESCC. Therefore, a thorough understanding of the mechanisms by which ESCC cells escape from anti-tumor immunity is necessary for a more effective multidisciplinary treatment strategy. It has been widely recognized that immune evasion is closely associated with the crosstalk between tumor cells and the tumor microenvironment (TME). TME is a dynamic complex and comprehensive system including not only cellular components but also non-cellular components, which influence hallmarks and fates of tumor cells from the outside. Novel immunotherapy targeting tumor-favorable TME represents a promising strategy to achieve better therapeutic responses for patients with ESCC. In this review, we provide an overview of immune evasion in ESCC, mainly focusing on the molecular mechanisms that underlie the role of TME in immune evasion of ESCC. In addition, we also discuss the challenges and opportunities of precision therapy for ESCC by targeting TME.

Impact of Spina Bifida on Sleep Quality: Current Insights.

Spina bifida (SB) is one of the most common birth defects in children. The care for patients with SB continues to evolve, and there has been notable improvement in survival outcomes, degree of disability and quality of life for these children. However, patients with SB continue to remain at higher risk for sleep-related breathing disorders (SRBD), unexplained sudden death, and potential alterations in their sleep chronotype. Previous studies report on abnormalities in the spinal cord, brainstem function, and dysfunction of upper airway maintenance as the likely mechanisms behind SRBD that is commonly seen in SB. Most studies looking at prevalence of SRBD in SB have been retrospective studies. A recent prospective study identified a prevalence as high as 42% when a polysomnography (PSG) was completed on all patients regardless of symptomatology. Treatment options vary depending on the type and severity of SRBD and can range widely. Despite advances in care for patients with SB and SRBD, a subset of these patients with myelomeningocele (MMC) continue to experience sudden unexplained death. Studies continue to evaluate ways to stratify which of these patients may be at higher risk of this devastating outcome. Given that SRBD is potentially treatable, early assessment and intervention could become an integral part of a multidisciplinary treatment strategy to optimize long-term medical and neurodevelopmental outcomes for this patient population. By understanding the impact that SB may have on a patient's sleep quality, their biological chronotype and their potential of developing SRBD, a provider may help to optimize the care a patient with SB receives from birth into adulthood.

Bambini vittime di maltrattamento e trascuratezza: il contributo dell’odontoiatra

Child maltreatment and neglect are still a major public health problem worldwide. Dentists are in a privileged position to recognize any childabuse and/or neglect because most of the lesions are found precisely in the facial area, involving teeth and oral cavity. Next to the pediatrician, who regularly examines the child as he grows up and occupies a privileged position in recognizing family situations at greater risk and in supporting the family, the dentist has an important diagnostic support function, having a specific competence for the recognition of non-accidental injuries and neglect with oro-facial localization. As indicated in the Ministry of Health’s guidelines for the management of dental trauma, it is desirable that, in the near future, standardized multidisciplinary intervention strategies be promoted, within which both professions, aware of their respective sentinel roles in protecting abused children, can actively collaborate in establishing detection and reporting protocols.