Special Considerations In Management Research Articles

12526 Acromegaly Secondary to Sparsely Granulated Adenoma

Abstract Disclosure: D. John: None. M. Kinaan: None. J. Titus: None. K. Lamar: None. The most common pathological finding in acromegaly is a densely granulated adenoma which is composed of large round eosinophilic cells with prominent nucleoli and spherical nuclei that closely resemble a somatotroph cell. Less common finding is a sparsely granulated adenoma that is composed of sheets of poorly cohesive, pleiomorphic nuclei, chromophobic cells. We present a case of a 58-year-old gentleman presenting to our endocrine clinic for evaluation of a pituitary macroadenoma. The patient was hospitalized for nausea, vertigo, headaches, and blurring of vision. CT brain at that time showed a pituitary mass measuring 2.4 x 1.6 x 1.7 cm centered in the right cavernous sinus and inseparable from the pituitary gland. Hormonal work-up in the hospital was remarkable for high GH level. IGF-1 level was not done. Patient was advised to follow-up with neurosurgery as outpatient and no emergent surgery was planned. In the clinic, patient denied symptoms of DI, adrenal insufficiency or hypothyroidism. He has history of hypogonadotropic hypogonadism and was on testosterone therapy, but he stopped it since his hospitalization. On physical examination, he was noted to have macroglossia, deep voice, prominent jawbone, and soft tissue swelling in the hands and feet. Patient did not have any visible joint swelling. He stated he did not notice these changes personally and that he’s always been a “big guy” and always had a deep voice since he was a teenager. Repeat hormonal workup (done at 8 AM) showed: normal CMP, ACTH, cortisol, prolactin, TSH, T4, and T3. Testosterone was low with LH and FSH inappropriately within the normal reference range consistent withhypogonadotropic hypogonadism. IGF-I was elevated at 628ng/mL with a Z score of 3.9. These findings were consistent with acromegaly. He underwent surgery for tumor resection and pathology report showed that about 40% of the cells demonstrated weak immunoreactivity for GH, and rare (less than 1%) prolactin-positive cells were present within the tumor. The specimen was negative for TSH, ACTH, FH, and LH immunostains. Immunostain for CAM5.2 showed predominantly perinuclear dot-like immunoreactivity. The *MIB1 proliferation index is about 1%. The findings were consistent with a sparsely granulated gonadotrophic adenoma, which may demonstrate aggressive behavior. Postoperative MRI showed postoperative changes with residual pituitary tissue (normal gland vs. residual tumor). Postoperative cortisol >16. Postoperative GH dropped from 4.39 to 2.69 after 1 month. After 3 months, patient was doing well with no symptoms. However, IGF1 level (>400) showing that surgery was not curative. Currently he is awaiting gamma knife radiation therapy with possible medical therapy afterwards. Our case will provide an overview of the specific management considerations for these tumor and how they differ from densely-granulated tumors. Presentation: 6/3/2024

Management of older adults with diabetes mellitus: Perspective from geriatric medicine.

Advances in diabetes medication and population aging are lengthening the lifespans of people with diabetes mellitus (DM). Older patients with diabetes mellitus often have multimorbidity and tend to have polypharmacy. In addition, diabetes mellitus is associated with frailty, functional decline, cognitive impairment, and geriatric syndrome. Although the numbers of patients with frailty, dementia, disability, and/or multimorbidity are increasing worldwide, the accumulated evidence on the safe and effective treatment of these populations remains insufficient. Older patients, especially those older than 75 years old, are often underrepresented in randomized controlled trials of various treatment effects, resulting in limited clinical evidence for this population. Therefore, a deeper understanding of the characteristics of older patients is essential to tailor management strategies to their needs. The clinical guidelines of several academic societies have begun to recognize the importance of relaxing glycemic control targets to prevent severe hypoglycemia and to maintain quality of life. However, glycemic control levels are thus far based on expert consensus rather than on robust clinical evidence. There is an urgent need for the personalized management of older adults with diabetes mellitus that considers their multimorbidity and function and strives to maintain a high quality of life through safe and effective medical treatment. Older adults with diabetes mellitus accompanied by frailty, functional decline, cognitive impairment, and multimorbidity require special management considerations and liaison with both carers and social resources.

More than pacemakers and defibrillators: perioperative management of implantable devices for patient safety.

The use of implantable medical devices (IMDs) continues to increase with estimates that 10% of the American population will have an IMD in their lifetime. IMDs require special considerations for management in the perioperative period to ensure optimal patient care and patient safety. This review summarizes the current perioperative considerations for IMDs. This review summarizes perioperative recommendations for spinal cord stimulators, deep brain stimulators, peripheral nerve stimulators, vagus nerve stimulators, muscle stimulators, intrathecal drug delivery systems, implantable infusion pumps, artificial pancreas devices, continuous glucose monitors, and cochlear implants. There are multiple publications and guidelines regarding the perioperative considerations of cardiac implantable electronic devices; thus, this review excludes those devices. This review includes recommendations on management of the device perioperatively, the potential complications, and postoperative care of the device. There are very few guidelines regarding the perioperative management of IMDs. Given the significant impact that these devices have on patient care and safety, evidence-based guidelines should be established.

Unruptured intracranial aneurysms in older adults: special considerations for treatment and management

Unruptured intracranial aneurysms in older adults: special considerations for treatment and management

Canadian Stroke Best Practice Recommendations, 7th Edition: Cerebral Venous Thrombosis, 2024.

The 7th edition of the Canadian Stroke Best Practice Recommendations (CSBPR) is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners, and intended to drive healthcare excellence, improved outcomes and more integrated health systems. This edition includes a new module on the management of cerebral venous thrombosis (CVT). Cerebral venous thrombosis is defined as thrombosis of the veins of the brain, including the dural venous sinuses and/or cortical or deep veins. Cerebral venous thrombosis is a rare but potentially life-threatening type of stroke, representing 0.5-1.0% of all stroke admissions. The reported rates of CVT are approximately 10-20 per million and appear to be increasing over time. The risk of CVT is higher in women and often associated with oral contraceptive use and with pregnancy and the puerperium. This guideline addresses care for adult individuals who present to the healthcare system with current or recent symptoms of CVT. The recommendations cover the continuum of care from diagnosis and initial clinical assessment of symptomatic CVT, to acute treatment of symptomatic CVT, post-acute management, person-centered care, special considerations in the long-term management of CVT, including pregnancy and considerations related to CVT in special circumstances such as trauma and vaccination. This module also includes supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Atrial fibrillation considerations in the fourth trimester (postpartum period).

Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.

P-034 Clinical experience with expanded carrier screening results on a sperm donor applicant population

Abstract Study question What is the frequency of clinically significant results from expanded carrier screening (ECS) in a sperm donor applicant population and how should these be managed? Summary answer ECS results revealed clinically significant information for approximately 1 in 51 donor applicants, which warrant specific management considerations in the context of third-party reproduction. What is known already The American Society of Reproductive Medicine (ASRM) Practice Committee published guidance in January 2021 that outlines the recommended carrier screening approach for gamete donors. However, there is no additional direction related to results management including donor suitability, counseling, and informed consent. Prior studies have illustrated the high frequency of donors who are identified as carriers of one or more recessive disorders on an ECS panel; thus, excluding all prospective gamete donors identified as carriers for recessive conditions is not feasible or appropriate given the availability of reciprocal screening for the reproductive partner. Study design, size, duration A retrospective review of donor genetic screening records from July 2017 to December 2021 was performed. Relevant data was extracted and categorized by carrier screening result. Genetic counselors evaluated the health and reproductive risks to the potential donors (PDs) associated with being a carrier of a pathogenic mutation in each gene using published data, reference laboratory interpretations, and the professional health management guidelines. Participants/materials, setting, methods ECS was performed on sperm donor applicants as part of the routine donor qualification process. Testing was performed at an outside reference laboratory after participants provided written consent for genetic testing. The genes included on the ECS panel were analyzed using multiple methodologies. Specific methodologies varied based upon laboratory offerings at the time in which the potential donor entered the donor program. Main results and the role of chance A total of 966 PDs had ECS during the specified timeframe. Of these applicants, 19 total PDs (1.97%) were identified as having potentially significant health risks based on their ECS results. Of those 19 PDs, eleven were found to be either heterozygous or hemizygous for conditions that may convey significant health risks to carriers. Of these, nine were positive for a variant in a gene typically associated with an AR condition and two carried variants in genes associated with X-linked conditions. Eight additional PDs were found to be either compound heterozygous or homozygous for variants in a gene associated with an autosomal recessive condition. Limitations, reasons for caution Donor recruitment was limited to select major metropolitan areas in the U.S.; thus, donor applicants may not represent all ethnic groups or socioeconomic backgrounds. Additionally, this study described results from a single reference laboratory and does not illustrate the variation in ECS panels across genetic testing laboratories. Wider implications of the findings While this study examined ECS results in a donor applicant population, findings are also applicable to the general reproductive population and illustrate the necessity of informed consent and post-test counseling. In some cases, ECS may provide insight on potential future health risks and health management opportunities. Trial registration number Not applicable

Best Practices in Pediatric Oncology Pain Management.

Pediatric oncology patients are vulnerable to pain that may be caused by the disease or its treatment, and this symptom can be challenging to manage. This article focuses on the importance of pain control, pain assessment and treatment, and special considerations in pediatric oncology pain management, including preparing children for painful procedures and the family's role in managing pain.

Colposcopy in special situations

Globally, cervical cancer is the fourth most common type of cancer in women and has the fourth highest death rate of cancers in women. Colposcopy is part of the resources available to medicine for the diagnosis and monitoring of preinvasive lesions and cervical cancer. Well-trained professionals are required to perform an accurate and safe colposcopy. The same cytologic outcome has a different risk of intraepithelial neoplasia 2, 3, or cancer in various groups of women, so several populations require special management considerations, including those younger than 25 years, pregnant women, immunosuppressed women, those who underwent hysterectomy, and those older than 65 years. We conducted this review to update the available information on colposcopy in these special populations.

Special Considerations in Management of Atypical Femur Fractures

Special Considerations in Management of Atypical Femur Fractures

Multicentre study protocol comparing standard NRP to deveLoped Educational Modules for Resuscitation of Neonates in the Delivery Room with Congenital Heart Disease (LEARN-CHD)

IntroductionInfants born with critical congenital heart defects (CCHDs) have unique transitional pathophysiology that often requires special resuscitation and management considerations in the delivery room (DR). While much is known about...

Marine protected areas in the southern south‐west Atlantic: Insights from marine top predator communities

AbstractThe marine ecosystem provides numerous goods and services, dampens the impacts of floods and storms, and provides climate control, through the regulation of carbon fluxes, nutrient cycling, and the bioremediation of human waste and tourism. However, the ocean is vulnerable to anthropogenic threats and has been severely altered by humans.Seabirds and marine mammals are long lived, highly mobile, easily identifiable, and occupy the upper levels of trophic webs. These ecological features make them suitable as sentinels of the marine ecosystem.Sighting data collected during eight oceanographic surveys were analysed to describe and compare the biodiversity of the communities of top predators within the marine protected areas (MPAs) of Namuncurá/Burdwood Bank I and II and the surrounding areas in two contrasting seasons (summer and winter). Data were grouped into six zones based on depth and geographic position.Twenty‐five species of seabirds and 13 species of marine mammals were recorded in 113 days of surveys between 2014 and 2018. Top predator community composition varied seasonally in the different zones.A suite of indicator species was identified according to their specificity and fidelity to a particular zone. Most of the species identified as potentially useful indicators differed between summer and winter, highlighting the importance of conducting systematic surveys in both periods.The MPAs Namuncurá/Burdwood Bank I and II are key areas for top predator communities in the region, mainly in summer when the number and abundance of species increase. However, the waters around Isla de los Estados and the channel between Isla de los Estados and Burdwood Bank were also identified as a relevant habitat for many species. This knowledge should be included to create a regional network of areas under special management considerations that connect the established MPAs with other key pelagic and coastal areas (as found in this study) for the conservation of subantarctic marine megafauna.

How I manage mantle cell lymphoma: indolent versus aggressive disease.

Mantle cell lymphoma (MCL) is a mature B-cell lymphoma with a variable clinical course and historically poor prognosis. Management is challenging in part due to the heterogeneity of the disease course, with indolent and aggressive subtypes now well recognised. Indolent MCL is often characterised by a leukaemic presentation, SOX11 negativity and low proliferation index (Ki-67). Aggressive MCL is characterised by rapid onset widespread lymphadenopathy, extra-nodal involvement, blastoid or pleomorphic histology and high Ki-67. Tumour protein p53 (TP53) aberrations in aggressive MCL are recognised with clear negative impact on survival. Until recently, trials have not addressed these specific subtypes separately. With the increasing availability of targeted novel agents and cellular therapies, the treatment landscape is constantly evolving. In this review, we describe the clinical presentation, biological factors, and specific management considerations of both indolent and aggressive MCL and discuss current and potential future evidence whichmay help move to a more personalised approach.

Special Considerations for Management of Diabetes in Adult Patients with Intellectual and Developmental Disabilities.

Diabetes mellitus (DM) is a chronic health condition that is very prevalent worldwide. It has been demonstrated that individuals with intellectual and developmental disabilities (IDDs) are at a disproportionately high risk for developing diabetes. Persons with IDDs are estimated to be 2-3 times more likely to develop DM compared to the general population. The elevated risk of developing diabetes within the population of adults with IDDs is multifactorial and includes contributions from genetics, lifestyle, medication use and misuse, boundaries to appropriate medical care, a higher incidence of comorbid mental health disorders, and others. Further, inadequate screening for and management of diabetes for these patients results in heightened risk for adverse cardiovascular events and inferior health care outcomes. To improve patient outcomes for this unique patient population, health care providers need to be well trained in the optimal modalities of screening, diagnosis, and management of diabetes in adults with IDDs. This requires the development of effective diabetes intervention and health promotion programs aimed at patients with IDDs, utilizing a patient-centered approach to screening and management, and conducting further research to assess the impact of these interventions.

The Association of Elevated Lactate Level and Rate of Intensive Care Unit Admissions, Endoscopies, and Transfusion of Packed Cell in Patients with Acute Gastrointestinal Bleeding

Background: Management of patients with Gastrointestinal Bleeding (GIB) based on chronicity and severity of it can vary from outpatient medical therapy to intensive caring in life-threatening cases. Initial clinical management decision in patients presenting to emergency department with acute GIB is often based on identifying high- and low-risk patients. Patients with high risks of adverse outcomes, such as death or re-bleeding, are more likely to benefit from early, aggressive management, whereas patients with lower risks may be considered for early hospital discharge or even outpatient management. Serum lactate level is generally an indicator of the overall adequacy of peripheral oxygenation. In severe cases of acute GIB, the hemodynamic of the patients disturbs. In this study, we are evaluating whether higher serum lactate level is potentially a biomarker for predicting the future need for special management considerations.
 Methods: 168 patients with confirmed acute GIB have entered this study. The serum lactate level of participants was measured and documented as well as their demographic data and their medical history. The participants’ need for ICU admission, blood transfusion, emergent endoscopy, and mortality rate were documented and assessed prospectively.
 Results: Patients with higher levels of serum lactate levels were more admitted to the intensive care unit in the upcoming days. Anticoagulant use and abdominal pain prevalence were also significantly different in the study groups (p>0.05). Other assessments were not statistically significant.
 Conclusion: Higher levels of serum lactate predict a higher probability of ICU admission in patients with acute GIB.

Duplicated fetal posterior cerebral artery in a patient with a ruptured fetal posterior cerebral artery aneurysm: a cerebrovascular variant.

The most common neurovascular variant is the fetal posterior cerebral artery (FPCA), in which the P1 branch is absent or hypoplastic, and the majority of P2 supply is derived from the anterior circulation. While there are reports of hyperplastic anterior choroidal arteries (AChA) with supply to the temporo-occipital and calcarine regions, no reports of a duplicated FPCA exist. This case report describes a patient with a ruptured right FPCA aneurysm. Digital subtraction angiogram (DSA) revealed an artery with origin distal to the FPCA associated with the aneurysm. This was not consistent with a typical AChA. The FPCA associated with the aneurysm had the typical origin, course, and supply of a FPCA. The distal FPCA had a similar course of a typical FPCA with significant supply to the typical PCA territory. The patient underwent successful clipping of the aneurysm, and the duplicated FPCA was identified during the craniotomy. The features of this duplicate FPCA, which has not been previously described, are discussed in comparison to another variant, the hyperplastic, anomalous AChA. The artery described in this report does not fit the typical criteria of this AChA variant. Therefore, the authors outline this variant as a duplicated FPCA. Recognition of variant cerebrovascular anatomy is vital to neurosurgeons and interventional neuroradiology specialists. FPCA aneurysms require special management considerations and are often more challenging to treat. This report discusses a duplicated FPCA. To our knowledge, this is the first description of this variant. A duplicated FPCA carries important management considerations in the management of neurovascular pathology.

Fibrillation atriale associée à l'ibrutinib : un challenge thérapeutique

Ibrutinib is a potent Bruton tyrosine kinase inhibitor and is an effective and well-tolerated treatment for a variety of lymphoid diseases. However, its use is associated with an increased incidence of atrial fibrillation ranging from 4% to 16%. New onset atrial fibrillation in cancer patients is associated with a significantly higher risk of heart failure and thromboembolism, even after adjusting for known risk factors. Ibrutinib also inhibits platelet activation and decisions regarding anticoagulation must be carefully weighed against this increased risk of bleeding.It is well-known that the anti-arrhythmic and antithrombotic strategy for atrial fibrillation related to ibrutinib has its own characteristics. Physicians should be familiar with the special management considerations imposed by this drug.Indeed, the co-prescription of therapy in combination with ibrutinib must be carefully weighed in view of its numerous drug interactions.We review the potential mechanisms and incidence of ibrutinib-associated atrial fibrillation.

The spectrum of diabetes in acute and chronic pancreatitis.

To discuss the spectrum of diabetes related to acute and chronic pancreatitis (which are types of pancreatogenic diabetes) and its overlapping features with type 1 and type 2 diabetes. Patients with diabetes related to acute and chronic pancreatitis present clinically within a spectrum of overlapping features with other forms of diabetes. In this spectrum, glucose metabolism alterations range from increased insulin resistance following acute pancreatitis (resembling type 2 diabetes) towards a permanent loss of beta-cell function and impaired insulin secretion in end-stage chronic pancreatitis. Overlapping features with type 1 diabetes (beta cell autoantibodies) and type 2 diabetes (obesity, dyslipidemia, and hereditary/genetic factors) contribute to the heterogeneity of this spectrum. Pancreatogenic diabetes secondary to acute or chronic pancreatitis is a heterogeneous entity with a variable clinical presentation, including many cases that are misdiagnosed and treated as type 2 diabetes. This is problematic as pancreatogenic diabetes is associated with a poor prognosis and entails special considerations for management. Recent discoveries showing overlapping features with type 1 and type 2 diabetes along with an improved understanding of its pathophysiology are expected to improve the diagnosis and treatment of these and other forms of pancreatogenic diabetes.

Prematurity and Congenital Heart Disease: A Contemporary Review.

Congenital heart disease (CHD) is the most commonly reported birth defect in newborns. Neonates with CHD are more likely to be born prematurely, and a higher proportion of preterm neonates have CHD than their term counterparts. The implications of preterm birth on the cardiac and noncardiac organ systems are vast and require special management considerations. The feasibility of surgical interventions in preterm neonates is frequently limited by patient size and delicacy of immature cardiac tissues. Thus, special care must be taken when considering the appropriate timing and type of cardiac intervention. Despite improvements in neonatal cardiac surgical outcomes, preterm and early term gestational ages and low birthweight remain important risk factors for in-hospital mortality. Understanding the risks of early delivery of neonates with prenatally diagnosed CHD may help guide perioperative management in neonates who are born preterm. In this review, we will describe the risks and benefits of early delivery, postnatal cardiac and noncardiac evaluation and management, surgical considerations, overall outcomes, and future directions regarding optimization of perinatal evaluation and management of fetuses and preterm and early term neonates with CHD.

The interplay between enterprise and entrepreneur in the flood risk management of small- and medium-sized enterprises in Austria

ABSTRACT Small- and medium-sized enterprises (SMEs) are the backbone of most economies across the globe. They are particularly vulnerable to floods because they typically have less structural adaptation measures and less resources and financial access for recovery than large companies. In SMEs, economic and personal interests in risk governance intersect, such as when business crises after flood impacts spill over to personal crises of entrepreneurs. Applying a qualitative research method comprising policy document analysis, interviews and workshops with 11 flood-affected owner-entrepreneurs and 10 local and federal experts, this article analyses SMEs in the manufacturing sector in Austria. SME vulnerability and coping capacity emerge from the close interaction of (1) the governance framework, foremost the public disaster compensation scheme; (2) enterprise-oriented factors, e.g. availability of capital, customer loyalty, labour force flexibility; and (3) entrepreneur-oriented factors, e.g. psychological resilience, social networks, political efficacy. Flood impacts may increase bankruptcy risk when coinciding with economic and personal challenges. SMEs merit special consideration in disaster risk management, therein accounting for the interplay of enterprise- and entrepreneur-oriented factors. Flood risk managers could introduce mentoring by flood-experienced entrepreneurial peers, consolidate informal local business and political networks, train risk competences of entrepreneurs and promote private insurance.