The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes

BACKGROUND

Delirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes.

OBJECTIVE

To assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium.

METHODS

This was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality.

RESULTS

A total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups.

CONCLUSION

Delirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

Surgical stabilization of rib fracture patients versus nonoperative controls treated by a multidisciplinary team in a single institution

Introduction

Despite promising evidence, surgical stabilization of rib fractures (SSRF) is not ubiquitously offered in all trauma centers. Some centers struggle with patient selection while some struggle due to surgeon comfort with the technique. To address this issue, our trauma center developed a multidisciplinary SSRF approach between orthopedic and trauma surgery.

Methods

This retrospective study compared 43 patients who underwent SSRF at a level 1 trauma center with 43 nonoperatively managed controls. Our study Indications were flail chest with >3 segments; non-flail with severe, bi-cortical displacement of >3 contiguous segments. Main outcome measures included mortality, ICU duration, hospital stay LOS, rates of ventilator-associated pneumonia (VAP) and ventilator days.

Results

Results of SSRF included decreases in mortality (2% vs 16.3%; p = 0.03) and in ICU duration. Patients with SSRF had a significantly shorter duration in the ICU than the nonoperative group (8.72 vs 14 days; p = 0.013) but a similar hospital duration (LOS mean, 12.81 vs 15.2; p = 0.29). Less patients in the SSRF group developed VAP but the difference was not significant (2% vs 14%, p = 0.055).

Discussion

SSRF patient outcomes supported prior evidence. The tandem approach had benefits as surgeons were able to leverage skills and expertise, increase collaboration between services, and complete more difficult reconstructions. Our experience may serve as a model for trauma centers interested in starting a new program or enhancing current service offerings.

30 years of primary health care reforms in Estonia: The role of financial incentives to achieve a multidisciplinary primary health care system

Estonia has a legacy of hospital-focused service provision, but since the 1990s, has introduced a series of reforms to strengthen primary health care (PHC). The recent PHC reforms have placed an increasing focus on multidisciplinary care, involving home nurses, midwives, and physiotherapists, and emphasize PHC centres over single physician practices. These incremental reforms, without a supporting legal basis nor explicitly defined timelines and targets, nonetheless demonstrated the ability of financial incentives to drive change. EU structural funds in particular provided essential funding for infrastructure investments in PHC. Yet not all stakeholders supported these initiatives, largely due to the uncertain sustainability of funding. The EHIF also adjusted contract and payment terms to support PHC reforms, with some concessions to PHC providers operating as single practitioners. Despite substantial progress over the last three decades to shift the focus to PHC, there are some important bottlenecks that hinder the progress. These include PHC providers' hesitance to give up their freedom as single practitioners, low interest from specialists to start working at the PHC level, and a lack of financial incentives and adequate funding for a broader scope of PHC services. This looks to become more challenging in the future, as nearly half of family physicians are 60 years old or older. The development of the new PHC strategy in 2023 is very timely to comprehensively address these bottlenecks and to set the vision for the future of PHC in Estonia.

The importance of including occupational therapists as part of the multidisciplinary team in the management of eating disorders: a narrative review incorporating lived experience

The literature demonstrates the importance of utilizing a multidisciplinary approach in the treatment of eating disorders, however there is limited literature identifying the optimal team of professionals for providing comprehensive and effective care. It is widely accepted that the multidisciplinary treatment team should include a physician, a mental health professional, and a dietitian, but there is minimal literature explaining what other professionals should be involved in the medical assessment and management of eating disorders. Additional team members might include a psychiatrist, therapist, social worker, activity therapist, or occupational therapist. Occupational therapists are healthcare professionals who help their clients participate in the daily activities, referred to as occupations, that they have to do, want to do, and enjoy doing. Many factors (e.g., medical, psychological, cognitive, physical) can impact a person's ability to actively engage in their occupations. When a person has an eating disorder, it is likely that all four of the aforementioned factors will be affected, thus individuals undergoing treatment for an eating disorder benefit from the incorporation of occupational therapy in supporting their recovery journey. This narrative review strives to provide education on the role of the occupational therapist in treating eating disorders and the need for increased inclusion of this profession on the multidisciplinary team. Additionally, this narrative review offers insight into an individual's personal experience with occupational therapy (i.e., lived experience) during her battle for eating disorder recovery and the unique value that occupational therapy offered her as she learned to manage her eating disorder. Research suggests that occupational therapy should be included in multidisciplinary teams focused on managing eating disorders as it empowers individuals to return to activities that bring personal meaning and identity.

Multidisciplinary approach to decreasing major amputation, improving outcomes, and mitigating disparities in diabetic foot and vascular disease

Major nontraumatic lower extremity amputation (LEA) is a morbid complication of longstanding or poorly controlled diabetes and/or end-stage peripheral artery disease. Incidence of major LEAs consistently declined during the 1990s and 2000s, but rates have plateaued or increased in many regions during the past decade. Marked racial, ethnic, socioeconomic, and geographic disparities in risk of LEA persist and are related to inequalities in access to care and differential rates of attempted limb preservation. Multidisciplinary diabetic foot care (MDFC) is increasingly recognized as a necessary model for optimal management of patients with diabetic foot and vascular disease. This article reviews the role of MDFC in reducing major LEAs and the specific ways in which MDFC can mitigate disparities in care delivery and limb preservation outcomes. Access to MDFC among vulnerable populations remains a significant barrier to systematic reduction in major LEAs.

Collaborative dietetic and psychological care in Interprofessional Enhanced Cognitive Behaviour Therapy for adults with Anorexia Nervosa: a novel treatment approach

Clinical practice guidelines for anorexia nervosa (AN) and atypical anorexia nervosa recommend treatment from a team including a mental health professional and a dietitian. To date, however, AN treatment models such as Enhanced Cognitive Behaviour Therapy (CBT-E) seldom include dietitians and have low to moderate treatment efficacy. Given interprofessional approaches to healthcare have been shown to improve treatment outcomes and enhance patient and clinician satisfaction, formalising collaborative dietetic and psychological treatment may be a feasible strategy to improve treatment outcomes and the patient and clinician experience of treatment. Moreover, malnutrition is a serious consequence of AN, and dietitians are considered experts in its diagnosis and treatment. This paper proposes a novel treatment approach, Interprofessional Enhanced Cognitive Behaviour Therapy (CBT-IE), an adaptation of CBT-E where dietitians deliver content related to malnutrition and dietary restraint and mental health professionals deliver content related to cognitive and behavioural change. The rationale for developing CBT-IE, treatment structure, and future research directions is discussed.

Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery

BACKGROUND

Hip fractures are devastating injuries, with high health and social care costs. Despite national standards and guidelines, substantial variation persists in hospital delivery of hip fracture care and patient outcomes. This qualitative study aimed to identify organisational processes that can be targeted to reduce variation in service provision and improve patient care.

METHODS

Interviews were conducted with 40 staff delivering hip fracture care in four UK hospitals. Twenty-three anonymised British Orthopaedic Association reports addressing under-performing hip fracture services were analysed. Following Thematic Analysis of both data sources, themes were transposed onto domains both along and across the hip fracture care pathway.

RESULTS

Effective pre-operative care required early alert of patient admission and the availability of staff in emergency departments to undertake assessments, investigations and administer analgesia. Coordinated decision-making between medical and surgical teams regarding surgery was key, with strategies to ensure flexible but efficient trauma lists. Orthogeriatric services were central to effective service delivery, with collaborative working and supervision of junior doctors, specialist nurses and therapists. Information sharing via multidisciplinary meetings was facilitated by joined up information and technology systems. Service provision was improved by embedding hip fracture pathway documents in induction and training and ensuring their consistent use by the whole team. Hospital executive leadership was important in prioritising hip fracture care and advocating service improvement. Nominated specialty leads, who jointly owned the pathway and met regularly, actively steered services and regularly monitored performance, investigating lapses and consistently feeding back to the multidisciplinary team.

CONCLUSION

Findings highlight the importance of representation from all teams and departments involved in the multidisciplinary care pathway, to deliver integrated hip fracture care. Complex, potentially modifiable, barriers and facilitators to care delivery were identified, informing recommendations to improve effective hip fracture care delivery, and assist hospital services when re-designing and implementing service improvements.

Management of purpura fulminans skin loss at a regional burns centre: Sixteen-year experience

INTRODUCTION

Purpura fulminans (PF) is a rare syndrome of cutaneous purpura which is the consequence of severe circulatory shock causing intravascular thrombosis, haemorrhagic necrosis, and consequent tissue loss. The aim of this study was to present our 16-year experience of managing PF in a regional burns centre.

METHODS

We performed a single-centre retrospective case series of all patients admitted to the St Andrews Burns Centre at Broomfield Hospital, Chelmsford, Essex, UK, between June 2006 and July 2022 with a diagnosis of PF. Data were extracted by retrospectively searching hospital case notes.

RESULTS

Thirteen individuals were identified [five children (mean age 5, range 1-14) and eight adults (mean age 39, range 24-54)]. The total body surface area of cutaneous necrosis ranged from 5% to 80%, with a mean of 27.2%. Patients were treated with an established surgical sequence of total wound debridement and immediate coverage with a cadaveric allograft, followed by staged wound autografting. The mean time from disease onset to wound autografting was 37.3 days (range 20-64 days). Eight individuals (61.6%) required major amputation of at least one limb (proximal to the ankle or wrist joint). Only one mortality (of 80% total body surface area skin loss) was observed in the identified cohort.

CONCLUSIONS

The large body surface areas often involved in PF cases make management of these wounds well suited for burns centres, wherein established facilities and multidisciplinary teams exist that are familiar with managing large cutaneous burns. We provide a suggested algorithm to aid the management of PF.

Multidisciplinary Management of Brain Metastasis from Breast Cancer

The management of patients with breast cancer and brain metastases (BMs) is exquisitely multidisciplinary. Patients presenting with a symptomatic BM may be offered neurosurgical resection, followed by radiation. Stereotactic radiosurgery (SRS) is preferred over whole-brain radiotherapy (WBRT) in most patients presenting with a limited number of BMs, whereas WBRT with hippocampal-sparing and concomitant memantine is preferred for patients with multiple BMs. There is a growing role for systemic therapy, in some cases in lieu of local therapy, particularly in patients with HER2+ breast cancer.

The radiologist's role in a multidisciplinary approach to cancer in pregnancy

Pregnancy-associated cancer (PAC) occurs in approximately 1 in 1000 pregnancies, and the incidence is expected to rise due to delayed childbearing (Silverstein et al. in JCO Oncol Pract 16:545-557, 2020; Woitek et al. in ESMO Open 1:e000017, 2016). Diagnosis and management of PACs are challenging and diagnosis is often delayed as symptoms may overlap with physiologic changes of pregnancy (Jha et al. in RadioGraphics 42:220005, 2022). These patients are best cared for by a multidisciplinary healthcare team composed of experts (Silverstein et al. in JCO Oncol Pract 16:545-557, 2020). Management of these patients must balance optimal maternal care with potentially harmful fetal effects. This involves honest, forthright, and sometimes difficult discussions between the care team and the patient throughout the entirety of care. Radiologists play a significant role in timely cancer diagnosis, staging and follow-up during and after pregnancy, accurate determination of gestational age, and in assessing fetal growth and well-being throughout pregnancy.

Differences in concussion knowledge between parents and their children in a multidisciplinary concussion clinic sample

PURPOSE

This study assessed concussion knowledge in concussed youth and parents treated at a multi-disciplinary concussion center.

METHODS

Youth (n = 50) and parents (n = 36) were approached at the beginning of a clinical visit. Participants completed a 22-item, previously published concussion knowledge survey before the visit.

RESULTS

Responses were compared with previously collected, published data from adolescents in a high school setting (n = 500). The patient group was divided into those with one (n = 23) vs. two or more concussions (n = 27). Chi-square analyses compared total correct responses between youth, parents, and the high school sample. T-tests assessed differences in knowledge based on prior concussions, age, and gender. All groups showed high accuracy for return-to-play guidelines (>90%) and similar knowledge of concussion-related symptoms (72.3% vs. 68.6%). Significant knowledge gaps about diagnosis, neurological consequences, and long-term risks were present across groups (19% to 68% accuracy). The patient group more often misattributed neck symptoms to concussion (X2  < 0.005). Prior concussion and gender were not significant predictors of concussion knowledge (p > 0.5).

CONCLUSION

Community and clinically-based educational techniques may not be effectively communicating knowledge about concussion diagnosis, symptoms, long-term risks, and neurological implications of concussion. Educational tools need to be tailored to specific settings and populations.

The impact of the multidisciplinary Endocarditis Team on the management of infective endocarditis

BACKGROUND

In their latest guidelines for infective endocarditis (IE) (2015), the European Society of Cardiology (ESC) introduced the implementation of the Endocarditis Team (ET) to facilitate the management of IE. This study presents our experiences and the diagnostic and therapeutic impact of the ET on the management of IE.

METHODS

From 2016-2020, data of all patients with suspected IE referred to the ET were prospectively collected. The final diagnosis was defined by the ET as either rejected, possible or definite IE. Diagnostic impact was scored as any change in initial diagnosis, the frequency of additional diagnostic tests advised by the ET and any change in diagnosis after these tests. Therapeutic impact was scored as any change in antibiotic therapy or change from conservative to invasive therapy or vice versa.

RESULTS

A total of 321 patients (median age 67 [55-77] years, 71% male) were enrolled. The final diagnosis was rejected IE in 47 (15%), possible IE in 34 (11%) and definite IE in 240 (75%) patients. A change of initial diagnosis was seen in 53/321(17%) patients. Additional microbiological tests were advised in 69/321 (21%) patients, and additional imaging tests in 136/321 (42%) patients, which resulted in subsequent change in diagnosis in 23/321 (7%) patients. Any change in antibiotic treatment was advised in 135/321 (42%) patients, and change from initial conservative to additional surgical treatment in 15/321 (5%) patients.

CONCLUSION

The ET had a clear impact on the therapeutic policy for patients with suspected IE and is useful in the management of this life-threatening disease. Broad implementation is warranted.

A multidisciplinary care pathway improves quality of life and reduces pain in patients with fibrous dysplasia/McCune-Albright syndrome: a multicenter prospective observational study

BACKGROUND

Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) may cause pain, impaired ambulation and decreased quality of life (QoL). International guidelines advocate management of FD/MAS in a tertiary multidisciplinary care pathway, but no longitudinal data are available to support this recommendation. This multicenter prospective observational study aimed to evaluate effects of 1 year of treatment in the FD/MAS care pathway in 2 tertiary clinics on QoL and pain, assessed by change in Short Form 36 and Brief Pain Inventory between baseline and follow-up. Patients completing baseline questionnaires < 1 year after intake were classified as new referrals, others as under chronic care.

RESULTS

92 patients were included, 61 females (66%). 22 patients (24%) had monostotic disease, 16 (17%) isolated craniofacial FD, 27 (40%) polyostotic FD and 17 (19%) MAS. 26 were new referrals (28%) and 66 chronic patients (72%). Median age at baseline was 47 years (Q1-Q3 36-56). Skeletal burden correlated with baseline Physical Function (r_s = - 0.281, p = 0.007). QoL was in all domains lower compared to the general population. New referrals reported clinically important differences (CID) over time in domains Physical Function (mean 67 ± SD24 to 74 ± 21, effect size (ES) 0.31, p = 0.020), Role Physical (39 ± 41 to 53 ± 43, ES 0.35, p = 0.066), Social Functioning (64 ± 24 to 76 ± 23, ES 0.49, p = 0.054), and Health Change (39 ± 19 to 53 ± 24, ES 0.76, p = 0.016), chronic patients in Physical Function (52 ± 46 to 66 ± 43, ES 0.31, p = 0.023) and Emotional Wellbeing (54 ± 27 to 70 ± 15, ES 0.59, p < 0.001). New referrals reported a CID of 1 point in maximum pain, average pain and pain interference, chronic patients reported stable scores. Change in pain interference and Role Physical were correlated (r_s = - 0.472, p < 0.001). Patients with limited disease extent improved more than patients with severe disease. Patients receiving FD-related therapy had lower baseline scores than patients not receiving therapy and reported improvements in QoL after 1 year. Yet also patients without FD-related therapy improved in Physical Function.

CONCLUSIONS

All FD-subtypes may induce pain and reduced QoL. A multidisciplinary care pathway for FD/MAS may improve pain and QoL, mainly in new referrals without MAS comorbidities with low baseline scores. Therefore, we recommend referral of patients with all subtypes of FD/MAS to specialized academic centers.

Participation of inpatients in multidisciplinary team meetings: An explorative study of mental healthcare workers' perception

AIM

To explore the perception of mental healthcare workers about participation of inpatients during multidisciplinary team meetings (MTMs) and to determine which demographic and contextual factors are associated with this perception.

METHODS

A cross-sectional multicentre study in 17 psychiatric hospitals with 701 mental healthcare workers was performed between 29 April and 19 May 2019. For measuring the perception of the mental healthcare workers, the Patient Participation during Multidisciplinary Team meetings Questionnaire was used.

RESULTS

93 % of the mental healthcare workers indicate that they are willing to allow patients to participate in a MTM. Most mental healthcare workers prefer an active role for the patient when participating in a MTM (93 %) and a collaborative role for the patient when making decisions in a MTM (75 %). Level of education, discipline, experience with patient participation in MTMs, working in a team where patient participation is applied, and recent training on patient participation, are associated with the mental healthcare worker's perception on patient participation in MTMs.

CONCLUSION

Mental healthcare workers report a great willingness to involve inpatients in MTMs. However, social workers, nurses, and pedagogues feel less competent and are less positive about the effects of patient participation in MTMs. Mental healthcare workers with recent training in patient participation and experience in patient participation in MTMs feel more competent and believe more often that the patient should fulfil a more autonomous role when participating in a MTM. These results can be used to understand and improve patient participation in MTMs in mental healthcare.

PI3K signalling at the intersection of cardio-oncology networks: cardiac safety in the era of AI

Class I phosphoinositide 3-kinases (PI3Ks) are a family of lipid kinases. They are super elevated in many human cancer types and exert their main cellular functions by activating Akt to trigger an array of distinct responses, affecting metabolism and cell polarity. The signal equally plays important roles in cardiovascular pathophysiology. PI3K is required for cardiogenesis and regulation of cardiac structure and function. Overexpression of PI3K governs the development of cardiac pressure overload adaptation and compensatory hypertrophy. Therefore, inhibition of PI3K shortens life span, enhances cardiac dysfunction and pathological hypertrophy. The inverse inhibition effect, however, desirably destroys many cancer cells by blocking several aspects of the tumorigenesis phenotype. Given the contrasting effects in cardio-oncology; the best therapeutic strategy to target PI3K in cancer, while maintaining or rather increasing cardiac safety is under intense investigational scrutiny. To improve our molecular understanding towards identifying cardiac safety signalling of PI3K and/or better therapeutic strategy for cancer treatment, this article reviews PI3K signalling in cardio-oncology. PI3K signalling at the interface of metabolism, inflammation and immunity, and autonomic innervation networks were examined. Examples were then given of cardiovascular drugs that target the networks, being repurposed for cancer treatment. This was followed by an intersection scheme of the networks that can be functionalised with machine learning for safety and risk prediction, diagnoses, and defining new novel encouraging leads and targets for clinical translation. This will hopefully overcome the challenges of the one-signalling-one-health-outcome alliance, and expand our knowledge of the totality of PI3K signalling in cardio-oncology.

Reduction in inpatient readmissions following implementation of a dedicated tracheostomy care team

OBJECTIVE

Pediatric tracheostomy patients are at risk for lengthy hospitalizations and multiple readmissions with rare but potentially disastrous tracheostomy-related complications. Several centers have formed multidisciplinary teams for pediatric tracheostomy patients to coordinate care and enhance caregiver education to aid in safe care delivery. Current literature has shown encouraging change in pediatric tracheostomy care with these interventions, but there remains an opportunity to better gauge alterations of morbidity. We aimed to review our institution's experience before and after development of a pediatric tracheostomy care team.

METHODS

Pediatric tracheostomy patients (<19 years) who underwent tracheostomy between January 2010 and June 2020 were included. A pediatric tracheostomy care team including a nurse practitioner and registered nurse was established in July 2017. Rates of readmission, outpatient visits, decannulation rates, and mortality are examined before and after implementation of the care team. Bivariate and multivariable analyses were utilized.

RESULTS

296 patients were included with 128 patients in the pre-intervention group, 82 in the post-intervention group, and 86 completing cross-over care. The groups were comparable in age at tracheostomy, tracheostomy indication, and underlying comorbidities. Mean outpatient visits per tracheostomy-year in the post-intervention group were higher than the pre-intervention group (2.3 vs. 2.2, p = .02). Fewer mean inpatient admissions per tracheostomy-year (0.02 vs. 0.11, p = .03) were observed after intervention. Time to decannulation did not differ significantly between the two groups (p = .57).

CONCLUSION

Implementation of a dedicated tracheostomy care team may help decrease inpatient admissions for tracheostomy-specific complications.

The need for a comprehensive and integrated approach to lung cancer policy in Europe

Lung cancer is the leading cause of cancer-related deaths in Europe. Europe's Beating Cancer Plan calls for a comprehensive approach to the disease in general but not specifically to lung cancer. Such a comprehensive approach, integrating efforts to strengthen anti-tobacco policies, early detection and underlying models of care, is sorely needed for lung cancer - particularly considering disruptions to care during the COVID-19 pandemic. In a recently published think piece, a multidisciplinary group of experts proposed four key policy priority areas. First, to reduce stigma and improve awareness of potential symptoms, there is a need to foster a better understanding of lung cancer - among the public and healthcare professionals. Second, opportunities for early detection should be enhanced, and the implementation of targeted screening through low-dose computed tomography should be encouraged as a complement to smoking cessation services. This complementarity should be recognised and built into joint policy proposals, with development and better integration of screening and smoking cessation programmes on the ground. Third, the socioeconomic inequalities underpinning disparities in outcomes in people with lung cancer must be addressed, with targeted approaches to overcome barriers to access Finally, the overall quality of lung cancer care must be improved, making multidisciplinary care available to all and ensuring survivorship is given due attention.

How I approach: Defining the scope of psychosocial care across disciplines in pediatric hematology-oncology

To provide the standard of psychosocial care for children with cancer and hematological disorders and their families, multidisciplinary teams must clearly define their scope and collaborate in ways that optimize the quality and efficiency of care. A new organizational structure was leveraged to delineate roles and scope for each psychosocial discipline at our institution. We developed a document, the scope of psychosocial care (SPC), that serves as a platform for making patient care decisions and provides opportunities for the reevaluation of programming. Herein, we present the process and outcome of the SPC and make recommendations for identifying roles in pediatric psychosocial hematology-oncology.

Integrated Behavioral Health in Primary Care for Adults with Complex Childhood Onset Medical and Developmental Diagnoses

Increased life expectancy for individuals with complex pediatric-onset conditions means most of this population survive into adulthood. While this is great news for individuals and their families, the traditional adult medical model must adapt to extend the care provided by specialty pediatric practices to primary care. In this paper, we introduce a model of integrated behavioral health (IBH) in a primary care practice for adults with childhood onset medical and developmental conditions. Our discussion includes the role of IBH providers (i.e., psychologists, psychiatrists, and social workers) as members of the integrated team, patient engagement and response to treatment, and innovative ways we strive to meet patient needs. Our review of electronic health records of patients seen at the UR Medicine Complex Care Center suggest that IBH is feasible and highly utilized, with 216 patients (40%) having had contact with an IBH provider on the team at least once. We discuss the challenges of meeting the longer-term needs of this complex patient population and our directions for future growth including creating peer and caregiver support networks, expanding services offered, and continued collaboration with community partners.

Curvularia and the Brain: Case Demonstration of Optimal Management

Background

Curvularia is a ubiquitous fungus found in tropical climates and has been reported to grow on marijuana leaves. Rarely, it can infect humans and propagate from the nasal sinuses into the brain.

Case

A 28-year-old immunocompetent patient presented with history of nasal polyps, headache, and subtle visual deficits on the right. Imaging revealed what appeared to be an invasive mass growing through the ethmoid and sphenoid sinuses into the anterior cranial fossa.

Results

Otolaryngology performed an endoscopic nasal biopsy with pathology and cultures consistent for Curvularia (figure 6). A combination case with neurosurgery and otolaryngology was planned. Surgeons used a bifrontal craniotomy and endonasal approach for gross total resection. Following resection, the patient was placed on 4 weeks of amphotericin treatment followed by 12 months of voriconazole based on recommendations by infectious disease. The patient has been stable since surgery.

Conclusion

Curvularia is a rare but potentially life threatening central nervous system infection that can be acquired from inhalational marijuana use. This illustrative case shows the importance of aggressive debridement followed by broad spectrum antifungal treatment to optimize outcome. With marijuana's increasing popularity, Curvalaria should be included on the differential diagnosis.

Both sides of the screen: Provider and patient perspective on telemedicine in pediatric surgery

BACKGROUND

There has been increased telemedicine use secondary to the COVID-19 pandemic. The objective of this study was to assess patient/parent satisfaction with their telemedicine experience, gauge provider perspective on telemedicine for the management of pediatric colorectal disease and evaluate the quality of telemedicine care being provided.

METHODS

A cross sectional study was performed at a single institution from March 2020-February 2021. Patients who completed a patient/parent telemedicine survey after a telemedicine appointment and nurse practitioners/surgeons who completed a provider telemedicine survey were included. Patient and provider characteristics and responses were analyzed using descriptive statistics. Differences between the levels of provider confidence to provide telemedicine care were analyzed using Pearson's chi-square test.

RESULTS

118 patients/parents completed the survey. The median age of patients was 7 years. Most patients were male (59%) and White (73%). The most common diagnosis was anorectal malformation (49%). 71% of parents felt the telemedicine visit was as effective or better than an in-person visit and over 70% said they prefer a telemedicine visit to an in-person visit. Ten surgeons and 8 nurse practitioners completed the provider survey. 28% had previous telemedicine experience and 94% planned to continue offering telemedicine appointments. Providers felt significantly more confident performing clinical duties via video telemedicine compared to telephone telemedicine.

CONCLUSIONS

Telemedicine is a useful adjunct or alternative in pediatric surgery for complex patients who require multidisciplinary care. Providers show confidence with the use of video telemedicine and parents show high satisfaction, with the majority preferring telemedicine visits over in-person visits.

LEVEL OF EVIDENCE

IV.

Multidisciplinary Care Considerations for Patients with Craniosynostosis

Infants and children with craniosynostosis require multidisciplinary care, and this is best accomplished when care is provided on a craniofacial team. Most patients with craniosynostosis will have non-syndromic presentations; however, longitudinal care remains critical to ensure appropriate growth and development throughout childhood. In patients with syndromic craniosynostoses, coordinated longitudinal care becomes even more paramount because of the high level of complexity across many different specialties or disciplines. Care delivery that includes perspective and expertise from multiple disciplines is important to help patients reach their full potential and optimal outcomes.

A case report of Actinomyces-associated vulvar necrotizing soft tissue infection: Aspects of multidisciplinary care

INTRODUCTION AND IMPORTANCE

Necrotizing soft-tissue infections are life-threatening infections with significant morbidity and mortality.

CASE PRESENTATION

A 36-year-old female gravida 1 para 1001 with a history of intravenous drug use and homelessness presented to the emergency department for a three-day history of labial pain, swelling, and fevers. A contrast tomography scan revealed necrotizing soft tissue infection of the mons and vulva with subcutaneous gas. Empiric broad-spectrum antibiotics were initiated. She underwent an emergent two-staged surgical debridement and delayed primary closure after 1-month in the hospital. She was discharged to complete a 9 to 12 month course of antibiotics. Multidisciplinary team was central to patient care.

CLINICAL DISCUSSION

Necrotizing soft tissue infections are a diverse group of infections affecting the subcutaneous tissue, muscle, and fascia. Actinomyces is a rare cause and require long-term antibiotics. Early recognition and emergent surgical debridement has been shown to reduce morbidity and mortality. A multidisciplinary approach is critical for proper wound care and healing, pain management, and long-term follow up.

CONCLUSIONS

Actinomyces-associated vulvar NSTIs are life-threatening infections requiring early surgical debridement, long-term antibiotics, and multidisciplinary approach.

Patients' and relatives' perspectives on best possible care in the context of developing a multidisciplinary center for endometriosis and adenomyosis: findings from a national survey

Background

Endometriosis and adenomyosis are common benign conditions compromising both physical and psychological health, with a negative impact on quality of life. This survey aimed to establish what the users’ perspectives are on best possible care in the context of developing a multidisciplinary center for endometriosis and adenomyosis in Norway.

Methods

An electronic questionnaire was developed in collaboration between the Norwegian Patient’s Endometriosis Society (NPES) and gynecologists with special interest in endometriosis and adenomyosis. The questionnaire was distributed digitally to the members of NPES in May 2021.

Results

938 participants answered the questionnaire. Better patient information, long term therapeutic plans and integration of their partners into their care were the main concerns. Multidisciplinary care was a key issue for the majority, with (n = 775) 89% stating a need for a consultation with a psychologist, (n = 744) 86% at least one consultation with a nutritionist, (n = 733) 85% a physiotherapist, and (n = 676) 78% needing a sex therapist and (n = 935) 99,7% consider research and (n = 934) 99,8% consider quality assurance initiated by the endometriosis center to be important. The qualitative analysis of free text answers revealed a great need for updated and easily accessible information, meeting competent health care professionals and being taken seriously/listened to.

Conclusions

This survey shows similar perceptions and a high level of agreement regarding their needs amongst people with endometriosis and/or adenomyosis. This survey supports recommendations by the experts that endometriosis/adenomyosis care should be centralized in specialized, multidisciplinary centers. The results of the present work will be valuable for the future planning and development of a multidisciplinary endometriosis center.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01798-8.

Surgical insights and management in patients with the 22q11.2 deletion syndrome

PURPOSE

22q11.2 deletion syndrome (22q11.2DS) can present with a variety challenges to patients and their caregivers, many of which require surgical evaluation and intervention. Surgical needs can also extend long into adulthood, prompting evaluation and intervention throughout development and beyond. Here, we identify common concerns and patient needs associated with the 22q11.2DS from a general surgery perspective, their management, and typical management based on our institution's experience with 1263 patients.

METHODS

1263 patients evaluated and treated at the 22q And You Center at the Children's Hospital of Philadelphia were enrolled and included in the study, from January 1992 to May 2017 Co-morbidities, procedures, and imaging studies performed were quantified and assessed via descriptive analysis.

RESULTS

Gastroesophageal reflux disease (GERD) and feeding difficulties were the most common surgical issues identified, while gastrostomy tube placement, anorectal procedures, and hernia repairs were the most common surgical interventions performed by general surgeons.

CONCLUSIONS

General surgical procedures are commonly needed in this population and are part of the complex needs these patients and their surgeons may encounter in the setting of a 22q11.2DS diagnosis. These findings will help to inform a well-coordinated, multidisciplinary approach to care.