Undiagnosed RASopathies in infertile men

RASopathies are syndromes caused by congenital defects in the Ras/mitogen-activated protein kinase (MAPK) pathway genes, with a population prevalence of 1 in 1,000. Patients are typically identified in childhood based on diverse characteristic features, including cryptorchidism (CR) in >50% of affected men. As CR predisposes to spermatogenic failure (SPGF; total sperm count per ejaculate 0-39 million), we hypothesized that men seeking infertility management include cases with undiagnosed RASopathies. Likely pathogenic or pathogenic (LP/P) variants in 22 RASopathy-linked genes were screened in 521 idiopathic SPGF patients (including 155 CR cases) and 323 normozoospermic controls using exome sequencing. All 844 men were recruited to the ESTonian ANDrology (ESTAND) cohort and underwent identical andrological phenotyping. RASopathy-specific variant interpretation guidelines were used for pathogenicity assessment. LP/P variants were identified in PTPN11 (two), SOS1 (three), SOS2 (one), LZTR1 (one), SPRED1 (one), NF1 (one), and MAP2K1 (one). The findings affected six of 155 cases with CR and SPGF, three of 366 men with SPGF only, and one (of 323) normozoospermic subfertile man. The subgroup "CR and SPGF" had over 13-fold enrichment of findings compared to controls (3.9% vs. 0.3%; Fisher's exact test, p = 5.5 × 10-3). All ESTAND subjects with LP/P variants in the Ras/MAPK pathway genes presented congenital genitourinary anomalies, skeletal and joint conditions, and other RASopathy-linked health concerns. Rare forms of malignancies (schwannomatosis and pancreatic and testicular cancer) were reported on four occasions. The Genetics of Male Infertility Initiative (GEMINI) cohort (1,416 SPGF cases and 317 fertile men) was used to validate the outcome. LP/P variants in PTPN11 (three), LZTR1 (three), and MRAS (one) were identified in six SPGF cases (including 4/31 GEMINI cases with CR) and one normozoospermic man. Undiagnosed RASopathies were detected in total for 17 ESTAND and GEMINI subjects, 15 SPGF patients (10 with CR), and two fertile men. Affected RASopathy genes showed high expression in spermatogenic and testicular somatic cells. In conclusion, congenital defects in the Ras/MAPK pathway genes represent a new congenital etiology of syndromic male infertility. Undiagnosed RASopathies were especially enriched among patients with a history of cryptorchidism. Given the relationship between RASopathies and other conditions, infertile men found to have this molecular diagnosis should be evaluated for known RASopathy-linked health concerns, including specific rare malignancies.

Unique Features of Cardiovascular Involvement and Progression in Children with Marfan Syndrome Justify Dedicated Multidisciplinary Care

Marfan syndrome (MIM: # 154700; MFS) is an autosomal dominant disease representing the most common form of heritable connective tissue disorder. The condition presents variable multiorgan expression, typically involving a triad of cardiovascular, eye, and skeletal manifestations. Other multisystemic features are often underdiagnosed. Moreover, the disease is characterized by age related penetrance. Diagnosis and management of MFS in the adult population are well-described in literature. Few studies are focused on MFS in the pediatric population, making the clinical approach (cardiac and multiorgan) to these cases challenging both in terms of diagnosis and serial follow-up. In this review, we provide an overview of MFS manifestations in children, with extensive revision of major organ involvement (cardiovascular ocular and skeletal). We attempt to shed light on minor aspects of MFS that can have a significant progressive impact on the health of affected children. MFS is an example of a syndrome where an early personalized approach to address a dynamic, genetically determined condition can make a difference in outcome. Applying an early multidisciplinary clinical approach to MFS cases can prevent acute and chronic complications, offer tailored management, and improve the quality of life of patients.

Chordae Tendinea Rupture and Pulmonary Valve Vegetation in Pediatric Endocarditis: A Rare Condition

Infective endocarditis (IE) is a severe yet rare condition in pediatric patients, often presenting with nonspecific symptoms, which can complicate diagnosis. Chordae tendinea rupture and pulmonary valve involvement are uncommon complications of IE, warranting timely recognition and management to prevent further morbidity and mortality. We present a case of a nine-year-old male child with a rare presentation of endocarditis complicated by chordae tendinea rupture and pulmonary valve vegetation. The child presented with a one-month history of abdominal pain, dyspnea, edema, and cough. Initial investigations revealed severe mitral regurgitation (MR) and tricuspid regurgitation (TR), chordae tendinea rupture, and vegetation on the pulmonary valve. Despite antibiotic therapy, the child's symptoms persisted, necessitating transfer to a tertiary care center for advanced cardiac management. Chordae tendinea rupture is a rare but critical complication of endocarditis, leading to significant valvular dysfunction. Pulmonary valve involvement in endocarditis is relatively uncommon, with most cases involving the mitral and aortic valves. Identifying vegetation on the pulmonary valve underscores the importance of comprehensive echocardiographic evaluation in patients with suspected endocarditis, regardless of valve involvement. Management of pediatric endocarditis involves a multidisciplinary approach, including antibiotic therapy and potential surgical intervention. Despite antibiotic therapy, the child continued to experience fever spikes in this case, indicating a potential need for surgical intervention. In conclusion, this case report highlights the rare presentation of chordae tendinea rupture and pulmonary valve vegetation in pediatric endocarditis. Timely diagnosis and appropriate management, including antibiotic therapy and potential surgical intervention, are essential for optimizing outcomes in affected children.

Multidisciplinary management based on clinical nursing pathway model for the treatment of hypertensive intracerebral hemorrhage: A randomized controlled trial

OBJECTIVE

To explore the effectiveness of multidisciplinary management based on a clinical nursing pathway model for the treatment of hypertensive intracerebral hemorrhage (HICH).

METHODS

A total of 124 patients with HICH admitted to our hospital between February 2021 and June 2023 were selected as research subjects in this randomized, controlled, unblinded study. They were divided into Control-group and Study-group using a random number table method, with 62 cases in each group. The Control-group received routine care and the Study-group adopted a multidisciplinary management approach based on the clinical nursing pathway model. A multidisciplinary intervention group including 1 attending physician, 1 psychotherapist, 1 nutritionist, 1 rehabilitation specialist, and 4 responsible nurses was constructed. From preoperative to postoperative day, patients were provided with psychological intervention, health education, respiratory tract management, and specific care for patients who were restless. One to 3 days after operation, the patients and their family members were guided in basic postoperative care and nutrition care. From the 4th day after surgery to the 1st day before discharge, patients were guided for rehabilitation exercises. Patients also received discharge advices upon discharge. Activities of daily living, neurological function, stress response indicators, incidence of complications, and nursing satisfaction before and after the intervention were compared between the 2 groups.

RESULTS

After the intervention, the activities of daily living and neurological function of the 2 groups were significantly improved compared to before the intervention, and the Study-group was significantly higher than the Control-group (P < .05). After intervention, the levels of stress response indicators in both groups significantly decreased compared to before the intervention, and the Study-group was significantly lower than the Control-group (P < .05). The incidence of complications in the Study-group (3.23%) was lower than that in the Control-group (15.00%) (P < .05). Nursing satisfaction in the Study-group (95.16%) was higher than that in the Control-group (83.33%) (P < .05).

CONCLUSIONS

Our findings indicate that adopting a multidisciplinary management approach based on clinical nursing pathways to intervene in patients with HICH can reduce stress response levels, reduce the risk of complications, and facilitate the recovery of neurological function and activities of daily living with high patient satisfaction.

Multidisciplinary management of a pregnant woman with hepatic rupture complicated with HELLP syndrome

A 32-year-old woman with preeclampsia who presented with persistent severe hypertension and epigastric pain underwent an emergency cesarean section for fetal distress and was diagnosed with hepatic rupture and HELLP (hemolysis, elevated liver enzymes, and a low platelet) syndrome. After the operation, the patient was transferred to the intensive care unit for supportive treatment and management of complications. Diagnosis and treatment decisions were made through multidisciplinary management. The patient received plasma exchange and continuous renal replacement therapy. One week after the operation, the patient developed deep vein thrombosis and received anticoagulant therapy, which triggered rebleeding. Conservative treatment was taken, including halving the dosage of anticoagulant medication and performing a blood transfusion, and the patient's condition gradually stabilized. The patient was discharged 44 days after the operation. Early diagnosis, effective treatment, and multidisciplinary management can help patients with this critical presentation achieve good clinical outcomes.

Fever Unveiling a Hidden Cardiac Condition: A Case of Pediatric Hypertrophic Obstructive Cardiomyopathy

This case report presents the clinical management of a 18-month-old female child who presented with fever, cough, and cold symptoms for eight days. Despite initial treatment with antipyretic syrup, the persistence of symptoms prompted further evaluation, revealing signs of hypertrophic obstructive cardiomyopathy (HOCM) on echocardiography. The patient was subsequently initiated on beta-blocker therapy and supportive care, leading to clinical improvement and eventual discharge. This case underscores the importance of considering cardiac etiologies in pediatric patients presenting with nonspecific symptoms. It highlights the role of timely diagnosis and multidisciplinary management in optimizing outcomes for affected individuals. Further research and awareness efforts are warranted to enhance diagnostic capabilities and refine treatment strategies for pediatric cardiac conditions like HOCM.

A Case Report of Malignant Mesenchymal Tumor Presenting As Anterior Thigh Swelling: A Diagnostic Challenge

This case report describes the presentation, diagnostic challenges, and management of a 64-year-old male with a malignant mesenchymal tumor presenting as a swelling in the anterior thigh. Despite initial misdiagnosis and treatment at a local hospital, the swelling worsened, leading to referral to a specialized hospital. Further investigations, including blood tests, ultrasonography (USG), and MRI, revealed a large solid cystic lesion compressing adjacent muscles, indicative of soft tissue sarcoma (STS). A skin biopsy confirmed the diagnosis of a malignant mesenchymal tumor. The patient, also suffering from hypertension and diabetes mellitus, was subsequently referred to the oncology department for further management. This case underscores the importance of thorough evaluation and histopathological confirmation for accurate diagnosis and management of STS, particularly in the context of atypical presentations and comorbidities.

A Surgeon's Challenge: Diagnosing and Managing Hidden Bile Duct Stones Post-cholecystectomy

This case report details the diagnostic and management challenges encountered with hidden bile duct stones post-cholecystectomy in a 58-year-old female patient. Despite a successful laparoscopic cholecystectomy, the patient developed sudden upper abdominal pain and jaundice, leading to the discovery of an impacted bile duct stone. The case underscores the limitations of conventional preoperative diagnostics and highlights the importance of advanced imaging techniques and a multidisciplinary approach for optimal outcomes. The successful extraction of the stone via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy demonstrates the efficacy of this therapeutic strategy. This report emphasizes the need for heightened vigilance and comprehensive evaluation in the postoperative management of gallstone disease, contributing valuable insights into the complexities of choledocholithiasis post-cholecystectomy.

Rare Coexistence: Pilocytic Astrocytoma With Atypical Teratoid/Rhabdoid Tumor Features in an Infant

This case report describes the presentation, diagnostic evaluation, and management challenges encountered in an eight-month-old female infant with fever, seizure, and a large cystic brain lesion initially diagnosed as pilocytic astrocytoma but later demonstrating atypical teratoid/rhabdoid tumor (AT/RT) features on histopathological examination-the infant presented with a fever and cold persisting for 10 days, followed by a seizure episode. Laboratory investigations revealed abnormalities, including anemia and leukocytosis. Imaging studies identified a large cystic lesion causing hydrocephalus. Despite initial treatment, the patient continued to experience seizures, prompting surgical intervention. Debulking surgery was performed, resulting in postoperative motor deficits. Subsequent imaging revealed persistent lesions, leading to further surgical intervention with shunt placement. Histopathological examination confirmed pilocytic astrocytoma with features suggestive of AT/RT. Despite counseling regarding poor prognosis and recommendations for chemotherapy, the parents declined further treatment, and the patient was discharged. This case underscores the diagnostic complexity and therapeutic dilemmas associated with rare histological overlaps in pediatric brain tumors, emphasizing the importance of multidisciplinary collaboration and tailored treatment strategies for optimal patient care.

Anterolateral Lingual Abscess in a Young Adult: A Comprehensive Case Study

Lingual abscesses, characterized by infectious collections of pus within the tongue parenchyma, are rare and poorly understood clinical entities. Despite their potential for severe complications, literature on lingual abscesses remains limited, consisting mainly of sporadic case reports. This comprehensive case study examines the challenges and successful management of a severe anterolateral tongue abscess in a young adult, contributing to the emerging body of knowledge on this condition. A young adult male presented with a progressively worsening painful, swollen tongue and dyspnea over 2 days. Urgent intervention was necessary to prevent potential airway compromise despite maintaining normal oxygen saturation. The patient's medical history showed no prior oral infections, illnesses, or relevant medical conditions. Detailed clinical assessment, utilization of imaging modalities such as contrast-enhanced computed tomography scan and ultrasonography, and collaboration with a maxillofacial surgeon guided accurate diagnosis and successful treatment. This case study provides valuable insights into the diagnosis and management of anterolateral lingual abscess in a young adult. It underscores the importance of heightened clinical awareness, precise diagnostic techniques, and multidisciplinary collaboration for optimal patient outcomes. The report contributes to the limited literature and emphasizes the need for further research to establish evidence-based guidelines for lingual abscess management.

Management of stage III non-small-cell lung cancer: rays of hope

Lung cancer remains the most common cause of cancer death across the world. Non-small-cell lung cancer (NSCLC) represents the most frequent type of lung cancer and is frequently diagnosed at an advanced stage. Stage III NSCLC, which encompasses 30% of cases, refers to a state between localized and metastatic disease, and is associated with poor prognosis. As highlighted in this review, stage III represents a heterogenous group, whose complex management includes multimodal treatment, discussed below, and requires discussion in multidisciplinary teams. The goal of this approach is a maximalist attitude in these patients with locally advanced and non-metastatic disease. However, many issues remain under debate including the optimal sequences of treatment between different treatment modalities, patient selection particularly for surgery, the duration of perioperative treatments and the identification of biomarkers to determine which patients might benefit of specific treatment like immunotherapy and targeted therapies. This review describes the current landscape of management of stage III NSCLC, discussing the critical issue of resectability, and highlighting the recent advancements in the field, particularly the incorporation of immune-checkpoint inhibitors (ICIs) and targeted therapies in this setting.

A Case of Type 2 Diastematomyelia With Spina Bifida in a Pediatric Female Patient

This case report presents the clinical and radiological findings of a seven-year-old female with type 2 diastematomyelia and spina bifida, emphasizing the complexity of congenital spinal anomalies in pediatric patients. The patient presented with a two-month history of lower back pain, prompting diagnostic investigations. Radiographic examination revealed spina bifida at the L3-L5 levels, subsequently confirmed by magnetic resonance imaging (MRI), which disclosed bifid spinous processes, an absent posterior arch, and a split spinal cord terminating at the L3-L4 disc levels. The Vancouver classification system facilitated a standardized characterization of congenital spinal anomalies. The multidisciplinary approach involving orthopedic and neurosurgical specialists led to a conclusive diagnosis of type 2 diastematomyelia with simple spinal dysraphism. Surgical intervention, encompassing laminectomy and correction of the split spinal cord, was successfully performed, resulting in the stabilization of the patient. This case underscores the importance of early diagnosis, advanced imaging modalities, and collaborative management in addressing rare congenital spinal anomalies. The discussion delves into the clinical implications, diagnostic challenges, and the pivotal role of surgical intervention. Insights from this case contribute to the existing literature, guiding healthcare professionals in understanding and managing similar cases with potential implications for future research and treatment strategies.

Transfer of Knowledge on Pneumoconiosis Care Among Rural-Based Members of a Digital Community of Practice: Cross-Sectional Study

BACKGROUND

Given the re-emergence of coal workers' pneumoconiosis in Appalachia and Mountain West United States, there is a tremendous need to train rural professionals in its multidisciplinary management. Since 2016, the Miners' Wellness TeleECHO (Extension for Community Health Outcomes) Program held by the University of New Mexico, Albuquerque, and Miners' Colfax Medical Center, Raton, New Mexico, provides structured longitudinal multidisciplinary telementoring to diverse professionals taking care of miners by creating a digital community of practice. Program sessions emphasize active learning through discussion, rather than didactic training. Professional stakeholder groups include respiratory therapists, home health professionals, benefits counselors, lawyers or attorneys, clinicians, and others. Rural-urban differences in knowledge transfer in such a community of practice, however, remain unknown.

OBJECTIVE

We aim to evaluate the role of the rurality of the patient or client base in the transfer of knowledge to professionals caring for miners using the digital community of practice approach.

METHODS

This is a cross-sectional study of 70 professionals participating in the Miners' Wellness TeleECHO Program between 2018 and 2019. Drawing insights from social network analysis, we examined the association between the rurality of participants' patient or client base and their self-reported receipt of knowledge. Our focal independent variable was the respondent's self-reported percentage of patients or clients who reside in rural areas. We measured knowledge transfer sources by asking participants if they received knowledge regarding the care of miners during and outside of TeleECHO sessions from each of the other participants. Our dependent variables included the number of knowledge sources, number of cross-stakeholder knowledge sources, number of same stakeholder knowledge sources, and range and heterogeneity of knowledge sources.

RESULTS

Respondents, on average, identified 4.46 (SD 3.16) unique knowledge sources within the community, with a greater number of cross-stakeholder knowledge sources (2.80) than same stakeholder knowledge sources (1.72). The mean knowledge source range was 2.50 (SD 1.29), indicating that, on average, respondents received knowledge sources from roughly half of the 5 stakeholder groups. Finally, the mean heterogeneity of knowledge sources, which can range between 0 and 0.80, was near the midpoint of the scale at 0.44 (SD 0.30). Multivariable analyses revealed that as the rurality of patient or client bases increased, participants reported more knowledge sources overall, more knowledge sources from outside of their stakeholder groups, a higher knowledge source range, and greater heterogeneity of knowledge sources (P<.05 for all comparisons).

CONCLUSIONS

Our findings suggest that participants who serve rural areas especially benefit from knowledge transfer within the TeleECHO community of practice. Additionally, the knowledge they receive comes from diverse information sources, emphasizing its multidisciplinary nature. Our results underscore the capacity of the TeleECHO model to leverage technology to promote rural health equity for miners.

Recurrent spinal atypical teratoid/rhabdoid tumor with pulmonary metastasis

BACKGROUND

Atypical teratoid/rhabdoid tumors (ATRT) are aggressive pediatric central nervous system malignancies that predominantly affect the brain and have poor survival outcomes. However, spinal ATRT is an uncommon subset of ATRT, and its clinical course and management are poorly understood.

CASE

We describe a case of spinal ATRT in a previously healthy 5-year-old girl who initially presented with rapid-onset gait disturbance. Magnetic resonance imaging (MRI) revealed an extramedullary tumor at thoracic level 5 (T5) without bony destruction or metastasis. The patient partially recovered after surgical resection. One month was required for a definitive diagnosis, and the pathology confirmed ATRT characterized by the loss of INI-1 protein expression. Chemoradiotherapy with local irradiation and high-dose chemotherapy with autologous peripheral blood stem cell transplantation led to complete remission and functional recovery for 5 months. However, the condition exhibited progression in the cerebrospinal fluid (CSF) region, resulting in cerebellar, cerebral, and spinal tumor development. Eventually, the disease metastasized to the lungs and disseminated to the entire cerebrospinal cord and fluid. The patient died 15 months after the initial diagnosis.

CONCLUSION

This case emphasizes the importance of considering ATRT as a potential diagnostic modality for pediatric spinal cord tumors, enabling prompt multidisciplinary intervention. The heterogeneous appearance of spinal ATRT may make distinguishing it from other spinal tumors difficult, resulting in delayed diagnosis and treatment. The treatment approach for ATRT remains challenging with no established standards. Local irradiation may be preferable to minimize neurodevelopmental effects, and initial craniospinal irradiation may potentially prevent recurrence. Our case emphasizes the likelihood of extracranial metastasis in ATRT, thereby highlighting the importance of a comprehensive assessment of both genetic and epigenetic profiles to identify any factors that may influence the clinical course of this disease. Prompt diagnosis and comprehensive therapeutic strategies are critical for improving outcomes in spinal ATRT patients.

Current Treatment Concepts for Extra-Abdominal Desmoid-Type Fibromatosis: A Narrative Review

Extra-abdominal desmoid-type fibromatosis (EADTF) is a rare neoplastic condition of monoclonal fibroblastic proliferation characterized by local aggressiveness with a distinct tendency to recur. Although EADTF is a benign disease entity, these tumors have a tendency to infiltrate surrounding normal tissues, making it difficult to completely eliminate them without adjacent healthy tissue injury. Surgical excision of these locally aggressive tumors without clear resection margins often leads to local recurrence. The aim of this thorough review was to assess the current treatment concepts for these rare tumors. A comprehensive search of articles published in the Cochrane Library, MEDLINE (PubMed), and EMBASE databases between January 2008 and February 2023 was conducted. Surgical intervention is no longer the first-line approach for most cases; instead, strategies like active surveillance or systemic therapies are used as initial treatment options. With the exception of EADTFs situated near vital structures, a minimum of 6-12 months of active surveillance is currently advocated for, during which some disease progression may be considered acceptable. Non-surgical interventions such as radiation or cryoablation may be employed in certain patients to achieve local control. The currently preferred systemic treatment options include tyrosine kinase inhibitors, low-dose chemotherapy, and gamma-secretase inhibitors, while hormone therapy is not advised. Nonsteroidal anti-inflammatory drugs are utilized primarily for pain management.

Comprehensive Multidisciplinary Management of Bilateral Cleft Lip and Palate

Cleft lip and palate (CLP) represent a multifaceted congenital deformity encompassing skeletal, dental, and functional discrepancies. This case report presents the management of a 13-year-old female with bilateral CLP, focusing on the challenges associated with permanent dentition and retained deciduous teeth. The patient's history included prior lip and palate repair surgeries, leading to poor aesthetics and functional concerns. A multidisciplinary approach involving orthodontics, oral surgery, and prosthodontics was implemented. Clinical examinations revealed dental abnormalities, oro-nasal fistula, and skeletal discrepancies, necessitating a comprehensive treatment plan. The orthodontic intervention aimed at aligning the dentition, followed by surgical closure of the oro-nasal fistula and alveolar bone grafting (ABG) to facilitate permanent canine eruption. Prosthetic replacement of missing maxillary lateral incisors was accomplished, enhancing aesthetics with minimal invasiveness. Results demonstrated significant improvements in profile, dental alignment, and functional stability. Cephalometric and dental parameter analyses confirmed the corrections and enhancements achieved, affirming the success of the multidisciplinary treatment. This case report emphasizes the importance of a collaborative multidisciplinary approach in effectively addressing the complexities of bilateral CLP in patients with permanent dentition and retained deciduous teeth. The comprehensive treatment strategy rectified dental and skeletal issues and positively impacted the patient's overall well-being and self-confidence.

Navigating Complexity: A Rare Case of Down Syndrome With Dural Venous Thrombosis in a Neonate

This case report presents a unique clinical scenario of a 2 kg male neonate with Down syndrome complicated by dural venous thrombosis. Born via normal vaginal delivery, the infant exhibited syndromic features characteristic of Down syndrome, necessitating admission to the neonatal intensive care unit (NICU) for respiratory distress. Confirmatory karyotyping established the diagnosis. Subsequent complications included germinal matrix haemorrhage, hypoxic-ischemic encephalopathy, and aspiration pneumonia. An MRI revealed dural venous thrombosis in the left transverse sinus, an uncommon manifestation in neonates with Down syndrome. Multidisciplinary management involved respiratory support, antibiotic therapy, and neurophysiotherapy. Infectious complications, including Klebsiella pneumoniae growth, required tailored antibiotic intervention. Despite intubation and CO2 retention challenges, the neonate improved and was ultimately discharged with favourable anthropometric measurements. This case underscores the importance of a comprehensive approach to neonatal care in the context of Down syndrome, emphasising the need for early recognition and management of rare complications such as venous thrombosis. The positive outcome highlights the efficacy of a multidisciplinary strategy in addressing complex neonatal conditions.

Management of oculo-orbital complications of odontogenic sinusitis in adults

Introduction: Odontogenic maxillary sinusitis (OMS) is an infectious inflammatory pathology caused by a dental condition. Considering the anatomical relations with the orbit, maxillary sinus infection can easily spread, evolving into severe oculo-orbital complications that can sometimes be life-threatening. Material and methods: We performed a retrospective study of over 2 years, examining the data of 18 patients diagnosed with OMS with oculo-orbital complications. The patients were evaluated regarding their dental history, symptoms, clinical and endoscopic findings, ophthalmologic evaluation, bacteriologic tests, computed tomography (CT) imaging, medical and surgical treatment, and outcomes. Results: The age of the patients was between 24 and 65 years old with an almost equal gender distribution: 10 female and 8 male patients. From the total, 7 patients had type II diabetes, 2 of whom were insulin-dependent, 1 patient had thrombophilia and 2 patients had renal failure with peritoneal dialysis. Regarding the type of oculo-orbital complications, 10 patients were diagnosed with preseptal cellulitis and 8 with orbital cellulitis. Just 5 patients with orbital cellulitis required surgical treatment and orbitotomy was performed, followed by endonasal endoscopic drainage. The evolution after surgical treatment was favorable for all operated patients. Discussions: Oculo-orbital complications of OMS are typically more severe than those of rhinogenic sinusitis because anaerobic bacteria are involved. Immunosuppression represents a favorable environment for the development of OMS and its complications, diabetes being the most common risk factor. A negative prognostic feature is the appearance of ophthalmological symptoms in both eyes, so visual function may be reduced. The treatment of oculo-orbital complications of OMS is urgent and depends on a broad-spectrum antibiotic therapy associated or not with surgical intervention. Conclusions: The diagnosis of oculo-orbital complications of OMS is complex and requires clinical experience as well as extensive medical knowledge to treat both the cause and the consequences of the conditions quickly and effectively. The proper management of oculo-orbital complications is based on a multidisciplinary team: ophthalmology, ENT, dentistry, imaging, and laboratory. Abbreviations: OMS = odontogenic maxillary sinusitis, CT = computed tomography, ENT = ear-nose-throat, MRI = magnetic resonance imaging, HNS = head and neck surgery.

Three-Dimensional Transperineal Ultrasound Guiding Early Secondary Repair of Obstetric Anal Sphincter Injury in an Incontinent Patient without Suture Dehiscence

We present the case of a 36-year-old primigravida who gave birth to a 3200 g baby by vacuum-assisted (Kiwi OmniCup™) operative vaginal delivery with mediolateral episiotomy. A "y"-shaped perineal tear with a grade IIIC obstetric anal sphincter injury (OASI) was diagnosed and repaired. Two days after delivery, in the absence of suture dehiscence, she started experiencing complete anal incontinence. A decision was made in association with a proctologic surgeon for an early secondary repair. Before surgery, a Three-dimensional transperineal ultrasound (TPUS) was performed. The exam revealed a major defect of the external anal sphincter at the 11 o'clock position. This allowed for the reopening of only a circumscribed area of the perineal suture and repair of the sphincters using the end-to-end technique. The symptoms regressed completely, and follow-up TPUS demonstrated the gradual wound healing process. Anal incontinence, secondary to obstetric anal sphincter injury (OASI), has a severe negative impact on women's quality of life. TPUS is an effective method to detect sphincter defects and monitor the healing process. This report investigates the feasibility of identifying the sphincter tear in an incontinent puerperal patient without suture dehiscence in order to target early secondary repair while minimizing its extent. TPUS has proven a safe and effective tool to guide early secondary repair of symptomatic OASI complications while minimizing the invasiveness of the procedure. Multidisciplinary management is crucial to ensure the adequate standard of care.

Wunderlich Syndrome in a Patient With Type 1 Diabetes Mellitus: Surgical Challenges and Management Strategies

Wunderlich syndrome, a rare manifestation of spontaneous renal hemorrhage often attributed to renal angiomyolipomas, presents a complex clinical scenario demanding nuanced management. This article delves into the multifaceted dimensions of this syndrome, dissecting its clinical, diagnostic, and therapeutic intricacies. Illustrating this complexity is the case of a 26-year-old female with Wunderlich syndrome and comorbid type 1 diabetes mellitus, revealing challenges at the intersection of these conditions. While initial intervention via laparoscopic drainage and antibiotic therapy yielded symptomatic relief, the subsequent recurrence of a renal abscess prompted a re-evaluation of the treatment strategy, culminating in a second surgical intervention. The intricate interplay between Wunderlich syndrome and diabetes introduces unique challenges, with fluctuations in hemoglobin and recurrent leukocytosis mirroring the underlying complexities of this clinical dyad. This case underscores the indispensability of a multidisciplinary approach, seamlessly integrating medical and surgical modalities, coupled with vigilant postoperative monitoring. Swift identification of complications and adaptability of the treatment plan emerged as pivotal in addressing recurrent manifestations and averting long-term sequelae. The necessity for continuous surveillance and personalized management strategies becomes evident, emphasizing Wunderlich syndrome as a clinical entity requiring bespoke attention. In conclusion, this case serves as an example, highlighting the intricate nature of Wunderlich syndrome, accentuated by the presence of type 1 diabetes mellitus. The initial therapeutic success, followed by a recurrence, underscores the need for ongoing research, paving the way for refined diagnostic and treatment paradigms. The synthesis of clinical complexities in this scenario elucidates the imperative for a comprehensive understanding, guiding future endeavors aimed at optimizing the prognosis of patients affected by this uncommon syndrome.

Addressing the unmet needs in patients with type 2 inflammatory diseases: when quality of life can make a difference

Background

Patients with asthma (AS), atopic dermatitis (AD), allergic rhinitis (AR), eosinophilic esophagitis (EoE), chronic rhinosinusitis with nasal polyps (CRSwNP), chronic urticaria (CU), non-steroidal anti-inflammatory drugs-exacerbated respiratory disease (N-ERD), and certain phenotypes of chronic obstructive pulmonary disease (COPD), among others, have a common underlying pathogenesis known as Type 2 inflammation (T2i). These diseases often coexist with other T2i conditions and have a substantial impact on the quality of life (QoL) of patients. However, limited data on patients' experiences, perspectives, and current management of T2i diseases have been published thus far.

Aims

This survey, promoted by the patient-driven T2i Network Project, aimed at identifying the common drivers and challenges related to the QoL of patients with T2i diseases by putting the patient's perspective at the force and including it in the design of new care strategies.

Methodology

An anonymous online survey was carried out through convenience sampling between May and June 2023. The survey was codesigned by members of different patient associations, healthcare professionals and healthcare quality experts, and implemented using EUSurvey and distributed through eight patient associations from Spain. The survey consisted of 29 questions related to the participant's sociodemographic features, a series of self-reported multiple choice or rating scale questions, including diagnosis, QoL measures, disease severity, healthcare resource utilization, and quality of care.

Results

The survey included 404 participants, members from eight patient associations, the majority of whom had moderate-to-severe self-reported disease severity (93%) and one or more coexisting pathologies related to T2i (59%). Patients with more than one pathology had a significantly greater impact on QoL than those with only one pathology (p < .001). Participants with self-reported severe symptoms reported significantly worse QoL than those with mild-to-moderate severity (p < .001). More than half of the patients (56%) felt constantly bothered by the unpredictability of their illness caused by potential exposure to known or unknown disease triggers. The lack of coordination between specialists and primary care was also expressed as an area of dissatisfaction by participants, with 52% indicating a complete lack of coordination and 21% indicating an average coordination.

Conclusion

This article reports the initial findings of a patient-led initiative, which highlights the common QoL challenges faced by individuals with type 2 inflammation-related diseases and emphasizes the importance of further clinical research to improve the management of this patient group. Considering the significant impact on QoL, a multidisciplinary approach integrated into new healthcare protocols has the potential to improve patient management and QoL, shorten the time to diagnosis and reduce healthcare resource utilization.

Surgical management of metastatic Hürthle cell carcinoma to the skull base, cortex, and spine: illustrative case

BACKGROUND

Hürthle cell carcinoma (HCC) is an unusual and aggressive variant of the follicular type of differentiated thyroid cancer (DTC), accounting for less than 3% of DTCs but posing the highest risk of metastasis. Brain metastases are uncommonly reported in the literature but pose a poor prognosis. The low rate of brain metastases from HCC coupled with ambiguous treatment protocols for the extracranial disease complicate successful disease management and definitive treatment strategy. The authors present the case of a patient with HCC metastasis to the skull base, cortex, and spine with recent tibial metastasis.

OBSERVATIONS

Despite the presence of metastasis to the cortex, skull base, and spine, the patient responded very well to radiation therapy, sellar mass resection, and cervical spine decompression and fixation and has made a remarkable recovery.

LESSONS

The authors' multidisciplinary approach to the patient's care, including a diverse team of specialists from oncology, neurosurgery, orthopedic surgery, radiology, endocrinology, and collaboration with clinical trial researchers, was fundamental to her successful outcome, demonstrating the utility of intersecting specialties in successful outcomes in neuro-oncological patient care.

Impact of a heart failure multidisciplinary clinic on the reduction of healthcare-related events and costs: the GEstIC study

Introduction

Heart failure (HF) is the leading cause of hospitalization in the elderly in developed countries and significantly impacts public health expenditures. Patients with HF usually have associated comorbidities that require multidisciplinary management. This study aims to demonstrate the benefits of a multidisciplinary clinic in reducing all-cause hospitalizations and HF events (HF hospitalizations and urgent HF visits) in a real-world setting. Finally, the study evaluates the associated costs of HF events.

Methods

This observational study included patients admitted to GEstIC, a multidisciplinary Portuguese HF clinic, from January 2013 to February 2019, who had one-year follow-up. Hospitalizations and HF events, total days spent in the hospital during HF hospitalizations, and HF events-related costs, in the year before and the year after GEstIC admission, were compared.

Results

Of the 487 patients admitted to the GEstIC, 287 were eligible for the study sample. After one year of HF patients' multidisciplinary management at GEstIC, there was a 53.7% reduction in all-cause hospitalizations (462 vs. 214), a 71.7% reduction in HF hospitalizations (392 vs. 111), and a 39.1% reduction in urgent HF visits (87 vs. 53). As a result, there was a significant decrease of 12.6 days in the length of hospital stay due to HF per patient (15.6 vs. 3.0, p < 0.001). This translated into the release of 9.9 hospital beds in the year following admission to GEstIC. The average total savings associated with the reduction of HF events was €5,439.77 per patient (6,774.15 vs. 1,334.38, p < 0.001), representing a total cost reduction of €1,561,213. Furthermore, the significant reduction in the number of all events was independent of the patient's left ventricular ejection fraction (LVEF).

Discussion

Significant reductions in all-cause and HF hospitalizations and urgent HF visits were observed with the implementation of this multidisciplinary clinic for HF patients' management. This was particularly important for patients with LVEF >40%. Before GEstIC, there was no medical intervention to improve the prognosis of these patients. The reduction of over one million euros in health-related costs after only one year of person-centered multidisciplinary management highlights the need to replicate this approach in other national healthcare institutions.

Management of Residual Risk in Chronic Coronary Syndromes. Clinical Pathways for a Quality-Based Secondary Prevention

Chronic coronary syndrome (CCS), which encompasses a broad spectrum of clinical presentations of coronary artery disease (CAD), is the leading cause of morbidity and mortality worldwide. Recent guidelines for the management of CCS emphasize the dynamic nature of the CAD process, replacing the term "stable" with "chronic", as this disease is never truly "stable". Despite significant advances in the treatment of CAD, patients with CCS remain at an elevated risk of major cardiovascular events (MACE) due to the so-called residual cardiovascular risk. Several pathogenetic pathways (thrombotic, inflammatory, metabolic, and procedural) may distinctly contribute to the residual risk in individual patients and represent a potential target for newer preventive treatments. Identifying the level and type of residual cardiovascular risk is essential for selecting the most appropriate diagnostic tests and follow-up procedures. In addition, new management strategies and healthcare models could further support available treatments and lead to important prognostic benefits. This review aims to provide an overview of the diagnostic and therapeutic challenges in the management of patients with CCS and to promote more effective multidisciplinary care.

Multidisciplinary management of thoracic esophageal fistula secondary to traumatic upper thoracic fracture (T3-4) with associated discitis/osteomyelitis and spinal epidural abscess: illustrative case

BACKGROUND

An esophageal fistula secondary to a traumatic upper thoracic (T3-4) fracture with resultant thoracic discitis/osteomyelitis and an epidural abscess with neurological compromise is a rare clinical entity. Early diagnosis is critical for an optimal clinical outcome avoiding grave and progressive spinal dissemination with structural instability and neurological deterioration.

OBSERVATIONS

The following case, not clearly described previously in the literature, highlights the clinical course and multidisciplinary approach to management including a single-stage posterior cervicothoracic (C3-T6) decompression with vertebral reconstruction with an expandable interbody cage (T2-4) and posterior cervicothoracic fusion and instrumentation (C3-T6), followed by direct esophageal fistula closure with AlloDerm and a vascularized latissimus dorsi muscle flap.

LESSONS

Early diagnosis and the potential treatment of a posttraumatic esophageal fistula requires a multidisciplinary approach.

Multidisciplinary Management of Rett Syndrome: Twenty Years' Experience

Over the last 20 years, the understanding and natural history of Rett syndrome has advanced, but to date no cure has emerged, with multidisciplinary management being symptomatic and supportive. This study provides a comprehensive review of the clinical features, comorbidities and multidisciplinary management of a well-characterized cohort of females with classical Rett syndrome. We aim to improve awareness and understanding of Rett syndrome amongst pediatricians, pediatric subspecialists and allied health professionals to enable early diagnosis and a streamlined enrolment approach for future clinical trials. Rett syndrome, a complex X-linked condition, affecting mainly females, is due to pathogenic variants of the MECP2 gene in most affected individuals. The Rett syndrome Multidisciplinary Management clinic at The Children's Hospital at Westmead, Sydney, Australia, was established in 2000. This retrospective analysis of individuals who attended the clinic from 2000 to 2020 was performed to identify the incidence and predicted age of onset of Rett syndrome related comorbidities, disease progression and to review management principles. Data collected included age of Rett syndrome diagnosis, MECP2 genotype, clinical features and medical comorbidities, such as sleep disturbance, seizures, breathing irregularities, scoliosis, mobility, hand stereotypies, hand function, constipation, feeding ability, use of gastrostomy, communication skills, QTc prolongation, anthropometry, and bruxism. Analysis of 103 girls who fulfilled the clinical diagnostic criteria for classical Rett syndrome with a pathogenic variant of the MECP2 gene showed a median age of diagnosis of 3 years. The most frequent MECP2 variant was c.502 C>T.

Resection of Retroperitoneal Extra-Adrenal Pheochromocytoma: A Case Report

Extra-adrenal pheochromocytomas are rare catecholamine-producing tumors that arise from chromaffin cells outside the adrenal glands. We report on the case of a 62-year-old male who initially presented with upper respiratory tract symptoms and was found to have a suprapubic pelvic mass and an asymptomatic right inguinal hernia. The diagnostic evaluation involved an abdominal ultrasound, a CT scan, followed by an MRI, which revealed a well-marginated large mass whose characteristics indicated a retroperitoneal sarcoma. Upon successful surgical resection, the mass was found to be encapsulated and no peripheral structure invasion was present; the right inguinal hernia was repaired, and a double J-stent was placed. Histopathological examination revealed extra-adrenal pheochromocytoma. This case report sheds light on diagnostic and therapeutic challenges when dealing with extra-adrenal pheochromocytomas and the importance of considering them as a differential diagnosis when presented with a case of retroperitoneal mass.

Multidisciplinary management in chronic myeloid leukemia improves cardiovascular risk measured by SCORE

Introduction: Cardiovascular events are one of the main long-term complications in patients with chronic myeloid leukemia (CML) receiving treatment with tyrosine kinase inhibitors (TKIs). The proper choice of TKI and the adequate management of risk factors may reduce cardiovascular comorbidity in this population. Methods: This study evaluated the cardiovascular risk of a cohort of patients with CML at diagnosis and after follow-up in a specialized cardiovascular risk consultation. In order to do this, we performed data analysis from 35 patients who received TKIs and were referred to the aforementioned consultation between 2015 and 2018 at our center. Cardiovascular risk factors were analyzed separately, as well as integrated into the cardiovascular SCORE, both at diagnosis and at the last visit to the specialized consultation. Results: At the time of diagnosis, 60% had some type of risk factor, 20% had a high or very high risk SCORE, 40% had an intermediate risk, and 40% belonged to the low risk category. During follow-up, the main cardiovascular adverse event observed was hypertension (diagnosed in 8 patients, 23%). 66% of patients quit smoking, achieving control of blood pressure in 95%, diabetes in 50%, weight in 76%, and dyslipidemia in 92%. 5.7% of patients suffered a thrombotic event and a significant percentage of patients showed a reduction in their SCORE. Conclusion: Our study shows the benefit of controlling cardiovascular risk factors through follow-up in a specialized consultation for patients with CML treated with TKI.

Impact of concomitant cardiovascular medications on overall survival in patients with liver cirrhosis

OBJECTIVES OF THE ARTICLE

Liver cirrhosis is the end-stage liver disease associated with poor prognosis and cardiovascular comorbidity could significantly impact mortality of cirrhotic patients. We conducted a large, retrospective study to investigate the survival impact of cardiovascular co-medications in patients with liver cirrhosis.

MATERIALS AND METHODS

A study-specific R package was processed on the local databases of partner institutions within the Observational Health Data Sciences and Informatics consortium, namely Columbia University, New York City (NYC), USA and Ajou University School of Medicine (AUSOM), South Korea. Patients with cirrhosis diagnosed between 2000 and 2020 were included. Final analysis of the anonymous survival data was performed at Medical Faculty Mannheim, Heidelberg University.

RESULTS

We investigated a total of 32,366 patients with liver cirrhosis. Our data showed that administration of antiarrhythmics amiodarone or digoxin presented as a negative prognostic indicator (p = 0.000 in both cohorts). Improved survival was associated with angiotensin-converting enzyme inhibitor ramipril (p = 0.005 in NYC cohort, p = 0.075 in AUSOM cohort) and angiotensin II receptor blocker losartan (p = 0.000 in NYC cohort, p = 0.005 in AUSOM cohort). Non-selective beta blocker carvedilol was associated with a survival advantage in the NYC (p = 0.000) cohort but not in the AUSOM cohort (p = 0.142). Patients who took platelet inhibitor clopidogrel had a prolonged overall survival compared to those without (p = 0.000 in NYC cohort, p = 0.003 in AUSOM cohort).

CONCLUSION

Concomitant cardiovascular medications are associated with distinct survival difference in cirrhotic patients. Multidisciplinary management is needed for a judicious choice of proper cardiovascular co-medications in cirrhotic patients.

Efficacy and safety of Janus kinase inhibitors in axial spondyloarthritis

Skin manifestations are common in axial spondyloarthritis (axSpA) and may precede axial involvement. Multidisciplinary management of patients with spondyloarthritis (SpA) is essential. Combined dermatology-rheumatology clinics are established for early recognition of the disease, comorbidities and a comprehensive treatment approach. Treatment options for axSpA are limited because conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and glucocorticoids are ineffective for axial symptoms. Janus kinase inhibitors (JAKi) are targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) that decrease transduction signalling to the nucleus, resulting in a reduced inflammatory response. Currently, tofacitinib and upadacitinib are approved for treating axSpA in patients with inadequate response to TNF inhibitors (TNFi). Upadacitinib has shown efficacy in non-radiographic axSpA (nr-axSpA), suggesting that JAKi are efficacious across the spectrum of axSpA. The availability of JAKi has opened more options for patients with active axSpA based on the efficacy data and the ease of administration.

The patients' perspective - a qualitative analysis of experiencing a fracture-related infection

Introduction

Fracture-related infection is a devastating complication confronting the patient with several challenges. To improve the management and to enhance the patients' wellbeing the focus of this study was to understand the emotional impact and patients' experiences during the process to identify challenges, difficulties, and resources. For this, a qualitative content analysis of semi-structured interviews according to Graneheim and Lundman was performed.

Methods

In total n = 20 patients of a German university orthopedic trauma centre specialized in bone and joint infections were recruited using a purposive sampling strategy. The patients were treated at the hospital between 2019 and 2021 and underwent at least one surgery. Individual in-person interviews were performed by one researcher based on a semi-structured guide, which was previously conceptualized. Content analysis according to Graneheim and Lundman was performed on the transcripts by two of the researchers independently.

Results

The following major themes emerged: (i) the emotional and mental aspects highlighting the fact that FRI patients faced severe restrictions in their day-to-day life, which resulted in dependency on others and frustration, as well as future concerns showing that patients could not overcome a state of anxiety and fear even after successful treatment, (ii) socioeconomic consequences confronting patients with consequences on the job and in finances where they often feel helpless, and (iii) resources emphasizing the role of spirituality as a coping strategy and yoga exercises for keeping the positivity.

Conclusion

This study emphasized the challenge of fracture-related infection management and associated consequences from the patients' perspective. Not being well informed about possible negative outcomes or restrictions makes it harder for patients to accept the situation and patients expressed a need for better information and certainty. Also, patients developed constant anxiety and other psychological disturbances, highlighting the potential benefit of psychological support and patient-peer support to exchange experiences.

Management of eosinophil-associated inflammatory diseases: the importance of a multidisciplinary approach

Elevated eosinophil counts in blood and tissue are a feature of many pathological processes. Eosinophils can migrate and accumulate in a wide variety of tissues and, by infiltrating a target organ, can mediate the development of several inflammatory diseases. The normalization of eosinophilia is a common biomarker of a treatable trait and can also be used as a prognostic and predictive biomarker since it implies a reduction in type 2 inflammation that contributes to disease pathogenesis. Biological therapies targeting this cell type and its proinflammatory mediators have been shown to be effective in the management of a number of eosinophilic diseases, and for this reason they constitute a potential common strategy in the treatment of patients with various multimorbidities that present with type 2 inflammation. Various biological options are available that could be used to simultaneously treat multiple target organs with a single drug, bearing in mind the need to offer personalized treatments under the umbrella of precision medicine in all patients with eosinophil-associated diseases (EADs). In addition to reviewing these issues, we also discuss a series of perspectives addressing the management of EAD patients from a multidisciplinary approach, with the collaboration of health professionals from different specialties who manage the different multimorbidities that frequently occur in these patients. We examine the basic principles of care that this multidisciplinary approach must cover and present a multidisciplinary expert opinion regarding the ideal management of patients with EADs, from diagnosis to therapeutic approach and follow-up.

Radiation-Induced Sarcomas of the Breast: A Review of a 20-Year Single-Center Experience

Background Radiation-induced sarcomas (RISs) are histologically proven sarcomas within or around a previously irradiated site, per Cahan's criteria. RIS incidence is higher in breast cancer compared to other solid cancers and the prognosis remains poor given limited treatment options. This study aimed to review 20-year experience with RISs at a large tertiary care center. Methodology Using our institutional cancer registry database, we included patients meeting Cahan's criteria diagnosed between 2000 and 2020. Patient demographics, oncologic treatment, and oncologic outcomes data were collected. Descriptive statistics were used to describe demographic data. Oncologic outcomes were assessed using the Kaplan-Meier method. Results A total of 19 patients were identified. The median age at RIS diagnosis was 72 years (range = 39-82 months), and the median latency period for the development of RIS was 112 months (range = 53-300 months). All patients underwent surgery, three patients received systemic therapy, and six patients received re-irradiation as salvage treatment. The median follow-up time was 31 months (range = 6-172 months) from the diagnosis of RIS. Overall, five patients had local recurrence, and one patient developed distant metastases. The median time to progression was seven months (range = 4-14 months). The progression-free survival (95% confidence interval (CI)) at two years was 56.1% (37.4-84.4%). At follow-up two years after the diagnosis of sarcoma, the overall survival (95% CI) was 88.9% (75.5-100%). Conclusions While breast RIS remains rare, when managed in a large tertiary care center, overall survival outcomes appear favorable. A significant proportion of patients recur locally after maximal treatment and require salvage therapy to improve outcomes. These patients should be managed in high-volume centers where multidisciplinary expertise is available.

Extraskeletal Ewing's sarcoma of the mediastinum: Case report

Background

Ewing sarcoma (ES) represents the second most common malignant bone tumor in children and young adults. ES is not a frequent finding in sites different from the skeletal. Common sites of appearance of ES are lower extremities, the pelvis, paravertebral spaces and head and neck. Primary extraskeletal ES located in the anterior mediastinum are very rare. These neoplasms should be discussed in specialized contests with a high volume of patients treated. Here, we present an uncommon mediastinal mass challenging in its characterization and management.

Case description

A thirty-year-old woman performed a thoracic CT scan for dyspnea and persistent cough. Imaging showed a solid mass of 14 x 11 cm involving the left thorax with mediastinal deviation to the right side. Patient underwent an en bloc resection of the mass. Initial histological examination was suggestive for B3 thymoma/thymic carcinoma. Patient was then referred to our rare tumor reference center where a histological review excluded the diagnosis of thymic/thymoma neoplasms meanwhile a third revision assessed a diagnosis of ES. Patient refused adjuvant chemotherapy due to her desire of maternity and radiation therapy was not indicated because surgery was performed too many months earlier. A close follow-up was considered. After a few months the patient relapsed and first line chemotherapy was proposed. She reached a complete response at the first evaluation maintained also at the end of the protocol. In order to consolidate the obtained response, high dose chemotherapy followed by autologous stem cell transplantation (HDCT/ASCT) was suggested and the patient agreed.

Conclusions

This case underlined that, potentially, ES can arise from any soft tissue site in the body, even in rare sites such as mediastinum. The evaluation of expert centers was critical to establish a correct diagnosis and therapeutic approach in this complex case. Taking into account the time lasting from the diagnosis and the aggressiveness of this kind of neoplasm, frequently relapsing, the patient after a multidisciplinary discussion was a candidate for a multimodal treatment.

Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature

Underlying cancer pain has heterogenous aetiologies and mechanisms. It requires detailed and comprehensive pain assessment, combined with personalized treatment. A multidisciplinary team is essential to providing the best management of cancer pain at every disease stage, improving the quality of life and outcomes in patients with cancer. This narrative literature review emphasizes the value of providing all patients with multidisciplinary pain management in their preferred care setting. Real-life experiences are also reported to witness the efforts of physicians to properly manage cancer pain. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.

Survival Associated With Consolidated Multidisciplinary Care in Head and Neck Cancer: A Retrospective Cohort Study

OBJECTIVE

To compare survival among patients with head and neck cancer before and after implementing a weekly multidisciplinary clinic and case conference.

METHODS

A retrospective cohort study with chart review was conducted of 3081 patients (1431 preimplementation, 1650 postimplementation) diagnosed with stage I-IVB tumors in the oral cavity, oropharynx, hypopharynx, nasopharynx, or larynx. Pre- and postimplementation differences in overall and disease-specific survival 1, 2, and 3 years after diagnosis were assessed with unadjusted Kaplan-Meier curves and multivariable Cox proportional hazard regression models adjusted for demographic characteristics, comorbidity burden, smoking status, tumor site and stage, p16 status for oropharyngeal squamous cell cancer, and initial treatment modality.

RESULTS

Patients less commonly presented with oropharyngeal squamous cell cancer and advanced tumors (III-IVB) and received primary treatment with surgery alone or with adjuvant therapy preimplementation than postimplementation. Overall survival at 3 years was 77.1% and 79.9% (P = .07) and disease-specific survival was 84.9% and 87.5% (P = .05) among pre- and postimplementation patients, respectively. At 3 years, preimplementation patients had slightly poorer overall (hazard ratio, 1.20; 95% CI, 1.02-1.40) and disease-specific (hazard ratio, 1.26; 95% CI, 1.03-1.54) adjusted survival than postimplementation patients. In unadjusted and adjusted analyses, survival improvements were more pronounced among patients with advanced disease.

DISCUSSION

A multidisciplinary clinic and case conference were associated with improved outcomes among patients with head and neck cancer, especially those with advanced tumors.

IMPLICATIONS FOR PRACTICE

All patients with head and neck cancer should receive multidisciplinary team management, especially those with advanced tumors.

Immune checkpoint inhibitor induced nephrotoxicity: An ongoing challenge

Although immune checkpoint inhibitors (ICIs) have dramatically revolutionized the field of oncology over the last decade, severe immune-related adverse events (irAEs) are potentially life-threatening. In comparison with toxicities involving the skin, gastrointestinal tract and endocrine system, nephrotoxicity is less common but often underestimated due to difficult diagnosis. Management usually consists of treatment discontinuation and/or corticosteroid use. In this review, we summarize current knowledge of ICI-induced nephrotoxicity, evaluating drawbacks and future perspectives.

Comorbidities of sarcoidosis

Sarcoidosis is a heterogeneous disease, which can affect virtually every body organ, even though lungs and intra thoracic lymph nodes are almost universally affected. The presence of noncaseating granulomas is the histopathological hallmark of the disease, and clinical picture depends on the organs affected. Data about interaction between sarcoidosis and comorbidities, such as cardiovascular and pulmonary diseases, autoimmune disorders, malignancy and drug-related adverse events are limited. Several lung conditions can be associated with sarcoidosis, such as pulmonary hypertension and fibrosis, making it difficult sometimes the differentiation between complications and distinctive pathologies. Their coexistence may complicate the diagnosis of sarcoidosis and contribute to the highly variable and unpredictable natural history, particularly if several diseases are recognised. A thorough assessment of specific disorders that can be associated with sarcoidosis should always be carried out, and future studies will need to evaluate sarcoidosis not only as a single disorder, but also in the light of possible concomitant conditions.Key messagesComorbidities in sarcoidosis are common, especially cardiovascular and pulmonary diseases.In the diagnostic workup, a distinction must be made between sarcoidosis-related complaints and complaints caused by other separate disorders. It can be very difficult to distinguish between complications of sarcoidosis and other concomitant conditions.The coexistence of multiple conditions may complicate the diagnosis of sarcoidosis, affect its natural course and response to treatment.

[Caregiving expertise and hospital management of the spinal surgery patient]

The care of spinal surgery patients requires the paramedical team to have precise, varied and adapted knowledge, whether it is a question of mobilization, nutrition, specific monitoring and the prevention of complications. The nurse - nursing assistant pair expresses all its know-how in the care of patients operated on a spine. Supporting the return to autonomy is a priority, especially for young patients who have undergone scoliosis surgery.

Transvaginal rectocoele repair for the surgical treatment of a "symptomatic" rectocoele when conservative measures fail: A 12 year experience of 215 patients

BACKGROUND

Conservative measures are first-line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery.

METHODS

We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in-hospital and 30 days post-operative complications and pre- and post-operative symptoms.

KEY RESULTS

The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in-hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow-up was 12.7 months (SD 13.9, range 1.4-71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS-related symptoms improved in 58% of cases.

CONCLUSIONS & INFERENCES

The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms.

The clinicopathological profile and value of multidisciplinary management of pediatric brain tumors in a low-income setting

Brain tumors are the most common solid tumors in children and a leading cause of cancer-related mortality in children worldwide. Data on the epidemiology and management of pediatric brain tumors in Uganda are limited. We aimed to assess the clinicopathological profile and management of pediatric brain tumors at the national oncology center in Uganda since the inception of weekly multidisciplinary meetings. Records of children younger than19 years diagnosed with primary brain tumors at Uganda Cancer Institute between 2017 and 2021 were retrospectively reviewed. Patient and tumor characteristics were collected with multidisciplinary team management treatment plans for analysis. There were 35 patients evaluated, most of whom were males (57.1%). Craniopharyngioma (n = 9, 25.7%) was the most common brain tumor, followed by astrocytoma (n = 5, 14.2%) and medulloblastoma (n = 4, 11.4%). Management included surgical resection in 28.5% of patients, chemotherapy (28.6%), radiotherapy (17.1%) and palliative care (20.0%). Over the last five years, there were increasing trends in the number of cases discussed in the multidisciplinary team and the number for whom the multidisciplinary management decisions were implemented. The majority (n = 18, 51.4%) of the children with brain tumors were alive and active in care, 34.2% abandoned treatment/lost to follow-up, and 8.6% died. The relative distribution of pediatric brain tumors types in Uganda Cancer Institute differs slightly from international reports, and there has been a notable increase in the number of cases over the years. Implementing multidisciplinary management decisions benefited patients and decreased abandonment and patient loss to follow-up.

Long-Term Trajectories in Weight and Health Outcomes Following Multidisciplinary Publicly Funded Bariatric Surgery in Patients with Clinically Severe Obesity (≥ 3 Associated Comorbidities): A Nine-Year Prospective Cohort Study in Australia

Background: Real-world data on long-term (> 5 years) weight loss and obesity-related complications after newer bariatric surgical procedures are currently limited. The aim of this longitudinal study was to examine the effectiveness and sustainability of bariatric surgery in a cohort with clinically severe obesity in a multidisciplinary publicly funded service in two teaching hospitals in New South Wales, Australia. Methods: Patients were adults with complex clinically severe obesity with a BMI ≥ 35 kg/m2 and at least three significant obesity-related comorbidities, who underwent bariatric surgeries between 2009 and 2017. Detailed obesity-related health outcomes were reported from annual clinical data and assessments for up to 9 years of follow-up. Data were also linked with the national joint replacement registry. Results: A total of 65 eligible patients were included (mean, 7; range, 3−12 significant obesity-related comorbidities); 53.8% female; age 54.2 ± 11.2 years, with baseline BMI 52.2 ± 12.5 kg/m2 and weight 149.2 ± 45.5 kg. Most underwent laparoscopic sleeve gastrectomy (80.0%), followed by laparoscopic adjustable gastric banding (10.8%) and one anastomosis gastric bypass (9.2%). Substantial weight loss was maintained over 9 years of follow-up (p < 0.001 versus baseline). Significant total weight loss (%TWL ± SE) was observed (13.2 ± 2.3%) following an initial 1-year preoperative intensive lifestyle intervention, and ranged from 26.5 ± 2.3% to 33.0 ± 2.0% between 1 and 8 years following surgery. Type 2 diabetes mellitus (T2DM), osteoarthritis-related joint pain and depression/severe anxiety were the most common metabolic, mechanical and mental health comorbidities, with a baseline prevalence of 81.5%, 75.4% and 55.4%, respectively. Clinically significant composite cumulative rates of remission and improvement occurred in T2DM (50.0−82.0%) and hypertension (73.7−82.9%) across 6 years. Dependence on continuous positive airway pressure treatment in patients with sleep-disordered breathing fell significantly from 63.1% to 41.2% in 6 years. Conclusion: Bariatric surgery using an intensive multidisciplinary approach led to significant long-term weight loss and improvement in obesity-related comorbidities among the population with clinically complex obesity. These findings have important implications in clinical care for the management of the highest severity of obesity and its medical consequences. Major challenges associated with successful outcomes of bariatric surgery in highly complex patients include improving mental health in the long run and reducing postoperative opioid use. Long-term follow-up with a higher volume of patients is needed in publicly funded bariatric surgery services to better monitor patient outcomes, enhance clinical data comparison between services, and improve multidisciplinary care delivery.

The Interdisciplinary Management of Lung Cancer in the European Community

Lung cancer continues to be the largest cause of cancer-related mortality among men and women globally, accounting for around 27% of all cancer-related deaths. Recent advances in lung cancer medicines, particularly for non-small-cell lung cancer (NSCLC), have increased the need for multidisciplinary disease care, thereby enhancing patient outcomes and quality of life. Different studies in the European community have evaluated the impact of multidisciplinary care on outcomes for lung cancer patients, including its impact on survival, adherence to guideline treatment, utilization of all treatment modalities, timeliness of treatment, patient satisfaction, quality of life, and referral to palliative care. This publication will examine the roles and duties of all multidisciplinary members and the influence of multidisciplinary care on lung cancer outcomes in Europe. Multidisciplinary treatment is the foundation of lung cancer treatment. The optimal setting for interdisciplinary collaboration between specialists with complementary functions is multidisciplinary meetings. Multidisciplinary care in lung cancer facilitates the delivery of a high-quality service, which may improve lung cancer patients’ survival, utilization of all treatment modalities, adherence to guideline management, and quality of life, despite the fact that only limited observational data have demonstrated these results. To confirm the relationship between multidisciplinary treatment and improved lung cancer patient outcomes, however, further research is required.

Overview of Checkpoint Inhibitors Mechanism of Action: Role of Immune-Related Adverse Events and Their Treatment on Progression of Underlying Cancer

In recent years, immunotherapy-based regimens have been included into the treatment's algorithm of several cancer types. Programmed death-1 (PD-1) and cytotoxic T lymphocyte antigen-4 (CTLA-4) interact with their ligands found on the surface of antigen presenting cells (APC) or tumor cells (PD-L1/2 and CD80/86). Through these interactions, stimulatory or inhibitory signals are established. Immune checkpoint inhibitors (ICIs), block these interactions, and when administered not only as monotherapy but also as part of combination regimens, have shown to improve survival results in multiple advanced cancers leading to an increasing number of patients treated with ICI and, as a consequence, a rise in the number of patients developing immune-related adverse events (irAEs). Presence of irAEs has been associated with greater benefit from treatment, especially when blocking PD-L1. Recent data suggests that treatment benefit persists after discontinuation of ICIs due to a treatment related adverse event, regardless of the grade. Patients experiencing grade 3-4 irAEs are at risk of toxicity recurrence after reintroducing immunotherapy and therefore, the decision to resume the treatment is challenging. In these cases, a multidisciplinary approach is always needed and several factors should be considered. Management of severe toxicities may require systemic corticosteroids which can impact on T-cell function. Due to their immunosuppressive properties, it is necessary to deeper determine how corticosteroids influence responses. In terms of overall survival (OS), the use of steroids as therapy for irAEs seems not to reduce OS and several studies have reported durable responses in patients experiencing autoimmune toxicities treated with corticosteroids.

Placenta accreta spectrum-A single-center retrospective observational cohort study of multidisciplinary management over time

OBJECTIVE

To evaluate whether the results of a previous study that showed a decrease in blood loss and transfusions with a multidisciplinary approach, including a fixed team when delivering women diagnosed with placenta accreta spectrum at Sahlgrenska University Hospital, remained low throughout time, and to investigate hospital stay and maternal and neonatal complications during a time period with varying team structure compared with previous periods.

METHODS

A retrospective observational cohort study comparing data from medical records including three cohorts of women diagnosed with placenta accreta spectrum between October 2003 and December 2020. Cohort 1 consisted of women delivered before the multidisciplinary approach was introduced. Cohort 2 and cohort 3 were both managed in a multidisciplinary manner, but while cohort 2 was managed by a fixed team, cohort 3 was managed by several different senior specialists. The data were analyzed using Kruskal-Wallis test.

RESULTS

Blood loss and need for transfusion were significantly lower for cohort 3 and cohort 2 compared with cohort 1. No significant difference was found between cohort 3 and cohort 2.

CONCLUSION

The multidisciplinary management and surgical method employed at Sahlgrenska University Hospital have lowered blood loss and the need for transfusions, even over time.

Urologic morbidity associated with placenta accreta spectrum surgeries: single-center experience with a multidisciplinary team

BACKGROUND

Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications.

OBJECTIVE

We sought to report a systematic description of such morbidity and associated factors.

STUDY DESIGN

This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion.

RESULTS

In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury (P=.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta.

CONCLUSION

Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Update on Management Recommendations for Advanced Cutaneous Squamous Cell Carcinoma

Simple Summary

Cutaneous squamous cell carcinoma (cSCC) is the second most common form of skin cancer, which predominantly occurs on the head and neck. Early detection and treatment of primary tumours is crucial to limit progression and local invasion of deep tissues. While high-risk markers of poor prognosis have been identified, factors predicting regional control or survival remain uncertain. Therefore, diagnosis and management of cSCC should be performed individually, considering patient’s clinicopathological profile and the best available treatment options. Surgical excision, radiotherapy, and/or systemic treatments can be selected depending on patient’s status and tumour stage. Considering that a more comprehensive assessment will be provided by a multidisciplinary team, we aimed to generate a practical document that may assist oncologists and dermatologists on the prognosis, diagnosis, management, and follow-up of patients with advanced cSCC.

Abstract

Cutaneous squamous cell carcinoma (cSCC) is the second most common form of skin cancer, the incidence of which has risen over the last years. Although cSCC rarely metastasizes, early detection and treatment of primary tumours are critical to limit progression and local invasion. Several prognostic factors related to patients’ clinicopathologic profile and tumour features have been identified as high-risk markers and included in the stratification scales, but their association with regional control or survival is uncertain. Therefore, decision-making on the diagnosis and management of cSCC should be made based on each individual patient’s characteristics. Recent advances in non-invasive imaging techniques and molecular testing have enhanced clinical diagnostic accuracy. Surgical excision is the mainstay of local treatment, whereas radiotherapy (RT) is recommended for patients with inoperable disease or in specific circumstances. Novel systemic treatments including immunotherapies and targeted therapies have changed the therapeutic landscape for cSCC. The anti-PD-1 agent cemiplimab is currently the only FDA/EMA-approved first-line therapy for patients with locally advanced or metastatic cSCC who are not candidates for curative surgery or RT. Given the likelihood of recurrence and the increased risk of developing multiple cSCC, close follow-up should be performed during the first years of treatment and continued long-term surveillance is warranted.

Critical care considerations in the post-operative period for the lung transplant patient

The post-operative management of a lung transplant recipient can be complex. Several factors including medical comorbidities, severity of illness at the time of transplant and intra-operative events can affect graft function and overall survival. During the immediate post-operative period, it becomes essential for early recognition of disease-specific sequelae as they can impact the patient’s outcome and quality of life. This often necessitates a multidisciplinary team of pulmonologists, surgeons, medical sub-specialists as well as skilled nurses and respiratory therapists familiar with caring for these patients. Based on the experiences of a high-volume transplant center, this chapter will outline key considerations within each organ system in this specific patient population in the Intensive Care Unit.