Clinical Pathway For Treatment Research Articles

In Silico-Enhanced Treatment and Rehabilitation Planning for Patients with Musculoskeletal Disorders: Can Musculoskeletal Modelling and Dynamic Simulations Really Impact Current Clinical Practice?

Over the past decades, the use of computational physics-based models representative of the musculoskeletal (MSK) system has become increasingly popular in many fields of clinically driven research, locomotor rehabilitation in particular. These models have been applied to various functional impairments given their ability to estimate parameters which cannot be readily measured in vivo but are of interest to clinicians. The use of MSK modelling and simulations allows analysis of relevant MSK biomarkers such as muscle and joint contact loading at a number of different stages in the clinical treatment pathway in order to benefit patient functional outcome. Applications of these methods include optimisation of rehabilitation programs, patient stratification, disease characterisation, surgical pre-planning, and assistive device and exoskeleton design and optimisation. This review provides an overview of current approaches, the components of standard MSK models, applications, limitations, and assumptions of these modelling and simulation methods, and finally proposes a future direction.

Psychosocial stress of dermatology inpatients and their relatives - Comparison of patients with and without cancer.

In the clinical treatment pathways of certified oncological centers, psychotherapeutic services are mandatory. Although patients with somatic, non-oncological illnesses show an equally high prevalence of psychosocial stress, these guidelines do not exist for the general hospital sector. Are these patients really less burdened and is psychological support only needed in individual cases? The example of dermatological patients will be used to show whether the need for psychosocial care and the desire for support vary between individuals with and without malignant disease. Using the Hornheider screening instrument and distress thermometer, 216 dermatological inpatients assessed their psychosocial stress and that of a close relative. In addition, they were asked about their desire for support and preferred support provider. i) Patients without skin cancer were more frequently and more severely distressed than cancer patients. ii) Patients of both groups assessed their relatives to be approximately equally distressed. Compared with their own distress, cancer patients assessed their relatives as more frequently and on average more severely distressed. More than 50% of all patients regarded their own disease as the cause of their relatives' distress. iii) The desire for support in both groups was about 18%. iv) Doctors and psychologists were usually named as potential contact persons. The expansion of psychosocial support services for non-tumor patients and their relatives seems necessary. The establishment of appropriate screening methods should be considered. Further studies in other clinical areas are required.

Out-of-hospital cardiac arrest: current diagnostic and therapeutical concepts

Out-of-hospital circulatory arrest represents a challenging situation in emergency medicine even until today. Despite optimal emergency care and clinical treatment pathways, we are faced with a mortality rate above 90 %. It is possible to improve the survival rate to more than 40 % under ideal clinical and preclinical conditions. Thus, more people's life could be saved by standardized SOPs and networks in emergency medicine. About 14.000 preclinical resuscitation cases are reported in Germany per year. The prognosis out-of-hospital circulatory arrest patients is determined by best preclinical treatment including early resuscitation by bystanders. However, ethical considerations for not performing cardiopulmonary resuscitation include comorbidities, advanced age, and prognostic markers of intensive care medicine like lactate level or neuron-specific enolase. Since myocardial infarction is the underlying disease in about 3quarters of acute circulatory arrest cases, early angiography and coronary revascularization is of upmost importance. In addition, it is essential to provide hemodynamic stabilization for prevention of multiorgan dysfunction syndrome. Neuroprotection by therapeutic hypothermia may further help to improve survival and quality of life. Mechanical circulatory support devices may be considered adjunct to pharmacological measures for hemodynamic stabilization. Due to lack of evidence, these devices are currently under evaluation and prospectively randomized trials. We expect new treatment algorithms for optimal care of these high-risk patients in the near future.

Intensive care for seriously ill patients affected by novel coronavirus sars - CoV - 2: Experience of the Crema Hospital, Italy.

Intensive care for seriously ill patients affected by novel coronavirus sars - CoV - 2: Experience of the Crema Hospital, Italy.

Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment.

Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes. In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N - 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model. Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy. At the authors' institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.

27 UTILIZATION OF AN ELECTONIC MEDICAL RECORD (EMR)-INTEGRATED DASHBOARD IMPROVES IDENTIFICATION AND TREATMENT OF IRON DEFICIENCY IN PEDIATRIC INFLAMMATORY BOWEL DISEASE

Abstract Background Anemia is frequently encountered in inflammatory bowel disease (IBD) with studies reporting an even greater prevalence among children (16–72%) than adults (4–67%) at any given time during disease course. Anemia is commonly a result of chronic iron deficiency (ID) and inflammation, with the two conditions often overlapping. Many studies have shown that gastroenterologists underecognize and undertreat these conditions. Moreover, there are currently no pediatric-specific guidelines. To align clinical practice with adult guideline recommendations and evidence-based publications, we developed a quality improvement (QI) initiative incorporating an algorithmic framework for recognition and treatment of iron deficiency anemia (IDA) in pediatric IBD. Methods The goals were twofold: improvement in 1) detection and 2) treatment rates of IDA in IBD patients. A multifaceted approach with a series of plan-do-study-act (PDSA) cycles was executed: 1. Public review of our current performance of anemia screening and treatment with all divisional providers (n=60) (11/2017), 2. Development of a new divisional clinical pathway for screening and treatment of IDA in patients with IBD (01/2018), 3. Educational sessions (02-04/2018), 4. Creation of an Epic order set and patient and family education (PFE) (02/2018), 5. Online availability of our pathway (11/2018), and 6. Utilization of an electronic medical record (EMR)-integrated dashboard to track our outcome metrics. A designated coordinator identified patients in the EMR and sent monthly reports to providers based on our automated dashboard which captured the percentage of patients with ordered hemoglobin (Hb) and ferritin, percentage of patients with anemia and/or iron deficiency, and percentage of patients with ordered iron therapy. Baseline data from July 2016 were compared to data after pathway implementation. Results In the pre-intervention period (July 2016-November 2017), 73.5% of our outpatient IBD population had a Hb ordered, with anemia prevalence of 36.3%. Only a minority of patients with anemia were being screened for ID (19.3%). Iron supplementation was prescribed in 38.1% of patients with documented anemia. Following the implementation of this QI initiative, rate of patients with biannual Hb testing completed increased to 80.1%, while prevalence of anemia decreased to 32.1%. Significant improvement was observed with screening and treatment rate increasing to 43.1% and 50.4% respectively by July 2019 as shown in Fig. 1–2. Notably, patients with moderate to severe anemia improved significantly from 48.7% to 62.1%. Conclusion ID and anemia are commonly underdiagnosed and undertreated in children with IBD. An evidence and expert based pathway combined with implementation of provider-based monthly reports using the EMR to support clinical decision may help increase screening and intervention and decrease rates of anemia prevalence. https://www.chop.edu/clinical-pathway

Magnetic resonance imaging in guiding choice of treatment pathway in patients with cholecystolithiasis and diffuse inflammatory thickening of gallbladder wall

Objective To investigate the use of conventional MR imaging to guide treatment in patients with cholecystolithiasis and diffuse inflammatory thickening of gallbladder wall. Methods The clinical data of patients who were treated in the Ningbo Huamei Hospital, University of the Chinese Academy of Sciences between January 2017 and January 2018 were analyzed. These patients were divided into two groups: patients with acute cholecystitis (n=139) and patients with viral hepatitis combined with cholecystolithiasis (n=67). Differences in the imaging signs in standardized upper abdominal contrast enhanced MRI examinations were retrospectively analyzed. Results The imaging signs, including stone location, continuity of gallbladder mucosa, exudation in peri-gallbladder space, edema of intrahepatic portal area showed significant differences between the two groups (all P<0.05). On stratification analysis, the type of thickened gallbladder wall, background of liver parenchyma and extent of edema in intrahepatic catchment area also showed significant differences (all P<0.05). The imaging signs, including non-gallbladder neck ductal stones, concentric thickening of gallbladder wall, continuous mucous membrane in gallbladder and no peri-gallbladder space exudation but diffuse edema of intrahepatic catchment area supported the diagnosis of viral hepatitis combined with gallstones. The imaging signs, including discontinuity of gallbladder mucosa, exudation of peri-gallbladder space, diffuse edema of gallbladder wall without a cirrhotic background and edema in intrahepatic portal area supported the diagnosis of acute calculous cholecystitis of gallbladder. Conclusions Routine upper abdominal contrast enhanced MRI plays an important role in demonstrating the underlying cause of gallbladder wall diffuse edema thickening in patients with gallstones. It provides an important reference for the choice of clinical treatment pathway. Key words: Cholecystolithiasis; Clinical protocols; Cholecystitis; Hepatitis B; Magnetic resonance imaging

PCN204 COST-ESTIMATE OF ADDING NEOADJUVANT PERTUZUMAB FOR THE TREATMENT OF HER2+ BREAST CANCER IN AN INSTITUTION IN PORTUGAL

The main objective was to estimate the average medical direct costs per patient when adding pertuzumab for neoadjuvant treatment of HER2+ breast cancer patients. It also aimed at exploring cost-effectiveness results of patients treated with pertuzumab in comparison with patients previously treated without pertuzumab. This was a retrospective cohort study, including patients who started the clinical pathway for treatment comprising neoadjuvant therapy with pertuzumab, followed by surgery and adjuvant therapy, from 2015 until 2017. Patients who underwent the same pathway, without pertuzumab, between 2012 and 2015, were also identified. Real-world data was collected from medical and administrative records. The micro-costing technique was used. All medical direct costs, from the diagnosis date to the end of adjuvant regimen, were accounted individually for each patient. The unit costs (2017) were obtained from National prices or from the institution costs. Multivariable logistic regression models were used for effectiveness and Gamma generalized linear models for costs. The ICER was calculated, using the complete pathological response rate as measure of effectiveness. A sensitivity analysis was also performed. Forty and fifty-four (40/54) patients were included in pertuzumab/without pertuzumab groups respectively (median age 43y/53y; 67.5%/59.3% hormone-receptor positive; 60.0%/27.8% operable; 25.0%/24.1% inflammatory). The average cost per patient was 56,375€, with pertuzumab accounting for 13,978€ (25%), whereas the average cost per patient in the group without pertuzumab was 40,393€ (p<0.001). Complete pathological response was higher in pertuzumab group (45% versus 33%), but without statistical significance. Clinical staging and hormone receptors status (HRS) were significantly associated with pathological response. The ICER was 1,370€. The cost per pathological complete response was 125,277€ in pertuzumab group (versus 121,180€) but this varied with staging and HRS. This study provides important insights regarding the impact of introducing pertuzumab for neoadjuvant treatment in clinical practice in Portugal. Additionally, it lays the groundwork for further research.

PSY3 DISEASE BURDEN OF RHEUMATOID ARTHRITIS IN CHINA

Rheumatoid arthritis (RA) is a heterogeneous, systemic and autoimmune disease with symmetric polyarthritis. Patients have a higher incidence of disability and functional limitations with a longer course. RA not only causes a decline in patients' physical function, quality of life and social participation, but also imposes a huge economic burden on patients' families and society. This study was to explore the disease burden of RA in China. The disease burden model was built in Microsoft Excel 2016 and the economic burden of disease was categorized into direct medical, direct non-medical, and indirect costs. Treatment pattern, quality of life, epidemiological and cost data were extracted from a systematic review of literature and public databases, real world data from Hospital Pharmacy Committee of Chinese Pharmaceutical Association were also included in analyses. Data synthesized were examined and the data-gaps were filled by in-depth interviews with clinical and health economic experts, and by advisory board meetings (Delphi Panel). One-way sensitivity analyses of key parameters were also conducted. In China, the prevalence of RA is about 0.41%. According to the calculations, the annual total cost of RA in China in 2018 was about ¥12,673,622,280 RMB, among which direct medical cost accounts for 33.3%, direct non-medical cost accounts for 29.8%, and indirect cost accounts for 37.0%. The indirect costs are high in current RA management as the effective treatment for RA is insufficient in China, leads to a heavy societal burden due to productivity loss caused by consequential deformity and disability. In order to improve the outcomes and quality of life of RA patients, it is needed to improve the awareness of the disease in patients and physicians, to facilitate the coverage of biological agents by reimbursement list, and to follow the standardized clinical treatment pathways for management of RA.

RESOURCES REQUIRED IN CLINICAL PATHWAY FOR TYPHOID FEVER TREATMENT AT KALIWATES GENERAL HOSPITAL IN 2017

Background: A clinical pathway is a concept of an integrated service which describes the stages of healthcare services from the admission until the return of patients based on the medical service standards and evidence-based nursing care with measurable results. Kaliwates General Hospital is an accredited hospital with a clinical pathway. Typhoid case was the highest disease in 2017 at Kaliwates General Hospital.Aims: This study aims to describe the resources at Kaliwates General Hospital in the implementation of clinical pathways, especially typhoid fever treatment.Method: This study was a descriptive and qualitative study. Nine respondents were selected using purposive sampling, including one internist and the quality team at Kaliwates General Hospital. The variables studied include human resource factors, budget factors, method factors, and time factors.Results: The results suggested that the human resources at Kaliwates General Hospital had high commitment, motivation, and moderate knowledge in the implementation of clinical pathways. All equipment and documents were considered adequate. The communication among the implementers was good, but compliance and training for staffs were considered less prominent. The task division of each staff was fairly distributed even though the pharmacy unit perceived that the division was quite unfair.Conclusion: The implementation of the clinical pathway for typhoid fever treatment at Kaliwates General Hospital runs quite well. The hospital must identify and plan staff training regularly, prepare the job description appropriately, and perform performance appraisal based on the job description that has been developed.Keywords: clinical pathway, typhoid fever, resource.

Evaluation of a Collaborative Protocolized Approach by Community Pharmacists and General Medical Practitioners for an Australian Minor Ailments Scheme: Protocol for a Cluster Randomized Controlled Trial.

BackgroundInternationally, governments have been investing in supporting pharmacists to take on an expanded role to support self-care for health system efficiency. There is consistent evidence that minor ailment schemes (MASs) promote efficiencies within the health care system. The cost savings and health outcomes demonstrated in the United Kingdom and Canada open up new opportunities for pharmacists to effect sustainable changes through MAS delivery in Australia.ObjectiveThis trial aims to evaluate the clinical, economic, and humanistic impact of an Australian Minor Ailments Service (AMAS) compared with usual pharmacy care in a cluster randomized controlled trial (cRCT) in Western Sydney, Australia.MethodsThe cRCT design has an intervention group and a control group, comparing individuals receiving a structured intervention (AMAS) with those receiving usual care for specific health ailments. Participants will be community pharmacies, general practices, and patients located in Western Sydney Primary Health Network (WSPHN) region. A total of 30 community pharmacies will be randomly assigned to either intervention or control group. Each will recruit 24 patients, aged 18 years or older, presenting to the pharmacy in person with a symptom-based or product-based request for one of the following ailments: reflux, cough, common cold, headache (tension or migraine), primary dysmenorrhea, or low back pain. Intervention pharmacists will deliver protocolized care to patients using clinical treatment pathways with agreed referral points and collaborative systems boosting clinician-pharmacist communication. Patients recruited in control pharmacies will receive usual care. The coprimary outcomes are rates of appropriate recommendation of nonprescription medicines and rates of appropriate medical referral. Secondary outcomes include self-reported symptom resolution, health services resource utilization, and EuroQoL Visual Analogue Scale. Differences in primary outcomes between groups will be analyzed at the individual patient level accounting for correlation within clusters with generalized estimating equations. The economic impact of the model will be evaluated by cost-utility and cost-effectiveness analysis compared with usual care.ResultsThe study began in July 2018. Thirty community pharmacies were recruited. Pharmacists from the 15 intervention pharmacies were trained. A total of 27 general practices consented. Pharmacy patient recruitment began in August 2018 and was completed on March 31, 2019.ConclusionsThis study may demonstrate the efficacy of a protocolized intervention to manage minor ailments in the community and will assess the clinical, economic, and humanistic impact of this intervention in Australian pharmacy practice. Pharmacists supporting patient self-care and appropriate self-medication may contribute to greater efficiency of health care resources and integration of self-care in the health system. The proposed model and developed educational content may form the basis of a national MAS service in Australia, using a robust framework for management and referral for common ailments.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000286246; http://www.anzctr.org.au/ACTRN12618000286246.aspxInternational Registered Report Identifier (IRRID)DERR1-10.2196/13973

PCN47 A RETROSPECTIVE ANALYSIS TO EVALUATE GENOME-BASED INTERVENTIONS IN THE LIFETIME TREATMENT PATHWAY OF COLORECTAL CANCER

The current landscape of genomic medicine is undergoing rapid-innovation, and genome-based interventions are being increasingly used in the screening, diagnosis and treatment decisions in clinical practice. Our objective was to estimate the costs and outcomes of using different genome-based interventions (Multi-targeted stool DNA test and 12-gene assay) as compared with non-genomic interventions (Fecal Immunochemical Test (FIT) and a clinical guideline-based approach) from pre-clinical to post-diagnostic treatment pathways in colorectal cancer patients. As a part of a larger study, we modeled the entire clinical treatment pathway of colorectal cancer disease to better understand the disease and treatment systems. The costs of screening tests, genomic tests, adjuvant chemotherapy, adverse events, and administration were considered. The costs were discounted annually at 3%. We investigated outcomes in three stages including no recurrence, recurrence (local or distant), and death. The model parameters were derived from published meta-analyses studies, randomized controlled trial studies, observational studies, health utility studies, and economic evaluation studies. We conducted a retrospective data analysis of 1,127 colorectal cancer patients and developed an interactive model. The sensitivity of Multi-targeted stool DNA testing to detect colorectal cancer was 92.3%, as compared to FIT (73.8%). The12-gene assay was used to group 711 stage II colorectal cancer patients into high risk (n=182, 25.60%) and low risk (n=529, 74.40%) strata based upon recurrence scores. To compare the use of the 12-gene assay with a clinical guideline-based approach, 416 stage II colorectal patients were categorized into high risk (n= 180, 43.30%) and low-risk (n=236, 56.70%) groups using well-established clinicopathological parameters. This study demonstrates that the genome-based interventions involved in the clinical treatment pathway of colorectal cancer may provide more precise information for the risk stratification of patients and can be used to compute the cost or disease burden.

Intensive monitoring for post-transplant diabetes mellitus and treatment with dipeptidyl peptidase-4 inhibitor therapy

AimCurrent monitoring practices fail to diagnose patients with post-transplant hyperglycaemia and tend to delay initiation of treatment, which potentially results in adverse graft and morbidity outcomes. This real-world study set out to assess the impact on insulin resistance indices of a new clinical pathway for diagnosis and treatment of hyperglycaemia following renal transplantation. MethodsA hundred and forty-seven adult renal transplant recipients, without pre-existing diabetes, from a single centre were included. Patients transplanted between January 2008 to September 2015 formed the historical cohort. Patients transplanted between October 2015 and February 2018 were subject to a new clinical pathway - if they had fasting blood sugar levels more than 7 mmol/L or random blood glucose levels more than 11.1 mmol/L, they had early introduction of oral therapy, using the DPP-4 inhibitor linagliptin. ResultsIn the historical cohort, 19.8% were diagnosed with PTDM, compared to 46.3% in the protocol cohort. Amongst patients with PTDM, there was a significant difference in HOMA-IR (p = 0.02) between the historical cohort (median HOMA-IR 3.33) and the protocol cohort (median HOMA-IR 2.21). There was a significant difference at each time point (0,1,2-h measurements) of blood glucose levels form oral glucose tolerance testing between patients with and without PTDM in the historical cohort (p < 0.001), but no difference between patients in the protocol cohort. ConclusionDetection of PTDM was higher with the new clinical pathway. Early treatment of hyperglycaemia resulted in better insulin resistance scores. Larger prospective controlled studies focussing on early detection and management of PTDM with linagliptin are warranted.

Antifibrinolytic Agents for Hemoptysis Management in Adults With Cystic Fibrosis

Hemoptysis is a major cause of morbidity and mortality in patients with cystic fibrosis (CF). Antifibrinolytic agents have shown efficacy in a broad range of bleeding disorders and conditions. The goal of this study was to examine the use of antifibrinolytic agents in managing hemoptysis in CF. We developed a clinical treatment pathway for inpatient and outpatient use, and rates of admission for bleeding prior to and following implementation of the pathway are reported. All adult patients with CF treated with systemic antifibrinolytic agents over a 54-month period according to the treatment pathway were analyzed. Data collected included demographic characteristics, baseline CF-related characteristics, and bleeding and treatment parameters. Effectiveness of the pathway was evaluated via comparison of annualized hemoptysis admission rates prior to and following pathway enrollment. Seventy-two distinct episodes of hemoptysis treated with antifibrinolytic agents were analyzed in a total of 21 adult patients with CF. Two-thirds of episodes treated involved moderate or massive hemoptysis. Bleeding ceased following a median of 2days. Outpatient treatment was associated with a 50%reduction in the annualized hemoptysis admission rate following pathway enrollment (2.44 vs1.23 admissions per year; P= .0024) that was independent of other changes in management. Antifibrinolytic therapy was well tolerated. One central catheter-associated upper extremity DVT was observed in a patient with previous thrombosis in the same vessel. A pathway using systemic antifibrinolytic therapy to treat hemoptysis in patients with CF was associated with a reduction in hospital admissions. No serious adverse events were observed. Additional studies are needed to further define the benefits of systemic antifibrinolytic use in patients with CF.

Clinical pathways and wait times for OSA care in Ontario, Canada: A population cohort study

RATIONALE: Lengthy wait times for obstructive sleep apnea (OSA) in Canada remain a concern.OBJECTIVES: To describe the clinical pathway for OSA and determine wait times from assessment of OSA until continuous positive airway pressure (CPAP) treatment in Ontario.METHODS: We conducted a population-based cohort study from 2006 to 2013. We used billing information to identify clinic visits for sleep complaints and polysomnography (PSG). We calculated the time from primary care visits until diagnostic PSG (diagnostic time) and from PSG until CPAP initiation (treatment time) for each year. We used logistic regression to identify factors associated with diagnostic and treatment time >6 months.RESULTS: A total of 216 514 CPAP users were included. Most (52%) had a diagnostic PSG without a sleep assessment and 52% underwent a titration PSG. The median diagnostic wait for hospital and community-based facilities were 260 (IQR 87–869) days and 203 (36–838) days, respectively, with less than 50% of patients undergoing PSG within 6 months of PC assessment. The median treatment wait was 108 days (57–193) at hospital and 82 days (45–143) at community-based facilities; less than 70% started on CPAP within 6 months. Female sex, recent hospitalization and having diagnostic PSG at a hospital were associated with longer diagnostic and treatment times.CONCLUSIONS: The clinical pathway for assessment and treatment of OSA in Ontario is highly variable and current wait times in Ontario remain lengthy. Interventions to improve physician education, redistribute sleep medicine resources and adopting new technologies should be considered.

Experience and Impact of a Locally-Based Peer, Volunteer Cancer Support Programme in Hospital Melaka, Melaka Malaysia

Background: Melaka is a small southern state in Peninsular Malaysia. On average, the state has an annual incidence of 200 odd breast cancer patients, largely treated out of its public, subsidized, single tertiary treatment center of Hospital Melaka. Hospital Melaka is an 800-bedded hospital with multiple specialties including surgery and radiology. Though the hospital does not have a dedicated oncology department, cancer treatment is carried out via phone consultations and visiting oncologists as well as a team of on-site nursing staff who are trained to initiate and monitor treatment. Feedback from Hospital Melaka staff highlighted that there was a drop-out rate of about 30% of patients from the treatment journey. Qualitative interviews with different stakeholders including patient revealed that the drop-out may be driven by factors such as: i) fear of surgery, ii) fear of chemotherapy, iii) fear of disfigurement, iv) loss of spouse v) emotional distress and shock; and vi) delay in waiting times for different levels of diagnostics and treatment. Aim: The aim of the initiative was to reduce the rate of patients who defaulted out from the cancer treatment journey via a three-pronged approach: a) improving understanding about cancer and treatment by patients and family members; b) integrating peer-support into the clinical treatment pathway at the hospital and reduction of waiting times; and c) maintaining a continuous interaction with the patient throughout the treatment journey. Methods: The inception and deployment of a locally-based peer, volunteer support program for breast cancer patients and families as part of the formal cancer treatment process in Hospital Melaka. Volunteers were consisted of a trained mix of cancer survivors, current and retired healthcare practitioners and provided information pertaining to treatment and care aspects of breast cancer as well as emotional support and follow-up of patients via phone or in person to ensure compliance to treatment. In this study, we engaged with various stakeholders including hospital management and clinicians. Then, support group's services were formalized into the care pathway for all patients with breast cancer; with both volunteers able to send and receive patient referrals. Results: Statistically significant reductions in patient delays in decision-making to seek treatment as well as a significant decrease of 12.5% in the number of defaulters. Conclusion: A support program built with support from all stakeholders and run by volunteers and embedded within the formal care process acts as a catalyst to enhance both service delivery as well as keeping patients engaged on the cancer care journey.

The role of exercise testing in predicting successful ambulation with a lower extremity prosthesis: a systematic literature review and clinical practice guideline

BackgroundGrowing discontent with the k-level system for functional classification of patients with limb loss and movement of healthcare toward evidence-based practice has resulted in the need for alternative forms of functional classification and development of clinical practice guidelines to improve access to quality prosthetic interventions. The purpose of this project was to develop and present a clinical practice recommendation for exercise testing in prosthetic patient care based on the results and synthesis of a systematic literature review.MethodsDatabase searches of PubMed, Google Scholar, Web of Science, and Cochrane were conducted and articles reviewed. Of the potential 1386 articles 10 met the criteria for inclusion. These articles were assessed using the critical appraisal tool of the United Kingdom National Service Framework for Long-Term Conditions. Of the 10 included articles eight were of high, one of medium, and one of low, quality. Data from these articles were synthesized into 6 empirical evidence statements, all qualifying for research grade A. These statements were used to develop the proposed clinical practice guideline.ResultsWhile the results of this systematic review were not able to support the direct connection between cardiorespiratory performance and K-levels, the literature did support the ability of exercise testing results to predict successful prosthetic ambulation in some demographics. Both continuous maximum-intensity single lower extremity ergometer propelled by a sound limb and intermittent submaximal upper extremity ergometer protocols were found to be viable evaluation tools of cardiorespiratory fitness and function in the target population.ConclusionThe ability to sustain an exercise intensity of ≥50% of a predicted VO2max value in single leg cycle ergometry testing and achievement of a sustained workload of 30 W in upper extremity ergometry testing were found to be the strongest correlates to successful ambulation with a prosthesis. VO2 values were found to increase in amputee subjects following a 6-week exercise program. These synthesized results of the systematic literature review regarding exercise testing in patients with loss of a lower extremity were used to develop and a present a clinical treatment pathway.

Predicting respiratory hospital admissions in young people with cerebral palsy: A 3-year longitudinal study using linked data

Respiratory disease is the leading cause of death in children and young people with cerebral palsy however the onset of the disease onset is insidious and clinical care pathways for prevention and treatment are unclear. The aim of this study is to determine the early predictors of respiratory hospital admissions in young people with cerebral palsy (CP). Design 3-year prospective cohort study using linked respiratory hospital admissions data for young people with CP, aged 1–26 years, who had previously provided self-reported and carer reported respiratory symptoms. The respiratory hospital admissions were defined by the International Statistical Classification of Diseases and Related Health Problems [ICD-10] codes. Incidence rate ratios (IRRs) were calculated for univariate and multivariate models. Four hundred and eighty-two participants (including 289 males) were recruited. They were aged 1 to 26 years (M 10 years, 10 months; SD 5 years, 11 months) at the commencement of the study, and represented all Gross Motor Function Classification Scale (GMFCS) levels. During the 3-year period, 55 (11.4%) participants had a total of 186 respiratory hospital admissions, and spent a total of 1475 days in hospital. Statistically significant risk factors for subsequent respiratory hospital admissions over 3 years in univariate analyses were GMFCS Level V, at least one respiratory hospital admission in the year preceding the survey, oropharyngeal dysphagia, seizures, frequent respiratory symptoms, gastroesophageal reflux disease (GERD), at least 2 courses of antibiotics in the year preceding the survey, mealtime respiratory symptoms, and nightly snoring. Most risk factors for respiratory hospital admissions are potentially modifiable. Early identification of oropharyngeal dysphagia and the management of seizures may help prevent serious respiratory illness. One respiratory hospital admission should trigger further evaluation and management to prevent subsequent respiratory illness.

The management of outpatient cellulitis at the Moncton hospital before and after the initiation of a clinical treatment pathway

The management of outpatient cellulitis at the Moncton hospital before and after the initiation of a clinical treatment pathway

Does ambulatory urodynamic assessment change the primary clinical diagnosis and/or treatment pathway in patients where conventional urodynamic assessment did not conclusively reproduce their symptoms

Does ambulatory urodynamic assessment change the primary clinical diagnosis and/or treatment pathway in patients where conventional urodynamic assessment did not conclusively reproduce their symptoms