Case Consultation Research Articles

The challenge of diagnosing neuroendocrine neoplasms: experience from a national reference center.

Correctly diagnosing neuroendocrine neoplasm (NEN) has become increasingly challenging, given that more histomorphologic and immunophenotypic NEN mimics have been identified in recent years. A systemic review was conducted on the 4795 consult cases submitted with initial diagnoses of NEN to a national reference center in China from 2013 to 2021. Among them, 443 cases were misdiagnosed as epithelial NENs after reevaluation with the help of immunohistochemical and/or molecular tests, ranging from 7.1 to 13.2%, with yearly increases. The misdiagnoses varied among age groups and tumor sites. Exocrine carcinoma was the most common (63.2%), followed by mesenchymal tumors. Other common tumors that were misdiagnosed included hepatocellular carcinoma, salivary gland tumor, and gastrointestinal stromal tumor. Aberrant expression of neuroendocrine markers was frequent (218/408, 53.4%), with diffuse positivity ranging from 8.2 to 51.7% for synaptophysin, chromogranin A, and INSM1 stains in all non-NEN cases. Selecting appropriate immunohistochemical stains based on H&E morphology is the key to avoiding diagnostic pitfalls. Medical history and molecular genomic information greatly assist in correctly diagnosing NENs and their mimics.

Prognostic impact of postoperative management by an intensive care unit intensivist after colonic perforation.

Postoperative management for colonic perforation is an important prognostic factor, but whether intensivists perform postoperative management varies between institutions. We investigated 291 patients with colonic perforation between 2018 and 2022. Patients were divided into those managed by an intensivists (ICU group; n = 40) and those not managed by an intensivists (non-ICU group; n = 251). We examined how management by intensivists affected prognosis using inverse probability weighting, and clarified which patients should consult an intensivists. The ICU group showed a significantly higher shock index (1.15 vs. 0.75, p < 0.01), higher APACHE II score (16.0 vs. 10.0, p < 0.001), and more severe comorbidities (Charlson Comorbidity Index 5.0 vs. 1.0, p < 0.001) and general peritonitis (85% vs. 38%, p < 0.001). Adjusted risk differences were - 24% (-34% to -13%) for 6-month mortality rate. Six-month mortality was improved by ICU intensivist management in patients with general peritonitis (risk difference - 22.8; 95% confidence interval - 34 to -11); APACHE II score ≥20 (-0.79; -1.06 to -0.52); lactate ≥1.6 (-0.38; -0.57 to -0.29); shock index ≥1.0 (-40.01; -54.87 to -25.16); and catecholamine index ≥10 (-41.16; -58.13 to -24.19). Intensivists were involved in treating patients in poor general condition, but prognosis was extremely good. Appropriate case consultation with intensivists is important.

Clinical Utility of Broad Range PCR for Infectious Organisms

Abstract Broad range PCR is used to identify infectious organisms when bacterial, fungal, and mycobacterial cultures are negative despite clinical evidence of infection. We performed a 6-month retrospective chart review to assess the actionability of broad range PCR and identify opportunities to improve the utility of this referral test at our institution. One hundred eleven broad range PCR tests were ordered from July to December 2023. Seventy-five (67.6%) results did not affect patient management, 18 (16.2%) results affected patient management, and the treatment impact of 18 (16.2%) results is unknown because they were from outside consult cases. There were no instances in which antibiotic therapy was completely discontinued due to a negative broad range PCR result. Concurrent in-house microbiology testing yielded a positive result in 15 (13.5%) cases, of which 8 (53%) had a negative broad range PCR result and 2 (13.3%) had a conflicting broad range PCR result. Thirty-eight (34.2%) specimens were formalin fixed paraffin embedded tissue, 29 (26.1%) were fresh tissue, 13 (11.7%) were ESWABS, and the remaining 31 specimens were various fluid types (27.9%). While fresh tissue is the preferred specimen, broad range PCR detected an organism in 20 (53%) formalin fixed paraffin embedded tissue specimens, 11 (37.9%) fresh tissue specimens, 3 (23.1%) ESWAB specimens, and 2 (6.5%) fluid specimens (abscess aspirate and cerebrospinal fluid). Improvements in physician communication and laboratory workflow are necessary to improve the specimen quality and thus the utility of this referral test at our institution.

Two Cases of Interstitial Cystitis and Nephrology Consultation

Two Cases of Interstitial Cystitis and Nephrology Consultation

A supervised consultation–Liaison psychiatry training model in a general hospital in China

Consultation–liaison (CL) psychiatry is becoming a recognized subspecialty in medical settings; it is a branch of psychiatry that addresses the treatment of the medically ill. Training for CL psychiatry is still insufficient in China. We introduce our training model, supervised CL based on the Union Psychosomatic Clinical Approach with Learning Exchange (UPSCALE) model, to improve consultation–liaison skills among psychiatrists. We describe the supervision process via a clinical case. The supervisee expresses learning needs, and the supervisor selects a consultation case and performs interviews via the UPSCALE model. After the interview, the doctors provide feedback to the patients and discuss the case. The experience includes reporting summaries and experience narratives from supervisees, as well as comments and guidance from supervisors. Through the supervised consultation–liaison training model, young psychiatrists have multiple opportunities to improve learning by observing, practising, and exchanging experiences in CL psychiatry.

TFE3-rearranged perivascular epithelioid cell tumors: a clinicopathological analysis of eight cases

Objective: To investigate the clinicopathological, immunohistochemical and molecular genetic characteristics of TFE3-rearranged perivascular epithelioid cell tumor (PEComa). Methods: Eight cases of PEComa with TFE3 rearrangement diagnosed in the First Affiliated Hospital of Air Force Medical University from January 2014 to July 2022 were collected. Three were consultation cases and 5 were collected from our hospital; 7 cases were resection specimens and 1 case was a needle biopsy specimen. Routine histolopathological analysis, immunohistochemical staining, fluorescence in situ hybridization (FISH) and the next-generation sequencing were performed. Clinical data were collected and the prognosis was assessed. Results: The 8 patients consisted of 5 females and 3 males with a median age of 45 years (ranged from 25 to 65 years). The tumor location included 1 uterus, 1 liver, 1 urachus, 2 kidneys, 1 abdominal cavity, 1 colon, and 1 retroperitoneum (3 subsequent recurrences in the abdominal cavity, pelvis and ovary, and abdominal cavity, respectively). Morphologically, the tumor cells were uniform and epithelioid with translucent or eosinophilic cytoplasm. They were arranged in nests or sheets, most of which were separated by thin-walled blood vessels. There were no papillary structures, and no overt smooth muscle or fat components. Atypical features were seen in 3 cases, with bizarre nuclei and tumor giant cells. Large areas of necrosis were visible, and mitosis was common (up to 28/50 HPF). Melanin deposition was present in 3 cases. Immunohistochemical staining showed diffuse and strong positivity for TFE3 in 8/8 cases and for HMB45 in 6/8 cases; focal positivity for Cathepsin K and Melan-A in 6/8 cases and for SMA in 2/8 of cases. All cases were negative for CKpan, PAX8 and Desmin. TFE3 gene break-apart was detected by FISH in all 8 cases, 4 of which underwent next-generation sequencing, and it revealed that 2 cases presented with SFPQ::TFE3 fusion, 1 case with ASPSCR1::TFE3 fusion, and 1 case with no chimeric fusion. Seven cases were followed up for 4-94 months. All cases were alive; 4 cases were disease-free, 2 cases showed recurrence, and 1 case had metastasis at initial diagnosis. Conclusions: TFE3-rearranged PEComa has unique histomorphological, immunohistochemical and molecular characteristics. The biological behavior is aggressive, which could lead to recurrence and metastasis, and warrants close clinical follow-up.

Comparing the Surgical Outcomes of Carotid Endarterectomy: Assessing the Impact of Consultant versus Trainee Cases on Patient Care and Surgical Training

ObjectiveThis study assesses the impact of having a surgical trainee performing a carotid endarterectomy procedure on the post-operative rates of stroke and death. DesignObservational Retrospective study MethodsConsecutive patients, who underwent carotid endarterectomy between 01/05/2016 and 31/7/2022, were entered into a retrospectively collected database. Patients were stratified into two categories – consultant-led cases and trainees-led cases. Primary outcomes were 30- day stroke rate, and 30-day morbimortality. A sub analysis was performed after grouping the patients in whether there was a neurological event in the previous six months – symptomatic or asymptomatic. Results/ConclusionsTrainees-led cases had significantly longer clamping times and higher rates of stroke in asymptomatic patients compared with consultant-led cases. Patient’s safety should be our top priority. Any practice leading to a significantly increased rate of post-operative stroke must be discontinued. Training protocols and adequate supervision must ensure that trainees possess the necessary skills and knowledge to safely and effectively perform carotid endarterectomy (CEA) procedures, thereby prioritizing patient safety.

Digital otoscopy in remote consultations.

Otoscopes and otomicroscopes are the most commonly used instruments for visualizing the ear. Digital otoscopy (DO) could be used to improve diagnostics in primary health care by utilizing image enlargement. The aim of the study was to explore the possibilities of DO in remote consultations. Based on real-life referrals, 45 otologic outpatients were recruited. DO was performed followed by an attending otologist's appointment, serving as the gold standard. Twenty-four patient cases were analyzed on a digital platform as remote consultation cases containing the given referral information supplemented with DO videos (DOVs). A total of 71 evaluations were performed by five otologists. The quality of the DOVs, their suitability for remote consultations, the accuracy of diagnoses and the usefulness of remote consultations were determined. The average DOV quality was judged to be 7.4 ± 0.3 (mean ± standard error of the mean; scale of 1-10). The diagnosis was correct in 79% of the cases. In 59% of the patients, the otologists considered that remote consultation could have replaced an in-person visit. In our simulated remote consultation setup, DOV quality was sufficient for diagnostic purposes, DO improved diagnostics and treatment planning in most cases and could be used to reduce the need for in-person visits. DO-aided remote consultation may improve diagnostics and access to care.Level of evidence: 3.

The clinical utility of the 90-gene expression assay on diagnosis and management in patients with cancer of unknown or unclear primary.

e15172 Background: The diagnosis and management of patients with cancer of unknown or unclear primary present significant clinical hurdles, often culminating in unfavorable outcomes. A randomized phase III trial (CUP001) has demonstrated that site-specific treatment guided by the 90-gene-expression assay (Canhelp-Origin Assay) resulted in more therapy options, and significantly improved progression-free survival compared with empirical chemotherapy in patients with cancer of unknown primary. This study evaluated the clinical utility of the 90-gene expression assay in the diagnosis and management of patients with cancer of unknown or unclear primary. Methods: Patients who underwent the 90-gene expression assay at Fudan University Shanghai Cancer Center (FUSCC) between February 2023 and December 2023 were enrolled in the study. Data collection encompassed patient demographics, clinical characteristics, and pathological features. Results: Patient enrollment began in February 2023 and closed in December 2023 after enrolling 303 patients with 51 inpatient cases and 244 pathological consultation cases (from 144 sites). Among them, 295 patients met all inclusion criteria, yielding an overall success rate of 97.4% (295/303). Tumor cells were enriched by either macrodissection (N = 257) or microdissection (N = 38), with median highest similarity scores of 57.5 and 67.1, respectively. Using a positive cutoff value of the highest similarity score ≥45.3, the positivity rates for macrodissection and microdissection were 66.5% (171/257) and 81.6% (31/38), respectively. Of the enrolled patients, 177 (60%) were male, and 118 (40%) were female, with a median age of 63 years (range: 25 to 85 years). Predictive results encompassed 21 tumor types, with the most common being gastroesophageal cancer (N = 40, 13.6%), lung cancer (N = 37, 12.5%), breast cancer (N = 36, 12.2%), head and neck squamous cell carcinoma (N = 29, 9.8%), and ovarian cancer (N = 28, 9.5%). Of 166 samples with an assigned grade, 89.8% were poorly differentiated or undifferentiated, 6.0% were moderately differentiated, and 4.2% were well differentiated. The consistency of prediction results and clinicopathological results will be further evaluated after follow-up. Conclusions: This study demonstrates that the 90-gene expression assay has diagnostic implications for patients with cancer of unknown or unclear primary. This affirms its clinical utility as a standard diagnostic approach in the diagnosis and management of these patients, facilitating the formulation of more precise treatment strategies and ultimately enhancing prognosis.

EMMA (Applying ethics multiprofessionally and methodically): a specific structured tool for ethics case consultations in long-term care

EMMA (Applying ethics multiprofessionally and methodically): a specific structured tool for ethics case consultations in long-term care

Digital Pathology is a Fast and Effective Platform for Providing Head and Neck Pathology Consultations.

Surgical pathology of the head and neck is one of the more challenging areas in all of diagnostic pathology. Its unparalleled diversity and complexity renders it highly vulnerable to diagnostic error compelling unconstrained access to specialized diagnostic expertise. Digital pathology (DP) is a state-of-the-art tool that could facilitate access to specialized expertise, but it is relatively untested in the context of pathology consultations. In a collaboration between Labcorp Dianon and a large academic hospital with subspecialized surgical pathology, DP was implemented to provide the pathology community access to head and neck pathology expertise. From this collaborative experience, glass slides from consecutive consult cases that had been previously diagnosed using DP were reviewed by an expert consultant in a blinded manner following an extended wash-out period. The intraobserver discrepancy rate was recorded. Major discrepancies were defined as those resulting in significant impact on clinical management and/or prognosis, whereas minor discrepancies were those with no impact on care or prognosis. Slides from 57 cases were available for review. The average wash-out period was 19 months. Five discrepancies were recorded (intraobserver concordance rate of 91%). All discrepancies were minor (major discrepancy rate, 0%; minor discrepancy rate, 9%). On appraisal of the discrepant cases, discordant diagnoses were attributed to subjective differences in interpretation rather than objective differences related to the inferiority of DP. DP decreased the median turnaround time by 97% (from 70h 26min to 2h 25min). DP provides efficient and fast access to expert consultants. The speed of case delivery does not compromise diagnostic precision. Discrepancies are uncommon, minor, and reflect subjective interpretative differences inherent to difficult and ambiguous head and neck cases, and not the inferiority of DP as a diagnostic platform. High concordance can be achieved even for those difficult and complex cases that are concentrated in the consultation practice. This observation carries profound implications regarding universal health care access to specialized diagnostic expertise.

Second opinion for pulmonary and pleural cytology is valuable for patient care

IntroductionThoracic cytology can be challenging due to limited procured material or overlapping morphology between benign and malignant entities. In such cases, expert consultation might be sought. This study aimed to characterize all pulmonary and pleural cytology consult cases submitted to our practice and provide recommendations on approaching difficult cases. Materials and MethodsAll thoracic (pulmonary and pleural) cytology cases submitted for expert consultation to the University of Michigan (MLabs) from 2013 to mid-2022 were reviewed. Cases where cytology was only part of a hematopathology or surgical pathology consult were excluded. Patient demographics, specimen location, procedure performed, referring diagnosis, and our diagnoses were recorded for each case. Diagnoses were categorized according to the Papanicolaou Society of Cytopathology recommendations for pulmonary and effusion cytology. Discordant diagnoses were stratified as major or minor. Data was analyzed using Chi-Square analysis and logistic models. ResultsWe received 784 thoracic cytology consult cases, including 530 exfoliative samples and 307 fine needle aspirations (FNAs). The most common anatomic locations sampled were the bronchial wall (n=194, 23%), lung nodule (n=322, 38%), and pleura (n=296, 35%). 413 cases had a diagnostic discrepancy (48.3%), with 274 (66%) minor and 139 (34%) major discrepancies. By location, pleural effusion specimens had the highest probability of a discrepant diagnosis (p=0.003). By specimen type, FNA samples were significantly more likely to have a discrepant diagnosis (p=0.06). ConclusionNearly half of the thoracic cytology cases submitted for expert second opinion had diagnostic discrepancies. Consequently, consulting a tertiary medical care center with cytopathology expertise for challenging thoracic cytology diagnoses is beneficial.

School-Based Screening and Brief Intervention for Adolescent Substance Use With Telehealth-Delivered Case Consultation and Education.

Screening, brief intervention, and referral to treatment (SBIRT) is a public health framework for addressing adolescent substance use. Implementation of SBIRT in schools carries the potential to improve substance use treatment access and service acceptance for students, but faces barriers related to knowledge deficits, low comfort, and lack of training in screening and brief interventions among school-based mental health (SBMH) providers. This report describes the development and acceptability evaluation of a school-based SBIRT program designed to overcome common implementation barriers of SBIRT related to provider confidence, knowledge, and training deficits by supplementing the traditional model with telehealth-delivered addiction consultation and education (ACE). Program components include core SBIRT trainings, telehealth-delivered ACE sessions, and outreach support for SBMH providers. Each ACE session included a didactic expert presentation on a clinical topic and a provider-presented patient case with discussion. Sessions were delivered using a Project ECHO-based hub-and-spoke format with monthly 1-hour virtual meetings. Interviews and surveys with SBMH providers on substance use screening and intervention practices and perceived barriers were used to inform program design choices and tailor the curriculum. Acceptability data were collected at 9 months. SBMH provider participants reported increased confidence, knowledge, and evidence-based screening and early intervention practices, and high acceptability, satisfaction, and benefit from the program. Ongoing barriers to referral to treatment were reported. This pilot study suggests that supplementing traditional SBIRT with telehealth-delivered ACE sessions can address common implementation barriers and serve as a scalable model to improve SBIRT adoption in schools.

Congenital spindle cell/sclerosing rhabdomyosarcoma: a clinicopathological analysis

Objective: To investigate the clinicopathological features, immunophenotype and molecular genetic characteristics of congenital spindle cell/sclerosing rhabdomyosarcoma. Methods: Sixteen cases (including 10 consultation cases) of congenital spindle cell/sclerosing rhabdomyosarcoma diagnosed at the Beijing Children's Hospital, Capital Medical University, Beijing China, from April 2017 to January 2022 were collected. These cases were evaluated for clinical profiles, histomorphological features, immunophenotype and molecular characteristics. Results: Among the 16 patients, 9 were male and 7 were female. Five cases were present during maternal pregnancy and 11 cases were found immediately after birth. The tumors were located in the chest wall, low back, retroperitoneum, extremities or perineum. The tumors consisted of fasciculated spindle-shaped cells with localized mesenchymal sclerosis and vitreous metaplasia. Immunohistochemistry showed that the tumor cells expressed Desmin, Myogenin, MyoD1, SMA, CD56 and ALK to varying degrees, but not other markers such as CD34, CD99, pan-TRK, S-100 and BCOR. FISH analyses with NCOA2 (8q13) and VGLL2 (6q22) gene breakage probes revealed a breakage translocation in chromosome NCOA2 (8q13) in 4 cases (4/11). In the 6 cases subject to sequencing, a mutation at the p.L122R locus of MYOD1 gene was detected in 1 case (1/6). Two cases were examined by electron microscopy, which showed bundle-arranged myofilaments with some primitive myofilament formation. Five cases were resected with simple surgery, 2 cases were biopsied and followed up with observation only, and 9 cases were treated with surgery and adjuvant chemotherapy. Follow-up was available in 12 cases. At the end of the follow-up, 2 of the 12 patients developed local recurrences and 2 patients survived with disease. Conclusions: Congenital spindle cell/sclerosing rhabdomyosarcoma is a rare subtype of congenital rhabdomyosarcoma. It more commonly occurs in the chest, back and lower limbs of infants than other sites. NCOA2/VGLL2 gene fusion seems to be the most common genetic change. Its prognosis is better than other subtypes of rhabdomyosarcoma and those in adolescents and adults with the same subtype. Analysis and summary of its clinicopathological features can help differentiate it from other soft tissue tumors in infants and children and provide the information for appropriate treatments.

74 Trial-CARE: Centralized Support Services for Investigator-Initiated Multi-Site Clinical Trials

OBJECTIVES/GOALS: To describe the impact of Trial-CARE (Coordination, Acceleration, and Recruitment Enhancement), a centralized service core at Washington University (WU), aimed at enhancing the capability of investigator-initiated multi-site clinical trials at WU and partner CTSA institutions. METHODS/STUDY POPULATION: Through review of our marketing materials and service tracking system we defined the following Trial-CARE offerings: Infrastructure: Trial-CARE is a centralized service core at WU. Whereby, a team member is sourced to an investigator-initiated multi-site clinical trial (II-MCT) to ensure the achievement of study milestones across any phase of the clinical trial life cycle. Team: Our team consists of research professionals with expertise in II-MCT project management, data management, and administrative/regulatory management. Services: * One free 60-minute case consultation * Tiers of Service * Academic Research Organization (ARO) support * Clinical Coordinating Center * Data Coordinating Center * II-MCT project management support * Time-limited targeted support RESULTS/ANTICIPATED RESULTS: Trial-CARE has completed 94 consultations in support of WU and partner CTSA institutions enabling the streamlining of study start-up; guidance for study recruitment, implementation, and operations; and offering resources to foster career development. Consultations can be completed at any phase in the clinical trial lifecycle, with Trial-CARE completing: * 12% in the idea phase * 45% in the grant development and submission stage * 28% after funding has been awarded Top reasons researchers connect with Trial-CARE about II-MCTs: * regulatory guidance (40%) * general information about Trial-CARE Services and II-MCTs (35%) * protocol development (21%) * data management (20%) * study budgeting (20%) DISCUSSION/SIGNIFICANCE: In response to a WU wide survey, Trial-CARE plans to generate informational webinars and is creating a clinical trial tracking dashboard, to pro-actively offer support services to researchers prior to grant funding. The goal is also to increase the percentage of consultations completed in the idea phase and the grant development and submission stage.

Abstract P292: Lessons Learned From the Implementation of a Peer-to-Peer Cardiology Consultation Program in Federally Qualified Health Centers

Introduction: Conventional access to specialist care for cardiovascular disease can be expensive, geographically limited, and unavailable to communities that need it most. Health consultations that include cardiovascular considerations can improve life expectancy without extra costs. The Doctors With Heart (DWH) is an initiative from the American Heart Association (AHA) initially developed to decrease gaps in care by using telemedicine as a vehicle for cardiovascular consultations between volunteer cardiologists and primary care providers at Federally Qualified Health Centers (Health Centers). Despite efforts to on-board and train Health Centers on the consultation process and benefits to patient care, consultation utilization remained low. Objective: Identify opportunities to enhance DWH to increase consultation utilization by understanding the need for and barriers to conducting consultations among Health Centers already participating in DWH. Methods: An AHA Program Evaluator and the DWH Program Director co-conducted interviews and focus groups with 31 health care professionals from five Health Centers in the Midwest participating in DWH. Thematic analysis revealed key themes across evaluation objectives. Results: Interviewees had mixed feelings about the need for consultations which was largely driven by the barriers they perceived to conducting them. Many interviewees felt consultations could be an effective way to expedite care for patients who need specialty cardiovascular care. They could also help patients with complex but manageable co-morbidities since the patient can receive cardiovascular care within the primary care setting. However, a few providers felt they already had sufficient access to cardiovascular care for their patients. Interviewees identified three key barriers to conducting consultations: time and administrative burden for providers and staff, providers forgetting the consultations exist, and provider hesitations and concerns. During Health Center on-boarding, DWH should work with Health Centers to integrate consultations into existing clinic workflows, identify a program champion at each site, train multiple clinic staff about the program, and secure buy-in from providers. After Health Center on-boarding, DWH and Health Center program champions should find ways to regularly remind providers about the program and determine whether non-provider staff can help providers identify potential consultation cases. Conclusion: While there was an identified need for cardiology consultations among many Health Centers, more support from DWH and Health Center staff and leadership is needed to establish the program within the clinic setting and ensure on-going consultation utilization. DWH can implement strategies to facilitate consultations during Health Center on-boarding and program implementation.

A Social Network Analysis of a Multi-sector Service System for Intimate Partner Violence in a Large US City

About one in four women in the US report having experienced some form of intimate partner violence (IPV) during their lifetime and an estimated 15.5 million children live in families in which IPV occurred in the past year. Families of young children with IPV experiences often face complex needs and require well-coordinated efforts among service providers across social and health sectors. One promising partnership aims to support pregnant and parenting IPV survivors through coordination between IPV agencies and community-based maternal and early childhood home visiting programs. This study used social network analysis (SNA) to understand the interconnectedness of the system of IPV prevention and intervention for families with young children in a large US city. The SNA included 43 agencies serving this population across various service domains spanning IPV, legal, maternal and child health, and public benefit programs. An SNA survey collected data on four forms of collaboration between agencies, including formal administrative relationship, referral reciprocity, case consultation, and shared activities in community committees/organizing bodies. Density and centrality were the primary outcomes of interest. A community detection analysis was performed as a secondary analysis. The overall level of interconnectedness between the 43 responding agencies was low. Making referrals to each other was the most common form of collaboration, with a network density of 30%. IPV agencies had the highest average number of connections in the networks. There was a high level of variation in external collaborations among home visiting agencies, with several home visiting agencies having very few connections in the community but one home visiting program endorsing collaborative relationships with upwards of 38 partner agencies in the network. In serving families at risk for IPV, home visiting agencies were most likely to have referral relationships with mental health provider agencies and substance use disorder service agencies. A community detection analysis identified distinct communities within the network and demonstrated that certain agency types were more connected to one another while others were typically siloed within the network. Notably, the IPV and home visiting communities infrequently overlapped. Sensitivity analyses showed that survey participants’ knowledge of their agencies’ external collaborations varied by their work roles and agencies overall had low levels of consensus about their connectedness to one another. We identified a heterogeneous service system available to families of young children at-risk for or experiencing IPV. Overall inter-agency connectedness was low, with many siloed agencies and a lack of shared knowledge of community resources. Understanding current collaborations, silos, and centrality of agencies is an effective public health tool for allocating scarce resources across diverse service sectors to efficiently improve the system serving families experiencing IPV.

Supportive Care Needs of Newly Diagnosed Cancer Patients in a Comprehensive Cancer Center: Identifying Care Profiles and Future Perspectives.

The prompt introduction of supportive care for patients with cancer leads to a better quality of life, potential survival benefits, and improvements in treatment safety. Considering that patients' needs vary, descriptive assessments could serve as a compass for an efficient and prompt healthcare response. The aim of this study was to identify supportive care needs in newly diagnosed patients according to cancer type. A retrospective study was conducted by collecting data from the case consultation and medical records of a comprehensive cancer center in France. Patients' needs were divided into twelve domains: nutrition, psychological support, psychiatric support, social care, physiotherapy, addictology, pain management, palliative care, pharmacology, complementary and alternative practice (CAM), sexual health, and speech therapy. Out of 6217 newly diagnosed patients of various cancer types who sought medical care at Gustave Roussy in 2021, 2541 (41%) required supportive cancer care (SCC), and of them, 1331 patients (52%) required two or more different SCC specialist interventions. The top five interventions were dietary (for 60% of patients), physiotherapy (33%), psychology (29%), social care (28%), and pain management (16%). Subgroup analysis according to cancer department highlighted additional specific needs: CAM for breast cancer patients (11%), speech specialist (27%) and addictologist (22%) interventions for ENT patients, psychiatry consultations for neurological patients (16%), and palliative care for dermatology patients (23%). The aforementioned data suggest that an early, multidisciplinary supportive care intervention should be required. Assembling human resources at the time of diagnosis within a dedicated day unit would be the next appropriate step in developing personalized care pathways related to the highlighted needs.

Specific Trends in Pediatric Ethical Decision-Making: An 18-Year Review of Ethics Consultation Cases in a Pediatric Hospital.

This is a qualitative examination of ethics consultation requests, outcomes, and ethics committee recommendations at a tertiary/quaternary pediatric hospital in the U.S. The purpose of this review of consults over an 18-year period is to identify specific trends in the types of ethical dilemmas presented in our pediatric setting, the impact of consultation and committee development on the number and type of consults provided, and any clinical features and/or challenges that emerged and contributed to the nature of ethical situations and dilemmas. Furthermore, in reviewing clinical ethics consultation trends for nearly two decades, we can identify topic areas for further ethics education and training for ethics consultants, ethics committee members, and pediatric healthcare teams and professionals based on our experiences. Our study with nearly two decades of data prior to the COVID-19 pandemic can serve as groundwork for future comparisons of consultation requests and ethics support for pediatric hospitals prior to, during, and following a pandemic.

Granulation tissue-like spindle cell (sarcomatoid) carcinoma of the head and neck: a deceptively bland-looking underdiagnosed malignancy

The diagnosis of head and neck spindle cell squamous carcinoma (SC-SCC) is often challenging. Lesions with a prominent inflammatory infiltrate and reactive vessels may have a granulation tissue-like appearance, therefore being difficult to distinguish from reactive lesions, like contact ulcers, post-intubation granulomas, inflammatory pseudotumors, or benign vascular lesions. In this study, we analyzed the clinicopathological features of a series of 17 head and neck SC-SCC with granulation tissue-like appearance. All patients, but two, were males, ranging in age between 57 and 80 years. The larynx was the most frequently affected site (n = 12), followed by the tongue (n = 4). One tumor was hypopharyngeal. Most consult cases were submitted with benign suggestion or because of unexpected recurrences of granulation tissue polyps. Histologically, all lesions consisted of an ulcerated polypoid proliferation of moderately to markedly atypical spindle cells, with a minor component of conventional invasive or in situ squamous carcinoma. At least one cytokeratin cocktail was positive in 13 cases. The staining was limited to a few neoplastic cells in most cases. Positivity for p63, p40, and cytokeratins 5/6 was detected only in the conventional squamous cell carcinoma component, when present. ALK1 was negative in all cases. Sixteen cases were tested for p53 and all showed aberrant expression (12 diffusely positive and 4 of null-phenotype). The diagnosis of granulation tissue-like SC-SCC is challenging due to the close clinical and histological overlap with several benign conditions. Since the expression of epithelial markers is limited, the use of an immunohistochemical panel including p53 is recommended.