Team Decision Research Articles

P63-5 Cases of atypical femur fractures; the rare adverse events requiring the multidisciplinary team decision-making

P63-5 Cases of atypical femur fractures; the rare adverse events requiring the multidisciplinary team decision-making

Safety and feasibility of a real-time electronic heart team decision-making approach in patients with complex coronary artery disease: a protocol for a randomised controlled trial (EHEART trial)

IntroductionThe implementation of a heart team still faces many challenges which may be facilitated with advanced communication technology. There is a knowledge gap to support the use of an electronic...

Evaluating the performance of artificial intelligence software for lung nodule detection on chest radiographs in a retrospective real-world UK population

ObjectivesEarly identification of lung cancer on chest radiographs improves patient outcomes. Artificial intelligence (AI) tools may increase diagnostic accuracy and streamline this pathway. This study evaluated the performance of commercially...

PAEDIATRIC-15 MANAGEMENT OF PEDIATRIC CENTRAL NERVOUS SYSTEM TUMORS BY A NEURO-ONCOLOGY MULTIDISCIPLINARY TEAM : OUR EXPERIENCE

Abstract The outcome of pediatric central nervous system tumors has improved over the past decades due to advances in diagnostic testing, treatment and increased understanding of the disease biology. Nevertheless, the probability of survival of this tumors remains much lower in low-to middle-income countries. The gaps that prevent optimal clinical management of brain tumors are multifactorial and mostly related to underdiagnosis; a lack of specialized and dedicated radiologic, histopathologic, neurosurgical, radiotherapeutic, and oncology services, and a deficiency of coordinated multidisciplinary care in many centers. The aim of this report was to evaluate the impact of multidisciplinary team meetings on the clinical management of pediatric central nervous system tumors in Abidjan (Côte d'Ivoire). We retrospectively reviewed the clinical data of pediatric patients (aged <15 years) with central nervous system tumors diagnosed and treated in the Neurosurgery Department and National Center of Radiotherapy between 2019 (the year a neuro-oncological multidisciplinary staff was established) and 2023. Data on patient demographics, clinical notes, imaging studies, tumor characteristics and multidisciplinary team decision were collected from the multidisciplinary team database. During the multidisciplinary team meetings era, 40 pediatric central nervous system tumors were diagnosed and treated. The median age at diagnosis was 8.5 years. The mostly histological types were high grade and low grade gliomas. Decision-making was largely consistent with available guidelines. Therapeutic were surgery, external beam radiation treatment with concurrent and adjuvant chemotherapy. Benefits of neuro-oncology multidisciplinary team include coordination, direction for complicated cases, education, and a forum for communication, and clinical trials.

Youth as essential problem-solvers of our futures

Youth as essential problem-solvers of our futures Nancy Butler Songer, Associate Provost of STEM Education at the University of Utah, discusses the importance of supporting and including young people as part of environmental decision-making teams and key problem-solvers of our futures. The New York Times calls the environmental threat of the Great Salt Lake in the United States an “Environmental Nuclear Bomb.” Even as water levels continue to decline (e.g., the 2022 average lake level was the lowest on record; Great Salt Lake Strike Team, 2023), regional population and water consumption continue to grow. The result is not only a dying off of the lake’s brine shrimp that support a stable ecosystem but the development of poisonous dust plumes that threaten human health.

Top Management Team Expansion Study: A New Approach Based on the Team Life Cycle

The top management team occupies the position at the top of the organizational management hierarchy, is charged with making strategic decisions, and is crucial to the success of the entire business. The study of top management teams has increased dramatically since the publication of the upper echelons theory. The research findings on the relationship between demographic characteristics and their differences and corporate performance, however, lack stability. This is true whether discussing the relationship between the characteristics of the top management team and organizational performance from the perspective of the team's demographic characteristics and their differences or concentrating on the top management team's interaction process to study the mediating role of team process variables between the team's demographic characteristics and strategic decisions and corporate performance. This paper explores a unique research path for the study of top management teams by reviewing the research lineage of these teams, analyzing the shortcomings of previous studies, and proposing a new line of inquiry based on the team life cycle viewpoint.

A Comprehensive Primer on Radiation Oncology for Non-Radiation Oncologists.

Background: Multidisciplinary management is crucial in cancer diagnosis and treatment. Multidisciplinary teams include specialists in surgery, medical therapies, and radiation therapy (RT), each playing unique roles in oncology care. One significant aspect is RT, guided by radiation oncologists (ROs). This paper serves as a detailed primer for non-oncologists, medical students, or non-clinical investigators, educating them on contemporary RT practices. Methods: This report follows the process of RT planning and execution. Starting from the decision-making in multidisciplinary teams to the completion of RT and subsequent patient follow-up, it aims to offer non-oncologists an understanding of the RO's work in a comprehensive manner. Results: The first step in RT is a planning session that includes obtaining a CT scan of the area to be treated, known as the CT simulation. The patients are imaged in the exact position in which they will receive treatment. The second step, which is the primary source of uncertainty, involves the delineation of treatment targets and organs at risk (OAR). The objective is to ensure precise irradiation of the target volume while sparing the OARs as much as possible. Various radiation modalities, such as external beam therapy with electrons, photons, or particles (including protons and carbon ions), as well as brachytherapy, are utilized. Within these modalities, several techniques, such as three-dimensional conformal RT, intensity-modulated RT, volumetric modulated arc therapy, scattering beam proton therapy, and intensity-modulated proton therapy, are employed to achieve optimal treatment outcomes. The RT plan development is an iterative process involving medical physicists, dosimetrists, and ROs. The complexity and time required vary, ranging from an hour to a week. Once approved, RT begins, with image-guided RT being standard practice for patient alignment. The RO manages acute toxicities during treatment and prepares a summary upon completion. There is a considerable variance in practices, with some ROs offering lifelong follow-up and managing potential late effects of treatment. Conclusions: Comprehension of RT clinical effects by non-oncologists providers significantly elevates long-term patient care quality. Hence, educating non-oncologists enhances care for RT patients, underlining this report's importance.

THU011 Cushing’s Disease Diagnosis Challenge With Standard Pituitary MRI: A Clinical Case Report

Abstract Disclosure: E. Kasiri: None. N. Shah: None. Introduction: Cushing’s disease (CD); the most common cause of endogenous Cushing’s syndrome (CS) is mainly caused by an adrenocorticotropin (ACTH)-secreting pituitary adenomas. Although MRI remains the preferred imaging to detect these adenomas, still about 50% of microadenomas may be missed using standard 1.5-Tesla MRI and on the other hand higher resolution MRI with 3T magnets is not widely used. Here we present a case of Cushing’s disease with equivocal 1.5T MRI which made a next step of management rather challenging. Case presentation: A 57-year-old female with history of hypertension, type 2 diabetes mellitus and obesity (BMI: 34.41 kg/m2) presented to our endocrinology clinic to establish care. Her main complaint was difficulty losing weight. She denied taking any steroids or oral contraceptive pill. Vitals showed BP: 124/85 mm Hg, HR: 100 bpm and T: 98.3 °F. Physical exam was significant for moon facies, buffalo hump and abdominal obesity. She was screened for Cushing syndrome with 1mg overnight low dose dexamethasone test which resulted in abnormal cortisol response with a level of 2.1mcg/dl (<1.8 mcg/dl). A 24hr urine free cortisol: 7.3 mcg/dl (<45 mcg/dl) and two late night salivary cortisol measurements resulted in 0.388 and 0.229 mcg/dl (> 3 times upper limit of normal). Other labs showed elevated baseline ACTH :67.4 pg/ ml (7.2 - 63.3 pg/mL), cortisol :19.4 mcg/dl (4.5-23 mcg/dl) and normal DHEAS:1864.1ng/ml (650-3400 ng/mL). We decided to distinguish ectopic vs pituitary source of hypercortisolism by an 8 mg (high dose) dexamethasone suppression test which showed suppressed ACTH <1.5 pg/ml, Cortisol :2.6 mcg/dl (>50% suppression from baseline) suggesting pituitary origin. The standard pituitary 1.5T MRI with and without contrast as next step resulted in questionable microadenoma in the right aspect of pituitary gland and was equivocal. Within the multidisciplinary team decision was made to perform 3T pituitary MRI rather than invasive inferior petrosal sinus sampling (IPSS) which confirmed the pituitary microadenoma of 8.1 mm size with no mass effect and patient is scheduled for transsphenoidal pituitary surgery without needing further testing. Discussion: 3T MRI, with higher magnetic field than 1.5T allows to improve image quality and help with tumor detection in Cushing’s disease. It reportedly has higher sensitivity (80%) and specificity (∼100%) compared to 1.5T MRI which has overall sensitivity and specificity of 71% and 87% respectively. However, it is not the first to order by the clinicians when evaluating the ACTH secreting pituitary adenoma. In the case of equivocal 1.5 T MRI usually the next step is IPSS which is invasive. With availability of Corticotropin Releasing Hormone in the USA being difficult, limited studies of using DDAVP and limitations in finding tertiary centers to perform IPSS, a 3T MRI would be more feasible as a next step to identify a pituitary adenoma. Presentation: Thursday, June 15, 2023

The impact of left circumflex coronary artery ostium stenosis on outcomes for patients after percutaneous coronary intervention for unprotected left main disease.

The impact of left circumflex coronary artery (LCX) ostium atherosclerosis in left main coronary artery (LM) bifurcation disease is not well-known. The study aimed to assess whether the involvement of LCX ostium carries prognostic implications in patients undergoing unprotected LM percutaneous coronary intervention (PCI). Consecutive 564 patients with unprotected LM (ULMCA) disease who underwent LM PCI between January 2015 and February 2021, with at least 1 year of available follow-up were included in the study. The first group was composed of 145 patients with ULMCA disease with LCX ostium stenosis, and the second group consisted of 419 patients with ULMCA disease without LCX ostium stenosis. Patients in the group with ULMCA disease with LCX ostium stenosis were significantly older and had more comorbidities. The two-stent technique was used more often in the group with LCX ostium stenosis (62.8% vs. 14.6%; P <0.001). During 7-year follow-up, all-cause mortality did not differ significantly between groups with and without LCX ostium stenosis (P = 0.50). The use of one-stent or two-stent technique also did not impact mortality in patients with LCX ostial lesions (P = 0.75). Long-term mortality subanalysis for three groups of patients: (1) patients with LM plus LCX ostium stenosis; (2) LM plus left anterior descending artery (LAD) ostium stenosis; (3) LM plus LCX ostium plus LAD ostium stenosis also did not differ significantly (P = 0.63). LCX ostium involvement in LM disease PCI is not associated with adverse long-term outcomes, which is highly beneficial for the Heart Team's decision-making process.

TCT-464 5-Year Outcomes in Patients With Multivessel Coronary Artery Disease Undergoing Revascularization Following Heart Team Decisions

TCT-464 5-Year Outcomes in Patients With Multivessel Coronary Artery Disease Undergoing Revascularization Following Heart Team Decisions

Sustainability and reliability-based hydrogen technologies prioritization for decarbonization in the oil refining industry: A decision support system under single-valued neutrosophic set

The purpose of the present work is to design an extended decision support system (DSS), namely the CRITIC (combining criteria interaction through inter-criteria correlation) & CRADIS (compromise ranking of alternatives from distance to ideal solution) model under the single-valued neutrosophic set. Its notable advantages are that it renders a more robust expression of uncertainty and the decision-making process is more closely managed. Also, it allows the DM to evaluate on a broader area and avoid data and conflict among the decision-making team. Therefore, the proposed extended DSS is implemented to help the strategic decision on the hydrogen technologies prioritization for decarbonization considering the sustainability and reliability principles in the oil refining industry. The results indicate that the alternative of green hydrogen from low-temperature electrolysis using solar renewable energy is the most suitable scenario for the decarbonization in the oil refineries located in south Iran, in particular the Abadan's oil refinery.

A case report of Rosai–Dorfman disease of the breast

Abstract Rosai-Dorfman disease (RDD), or sinus histiocytosis with massive lymphadenopathy, is a benign, self-limiting disease. In the majority of cases, there is massive and painless lymphadenopathy in any lymph node group but most commonly in the cervical lymph nodes, associated with constitutional symptoms. Extranodal involvement has been reported to occur in almost every organ system, with or without concomitant nodal disease. The breast is a rare site of presentation of this disease. A 52-year-old female presented with a hard, nodular swelling(3x2cm) in the left breast, with a clinical suspicion of malignancy. Atypical cells were note in fine needle aspiration smears. Histopathology and immunohistochemistry were of critical importance and showed a specific pattern of histiocytosis. A diagnosis of Rosai-Dorfman disease (RDD) was made. RDD of the breast is a rare form of histiocytosis, with fewer than 100 globally published cases. Although the management of this disease is not established yet by guidelines, a follow-up approach should be enough for these patients, and surgery might be overtreatment. Mortality from RDD is very low due to comorbidities. A multidisciplinary team decision is important, and abstinence might significantly benefit these patients.

A fuzzy multiobjective team decision model for CODP and supplier selection in customized logistics service supply chain

To address information vagueness and uncertainty of the order demand, the logistics service provider (LSP) service capacity and the target preference caused by emergency events, a multiobjective team optimization model is developed for the customer order decoupling point (CODP) decision, supplier selection and order quantity allocation problems in customized logistics service supply chain. Three important techniques are described: (1) Fuzzy objective coefficients due to the uncertainty of the order and objective weights. (2) Fuzzy constraint parameters due to LSP service capacity and order demand variations. (3) A fuzzy single objective weighting technique with acceptance coefficient of constraint and fuzzy parameters that reflects decision-maker preferences. The acceptance coefficients of the constraints are integrated into the single objective model, which reflects the satisfaction level of the logistics service integrator (LSI) for feasible solutions. Then, we perform fuzzy decision and feasible solution design based on the center of gravity method defuzzification and maximum membership degree principle. To optimize decisions for decision-makers, the effects of some important fuzzy objective coefficients and fuzzy constraint parameters on the CODP decision and the acceptance coefficient of constraint was explored through sensitivity analysis. Numerical experiments show that the scale effect coefficient and objective function threshold have greater effects on the CODP decision.

Changes in multidisciplinary team decisions in a high volume head and neck oncological center following those made in its preferred partner.

Head and neck cancer care is highly complex, and multidisciplinary team meetings (MDTs) are vital for improved outcomes. In the Netherlands, head and neck cancer care is practiced in eight high-volume head and neck oncologic centers (HNOC) and six affiliated hospitals preferred partner (PP) centers. Patients treated in the PP are presented and discussed in the HNOC. To evaluate the importance of these mandatory and decisive steps in decision making, we have assessed the changes in treatment. Retrospective evaluation of head and neck cancer patients referred between January 2011 and October 2018 for a MDT evaluation to the HNOC was conducted. The differences in MDT recommendation were classified with regards to major and minor changes. Management recommendation(MR) changed after 113 of 515 MDT discussions within the PP (487 patients; 22%), of which 86 cases (16%) were major changes. In 67 cases (59.3%), escalation of management was recommended, while in 43 cases (38.1%) de-escalation was recommended. There was a high rate of change of MRs, when comparing the PP recommendations with the HNOC recommendations. Since patient and tumor characteristics seem unable to predict these changes, we recommend all patients be seen for a clinical presentation, revision of diagnostics, and MDT discussion in a high volume HNOC.

Prevalence and Risk Factors for Moral Distress in Pediatric Oncology Health Care Professionals.

Moral distress (MoD) is prevalent among health care professionals (HCPs) in oncology and is associated with burnout. The objectives of this study were to quantify MoD among pediatric oncology healthcare professionals (HCPs) at a Canadian quaternary care hospital, identify root causes, and evaluate change over time. Eligible pediatric oncology HCPs were identified, and consenting participants completed the Measure of Moral Distress-Healthcare Professionals (MMD-HP) and MoD Thermometer (MDT) at baseline, followed by biweekly MDTs over 12 weeks. A total of 139 HCPs participated. The mean MMD-HP score was 123 ± 57.0, range 9-288. Demographic risk factors identified for elevated MMD-HP scores were female sex (female 127.1 and male 83.6, P = .01) and nursing role (nurse 136.3 and most responsible physician 85.3, P = .02). Higher MMD-HP scores were found in HCPs who were currently considering resigning because of MoD compared with those who were not (169.9 v 115.4, P < .001). Situations involving administration of treatment to children with poor prognosis cancers that was perceived to be overly aggressive were ranked as the greatest environmental contributor to MoD. Baseline and mean MDT scores over time strongly correlated with MMD-HP scores (P < .0001 and P = .0003, respectively), with mean MDT scores showing no significant fluctuation over the 12-week period. MoD was common among pediatric oncology HCPs. Risk factors for elevated levels of MoD included both demographic and environmental factors. Implementation of systems to improve team communication and decision making, especially in the care of patients with poor prognosis cancers, may affect HCP MoD.

27 Neuroendocrine tumour of the breast: A case report &amp; Literature review

Abstract Introduction Neuroendocrine differentiation in breast carcinomas was first described by Feyrter and Hartmann in 1963, based on positive silver staining in mucinous carcinomas of the breast. NEBC are heterogeneous group of rare breast tumours which account for &amp;lt; 0.1 % of breast tumour and &amp;lt; 1% of neuroendocrine tumours. Case A 65-year-old female presented with a 12 x 10 cm non-tender hard globular slightly mobile mass in upper medial /inner quadrant of right breast with overlying 2 cm scar mark and bilateral axillary lymphadenopathy. Mammography revealed a BIRADS-4 lesion and FNAC showed atypical cells. Octreotide Scan showed that the mass was neuroendocrine in origin. Further CT imaging showed no other site for metastasis. She was managed with a Right sided modified radical mastectomy (MRM) after multidisciplinary team (MDT) decision. Biopsy of the Lesion showed ER, PR receptor &amp; synaptophysin receptor positivity, negative Her 2-neu status, ki-67 proliferation index of 10% &amp; grade II NET. Conclusion Primary neuroendocrine tumours of the breast are infrequent tumours that appear in women aged 60–70 years. Their diagnosis is complex as they lack defining clinical and radiological characteristics. Their low incidence makes it impossible to establish an optimal treatment protocol.

The Importance of Looking at the REST of the Swallow in Patients With Head and Neck Cancer

Purpose: The swallowing continuum is highly complex and interrelated and has both upstream and downstream implications for volitional swallowing behaviors, anatomic and physiologic impairments, and interventions. Pathologic reflux can cause a plethora of upstream anatomic and physiologic changes in the swallow with associated consequences. Although pathologic reflux can occur in isolation, there is a high incidence of both pathologic reflux and esophageal pathology in patients with head and neck cancer. Along with their known oropharyngeal dysfunction that can evolve over time posttreatment and cause downstream effects in the swallowing continuum, pathologic reflux and esophageal pathology can cause upstream effects, further complicating the interplay and contributing to the overall swallowing impairment. Conclusions: The entire swallowing continuum should be evaluated with videofluoroscopy at yearly intervals in patients with head and neck cancer so that the multidisciplinary dysphagia team understands the interplay, which informs best interventions. The Robust Esophageal Screening Test (REST) is a standardized, validated esophageal screening protocol that can be implemented during the videofluoroscopic swallowing study to better identify potential esophageal pathology, which can be of complex etiology in this population. Results of a recent quality improvement project implementing REST protocol with patients with head and neck cancer found significant esophageal pathology and enhanced team collaborations and decision making for optimal patient care (Gregor &amp; Watts, 2022).

Structure of multidisciplinary heart teams, a survey-based heart team study.

Multidisciplinary approach is well established in various disciplines, with evidence highlighting improved patient outcomes. The objective of this survey was to determine the real-world practice of heart teams across Europe. The survey was drafted after a consensus opinion from the authors. The survey was sent to cardiac surgeons and cardiologists identified through electronic search. The survey link and the information sheet were sent through email followed by survey completion reminders. The survey responses were cumulated and analysed. Among 2188 invited clinicians, 220 clinicians from 26 countries took part in the survey (response rate 10%). The completion rate for the survey questions was 85%. A total of 140 (64%) were cardiac surgeons and 80 (36%) were cardiologists. The heart team meeting frequency was weekly according to 104 (55%) respondents. This was conducted face to face according to 139 (73%) of the responses. Eighty-seven (56%) of the respondents reported 10-20% of patients undergoing percutaneous coronary intervention were discussed at the heart team meeting. Seventy-nine (47%) respondents had ad hoc percutaneous coronary intervention institutional guidelines. Fifty-four (32%) respondents reported an audit process for the heart team decisions. This survey suggests that there is marked variability in the infra-structure and execution of heart teams in different institutions. The results of the survey suggest a need to formulate guidelines on the composition and execution of heart teams which may result in an increase in transparency of decision-making within different institutions in reporting and comparing outcomes.

The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine.

Despite general agreement on the benefits of the Heart Team approach for patients with cardiac diseases, few data are available on its real impact on the decision-making process. The aim of the study is to define the evolution over time of the level of agreement with the systematic discussion of patients in the Heart Team and to evaluate the adherence to the Heart Team recommendations and the impact of the Heart Team on the clinical outcome of the patients. In 2015--2016, an experienced cardiac surgeon and a cardiologist independently reviewed clinical data of a series of 100 patients (Group 1, G1) and subsequently for each patient recommended treatment (surgical, percutaneous, hybrid or medical therapy) or further diagnostic investigations. The next day, each case was discussed by the Hospital Heart Team. The Heart Team recommendation, the subsequent treatment received by the patient and the in-hospital outcome were recorded. The same study procedure was repeated in 2017 in a second (G2) and in 2018 in a third (G3) group, both of them including 100 patients. Complete agreement in treatment selection by the cardiac surgeon, cardiologist and the Heart Team was observed in 43% of cases in G1 and in 70% and 68% in G2 and G3, respectively (G1 vs. G2: P < 0.001, G1 vs. G3: P = 0.01, G2 vs. G3: P = 0.30). Agreement was less frequent in patients with a higher risk profile and in patients with aortic valve stenosis. The Heart Team decision was implemented in 95% of cases with a 30-day mortality of 0.67%. Agreement in treatment selection among the cardiac surgeon, cardiologist and Heart Team appears to be low in the initial experience. Subsequently, it seems to steadily increase over time up to a limit, when it reaches a plateau of stable results. Heart Team clinical cases discussion, based on both guidelines and multidisciplinary experience, represents a key step in defining the best patient treatment pathway, potentially improving the decision-making process and clinical results.

Demystifying Critical Success Factors for Applying Value Management in Construction Projects along the Belt and Road Regions: Focus Group Study

The Belt and Road (B&R) initiative creates a highly competitive and dynamic environment and cooperation network for construction projects in specific regions. By using the experience of other countries, construction professionals can be well-equipped with management skills for solving intractable problems during the project management process of a construction project. Value management (VM) is a systematic team decision-making methodology used to achieve the best project value, but it is rarely applied in developing regions along the B&R. This study aims to identify critical success factors for the implementation of VM in construction projects in both developed and developing regions along the B&R. Six focus groups targeting three groups of regions were conducted, including advanced VM developed regions (Regions 1), advanced VM developing regions (Regions 2), and unadvanced VM developing regions (Regions 3). Three main groups of critical success factors were identified by using contextual analysis: technical process, team behaviors, and outcomes. By comparing VM in advanced VM regions (Regions 1 and Regions 2) and traditional team decision-making in unadvanced VM regions (Regions 3), the study revealed that (1) practitioners in Regions 1 applied VM to achieve project success with a logical process and positive team behaviors, although several problems were also encountered; (2) surprisingly, in some technical respects, VM practitioners in Region 2 performed better than those in Regions 1, but positive team behaviors were still not emphasized; and (3) inefficient traditional decision-making activities with illogical technical processes and negative team behaviors in Regions 3 often led to poor project outcomes. A propositional model is established based on the identified critical success factors and comparison results among the three groups of regions. Finally, several practical recommendations are proposed to ensure effective VM application and promotion in both developed and developing regions along the B&R.