Implementation Of Multidisciplinary Team Research Articles

The role of the vascular surgeon in transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic valve stenosis in patients at increased surgical risk. Percutaneous transfemoral (TF) is the access of choice due to its reduced invasiveness and perioperative morbidity/mortality compared with the trans-axillary, aortic, and apical routes. On the other hand, vascular access complications (VACs) of the TF access are associated with prolonged hospitalization, 30-day, and 1-year mortality. In addition, the concomitance of peripheral arterial disease may require associated endovascular management. A multidisciplinary team with Interventional Cardiologists and Vascular Surgeons may minimize the rate of VACs in patients with challenging femoral-iliac access or concomitant disease of other vascular districts, thus optimizing the outcome of TF-TAVI. The aim of this study was to evaluate the role of Vascular Surgeons in TF TAVI procedures. We conducted a retrospective single-center review of all TF-TAVI procedures assisted by Vascular Surgeons between January 2016 and December 2020 in a high-volume tertiary hospital. Pre, intra, and postoperative data were analyzed by a dedicated group of Interventional Cardiologists and Vascular Surgeons. VACs were defined according with the Valve Academic Research Consortium (VARC) three guidelines. The outcomes of TF-TAVI procedures with Vascular Surgeons involvement were assessed as study's endpoints. Overall, 937 TAVI procedures were performed with a TF approach ranging between 78% (2016) and 98% (2020). Vascular Surgeons were involved in 67 (7%) procedures with the following indications: concomitant abdominal aortic aneurysm (EVAR + TAVI) - 3 (4%), carotid stenosis (TAVI + CAS) - 2 (3%), hostile femoral/iliac access, or VACs - 62 (93%). Balloon angioplasty of iliac artery pre-TAVI implantation was performed in 51 cases (conventional PTA: 38/51%-75%; conventional PTA + intravascular lithotripsy: 13/51%-25%; stenting: 5/51%-10%). TAVI procedure was successfully completed by percutaneous TF approach in all 62 cases with challenging femoral/iliac access. VACs necessitating interventions were 18/937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively. They were managed by surgical or endovascular maneuvers in 3/18 (17%) and 15/18 (83%) cases, respectively. Fifteen/18 (83%) VACs were treated during the index procedure. There was no procedure-related mortality or 30-day readmission. In our experience, Vascular Surgeon assistance in TAVI procedures was not infrequent and allowed safe and effective device introduction through challenging TF access. Similarly, the concomitant significant disease of other vascular districts could be safely addressed, potentially reducing postoperative related mortality and morbidity. The implementation of multidisciplinary team with interventional cardiologists and vascular surgeons should be encouraged whenever possible.

1958 Promoting Bone Health by ensuring in-patient Ortho-geriatrician Bone Health plan in notes following Neck of Femur Fracture

Abstract Introduction and Aims Osteoporosis affects 3 million people in the UK with more than 500,000 hospital presentations annually due to fragility fractures costing in excess of £4.4 billion to the NHS. Bone protective medications are a cost-effective way of reducing fracture and admission following a fall. The Royal College of Physicians National Hip Fracture Database targets that patients are: “given suitable bone strengthening treatment and followed up to ensure that they are still receiving this protection 120 days after fracture”. Lewisham Hospital achieves this in only 22% of suitable patients against a national average of 35%. This project aimed to increase the number of eligible NOF patients on bone protective medication. Method Data was collected for patients over the age of 65 admitted with NOF. 22 eligible patients were admitted from 01/01/23 to 28/02/23 and 16 from 01/03/23 to 31/05/23. It was identified whether an appropriate bone health plan, including FRAX and calcium/vitamin D supplementation, was recorded in the medical notes and electronic departure note (EDN). Interventions included an advice sheet for rotating doctors, additional education at induction and a bone health proforma for medical notes and EDNs. Results 86% of patients in cohort one had bone health plans in their notes and 59% in their EDN. 64% commenced bisphosphonates with 1 eligible patient (4.5%) not receiving medication. After the interventions 100% patients had a bone health plan in their notes and 80% on their EDN. 46.7% of this cohort commenced on bisphosphonates which equated to 100% of patients appropriate for bone protective medication. Conclusion(s) Providing guidance and education to rotating doctors to ensure Geriatrician-led bone health planning resulted in all eligible patients commencing bone protective medication and total numbers above the national average.

2009 Integrated physical-mental health care models for older people under specialist mental health services: a systematic review

Abstract Background Older people have complex health needs, with the inter-play between physical and mental health being a prominent issue. The ageing population has resulted in a large proportion of older people living with co-occurring physical and mental health disorders, which can prove challenging to manage simultaneously, particularly for serious mental illness. The aim of this systematic review was to explore models of integrated physical-mental health care available for older people, and whether these result in improved health outcomes. Sources of heterogeneity in the current evidence base alongside limitations were also explored. Methods Medline, Embase, CINAHL, PsycINFO and Scopus were searched with a predefined search strategy, generating 5257 articles. Studies were suitable for inclusion where an integrated physical-mental health care service model was utilised in a population of older people (aged >60 years) with a mental health diagnosis and at least one concomitant physical health condition requiring physical health care input. All studies were quality assessed for risk of bias and results were synthesised narratively. Results Ten studies met the inclusion criteria. All studies incorporated service models involving integrated and/or multidisciplinary care. These included joint medical-mental health wards as well as the implementation of multidisciplinary teams in hospital and care facilities. Overall, this enhanced the quality of care for elderly patients with benefits including but not limited to, enhanced patient experience, the expansion of multidisciplinary team practice, improved management of illness, and timely intervention. Conclusions Multidisciplinary and integrated care resulted in improvement of a range of health outcomes for older people with combined physical and mental health needs. Larger and more robust studies are needed to explore the development of these service models further, with cost-effectiveness analyses.

P242 CARDIOGENIC SHOCK WITH ISCHEMIC PHENOTYPE SECONDARY TO INCESSANT VENTRICULAR TACHYCARDIA: A CALL FOR IMPLEMENTATION OF HUB–AND–SPOKE MODEL

Abstract A 55–years–old patient presents to emergency room with extensive anterior STEMI, complicated by acute pulmonary edema. The ECG showed sinusal tachycardia, Q waves in V1–V3, ST elevation >2mm V2–V6. The echocardiogram showed akinesia of the apex and anterolateral wall with severe reduction of contractile function (LVEF 30%). The patient was treated with CPAP, dual antiplatelet therapy and diuretics; the urgent coronary angiography showed three–vessel disease with occlusion of the proximal LAD, treated with PCI and two drug–eluting stents implantation. 48 after admission to ICU, the patient developed "combined" shock (IC↓ RVS↓ WP↑), sustained by both severe cardiac dysfunction and a septic complication, requiring inotropes and targeted antibiotic therapy (noradrenaline 0.02 gamma/Kg/min and piperacillin/tazobactam i.v). At 96 hours there was a recovery of contractile function and haemodynamics (CI from 1.8 to 2.7). Weaned from inotropes, he began therapy with low doses of ACE inhibitor, beta blocker, antialdosteronic. On the 7th day of hospitalization, without ischemic and/or electrolyte "triggers", the patient developed "arrhythmic storm" with incessant sustained ventricular tachycardias. Arrhythmias persisted despite antiarrhythmics (magnesium sulfate, amiodarone, lidocaine), IOT, sedation, mechanical ventilation. The temporary pacemaker for overdrive pacing was placed in. After placement of IABP, the patient underwent revascularization of residual coronary artery stenosis. Despite 1 hour of assistance (ABLS), incessant ventricular tachycardia persisted; a third–level center for VA–ECMO inside support was called. After positioning VA–ECMO there was progressive clinical stabilization and –concomitantly– a progressive reduction of ventricular tachycardias. ECMO support was needed for over 7 days due to persistence of arrhythmic storm; it was slowly weaned with stabilization of the patient; an AICD was implanted. Residual function of the left ventricle was mild reduced (LVEF40%) despite protracted CPR. There wasn’t residual cognitive impairment. Implementation of multidisciplinary teams in the spoke centers would improve protocols and early treatments in patients with cardiogenic shock; spoke centers would provide early access to life–saving therapies and safe transfer to hub centers.

Competences of nurses in the Family Health Strategy: an integrative literature review

The Family Health Strategy is recognized as a proposal for the reorientation of the care model, carried out through the implementation of multidisciplinary teams in basic health units. The practical management of nurses is an important instrument for the implementation of health policies. The aim of this research is to identify the scientific evidence available in the literature on the competencies of nurses in the Family Health Strategy. The study presents the results of an integrative review of the literature on the process of practical management of nursing care in the Family Health Strategy. We analyzed 17 articles from the selection in the databases of the Virtual Health Library, with a time frame from 2018 to 2022. The PICo strategy was used, where P = Participants, I = Area of Interest, Co = Outcome of the study. The analysis of the literature highlights the importance of nurses inserted in the work process of the Family Health Strategy. The results show that practical management and care are inseparable for the work organization process.

Global Perspectives in Acute Kidney Injury: Spain.

Global Perspectives in Acute Kidney Injury: Spain.

Innovative Methodology for Strengthening a Multidisciplinary Team Approach in Cities in Low- and Middle-Income Countries.

Delivering high-quality cancer care to patients through a multidisciplinary team (MDT) care approach remains a challenge, particularly in low- and middle-income countries characterized by fragmented health systems and limited human resources for cancer care. City Cancer Challenge (C/Can) is supporting cities in low- and middle-income countries as they work to improve access to equitable quality cancer care. C/Can has developed an innovative methodology to address the MDT gap, piloted in four cities-Asunciòn, Cali, Kumasi, and Yangon. Collaborating with a network of partners, C/Can and ASCO have developed a package of technical cooperation support focusing on two priority areas that have emerged as core needs: first developing consensus-based, city-wide patient management guidelines for the most common cancers and second, building capacity for the implementation of MDTs in institutions providing cancer care in the city. The real-time application of C/Can's MDT approach in Cali and Asuncion underlined the importance of engaging the right stakeholders early on and embedding MDT guidelines in local and national regulatory frameworks to achieve their sustainable uptake. The results in Cali and Asuncion were essential for informing the process in Yangon, asserting the clear benefits of city-to-city knowledge exchange. Finally, the global COVID-19 pandemic prompted a rapid adaptation of the methodology from an in-person to virtual format; the unexpected success of the virtual program in Kumasi has led to its application in subsequent C/Can cities. The application of C/Can's methodology in this first set of cities has reinforced not only the importance of both resource appropriate guidelines and a highly trained health workforce but also the need for commitment to work across institutions and disciplines.

Child disability and family-centred care in East Africa: Perspectives from a workshop with stakeholders and health practitioners.

BackgroundOur understanding of child disability has undergone major changes over the last three decades transforming our approach to assessment and management. Globally there are significant gaps in the application of these 21st century models of care. There is recognition that economic, cultural, and social factors influence transitions in care and there is need to consider contextual factors.ObjectivesA two-day workshop brought together key stakeholders to discuss current models of care and their application in the East African context. This article summarises workshop proceedings and identifies a broadly supported set of recommendations that serve to set a direction for health professionals, families, family-based disability organisations, communities and government.MethodPresentations followed by facilitated round-table sessions explored specific themes with participants reporting their responses communally. Future actions were agreed upon by relevant stakeholders.ResultsMany barriers exist to care for children with disabilities in East Africa, including stigma and a lack of human and infrastructural resources. In addition, significant disparities exist with regard to access to medication and specialist care. The International Classification of Functioning framework needs to be translated to clinical practice within East Africa, with due recognition of the importance of family-centred care and emphasis on the life course theory for disability care. Family-centred care, educational initiatives, advocacy on the part of stakeholders and involvement of government policymakers are important avenues to improve outcomes.ConclusionFurther education and data are needed to inform family-centred care and multidisciplinary team implementation across East African care contexts for children with disabilities.

From "Cure" to "Care": The Role of the MultiDisciplinary Team on Colorectal Cancer Patients' Satisfaction and Oncological Outcomes.

BackgroundMultiDisciplinary Team (MDT) are held to undertake decisions regarding the whole aspect of oncological diseases. Over the years, they acquired a collaborative approach where clinical decisions are shared by all members. Different guidelines recommend the implementation of MDT, in order to improve the outcomes of these patients. Our aim is to evaluate how the implementation of MDT affects the patients’ satisfaction and adherence to treatment.MethodsA survey was submitted to every patient affected by colorectal cancer treated by the MDT of Sant’Andrea Hospital (Rome, IT). The investigation period was January 2017–March 2020. Data from patients inside the MDT were compared with patients outside the MDT to evaluate a reduction in waiting times.ResultsA total of 591 patients were collected. A total of 355 patients with colorectal neoplasia were included in our analysis. Cumulative overall survival was 79%. The average waiting time for computed tomography or colonoscopy was 14.9 days for patients in the MDT versus 24.5. A total of 201 patients were eligible for our satisfaction survey. An 89.5% of patients felt followed in their treatment. A 93.5% of patients expressed a high grade of satisfaction for the MDT design.ConclusionOur study confirms the importance of a well-structured MDT. Dedicated slots shorten the waiting time, leading to better satisfaction and faster diagnosis. Patients’ satisfaction should be considered as an index of good practice when it comes to oncological patients’ treatment.

Investigating the system effect of reporting multidisciplinary care measures for cancer services in New South Wales, Australia

BackgroundMultidisciplinary cancer care to facilitate the provision of patient centred and evidence-based care is considered best practice internationally. In 2016 multidisciplinary care measures were developed for all local health districts across NSW. The aim of this study was to identify system-level changes and quality improvement activities across the NSW cancer system linked to reporting on these measures.MethodsFocus group discussions were used to generate a synergy of ideas from key stakeholders. An exploratory descriptive approach was used within the ontological position of Framework Analysis, the analysis method chosen for this research study, sitting most closely within pragmatism. The use of Framework Analysis in the analytic strategy is because it is well-suited to addressing policy issues and maintaining specific focus within a wider dataset.ResultsTwo focus groups were held with a total of 18 purposively selected participants. Four primary themes emerged: value of electronic documentation; role clarity; relationships; and future development of measures. Key findings included that the reporting of performance measures has expedited the development of electronic documentation and data extraction from the multidisciplinary team meeting (MDT), identified barriers and facilitators to MDT data collection and supported MDT improvement activities across NSW.ConclusionsThe findings of this study have highlighted that MDTs and their meetings across NSW are harnessing technological advancements to support and further develop their MDTs, as well as the challenges of implementing new processes within the MDTM. This study adds a unique contribution to knowledge of how the reporting of measures can assist in understanding variation in the development and implementation of multidisciplinary teams, as well as highlighting future programs of work to decrease variation in multidisciplinary team meetings and quality improvement activities.

SP-0003 Multidisciplinary cancer care: Adding value in times of change

The complexity of cancer diagnosis and treatment, with the involvement of several medical specialties, levels of care and hospitals, makes the care organisation relevant in explaining quality of cancer care, both perceived by patients and in terms of clinical outcomes. Multidisciplinary teams (MDTs) working around disease-based tumor boards are the most appropriate way to deal with the clinical decision making, although they are implemented through different ways in the healthcare services. A review of the evidence showed the impact of this approach on improved quality of care and clinical outcomes, even though there are limitations related to the observational nature of most of these studies. Nevertheless, the implementation of MDTs is an ongoing process with different pace and approaches and other endpoints (e.g., care coordination, enrolment to clinical trials) than the clinical ones should be taken into consideration. There are deep changes co-occurring in these times and this could affect how MDTs are conceived and organized. First, the value-based health care would be discussed as an emerging paradigm in cancer care. The contribution of MDTs should consider this framework, which is focused on outcomes as assessed by patients and its associated costs. In this sense, the way patients interact with MDTs could be a relevant point, for instance with the use of PROMs, which together with the information provided by Clinical-Decision Support Systems, modify the exclusive use of medical information by healthcare professionals when making decisions. Networks are another organizational change in the way cancer care is delivered. Whatever way the collaborative networking is formulated, this approach raises some additional questions on radiation oncology due to the concentration of most of the equipment in tertiary hospitals. Radiation oncology should discuss the role they should play in this dynamic environment in which MDTs are increasingly interconnected with the larger health ecosystem (beyond the hospital setting). The need for radiation oncologists to work within the MDTs in a network to coordinate the journey of the patients through different providers and levels of care, or the need to consult expert professionals from other institutions, is a reality to be faced while preserving the involvement of all medical specialties in the therapeutic decision-making process. Finally, a third point to be discussed in the presentation will be the impact of information and communication technologies (ICTs) in MDTs work. COVID pandemic has had as a major consequence the acceleration of ICTs in daily clinical practice (e.g. through teleconsultations) and the use of hypofractionated schemes, which raises the question of how innovations are disseminated and adopted across healthcare services.

Abstract PS1-05: Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system

Abstract Introduction Although temporal trends in breast conserving surgery (BCS) have been described for developed countries like the United States (US), there is a lack of information regarding the uptake of breast conservation in developing regions of the world. In developing countries, the implementation of breast conservation might be hindered by the availability of radiation therapy, lack of training among surgeons, or concerns regarding compliance with follow-up care and surveillance. In 2006, the Mexican government created Seguro Popular, which provided coverage for breast cancer care for all Mexican women, thus potentially mitigating the difficulties with obtaining care after BCS and improving access to multidisciplinary care. We undertook an overview of ten years of breast cancer surgery at our Mexican cancer center following the implementation of Seguro Popular, and explored changes in surgical technique over time. Methods A retrospective cohort analysis was conducted using the National Cancer Institute of Mexico (INCAN) database from 2006 to 2016. All patients with a diagnosis of breast cancer seen during that period were included. Patients who received surgery for breast cancer where then grouped together based on the type of surgery (mastectomy versus BCS). The effect of the year of diagnosis and of clinical stage at the time of presentation was evaluated. Logistic regression was used to model temporal trends in use of BCS over mastectomy for three 3-year periods (2006-2009, 2010-2012, and 2013-2016). Results The patient cohort consisted of 5289 women from the INCAN database, of which 4519 received some form of local surgical treatment. Sixty-one percent (n = 2764) had locally advanced disease (stages IIB-IIIC) at the time of presentation, and a quarter (n = 1156) had ≥60 days between diagnosis and receipt of surgical treatment. Eighty percent of the patients in the entire cohort (n = 3611) were treated with mastectomy, while 20% (n = 908) received BCS. For the 2006-2009 period, out of 1596 total surgeries, 9.9% were BCS (n = 158). The proportion of BCS increased for each of the other two studied periods, being 18.5% for the 2010-2012 period (n = 276/1490), and 33.1% for the 2013-2016 period (n = 474/1433) (p<0.01 for trend). While the increase in BCS was significant for all stages, it was most pronounced for women with early-stage disease (Stages I-IIA), going from 17% in 2006-2009 to 52% in 2013-2016 (p<0.01), than in those with locally-advanced disease (6.5 to 18%, p<0.01). Conclusions In the ten years after the start of the Seguro Popular public insurance program, the proportion of BCS at a Mexican cancer center increased significantly, particularly for women with early-stage disease. The rates seen at INCAN for the period between 2013-2106 resemble those reported by the US National Cancer Database, in which approximately 61% of women with stage I-II breast cancer and 20% of women with stage III disease receive BCS. Potential reasons for the increase in the uptake of BCS include improved access to adjuvant radiation therapy, improved access to systemic treatment, and higher adherence to follow-up care after the start of Seguro Popular, as well as improvements in surgical training. In addition, changes in BCS may also be related to improvements in the implementation of multidisciplinary teams over time, which may lead to a more homogeneous and comprehensive care. Our results show that improving access to care for patients living in developing countries positively impacts the uptake of BCS for women with breast cancer. Citation Format: Enrique Bargalló-Rocha, Nancy Reynoso-Noveron, Jaime Corona, Nereida Esparza-Arias, María Teresa Ramírez-Ugalde, Caros Daniel Robles-Vidal, Robin Shaw-Dulin, Armen Stankov, Rafael Vazquez-Romo, Patricia Villarreal-Colin, Sergio Aguilar-Villanueva, Jaime Hidalgo-Bahena, Milagros Perez-Quintanilla, Fernando U Lara-Medina, Juan Alejandro Torres, Enrique Soto-Perez-de-Celis, Paula Cabrera-Galeana, Alejandro Mohar, Abelardo Meneses-García. Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-05.

Toxicités sévères immuno-induites par les inhibiteurs de points de contrôle immunitaire : implications pour le réanimateur

Depuis la révolution de l’immunothérapie utilisant les inhibiteurs de points de contrôle immunitaire dans la prise en charge de nombreux cancers, les oncologues font face à de nouveaux types de toxicités dites immuno-induites. La compréhension de leurs mécanismes et la mise en place de recommandations claires sont les clés de leur prise en charge. La gravité potentielle de ces toxicités et la très nette amélioration du pronostic apportée par ces traitements pour les patients porteurs de cancers métastatiques rend le rôle du réanimateur primordial. Le but de cette mise au point est d’effectuer une synthèse des toxicités immuno-induites pouvant conduire les patients en cours de traitement par inhibiteur de points de contrôle immunitaireen réanimation et ainsi de proposer des recommandations dans leur prise en charge afin d’aider le réanimateur dans sa démarche diagnostique et thérapeutique. L’imbrication de toxicités immuno-induites pouvant toucher plusieurs organes de façon concomitante, impose une prise en charge pluridisciplinaire regroupant oncologue, spécialiste d’organes et réanimateur. La mise en place de réunion de concertation pluridisciplinaire dédiée à ce type de toxicités permet ce regroupement, de même que le développement d’une expertise commune au sein d’un centre, la création de protocoles de soins et de recherche dédiés à la compréhension et la prise en charge de ces toxicités, et ce afin d’optimiser la gestion de ces patients.

Wilms Tumor in Sub-Saharan Africa: Molecular and Social Determinants of a Global Pediatric Health Disparity.

Wilms tumor (WT) is the most common renal malignancy of childhood. Global disparities in WT have been reported with the highest incidence and lowest overall survival occurring in sub-Saharan African nations. After a detailed search of PubMed, we reviewed available literature on WT in sub-Saharan Africa and summarized findings that explore biologic and social factors contributing to this alarming cancer health disparity. Access to care and treatment abandonment are the most frequently reported factors associated with decreased outcomes. Implementation of multidisciplinary teams, collaborative networks, and financial support has improved overall survival in some nations. However, treatment abandonment remains a challenge. In high-income countries globally, WT therapy now is risk-stratified according to biology and histology. To a significantly lesser extent, biologic features have been studied only recently in sub-Saharan African WT, yet unique molecular and genetic signatures, including congenital anomaly-associated syndromes and biomarkers associated with treatment-resistance and poor prognosis have been identified. Together, challenges with access to and delivery of health care in addition to adverse biologic features likely contribute to increased burden of disease in sub-Saharan African children having WT. Publications on biologic features of WT that inform treatment stratification and personalized therapy in resource-limited regions of sub-Saharan Africa have lagged in comparison to publications that discuss social determinants of health. Further efforts to understand both WT biology and social factors relevant to appropriate treatment delivery should be prioritized in order to reduce health disparities for children residing in resource-limited areas of sub-Saharan Africa battling this lethal childhood cancer.

A ATUAÇÃO DE PSICÓLOGOS EM CONSELHOS TUTELARES

O objetivo deste ensaio teórico é sugerir diretrizes para a atuação de psicólogos no Conselho Tutelar (CT). Sua escrita encontra-se motivada pelo entendimento de que a inserção da psicologia no CT ocorre recorrentemente por meio de práticas que desconfiguram o CT como órgão autônomo de função político-administrativa. Os psicólogos inseridos no CT não devem, assim, se ocupar de serviços periciais e socioassistenciais ausentes ou precários no município, mas exercer funções que vão subsidiar as ações executadas pelos conselheiros tutelares. São apresentadas três possíveis atribuições nesses contextos: 1) capacitação e formação continuada a conselheiros tutelares; 2) supervisão técnica à delegação de medidas protetivas e encaminhamentos jurídicos; e 3) apoio técnico às atividades de caráter preventivo, de fiscalização e de cobrança. Sugere-se que a implementação de equipes multidisciplinares destinadas a assessorar o CT em suas funções deva ser regulamentada em nível federal.

Evidence-based medicine should be emphasized to improve the quality of gastrointestinal surgery

With the further application of evidence-based medicine and the change of disease spectrum, gastrointestinal surgery is facing the novel challenge and opportunity. Systemic quality control of surgery will have positive effects on the subject development. Absence of high level of evidence, the popularization of mini-invasive surgery should be carried out cautiously. Standardization of definition of complications and unified management will be helpful to the clinical researches, prevention and treatment of complications. Conception and implementation of multidisciplinary team and enhanced recovery after surgery will provide every patient individualized and standard treatment. Key words: Evidence-based medicine; Gastrointestinal surgery; Quality control; Enhanced recovery after surgery; Multidisciplinary team

Evolution of forensic psychiatry in Italy over the past 40 years (1978–2018)

In Italy, following the closure of psychiatric hospitals in 1978 and the release of psychiatric patients into community care, there was a mismatch between common psychiatric patients and the convicted mentally ill who were sentenced to serve in state forensic psychiatric hospitals. The recent closure of such structures following the Prime Minister's Decree of April 1, 2008, fostered the need to create new structures. These are called “REMS,” and they are based in the community and led by psychiatrists and healthcare staff who may rely on the collaboration of public security staff. This act completed a course of progressive deinstitutionalization of all psychiatric patients. However, some problems remain, and persons regarded as “partially mentally disabled” at the time of crime perpetration must serve part of their sentence in prison and the rest in the aforementioned structures or in psychiatric rehabilitation communities, depending on their claimed “social dangerousness.” Psychiatric services now face the ambiguity of treating persons who are considered dangerous by court orders, while the civil law criteria for involuntary hospitalization is based only on the need of care. The complete closure of forensic hospitals may be considered a decisive step forward in the humanization of society, but there are still some issues to address to make it work better. The implementation of multidisciplinary teams and effective psychotherapy, psychoeducational, and rehabilitation interventions can help.

Implementation of National Health Reform on China Genitourinary Multidisciplinary Team Consultation Platform

Background and context:: Comprehensive management of multidisciplinary team (MDT) is the most effective mode in genitourinary(GU) cancers. Due to the uneven level in the management of GU cancers in China, top GU MDT services do not meet the medical needs of people. The blooming of “Internet+” mode promotes remote medical services, and is supported by health administrations. Aim: The country wide accessibility of high level medical services, and national health reform, especially in the field of GU cancers, will be addressed by the project. Strategy/Tactics: We developed an Internet platform of MDT management for GU cancers across China: “China GU MDT Consultation Platform (CUMP)”. Led by senior clinical staffs, and based on advanced internet and mobile technologies, CUMP is to meet the needs of clinical practices. With compatibility, universality and practicality, CUMP has the following advantages: unified data management, flexible models, stable and reliable remote video conference system, efficient cooperation, and convenient participation. Program/Policy process: Recruit top GU MDT and experts in China, and make consensus and guidelines of the implementations of MDT in GU cancers; Help other local institutions develop GU MDT and provide services, which are authenticated by the platform; Build a system that a single patient can receive top level GU MDT service locally and remotely, provided by the platform. Outcomes: Since April 2017, CUMP has successfully carried out remote MDT consultations involved 16 medical centers with GU MDT services or individual GU experts across China. As a start, 18 difficult cases were discussed and managed. More than 600 Chinese GU experts from medical institutions at all levels, have registered on CUMP, ready for submitting or accepting MDT service; another 34 top Chinese GU MDT units are on the waiting list to be technically authorized on CUMP. One Chinese consensus on the implementation of GU MDT was released last December. What was learned: The project was relevant to current obstacles in China's health reform by greatly enhancing the accessibility of GU MDT service. The majority of GU cancer patients can receive domestic top-level MDT service in a local institution; this project also helped to provide a great convenience to the development of local MDT service, so as to improve medical qualities, especially in GU cancers in different regions of China. The project made the technology and medical service transcend the boundary of administrative division and institution.

Is multidisciplinary team care for head and neck cancer worth it?

Is multidisciplinary team care for head and neck cancer worth it?

Multidisciplinary Gynecologic Oncology Clinic in Botswana: A Model for Multidisciplinary Oncology Care in Low- and Middle-Income Settings.

PurposeCervical cancer is a major cause of mortality in low- and middle-income countries (LMICs) and the most common cancer diagnosed in women in Botswana. Most women present with locally advanced disease, requiring chemotherapy and radiation. Care co-ordination requires input from a multidisciplinary team (MDT) to deliver appropriate, timely treatment. However, there are limited published examples of MDT implementation in LMICs.MethodsIn May 2015, a weekly MDT clinic for gynecologic cancer care was initiated at Botswana’s national referral facility. The MDT clinic served as a forum for discussion and coordination of patients with gynecologic cancer and consisted of a gynecologist, pathologist, medical oncologist, radiation oncologist, palliative care specialist, and nurse coordinator.ResultsBetween May 2015 and December 2015, 135 patients were seen in the MDT clinic. The mean age of the patients was 49 years. Most (60%) of the patients were HIV positive. The most common diagnosis was cervical cancer (60%), followed by high-grade cervical intraepithelial neoplastic lesions (12%) and vulvar cancer (11%). Only data up to September 2015 were assessed for treatment delays. It was found that only 38% of patients needed more than one visit for care coordination before treatment initiation. Among patients with cervical cancer, the median delay from date of biopsy to start of radiation treatment was 39 days (interquartile range, 34 to 57 days) for patients treated after MDT initiation, compared with 108 days (interquartile range, 71 to 147 days) for patients treated before MDT initiation (P < .001).ConclusionImplementation of MDT clinics in LMICs is feasible and can help reduce delays in treatment initiation, as demonstrated by a gynecologic MDT clinic in Botswana. Streamlining care through MDT clinics can enhance care coordination and improve clinical outcomes. This model can apply to cancer care in other LMICs.