Interdisciplinary Patient Care Research Articles

Establishing an oncocardiology service.

Oncocardiology is an emerging field in cardiovascular healthcare. Besides establishing surveillance and follow-up strategies for cancer patients, it will be essential to set up specialized oncocardiology services. However, there is a lack of clinical studies to give evidence-based recommendations regarding cardiological diagnostic and therapeutic approaches for cancer patients. An oncocardiology service is a patient-centered structure that aims to integrate research and interdisciplinary patient care to bridge this gap. We discuss the current challenges in developing an oncocardiology service and review the literature on this topic. We further provide an overview of the essential diagnostic tools and upcoming ethical issues to be considered in the management of oncology patients.

Severe Pulmonary Hypertension in the Setting of Complex Structural Heart Disease

Pulmonary hypertension (pHTN) complicating structural heart disease leads to distinct diagnostic and management dilemmas. We present a case of severe pulmonary hypertension in the setting of perimembranous VSD and severe AS. 76 yo female with restrictive VSD and severe AS presented with heart failure. Cardiac findings included RV heave and AS murmur. TTE revealed normal EF with severe pHTN, severe RV dysfunction, and severe AS. Her perimembranous septum was aneurysmal, with systolic jet velocity of 4.5 m/s. There was no CAD. RHC demonstrated PAP of 96/38/57 mmHg, PVR of 7.2 WU, PCWP 23 mmHg, CI of 3.04, and Qp/Qs of 1.1. The PCWP and PVR indicated pre- and post-capillary pHTN due to longstanding AS. She was deemed inoperable and was high risk for TAVR given aortic annular continuity with the VSD and ∼25% annular deficiency. There was concern that her elevated LVEDP was masking Eisenmenger physiology, and that relieving the AS may precipitate hypoxia. Balloon aortic valvuloplasty (BAV) was performed as bridge to decision. This enabled assessment of the integrity of the aortic annulus, the pulmonary pressure response to LV unloading, and development of right to left shunting after a decrease in LVEDP. Successful BAV was performed, and the patient was discharged. Following improvement in both PA pressures and her symptoms, a TAVR was offered. A self-expanding valve was selected to minimize risk of annular rupture. After successful deployment, her PAP were 78/42/54 and PCWP 23. She was diuresed and discharged. Our case highlights important points in management of such complex patients with pHTN. Careful evaluation of hemodynamics is paramount in guiding decision making. The preserved PAPi with minimal shunting suggested the VSD was not significantly contributing to the severe pHTN. Additionally, BAV plays an important role as a bridge to determine potential response to TAVR. Although patients with WHO II pHTN can develop an irreversible pre-capillary component, such assessment can only be made following durable reduction in LVEDP. Lastly, interdisciplinary patient care is essential. Successful management of our patient required input from a multidisciplinary team consisting of pulmonology, structural cardiology, critical care cardiology and heart failure.

Management of plaque psoriasis in adults

In Germany, approximately 2% of the population suffers from psoriasis, which is no longer considered only acutaneous, but rather asystemic disease. Accordingly, common comorbidities and potential joint involvement in psoriasis must be recorded. If necessary, interdisciplinary patient care has to be organized. The use of validated scores is recommended to complete the patient's medical history. The individual treatment should include intensified topical therapies as well as short-term phototherapy in case of an acute phase. In addition to conventional systemic therapies (e.g., fumarates, methotrexate), anumber of new therapeutics for psoriasis are in development. Apart from the PDE‑4 inhibitor apremilast, targeted therapies are currently available to block TNF-alpha, IL-17A, the IL-17 receptor and IL-23. Decisions on individualized, patient-centered psoriasis management should be based on assessment of disease severity and the existence of comorbidities. Furthermore, economic aspects should be taken into account.

Inappropriate use of laboratory tests: How availability triggers demand – Examples across Europe

IntroductionThe appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe. MethodsWe collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation. ResultsThe collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15–61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a “liver function” profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)2-Vitamin D measurements, leading to a 378% increase of these analyses. ConclusionThe six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.

Mobilization for Persons With Acute Stroke: A Survey of Current Physical Therapy Clinical Practice

Purpose: To examine reported practice patterns of physical therapists (PTs) related to mobilization of persons with acute stroke. The researchers hypothesized that (1) facilities certified as primary stroke centers by The Joint Commission (TJC) will mobilize persons with acute stroke 24 hours or less after symptom onset; (2) persons with fewer impairments following acute stroke and those with ischemic stroke, who did not receive tissue plasminogen activator (tPA), are mobilized sooner; (3) PTs are the first to mobilize among interdisciplinary team members; and (4) PTs with more experience will mobilize sooner than novice PTs. Methods Survey Development: All members of the research team independently searched and reviewed the current literature describing the timing of initial mobilization after stroke. A pilot survey was developed from themes in the literature emphasizing areas hypothesized. Once the feedback from the pilot survey was reviewed, the survey was finalized and converted to an online survey using SurveyMonkey. Survey Implementation and Analysis: The target audience for the survey was PTs who treat persons with acute stroke. “Acute stroke,” for this survey, was defined as a stroke less than 1 week from onset of stroke symptoms. Potential respondents were contacted via e-mail through the APTA acute care and neurologic listservs. The survey contained 26 questions related to participant demographics, the timing and frequency of mobilization for persons with acute stroke based on defined impairment levels, perceptions about influences on mobilization, and knowledge of current related evidence. Descriptive result statistics were generated by SurveyMonkey. One-way analysis of variance was used to compare responses by practice setting, degree, APTA membership, and specialist certification. Spearman's rank correlation was used to correlate results based on participant characteristics. Results: A total of 161 PTs participated with a mean of 15 years' clinical practice. Most (67%) of the respondents report mobilizing persons with minimal impairment and uncomplicated ischemic stroke, not treated with tPA, in 24 hours or less. PTs were identified as the first to mobilize persons after stroke with severe (95%) and moderate impairments (91%). Recipients of tPA, persons with severe impairment, and those who received neurosurgical intervention were initially mobilized between 25 and 48 hours majority of the time. PTs working for a TJC stroke-certified institution did not mobilize sooner. The number of years of PT experience had a weak negative correlation to the timing of mobilization. Most respondents (58%) reported that mobilization more than 2 times per day is optimal. The barriers to more frequent mobilization included increased caseload, lack of resources, and lack of interdisciplinary patient care coordination. Conclusions: The frequency of mobilization reported in this survey is less than proposed by the results of the most recent “A Very Early Rehabilitation Trial” (AVERT) after stroke, phase 3 trial. This study found a positive correlation between increased session frequency and recovery of walking at 3 months, survival, and a modified Rankin Scale (mRS) score of 2 or less. Respondents believe additional mobilization would be beneficial, but report barriers to implementation that include increased PT caseloads and lack of resources. Additional research is required to determine the influence of mobilization timing and frequency on patient outcomes such as the degree of disability after stroke.

Moving from stigmatization toward competent interdisciplinary care of patients with functional neurological disorders: focus group interviews

Purpose To explore facilitating and inhibiting factors in the inpatient care of patients with functional neurological disorders as experienced by interdisciplinary teams of healthcare professionals. Method Qualitative focus group interviews were conducted with 18 healthcare professionals of various professions. Data were analyzed using qualitative content analysis with inductive coding of data. Results Two main categories were formulated: (a) Giving the diagnosis to patients – a moment of fragility and opportunities, and (b) Organization of care – ensuring the continuity and protecting patients’ self-image. One overarching theme tied the two categories together: Establishing coherence in the inpatient trajectory – moving from stigmatization toward competent care. Coherence and steadiness in care was a prerequisite for transparency in goalsetting and for designating the responsibilities of individual healthcare professionals. Stigma and having clinical experience and knowledge of functional neurological disorders, as two counter-factors, influenced the extent to which this was achieved. Examples of facilitating factors for enhancing competent care were documentation of symptoms, effective ways of passing on clinical information, education, professional dialog, and organizational support. Discussion To nurture competent care, guidelines, structured educational initiatives and other supportive actions should be promoted. We provide ideas for the next logical steps for clinical practice and research. IMPLICATIONS FOR REHABILITATION Close collaboration between interdisciplinary healthcare professionals plays an important role for reaching optimal results in the rehabilitation of inpatients with functional neurological disorder. There is currently limited knowledge regarding the facilitating and inhibiting features encountered by interdisciplinary healthcare professionals in the provision of care for patients with a functional neurological disorder. The findings show that a working environment that endorses a skillful culture of practice and which facilitates actions to reduce problems that hamper effective teamwork needs to be promoted. Solutions that help to solve many obstacles encountered by the team of healthcare professionals in the care provision of patients with functional neurological disorders include open dialog regarding symptoms, diagnosis and treatment, effective ways of documenting and reporting symptoms, and availability of guidelines and supporting educational material.

Characteristics of swallowing disorders in patients with dysphonia.

Coexistence of dysphagia with voice disorders is a topic rarely raised in the literature. Particular attention is paid to the aspect of dysfunction of laryngeal and pharyngeal muscles. The aim of the study was to analyse cases of patients with dysphonia in relation to coexistence of swallowing disorder. The material of the study included 515 patients hospitalised due to dysphonia in 2018. Patients whose interview indicated swallowing difficulties were subjected to additional diagnosis for dysphagia (FEES, extended speech therapy test, SEMG). R esults: 11.8% of people requiring treatment for voice disorders reported coexistence of swallowing difficulties. Dysphagia was diagnosed in 9.3%. The percentage of respondents diagnosed with swallowing disorder differed depending on the type of underlying disease and was the highest in the group with neurological disorders. Analysis of the correlation between the severity of dysphagia (according to the assessed grade, DHI, EAT-10 results) and the severity of VHI showed a weak correlation between VHI and EAT-10 (p = 0.1), statistically significant correlations (p < 0,05) between the value of VHI and RSI in people with diagnosed neurological disease, between the value of VHI and DHI in people with hyperfunctional dysphonia and the value of VHI and BMI and EAT- 10 in people with chronic laryngitis. Moreover, statistically significant correlations were found between the severity of dysphagia and EAT-10 and DHI (p < 0.05). The speech therapy test indicated the co-existing problem of non-normative swallowing pattern. The electromyographic study showed the largest asymmetries in recording the average and maximum amplitude from masseters. C onclusions: Treatment of patients with voice disorders requires interdisciplinary care. A history of dysphagia in these patients should complement the medical history of voice disorders. The characteristics of swallowing disorders vary depending on the cause of the voice disorder and their co-occurrence affects on average 9.3% of patients. Coexistence of muscle tension dysphagia with voice disorder requires separate diagnostic protocol. Logopaedic procedure ought to be a key element in the interdisciplinary care of patients suffering from muscle tension dysphagia.

Simulation-based interdisciplinary education improves intern attitudes and outlook toward colleagues in other disciplines

BackgroundCooperative interdisciplinary patient care is a modern healthcare necessity. While various medical and surgical disciplines have independent educational requirements, a system-wide simulation-based curriculum composed of different disciplines provides a unique forum to observe the effect of interdisciplinary simulation-based education (IDSE). Our hypothesis: IDSE positively affects intern outlook and attitudes towards other medical disciplines.MethodsUsing an established interdisciplinary simulation curriculum designed for first year interns, we explored the relative effect of IDSE on between-discipline intern attitudes in a convergent, parallel, mixed-methods study. Data sources included novel pre-post anonymous survey measurements (10-point Likert scale), focus groups, direct observations, and reflective field notes. This quasi-experimental pilot study was conducted at an academic, tertiary care medical center with two cohorts of interns: one exposed to IDSE and one exposed to an independent within-discipline simulation curriculum.ResultsIDSE exposed interns demonstrated statistically significant improvements when comparing mean pre-test and post-test score differences in five of seven areas: perceived interdisciplinary collegiality ( overline{x} = 0.855; p = 0.0002), respect (x̅ = 0.436; p = 0.0312), work interactions ( overline{x} = 0.691; p = 0.0069), perceived interdisciplinary attitudes (x̅ = 0.764; p = 0.0031), and comfort in interdisciplinary learning (x̅ = 1.164; p < 0.0001). There were no changes in interdisciplinary viewpoints observed among non-IDSE interns. IDSE interns were comfortable when learning with interns of different disciplines and believed others viewed their discipline positively compared to non-IDSE interns. Qualitative data uncovered the following themes related to the impact of IDSE including: 1) Relationship building, 2) Communication openness, 3) Attitude shifting, and 4) Enhanced learner experience.ConclusionsIDSE positively influenced intern outlook on and attitudes towards other medical disciplines. This unique learning environment provided interns an opportunity to learn clinical case management while learning about, from, and with each other; subsequently breaking traditional discipline-specific stereotypes and improving interdisciplinary relations. Future explicit focus on IDSE offers opportunity to improve interdisciplinary interactions and patient care.

Orthotic Care Based on the Ferrari Concept for Children and Adults with Meningomyelocele.

Even today, myelomeningocele (MMC) is still encountered in clinical medicine and its incidence has not decreased over the last 20 years despite a known reduction in risk due to the use of folic acid supplements. The spectrum of clinical symptoms is extremely broad and, depending on the level of the defect, varies from mild to severe. Subject to the degree of paralysis, patients are reliant on the use of orthopaedic aids and orthoses for the treatment of primary contractures and deformities and the prevention of secondary ones. This forms the basis for attaining or maintaining mobility in many patients. The objective of the study was to determine the practical application of the proposed Ferrari concept for the provision of orthoses for children and adults. The retrospective study comprised medical records of 180 patients (97 m) with an average age of 19.44 years (3 - 52 years, SD 9.3) at the time of investigation. The average duration of treatment was 15.34 years (1 - 38 years, SD 8.96). Data relating to deformities of the vertebral column and lower limbs, provision of hydrocephalus shunts and orthoses, and patient mobility was evaluated. Most patients were given systematic treatment with orthoses at an early stage. In 58,9% of cases, it was possible to implement the proposed concept for providing patients with dynamic orthoses, whereby the treatment concept was more difficult to implement with high lumbar lesions than with lower lesions. Moreover, a decrease in the patients' mobility with increasing age was noticeable. Some 42.3% of adult patients were able to walk with marked variations in mobility in relation to the different levels of lesions. Taking into consideration the complexity of both the clinical picture and therefore the provision of orthopaedic devices, the result of the implementation of the proposed orthotic concept can be considered positive. Similarly, early commencement of provision of orthoses and hence the possibility of achieving a positive influence on later mobility can be considered a success. The need for individual concepts and further development in order to increase mobility particularly in the case of patients with thoracic or high lumbar lesions is evident. A more comprehensive provision of information to patients regarding orthotic treatment options and their consequences for prophylaxis and quality of life should be an important component of interdisciplinary long-term patient care.

Standardized endocystectomy technique for surgical treatment of uncomplicated hepatic cystic echinococcosis.

BackgroundTwo surgical options are available for cystic echinococcosis (CE). The two principal approaches are radical (resection of the cyst) and conservative (evacuation of the cyst content and partial removal of the cyst capsule). Here, we describe a standardized endocystectomy technique for hepatic echinococcosis.Subjects and methodsTwenty-one patients (male/female: 4/3; median age: 28 years) with uncomplicated, isolated hepatic CE (cyst stages WHO CE1, 2, 3a, and 3b) that were treated with the standardized endocystectomy described in this paper. Before the operation and during the follow-up period (mean: 33.8 months, median: 24 months), patients underwent clinical and sonographical and/or magnetic resonance imaging assessment during regular visits managed by an interdisciplinary team.ResultsForty-seven cysts were treated with the standardized endocystectomy technique. The median number of cysts per patient was two (range: 1–8). Nine patients (43%) had a single cystic lesion. The median operation time was 165 minutes and the median intraoperative bleeding volume was 200 mL. The median hospital stay was nine days (range: 6–28 days). Morbidity (Clavien-Dindo III) occurred in four patients (19%). No mortality and no recurrence were found during the median follow-up time of 24 months.ConclusionsThe standardized endocystectomy technique presented is a safe procedure with acceptable morbidity, no mortality, and without recurrences in our patient series. Important components of our CE management are interdisciplinary patient care, adequate diagnostic work-ups, and regular pre- and postoperative visits, including long-term follow-up for early and reliable capture of recurrences.

Practical knowledge and skills management- Why to participate?

The appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe.We collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation.The collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15–61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a “liver function” profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)2-Vitamin D measurements, leading to a 378% increase of these analyses.The six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.

Interdisciplinary care in the treatment of orofacial pain. Case report

ABSTRACT BACKGROUND AND OBJECTIVES: The importance of interdisciplinary action has been increasingly recognized in the area of health due to the global effect that has on the various symptoms of the patient. Interdisciplinarity is possible when professionals allow the exchange of knowledge through clinical meetings and jointly follow-up of the case. The objective of this study was to document the interdisciplinary care of patients with orofacial pain symptoms and comorbidities. CASE REPORT: Female patient, 48 years old, diagnosed with muscular temporomandibular disorder and oral opening limitation, labyrinthine cervicalgia, tinnitus, sleep disorder, eating disorders and anxiety after evaluation with an odontologist, otorhinolaryngologist, physiotherapist, acupuncturist, psychologist and nutritionist. The 1-year follow-up with monthly visits with the dentist and nutritionist, and biweekly visits with a psychologist, physiotherapist, and acupuncturist showed symptoms control with total remission of the orofacial pain, cervicalgia, labyrinthitis. Tinnitus did not improve in the sense of frequency that remained constant, but according to the patient, there was an improvement in the adaptation to tinnitus in places with excessive noise, thus allowing a better social interaction. Nutrition and psychology made a great contribution to self-esteem and social routine as well as to seek for a better quality of life. CONCLUSION: The interdisciplinary work promoted a global approach to the patient’s symptoms.

Genetic testing to prevent sudden cardiac death

Successfully incorporating genetic testing into clinical practice to prevent sudden cardiac death (SCD) requires (1)appropriate recognition of an inherited cardiovascular condition, (2)identification of appropriate family members at risk and for genetic testing, (3)selection of the appropriate genetic test and information about the expected diagnostic yield, (4)understanding the complexity of result interpretation and distinct handling of incidental findings and (5)providing effective communication and medical advice regarding the genetic and medical results and implications to the patient and his family. Molecular autopsy in SCD victims will be of future importance to determine the cause of death. Interdisciplinary patient care should be provided in specialized centers with ahigh level of cardiogenetic expertise and is recommended to provide precise and individualized patient management.

The role of electronic health records in clinical reasoning.

Electronic health records (eHRs) play an increasingly important role in documentation and exchange of information in multi-and interdisciplinary patient care. Although eHRs are associated with mixed evidence in terms of effectiveness, they are undeniably the health record form of the future. This poses several learning opportunities and challenges for medical education. This review aims to connect the concept of eHRs to key competencies of physicians and elaborates current learning science perspectives on diagnostic and clinical reasoning based on a theoretical framework of scientific reasoning and argumentation. It concludes with an integrative vision of the use of eHRs, and the special role of the patient, for teaching and learning in medicine.

Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) – Protocol for a pragmatic cluster randomized trial

BackgroundChronic pain is one of the most common, disabling, and expensive public health problems in the United States. Interdisciplinary pain management treatments that employ behavioral approaches have been successful in helping patients with chronic pain reduce symptoms and regain functioning. However, most patients lack access to such treatments. We are conducting a pragmatic clinical trial to test the hypothesis that patients who receive an interdisciplinary biopsychosocial intervention, the Pain Program for Active Coping and Training (PPACT), at their primary care clinic will have a greater reduction in pain impact in the year following than patients receiving usual care. Methods/designThis is an effectiveness-implementation hybrid pragmatic clinical trial in which we randomize clusters of primary care providers and their patients with chronic pain who are on long-term opioid therapy to 1) receive an interdisciplinary behavioral intervention in conjunction with their current health care or 2) continue with current health care services. Our primary outcome is pain impact (a composite of pain intensity and pain-related interference) measured using the PEG, a validated three-item assessment. Secondary outcomes include pain-related disability, patient satisfaction, opioids dispensed and health care utilization. An economic evaluation assesses the resources and costs necessary to deliver the intervention and its cost-effectiveness compared with usual care. A formative evaluation employs mixed methods to understand the context for implementation in the participating health care systems. DiscussionThis trial will inform the feasibility of implementing interdisciplinary behavioral approaches to pain management in the primary care setting, potentially providing a more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment.Clinical Trials Registration Number: NCT02113592

309 - Occupational Therapy's Role in Maximizing Quality of Life in Bone Marrow Transplant

Currently, an estimated 1,290,773 people in the United States are living with or in remission from general blood cancers; a number that has increased by more than 50,000 individuals since last year. Furthermore, an estimated 172,910 people in the United States are expected to be diagnosed with leukemia, lymphoma, or myeloma in 2017 (Leukemia & Lymphoma Society, 2017). As bone marrow transplantation (BMT) is a progressive treatment option for blood-related cancers, side effects lead to challenges across multiple functional domains. These side effects may include difficulty with: endurance, sleep hygiene, exercise and activity engagement, self-concept, psychosocial adjustment, and well-being (Bevans et al., 2008; Bieri et al., 2008; Rischer et al., 2009). It is imperative to assess and address quality of life and psychosocial effects amongst those undergoing transplant. Occupational therapy practitioners are uniquely skilled to address symptom distress, activity engagement, adaptation to the environment, and other issues affecting life satisfaction during one's inpatient stay in the hospital (Christiansen & Matsuka, 2006). Occupation is defined to include all the activities that people do to occupy themselves, including looking after themselves and enjoying life (Townsend & Polatakjo, 2013). Consistent with literature, participation in meaningful occupations promotes occupational performance and contributes to good health and well-being (Hocking, 2009). Evidence based practice within occupational therapy supports providing treatment, including the following areas: modification of daily routines, incorporation of new coping strategies for healthful stress management and sleep hygiene, medication management and tracking symptomatology, fatigue management, and self-management of one's overall quality of life (Bevans et al., 2008; Christiansen & Matsuka, 2006; Demiralp, 2010; Kangas, Bovbjerg, & Montgomery, 2008; Paul, 2011). This presentation will examine the role of occupational therapists in providing supportive care for individuals undergoing bone marrow transplant. Occupational therapy efforts to maximize quality of life and promote psychosocial well being will be highlighted through a general intervention framework and case examples. Occupational therapy can be effective in enhancing patients' experience, self efficacy, and overall well-being throughout their transplant stay in an acute inpatient hospital setting; a process that has been identified to hinder a person's ability to spontaneously engage in activities across their daily routine of life (Paul, 2011). In conclusion, occupational therapy can contribute to the interdisciplinary effort and patient care by maximizing individuals' well being, addressing psychosocial needs, and ultimately enhancing quality of life.

Overcoming barriers to interprofessional education in gerontology: the Interprofessional Curriculum for the Care of Older Adults.

A fragmented workforce consisting of multiple disciplines with varying levels of training and limited ability to work as a team often provides care to older adults. Interprofessional education (IPE) is essential for preparing practitioners for the effective teamwork required for community-based, holistic, person-centered care of the older adults. Despite numerous programs and offerings to advance education and interdisciplinary patient care, there is an unmet need for geriatric IPE, especially as it relates to community-dwelling older adults and caregivers in medically underserved areas. A core group of university faculty from multiple disciplines received funding from the Health Resources and Services Administration Geriatric Workforce Enhancement Program to collaborate with community-based providers from several Area Agencies on Aging in the creation and implementation of the Interprofessional Curriculum for the Care of Older Adults (iCCOA). This geriatric curriculum is interprofessional, comprehensive, and community-based. Learners include third-year nursing students, nurse practitioner students, third-year medical students, internal medicine and family medicine residents, master’s level social work students, third-year pharmacy students, pharmacy residents, third-year dental students, dental hygiene students, community-based organization professionals, practicing community organizers, and community health navigators. This article describes the efforts, successes, and challenges experienced with this endeavor, including securing funding, ensuring equal representation of the disciplines, adding new components to already crowded curricula, building curriculum on best practices, improving faculty expertise in IPE, managing logistics, and ensuring comprehensive evaluation. The results summarize the iCCOA components, as well as the interprofessional domains, knowledge, and competencies.

The sixth vital sign: what reproduction tells us about overall health. Proceedings from a NICHD/CDC workshop.

Does the fertility status of an individual act as a biomarker for their future health? Data support an association between reproductive health and overall health for men and women. Various chronic conditions, such as diabetes, obesity and cancer, can compromise fertility, but there are limited data for the converse situation, in which fertility status can influence or act as a marker for future health. Data reveal an association between infertility and incident cardiovascular disease and cancer in both men and women. A National Institute of Child Health and Human Development-Centers for Disease Control and Prevention workshop in April 2016 was convened that brought together experts in both somatic diseases and conditions, and reproductive health. Goals of the workshop included obtaining information about the current state of the science linking fertility status and overall health, identifying potential gaps and barriers limiting progress in the field, and outlining the highest priorities to move the field forward. Approximately 40 experts participated in the workshop. While the etiology remains uncertain for infertility, there is evidence for an association between male and female infertility and later health. The current body of evidence suggests four main categories for considering biological explanations: genetic factors, hormonal factors, in utero factors, and lifestyle/health factors. These categories would be key to include in future studies to develop a comprehensive and possibly standardized look at fertility status and overall health. Several themes emerged from the group discussion including strategies for maximizing use of existing resources and databases, the need for additional epidemiologic studies and public health surveillance, development of strategies to frame research so results could ultimately influence clinical practice, and the identification of short and long-term goals and the best means to achieve them. Further research may not indicate an association between fertility status and overall health. Currently medical care is compartmentalized. Reproductive medicine physicians treat patients for a short period of time before they transition to others for future care. Going forward, it is critical to take an interdisciplinary patient care approach that would involve experts in a broad range of medical specialties in order to more fully understand the complex interrelationships between fertility and overall health. If infertility is confirmed as an early marker of chronic disease then screening practices could be adjusted, as they are for patients with a family history of malignancy. Funding for the workshop was provided by the Fertility and Infertility Branch, National Institute of Child Health and Human Development, National Institutes of Health and the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. There are no conflicts of interest to declare. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Institutes of Health. Not applicable.

The German Thorax Registry: Implementation of an Established Tool of Perioperative Health Care Research

The collection of clinical treatment data in registry databases is an important aspect of health services research. It allows for a critical evaluation of the safety, efficacy and cost-effectiveness of clinical treatment concepts in large patient populations. The findings of registry research represent real-world patients and treatment structures as they are not limited by strict inclusion criteria or unrealistic conditions as applied in prospective clinical trials. The implementation of the German Thorax Registry has enabled the collection and analysis of data on the interdisciplinary care (thoracic surgery, anaesthesiology, intensive care, pain management) of patients undergoing thoracic surgery. Under the auspices of the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Thoracic Surgery, a registry of the Hospital of the University Witten/Herdecke-Cologne, purely surgical at first, was expanded in close cooperation with the University Hospital of Freiburg. After a comprehensive data protection concept was drafted and a test phase completed, the German Thorax Registry was officially launched in January 2016. Most notably, participating hospitals profit from the registry's "benchmarking" services. "Benchmarking", i.e. the comparison of treatment quality between different hospitals, enables participants to identify individual profiles, strengths and weaknesses on a nation-wide level and follow their own progress over the course of several years. An online database for data entry and benchmarking is always accessible (www.thoraxregister.de). In October 2016, the spectrum of participants was expanded to include all hospitals performing at least 50 thoracic operations a year.

The Diagnosis and Treatment of Sjögren's Syndrome.

Sjögren's syndrome is one of the more common inflammatory rheumatological diseases, with a prevalence of at least 0.4% in Germany. This review is based on pertinent articles retrieved by a selective search in PubMed. Special attention is drawn to updated classification criteria and current treatment recommendations. Sjögren's syndrome has a wide variety of presentations, ranging from the local involvement of exocrine glands with keratoconjunctivitis sicca and xerostomia (the leading signs of the disease) to the systemic, extraglandular involvement of multiple organs. Fatigue also markedly worsens the patients' quality of life. Serologic testing reveals antinuclear auto-antibodies (anti-Ro/ SSA and anti-La/SSB) as well as rheumatoid factors. The histological hallmark of the disease is focal lymphocytic infiltration in otherwise normal-appearing glandular acini. The disease also markedly elevates the risk of non-Hodgkin lymphoma of the B-cell series, which arises in about 5% of patients. Primary Sjögren's syndrome (pSS) differs from the secondary form (sSS), which appears in the setting of another autoimmune disease, particularly systemic lupus erythematosus (15-36%), rheumatoid arthritis (20-32%), and limited or progressive systemic sclerosis (11-24%). Disease-modifying therapy is reserved for patients with systemic involvement; there is limited evidence for its efficacy. Because of the complexity of this disease, some of its clinical manifestations may require interdisciplinary treatment. The main considerations in the interdisciplinary care of patients with Sjögren's disease are measures to improve quality of life, pharmacological and non-pharmacological treatments to keep disease activity in check, and management of the risk of lymphoma. Future therapeutic approaches must take the heterogeneity of the disease into account.