Multidisciplinary Patient Care Research Articles

Oncologists’ management of non-cancer conditions: An observational study.

23 Background: Cancer diagnoses introduce layers of complexity for care coordination. Oncologists often find themselves independently managing coincident, non-cancer illnesses. How often oncologists engage in direct management of non-cancer conditions, rather than coordinating with patients' other providers, is not well understood. We examined how often oncologists prescribe medications to manage non-oncologic conditions, as a proxy for assuming primary-care responsibilities. Methods: The cohort included all US physicians with a specialty of Hematology-Oncology or Medical Oncology from 2016-2020, available in the Centers for Medicare & Medicaid Services Part D Prescribers dataset. Prescription drugs were categorized as “cancer-directed”, “cancer-related” (eg., opioid pain medications), or “non-cancer” (eg., antihypertensives). Primary outcomes included prescription of cancer-directed, non-cancer, and cancer-related medications. Multivariate logistic regression assessed the association between non-cancer medication prescriptions and provider location, medical school graduation year, gender, and practice affiliation during 2020. Results: A mean of 8.3% (median 5.3%, IQR 0% – 12.5%) of oncologists’ prescriptions were for non-cancer medications; this decreased during the study period, falling from 9.5% in 2016 to 7.4% in 2020 (p<0.001 on Kruskal Wallis test for non-parametric data). Providers practicing in the Midwest (aOR 1.3, 95%CI [1.2-1.5]), Southeast (1.5 [1.3-1.7]), and Southwest (1.6 [1.4-1.9]) were more to prescribe non-cancer medications, as were providers who graduated >10 years prior to the end of the study period, most notable in providers graduating 1990–1991 (2.2 [1.9-2.6]). Those at academic institutions (0.7 [0.6-0.8]) were less likely to prescribe non-cancer medications. Conclusions: A small but substantive portion of oncologists’ prescriptions are for medications unrelated to cancer care. The downtrend in non-cancer prescriptions may reflect that coordinated co-management of patients with cancer is increasing. The rise in telemedicine and digital health represents an opportunity to establish stronger multidisciplinary care for patients with cancer through hybrid cross-collaboration between primary care physicians and oncologists. This is especially advantageous in regions where in-person integration of physician groups may not be possible. Additionally virtual continuing medical education sessions may aid primary care physicians in managing non-cancer medications for the cancer population. Trends in oncologists’ prescribing patterns from 2016–2020: Mean per-provider proportion of non-cancer medication prescription (%). Medication Class 2016 2017 2018 2019 2020 Cancer-Directed 30.4 31.1 32.2 32.7 33.9 Non-Cancer 9.5 8.9 8.2 7.6 7.4

Bridging the gap — Establishing a dental-oncology service in a cancer centre

Dental disease remains the most common non-communicable disease worldwide. It predisposes patients to significant morbidities following bone modifying agents or radiation therapy to the head and neck. Preventative dental regimes effectively reduce the risk of both medication-related osteonecrosis of the jaw (MRONJ) and osteoradionecrosis (ORN) in these patients. Co-ordination of routine dental care as a component of mainstream oncology treatment optimises long term outcomes for oncology patients. This case series offers insights into patient, institutional and social difficulties that challenge the dental-oncology interface. These obstacles and subsequent resolutions experienced whilst establishing a dental-oncology service in a cancer centre highlight the importance of effective multidisciplinary lead care for oncology patients. It reinforces the need for structured, supported dental pathways for these oncology patients.

EP421 - The multidisciplinary management of acute pancreatitis at a district general hospital – an NCEPOD audit

Abstract Aim To assess adherence to NCEPOD Acute Pancreatitis 2016 guidelines in order to optimise the multidisciplinary care of patients presenting with acute pancreatitis. Methods A retrospective case-based audit was conducted of the last 10 admissions with acute pancreatitis. Data on demographics, investigations and management were collected and audited against the NCEPOD evidence-based recommendations. Results The average age was 54 years (33-84) and 70% were male. The cause of the acute pancreatitis was identified as gallstones in 40%, alcohol in 30% and was unknown in the remaining 30%. All patients with alcoholic pancreatitis were referred to alcohol support services. 80% of all patients had significant co-morbidities at presentation: in 63% of patients these were well-controlled; of those uncontrolled, none received onwards referrals. Nutritional assessment only occurred in 10% of patients. Conclusions Our audit showed that we successfully identified a cause of acute pancreatitis in 70% of patients and involved alcohol services in 100% of alcoholic pancreatitis cases. This demonstrates good organisational infrastructure in managing these patients. However, despite the highlighted importance in the NCEPOD report, patients were not appropriately referred to dietitians or other medical specialities. We have therefore developed a series of multi-disciplinary team teaching sessions and an admission proforma to address these areas of the report and improve compliance. A second audit loop will be conducted to demonstrate impact.

Pregnancy Outcomes from a Multidisciplinary Obstetric-Medicine/Rheumatology Clinic in the United States: A Five-Year Retrospective Analysis.

At Women & Infants Hospital in Providence, Rhode Island, the Specialty Care in Pregnancy clinic combines obstetric-medicine internists with rheumatologists to care for pregnant women with rheumatologic conditions. These clinics are scarce, with only three known similar clinics in the United States. This study aims to characterize the population cared for in this clinic, identify interventions, and analyze pregnancy outcomes for the mothers and newborns. A five-year retrospective chart review was performed from January 1st, 2016, through December 31st, 2021. Of 81 patients, 62% had a clinically diagnosed rheumatic disorder. Of 87 patient visits, which included preconception, prenatal and postpartum encounters, 54% were on conventional synthetic disease modifying antirheumatic drugs and 17% were on biologic disease modifying antirheumatic drugs. New medications were started in 52% of patients. 52% of pregnancies resulted in live births with 2% resulting in miscarriages. Prematurity occurred in 19% of newborns, and 9% had intrauterine growth restriction. Our study illustrates the benefits of multidisciplinary care in patients with rheumatologic disorders during their prenatal and perinatal periods. The expertise from both the obstetric-medicine internists and rheumatologists was critical in making complex decisions that weigh the benefits of therapy against potential risks for the fetus. Our multidisciplinary approach resulted in doubling of the number of patients on disease modifying therapy and increased prophylaxis with hydroxychloroquine and/or aspirin therapy as recommended by current guidelines. Additional multidisciplinary clinics of this type would help coordinate care between physicians that frequently treat these high-risk, unique patients and open the door for more research of this understudied population.

Prevention of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy.

Osteoradionecrosis is a long-term, serious side effect of head and neck radiation therapy and is associated with significant morbidity and quality of life issues. This paper sought to determine consensus on the prevention and management of osteoradionecrosis by an international panel of multidisciplinary professionals expert in the management of patients with head and neck cancer using a Delphi methodology. Unique to this work is our direct inclusion of the views of patients and carers in our findings. This study reached consensus on the importance of pre and post oral health assessment and education for patients with head and neck cancer. This was also noted by the patients and carers who took part in the study. This work highlights the need for a standardized oral health assessment tool and multidisciplinary care of patients to prevent and manage osteoradionecrosis.

Palliative Care for Dialysis-Dependent Pediatric Patients: A Survey of Providers, Nurses, and Caregivers.

Dialysis-dependent pediatric patients and their families face significant biopsychosocial burdens and low health-related quality of life. Palliative care consultations can alleviate some degree of suffering for patients and families but remain underutilized within pediatric nephrology. Little is known about how providers, nurses, and caregivers perceive palliative care integration into the multidisciplinary care of dialysis-dependent pediatric patients. This study surveyed pediatric nephrology providers (physicians and advanced practice providers), inpatient pediatric nephrology bedside nurses, and caregivers of dialysis-dependent pediatric patients at a freestanding tertiary care children's hospital in Dallas, Texas. Participants completed a survey regarding knowledge about, experiences with, and perceptions of palliative care in pediatric nephrology. 10 providers, 20 nurses, and 18 caregivers completed the survey. Although 80% of providers and all nurses agreed that palliative care would benefit dialysis-dependent pediatric patients, most believed that palliative care is not as important in pediatric nephrology as it should be. 70% of providers and 45% of nurses believed that they understand the scope of palliative care. 90% of providers and all nurses desired more palliative care education. Of the 22% of caregivers whose child had already received palliative care services, all found the consultation to be helpful. Many providers and nurses worried that a palliative care consultation would signal to families that the nephrology team would be giving up on their child and that their child is approaching the end of life. However, no caregivers thought that a consultation would mean that the nephrology team would be giving up on their child and only 6% worried that it would indicate that their child is approaching the end of life. These data support further palliative care education for pediatric nephrology providers and nurses and more robust and systematic involvement of subspecialty palliative care for dialysis-dependent pediatric patients.

Multidisciplinary Perspectives on Medical Decision-Making for Ostomy Surgery in Pediatric IBD: Themes from Focus Groups.

Pediatric Inflammatory Bowel Disease (IBD) is a chronic illness where patients may undergo ostomy surgery. Medical decision-making (MDM) for ostomy surgery is complex for patients/families and multidisciplinary healthcare professionals (HCPs) alike, with current uncertainty about how multidisciplinary HCPs think about ostomy care to inform future interventions to facilitate equitable multidisciplinary care for patients. This study sought to understand pediatric IBD multidisciplinary HCPs' perceptions regarding ostomy-related MDM and education. Multidisciplinary HCPs (e.g., gastroenterology medical providers, social workers, surgeons, and ostomy nurses) participated in semi-structured focus groups. Focus group data underwent qualitative analysis to identify themes. Three multidisciplinary focus groups were conducted, with n = 12 participants across all groups. Qualitative analysis identified three main themes, including (1) HCP perceptions of ostomies, (2) Patient/family-related factors, and (3) Professional roles and collaboration challenges. Ostomy surgery in pediatric IBD requires complex multidisciplinary MDM and education. Perspectives of multidisciplinary HCPs identified patient, HCP, and systems factors that may impact MDM for ostomy surgery. This work highlights nuances in MDM and education in IBD, and the critical role of ongoing research and improved standardized processes to coordinate multidisciplinary ostomy-related MDM and education in this population.

Homecare amyotrophic lateral sclerosis (ALS): A multidisciplinary, home-based model of care for patients with ALS and their caregivers.

Multidisciplinary care for patients with amyotrophic lateral sclerosis (ALS) is recommended in international guidelines, but reaches its limits when immobility increases. This pilot project addresses this gap by delivering home-based, specialized, multiprofessional support to ALS patients who are not able to attend outpatient care. The study assessed the feasibility of this model of care and the satisfaction of both patients and caregivers. This was a longitudinal cohort study of patients with ALS and their caregivers in the surroundings of Munich, Germany. Patients were regularly visited at home by a multiprofessional team (neurologists/palliative care physicians, nurse, social worker, chaplain). A total of 94 patients with ALS were included in the homecare project and 88 patients and 74 caregivers were enrolled in the accompanying study. The mean care duration was 221 days, enabling 61% of the 49 deceased patients to die at home. Notably, 20% of patients chose a way to hasten death. Patient satisfaction (ICECAP Supportive Care Measure [SCM]: 23.7/28, CollaboRATE: 10.6/12) and caregiver perception of the end-of-life phase (Caregiver Evaluation of the Quality of End-Of-Life Care [CEQUEL]: 24.9/26) were high. This pilot project successfully implemented specialized, home-based multidisciplinary care for ALS patients and caregivers, demonstrating both feasibility and high satisfaction. The program enabled a large proportion of patients to remain in their homes, reducing the need for hospital care. The multiprofessional approach, including neuropalliative, psychosocial and spiritual support provided comprehensive care that addressed needs of patients and caregivers. Further research is warranted to explore cost-effectiveness.

Is Access to Optimal Concussion Care for Pediatric Athletes Limited by Geography?

To evaluate access to optimal concussion care based on a pediatric patients' geography; the hypothesis is that differential access across the Unites States exists. Employed a novel strategy using internet searches to find local care, mimicking what families might do in different parts of the country. Virtual internet searches. Not applicable. Various metropolitan and rural geographic regions within each state in the United States. Evaluate access (defined as distance to clinic and ability to see pediatric patients) and optimal care (defined as self-referral process and presence of multidisciplinary care). Search strategy yielded 490 results. Overall ∼60% were within 50 miles of searched locations with significant differences in access based on rural versus metropolitan areas ( P < 0.0001); in rural areas, only ∼22% of results were within 50 miles. Only about one-third of the results (n = 157) saw pediatric patient with no differences between regions. There was significant regional and geographic variation for optimal care regarding both self-referral processes and access to multidisciplinary care. A diverse group of specialists was represented in search results for concussion care. Nationwide, there is an overall lack of access to multidisciplinary concussion care for pediatric patients. Additionally, those in rural communities face more limitations related to access to facilities with increased distances from closest clinic sites.

The dental management of patients with Brugada syndrome: A case series

AbstractBrugada syndrome is an inherited cardiovascular disorder, which can affect the rhythm of the heart. Dental treatment can often present as an obstacle for patients with Brugada syndrome as the use of local anaesthetic can have adverse effects on the electrical conduction system of the heart.AimThe aim of this series is to discuss the aetiopathogenesis, presentation and management of Brugada syndrome and its relevance to dentistry and the dental team.MethodsThe authors present a series of three Brugada syndrome patients who underwent dental intervention in a hospital setting.Results and ConclusionThe series highlighted the importance of multidisciplinary care for patients with Brugada syndrome. Liaising with other teams, such as cariologists and GMPs, allows a patient centred approach and better understanding of patient management.

Carcinoid Heart Disease.

Carcinoid heart disease (CHD) is a rare but potentially life-threatening sequela of advanced neuroendocrine neoplasm with carcinoid syndrome. These tumors can secrete vasoactive substances of which serotonin is the most prevalent. Carcinoid heart disease typically involves the right-sided heart valves and eventually leads to right heart failure. Monitoring N-terminal pro-B-type natriuretic peptide and 5-hydroxyindoleacetic acid at diagnosis and during treatment, as well as cardiac echocardiogram, helps to screen for CHD. Many patients are not screened for this appropriately. Multidisciplinary care for patients with CHD is ideal and involves medical oncology, cardiology, and cardiothoracic surgery.

Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study.

The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency. This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units. A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data. Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units. A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

Multidisciplinary care use in neurodegenerative complex diseases: The example of progressive supranuclear palsy and advanced Parkinson's disease in real-life

BackgroundIn spite of being considered the gold-standard of care, little is known about the real-life use of in-home and multidisciplinary care in atypical parkinsonism. ObjectivePrimary: Examine real-life multidisciplinary care use for Progressive Supranuclear Palsy (PSP). Secondary: a) Compare PSP care to advanced Parkinson's disease (APD) care; (b) Explore demographic and clinical variables associated with care needs in both groups. MethodsA cross-sectional multicenter observational study enrolled 129 PSP patients and 65 APD patients (Hoehn and Yahr ≥3), matched for sex and age. Univariate and multivariate regression analysis were performed. ResultsOver the previous year, 40 % of PSP patients did not encounter a physical therapist, while only one-third met a speech and language therapist and 5 % an occupational therapist. More than 20 % received in-home care and 32 % needed home structural changes. Compared to APD, PSP patients required more day-time, night-time and home structural changes. When considering both PSP and APD in multivariate analysis, reduced functional autonomy and living without a family caregiver were both related to day-time home assistance and to the need of at least one home care service. A PSP diagnosis compared to APD was a risk factor for having at least four multidisciplinary visits in a year. Finally, PSP diagnosis and being from the Northern Italy were significantly related with home structural changes. ConclusionsThere's a significant gap in providing multidisciplinary care for PSP patients. Our findings emphasize the need for a shared, integrated care plan at a national level for patients with atypical parkinsonism.

NURSE'S ROLE IN CARING FOR A PATIENT WITH FOURNIER'S GANGRENE

Fournier's gangrene is a life-threatening condition characterized by rapidly progressive necrotizing fasciitis, often leading to sepsis and multiple organ failure. While historically associated with males, the condition can affect both genders, with varying degrees of severity. This case report explores the complex management of a 59-year-old male patient with a history of alcohol abuse, diabetes, cirrhosis, and a long-term smoking habit, who presented with Fournier's gangrene. The patient's critical condition and complex medical history presented significant challenges for healthcare providers, particularly nurses, who played a pivotal role in his care. These cases occur rarely in practice and require specific care and compliance with surgical nursing techniques per protocol. This case report not only sheds light on the growing incidence of Fournier's gangrene among both genders but also underscores the indispensable role of nurses in the multidisciplinary care of patients with this challenging condition. Comprehensive nursing care, patient education, and meticulous attention to detail are essential in improving patient outcomes and reducing mortality rates associated with Fournier's gangrene.

Multidisciplinary care for patients with gastroesophageal cancers (GEC): A quality improvement initiative in community cancer clinics.

e16096 Background: Evidence-based guidelines for GEC management recommend multimodal care, which involves close coordination between medical, surgical, and radiation oncologists, together with specialists to manage symptoms and treatment-related adverse events (AEs). Optimizing the high level of multidisciplinary care required for effective GEC management poses substantial challenges for community oncology care teams. Methods: In August-October 2023, 57 healthcare providers (HCPs) from 4 US community oncology clinics completed surveys on challenges, barriers, and improvements needed in the multimodal care of patients with GEC. Based on findings from the baseline data, 70 HCPs participated in audit/feedback (AF) sessions to review site-specific gaps and challenges and develop action plans to address identified gaps. Follow-up surveys will evaluate the impact of changes in practice following action plan implementation. Results: Providers identified their 3 top challenges to providing care for patients with GEC: interdisciplinary care coordination, providing patient-centered supportive care, and managing AEs. They reported that care coordination was hampered by low frequency and poor-quality communication between medical oncology and surgical teams, by misalignment on methods of communication, and by a lack of relationship between the specialties. About one-third of HCPs reported recognizing and managing AEs as the most challenging aspect of caring for patients with GEC, including AEs that were immune-related (26%), dermatologic (19%), gastrointestinal (19%), neurologic (14%), immunosuppression-related (10%), and respiratory (5%). After the AF sessions, HCPs reported improving communication and coordination among care team members as an important means of improving and individualizing patient care plans and integrating new therapies into clinical workflows. Action plans included streamlining communication with surgical teams, increased use of patient navigation, and ensuring that every patient is reviewed through the multidisciplinary tumor board. With regard to AE management, action plans included improving patient education on AE identification, and better communication within the team on nutritional support. HCPs who participated showed improved confidence, knowledge, and competence in appropriately sequencing systemic therapy and surgical interventions. Conclusions: GEC care teams from community cancer clinics reported dissatisfaction with multidisciplinary care coordination, including poor communication between specialists involved in multimodal care of patients with GEC. Integration of sustainable changes in clinical workflows driven by this initiative improved oversight of multimodal care, improved workflows, and improved AE management.

The effect of an online micro CE/CME on the multidisciplinary care of patients with nonmelanoma skin cancer.

e21006 Background: Nonmelanoma skin cancers (NMSCs), including basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (CSCC), are the most common malignancies diagnosed in the US and worldwide. While most are successfully cured with local therapies or surgery alone, immunotherapy agents have been added to the arsenal for advanced tumors that are unresectable or unlikely to be cured with surgery alone. Thus, the multidisciplinary care model in this clinical setting has numerous advantages; however, many healthcare professionals (HCPs) may not fully recognize the role of their colleagues and their value in caring for affected patients. The objective of this study was to assess the educational impact of an online micro continuing [medical] education (CE/CME) activity on the knowledge and competence of HCPs’ with respect to the role and value of the multidisciplinary team in the optimal care of patients receiving immunotherapy for NMSC. Methods: The educational activity consisted of a collection of six online video-based micro-CE/CME-certified chapters, presented by six respected NMSC experts, allowing learners to choose their chapters for participation. Educational impact was assessed with repeated paired pre-/post-assessment study design, where individual participants served as their own control. A McNemar’s test assessed significant levels of changes reported with P values &lt;.05 considered statistically significant. The activity launched September 2023; data were collected until January 2024. Results: The educational activity resulted in overall statistically significant improvements in HCPs’ knowledge and competence after education by chapter and by HCP audience type ( P &lt; .01), including oncologists, dermatologists, surgeons, nurses, and pharmacists. Results presented below highlight the improvements in HCPs’ knowledge and competence by chapter. Conclusions: This analysis demonstrates the success of an online CE/CME activity with micro video chapters on improving HCPs’ knowledge and competence related to the value of the multidisciplinary team members in the comprehensive care of patients receiving immunotherapy for the treatment of NMSCs. Despite these significant improvements, additional educational activities are needed to address residual gaps and further increase HCPs’ ability and comfort in providing care in this clinical setting. [Table: see text]

The Predictors of Osteoarthritis Among U.S. Adults: National Health and Nutrition Examination Survey, 2005 to 2018.

Background Osteoarthritis (OA) is a leading cause of disability in the United States (U.S.) population, and its prevalence continues to rise. Traditionally, extreme joint loading was described as the leading cause of OA; however, recent studies suggest OA may arise from more complex mechanisms. This study aimed to identify the association between OA and various health predictors among U.S. adults. Methods National Health and Nutrition Examination Survey (NHANES) data of adult participants from 2005 to 2018 was reviewed. OA diagnosis was patient-reported, and other health variables were assessed based on patient-reported, laboratory, and examination data. A multivariable survey logistic regression model was used to estimate adjusted odds ratios and confidence intervals (95% CIs).Stratified analysis based on BMI category was additionally performed to assess the modifying effect of obesity on the association between OA and health predictors. Results A total of 42,143 participants were included in this study. OA prevalence was highest in patients ages [Formula: see text]65 years, females, non-obese individuals, non-Hispanic Whites, and those with at least college education. After controlling for multiple confounding demographic variables and comorbidities, the odds of OA increased with aging, female sex, obesity, high cholesterol, hypertension, diabetes, depression, and thyroid disease. Non-Hispanic White patients and those with less than a high school education also had higher odds of OA. After stratified analysis, aging, female sex, and severe depression demonstrated similar associations with OA across each BMI strata. Having at least a college-level education additionally conferred a similar association with OA across each BMI strata. Conclusion The odds of OA increased with aging, female sex, obesity, less than high school education, high cholesterol, hypertension, diabetes, depression, and thyroid disease. Further studies are needed to characterize the mechanisms of these associations. Given the myriad of factors that influence OA development and progression, the utilization of multidisciplinary and holistic care of OA patients is recommended to limit the influence of other health predictors and reduce ensuing pain, disability, and other complications that result from OA.

Risk of severe cardiovascular events following COPD exacerbations: results from the EXACOS-CV study in Spain

Introduction and objectivesThis real-world study—the first of its kind in a Spanish population—aimed to explore severe risk for cardiovascular events and all-cause death following exacerbations in a large cohort of patients with chronic obstructive pulmonary disease (COPD). MethodsWe included individuals with a COPD diagnosis code between 2014 and 2018 from the BIG-PAC health care claims database. The primary outcome was a composite of a first severe cardiovascular event (acute coronary syndrome, heart failure decompensation, cerebral ischemia, arrhythmia) or all-cause death following inclusion in the cohort. Time-dependent Cox proportional hazards models estimated HRs for associations between exposed time periods (1-7, 8-14, 15-30, 31-180, 181-365, and >365 days) following an exacerbation of any severity, and following moderate or severe exacerbations separately (vs unexposed time before a first exacerbation following cohort inclusion). ResultsDuring a median follow-up of 3.03 years, 18 901 of 24 393 patients (77.5%) experienced ≥ 1 moderate/severe exacerbation, and 8741 (35.8%) experienced the primary outcome. The risk of a severe cardiovascular event increased following moderate/severe COPD exacerbation onset vs the unexposed period, with rates being most increased during the first 1 to 7 days following exacerbation onset (HR, 10.10; 95%CI, 9.29-10.97) and remaining increased >365 days after exacerbation onset (HR, 1.65; 95%CI, 1.49-1.82). ConclusionsThe risk of severe cardiovascular events or death increased following moderate/severe exacerbation onset, illustrating the need for proactive multidisciplinary care of patients with COPD to prevent exacerbations and address other cardiovascular risk factors.

Cutaneous Reactions in Pediatric Patients Treated with MEK Inhibitors: A Retrospective Single-Center Study

Introduction: Mitogen-activated extracellular signal-regulated kinase (MEK) inhibitors are in use for several indications for adults and children. Cutaneous toxicities are among the most common adverse effects. We aimed to describe the spectrum of cutaneous adverse events, its frequency, and severity in a cohort of pediatric patients. Methods: We reviewed all records of patients in our tertiary treatment center treated with MEK inhibitors between January 2016 and January 2023 for all indications. Results: Among 33 patients, 76% reported cutaneous adverse effects. The highest prevalence was in the group of patients treated with trametinib (90%), followed by the group treated with selumetinib (50%) and the group treated with a combination of trametinib and B-Raf proto-oncogene serine/threonine-protein kinase inhibitor (dabrafenib, 34%). Xerosis, dermatitis, paronychia, and hair heterochromia were most frequently reported. Severity was graded 1 or 2 for most adverse events, and 237 visits to the dermatology clinic related to these adverse events were recorded. Conclusions: Cutaneous adverse events are common in the pediatric population as in adults, but the clinical spectrum is different. Although considered mild, multiple dermatological consultations reflect the distress caused by these events. Dermatologists have a central role in the multidisciplinary care of pediatric patients receiving these agents.

UK guidelines for the management of soft tissue sarcomas.

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.