Multidisciplinary Patient Care Research Articles

Cost-Utility Analysis of Specialized Multidisciplinary Care Versus Standard Care in the Management of Patients with Reduced Ejection Fraction Heart Failure in Thailand

Objective: To compare the cost-utility of specialized multidisciplinary care (MC) and standard care (SC) of patients with reduced ejection fraction heart failure (HFrEF). Materials and Methods: The present study was a retrospective analytical cohort study on societal perspective in the 12-month follow-up of patients in the tertiary hospitals in Thailand. Conventional care was offered to the patients in the SC group by the hospitals, and the MC group received additional care in the specialized care of the multidisciplinary heart failure clinic. The authors collected data pertaining to resource utilization from the hospital medical records. The unit cost was based on the Thai Health Technology Assessment’s standard cost list. Quality-adjusted life years (QALYs) were the health outcome of the study. Results: The total cost per patient in MC group was $835.24 versus $933.10 in the SC group. SC and MC QALYs were 0.72 and 0.78, respectively. MC is an outstanding alternative to save cost of $97.86 annually per patient. Patients in the MC group used fewer resources because the complication and hospitalization rates were lower. Conclusion: MC appeared to be a cost-saving approach compared with ambulatory care delivery from SC to patients with HFrEF. Keywords: Cost-utility analysis; Reduced ejection fraction heart failure; Heart failure clinic; Multidisciplinary care

Diabetes Treatment and Mental Illness: A Call for an Integrated Health Care System in Underserved Semi-Rural Malaysia.

Diabetes mellitus (DM) management imposes a tremendous psychological burden on patients. The study investigates the association between DM treatment with blood glucose (BG) control and common mental health conditions. A cross-sectional study was conducted among 1821 individuals with DM in a community-based survey conducted in 2013. Information on respondents’ sociodemographic, mental health, DM treatment, and BG levels was collected. Multinomial logistic regression was employed to examine the association of diabetes treatment with controlled BG levels (<11.1 mmol/L) (42.5%, n = 774) or uncontrolled BG levels (34.3%, n = 625) compared with those not undergoing treatment (23.2%, n = 422) on depression anxiety, and stress. Having DM treatment and controlled BG was associated with high depressive symptoms (Relative Risk Ratio, RRR: 2.42; 95% CI 1.33–4.41) and high anxiety symptoms (1.66; 1.08–2.56) but not with perceived stress. However, treated DM with uncontrolled BG was associated with anxiety (high: 1.64; 1.05–2.56; low: 2.59; 1.10–6.09) but not depression or perceived stress. Our results suggest that being treated for DM, regardless of glucose control status, was associated with anxiety symptoms, whereas being treated with controlled BG was associated with high depressive symptoms. This situation highlights the need for integrative, multidisciplinary care for DM patients with mental health comorbidities.

Enhanced Recovery After Surgery (ERAS) protocol in minimally invasive gynecological surgery: a review of the literature.

Enhanced Recovery After Surgery (ERAS) is a complex system of procedures that necessitates multidisciplinary patient care during the preoperative, intraoperative, and postoperative phases. Over the last two decades, the ERAS protocol, which was initially described in colorectal surgery, has gradually expanded to other surgical specialties. Gynecological surgery is no exception, whether for benign or malignant conditions. The ERAS program&apos;s primary objective is to overcome the pathophysiological processes associated with surgical stress and to facilitate the patient&apos;s rapid recovery, while minimizing complications, hospital stays, and costs. The objectives of minimally invasive surgical procedures largely overlap with the objectives of the ERAS program. We analyzed scientific data from studies examining the ERAS system&apos;s application in minimally invasive gynecological surgery (MIGS) and present them in this review. The central question is whether the ERAS protocol can provide additional benefits beyond those inherent in minimally invasive surgical procedures.

Evaluation of a Radiation Oncology Microclerkship as a Component of Medical Student Training

Background Many US medical students gain clinical exposure to oncology specialties such as medical and/or surgical oncology throughout their core clerkships. Radiation oncology (RO), however, lacks similar representation during the standard curriculum, and few students pursue a dedicated RO elective. This substantially limits the broader understanding of the role of radiation therapy (RT) in multidisciplinary cancer care, including the role of palliative RT and survivorship care. The hypothesis of this study is that incorporating a 1-day "microclerkship" in RO as part of related clerkships will be feasible and perceived as valuable to participating students. Methods The RO clerkship director at a single institution partnered with clerkship directors in medical oncology, palliative care, and radiology so that every 3rd or 4th year medical student rotating in those specialties would spend 1 day in RO during each clerkship. Students were given educational materials to review beforehand, including a 30-minute introductory recorded presentation about general RO principles, and a slide deck and article describing how radiation therapy is relevant to patient care in primary care and other medical subspecialties. At minimum, the day in RO included shadowing one radiation oncologist (and any resident working with them) in clinic and observation of patient treatments, including attending tumor board, brachytherapy procedures, or treatment planning sessions if feasible. Students were invited to complete an anonymous electronic survey immediately after their experience, containing multiple choice and Likert-type questions (1=not at all valuable, 5=extremely valuable). Results Pilot data from 15 students are reported. No student had visited a RO department previously, and only 1 had attended a prior lecture from a radiation oncologist. Students reported the experience to be valuable (median 4, [4-4.5 interquartile range (IQR)]). 13 students (87%) rated the experience quite or extremely valuable. 14 students (93%) felt moderately, very, or extremely more knowledgeable about the role of radiation therapy in cancer management. After the microclerkship experience, some students were more interested in a full 2-4 week RO rotation (8 of 13, 62%) and RO career (4 of 13, 31%). Discussion Preliminary data suggest a valuable role of incorporating RO exposure into related medical student clerkships. Future plans include increasing student participation from these and other related clerkships and expanding the program to other institutions. We hypothesize that this approach will improve US medical student exposure to RO, which could make a subsequent positive impact on referral patterns and multidisciplinary patient care. Many US medical students gain clinical exposure to oncology specialties such as medical and/or surgical oncology throughout their core clerkships. Radiation oncology (RO), however, lacks similar representation during the standard curriculum, and few students pursue a dedicated RO elective. This substantially limits the broader understanding of the role of radiation therapy (RT) in multidisciplinary cancer care, including the role of palliative RT and survivorship care. The hypothesis of this study is that incorporating a 1-day "microclerkship" in RO as part of related clerkships will be feasible and perceived as valuable to participating students. The RO clerkship director at a single institution partnered with clerkship directors in medical oncology, palliative care, and radiology so that every 3rd or 4th year medical student rotating in those specialties would spend 1 day in RO during each clerkship. Students were given educational materials to review beforehand, including a 30-minute introductory recorded presentation about general RO principles, and a slide deck and article describing how radiation therapy is relevant to patient care in primary care and other medical subspecialties. At minimum, the day in RO included shadowing one radiation oncologist (and any resident working with them) in clinic and observation of patient treatments, including attending tumor board, brachytherapy procedures, or treatment planning sessions if feasible. Students were invited to complete an anonymous electronic survey immediately after their experience, containing multiple choice and Likert-type questions (1=not at all valuable, 5=extremely valuable). Pilot data from 15 students are reported. No student had visited a RO department previously, and only 1 had attended a prior lecture from a radiation oncologist. Students reported the experience to be valuable (median 4, [4-4.5 interquartile range (IQR)]). 13 students (87%) rated the experience quite or extremely valuable. 14 students (93%) felt moderately, very, or extremely more knowledgeable about the role of radiation therapy in cancer management. After the microclerkship experience, some students were more interested in a full 2-4 week RO rotation (8 of 13, 62%) and RO career (4 of 13, 31%). Preliminary data suggest a valuable role of incorporating RO exposure into related medical student clerkships. Future plans include increasing student participation from these and other related clerkships and expanding the program to other institutions. We hypothesize that this approach will improve US medical student exposure to RO, which could make a subsequent positive impact on referral patterns and multidisciplinary patient care.

Pregnancy Considerations in the Multidisciplinary Care of Patients with Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) is a vasoconstrictive disease of the distal pulmonary vasculature resulting in adverse right heart remodeling. Pregnancy in PAH patients is associated with high maternal morbidity and mortality as well as neonatal and fetal complications. Pregnancy-associated changes in the cardiovascular, pulmonary, hormonal, and thrombotic systems challenge the complex PAH physiology. Due to the high risks, patients with PAH are currently counseled against pregnancy based on international consensus guidelines, but there are promising signs of improving outcomes, particularly for patients with mild disease. For patients who become pregnant, multidisciplinary care at a PAH specialist center is needed for peripartum monitoring, medication management, delivery, postpartum care, and complication management. Patients with PAH also require disease-specific counseling on contraception and breastfeeding. In this review, we detail the considerations for reproductive planning, pregnancy, and delivery for the multidisciplinary care of a patient with PAH.

Role of interventional radiology in management of post-liver transplant anastomotic complications

BackgroundLiver transplantation is considered to be the treatment of choice in cases of end-stage liver disease; however, as a major procedure, the operation is fraught with complications. The etiology, symptoms, and diagnostic methods for arterial, portal, and biliary issues are thoroughly discussed. Interventional procedures such as balloon angioplasty and stent placement in the arterial and portal systems, as well as biliary interventional procedures, are described.ResultsIn our study, we reviewed 25 cases of post-living donor transplanted liver, with anastomotic complications including biliary stenosis 40%, hepatic vein stenosis 20%, portal vein stenosis 16%, biliary leakage 16%, and hepatic artery stenosis or pseudo-aneurysm 16%. We had 10 cases of biliary stenosis, 7 of which were successfully treated with the insertion of an internal/external drain, and one case failed. Two patients died. We had four cases of hepatic venous obstruction with successfully implanted stents and a perfect outcome, efficacy, and patency rate of 100%. We also had two cases of hepatic artery stenosis that were perfectly managed by stent placement, with a patency rate of 100%. We came across two cases of hepatic artery pseudo-aneurysm. One case failed due to large sac size, while the other was successful. Finally, in our study, we had a 100% success rate in 5 cases of portal vein stenosis in the early postoperative period.ConclusionsPercutaneous IR was effective treatment for hepatic vein occlusion, portal vein stenosis, hepatic artery stenosis, and anastomotic biliary stricture after living donor liver transplantation. The interventional radiology team is now an integral part of the multi-disciplinary care of transplant patients. As new interventional instruments are developed and experience is gained, the outcomes of interventional treatments will continue to improve.

A qualitative study exploring barriers and facilitators to establishing nurse-led, multidisciplinary psychological care for trauma patients: experiences from doctors and nurses

BackgroundTrauma patients are often in a state of psychological stress, experiencing helplessness, sadness, frustration, irritation, avoidance, irritability and other adverse emotions. Doctors and nurses are at the forefront of caring trauma patients and they play a crucial role in psychological supports and mental health care. However, few qualitative studies had based on the framework of the Theory of Planned Behavior (TPB) to explore the experiences in providing psychological care for trauma patients. We examined attitudinal, normative, and control beliefs underpinning medical staffs’ decisions to perform psychological care.MethodA qualitative study of in-depth semi-structured interviews was conducted among 14 doctors and nurses engaging in trauma care. The participants came from six tertiary hospitals in Chongqing, China. Data analysis was performed using the approach of Colaizzi. According to the framework of TPB, the researchers identified and summarized the themes.ResultsImportant advantages (mutual trust, patients' adherence and recovery), disadvantages (workload, short-term ineffective, practice unconfidently), referents (supportive: managers, patients, kinsfolk, nursing culture; unsupportive: some colleagues and patients), barriers (insufficient time or energy, resources situations), and facilitators (access to psychologist, training/education, reminders) were identified. Some demands, such as training diversity, multidisciplinary cooperation and families' support, reflected by doctors and nurses were important for them to carry out psychological care.ConclusionAccording to the TPB, this article explored the internal and external promotion and hindrance factors that affecting the intentions and behaviors of doctors and nurses in implementing psychological care for trauma patients. We also focused on the experience and demands of health professionals in conducting psychological care, which could provide references for managers to formulate corresponding psychological care procedures and norms.

The chance of transition: strategies for multidisciplinary collaboration.

Many long-term childhood cancer survivors suffer from treatment-related late effects, which may occur in any organ and include a wide spectrum of conditions. Long-term follow-up (LTFU) is recommended to facilitate early diagnosis and to ensure better health outcomes. Due to the heterogeneity of these sequelae, different specialists work together in the diagnosis and treatment of these conditions. Experts from both pediatric and internal medicine are involved in age-appropriate care by providing a transition process. Hence, LTFU of childhood cancer survivors is a prototypic example of multidisciplinary care for patients with complex needs treated in a specialized setting. International collaborations of healthcare professionals and scientists involved in LTFU of childhood cancer survivors, such as the International Guideline Harmonization Group, compile surveillance recommendations that can be clinically adopted all over the world. These global networks of clinicians and researchers make a joint effort to address gaps in knowledge, increase visibility and awareness of cancer survivorship and provide an excellent example of how progress in clinical care and scientific research may be achieved by international and multidisciplinary collaboration.

Clinical Predictors and Outcomes Associated with Postoperative Delirium Following Infrainguinal Bypass Surgery

Post-operative delirium (POD) is common yet often underdiagnosed following vascular surgery. Elderly patients with advanced peripheral artery disease may be at particular risk for POD yet understanding of the clinical predictors and impact of POD is incomplete. We sought to identify POD predictors and associated resource utilization after infrainguinal lower extremity bypass. This single center retrospective analysis included all infrainguinal bypass cases performed for peripheral arterial disease from 2012-2020. The primary outcome was inpatient POD. Delirium sequelae were also evaluated. Key secondary outcomes were length of stay, nonhome discharge, readmission, 30-day amputation, post-operative myocardial infarction, mortality, and 2-year survival. Regression analysis was used to evaluate risk factors for delirium in addition to association with 2-year survival and amputation free survival. Among 420 subjects undergoing infrainguinal lower extremity bypass, 105 (25%) developed POD. Individuals with POD were older and more likely to have non-elective surgery (P<0.05). On multivariable analysis, independent predictors of POD were age 60-89years old, chronic limb threatening ischemia, female sex, and nonelective procedure. Consultations for POD took place for 25 cases (24%); 13 (52%) were with pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for those with POD was higher (17days vs. 9days; P<0.001). POD was associated with increased non-home discharge (61.8% vs. 22.1%; P<0.001), 30-day major amputation (6.7% vs. 1.6%; P<0.01), 30-day postoperative myocardial infarction (11.4% vs. 4.1%; P<0.01), and 90-day mortality (7.6% vs. 2.9%; P=0.03). Survival at 2years was lower in those with delirium (89% vs. 75%; P<0.001). In a Cox proportional hazards model, delirium was independently associated with decreased survival (HR=2.0; 95% CI=1.15-3.38; P=0.014) and decreased major-amputation free survival (HR=1.9; 95% CI=1.18-2.96; P=0.007). POD is common following infrainguinal lower extremity bypass and is associated with other adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, nonhome discharge, and worse 2-year survival. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing infrainguinal lower extremity bypass.

Multidisciplinary Extremity Preservation Program Improves Quality of Life for Patients with Advanced Limb Threat

The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution. Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions. From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft-tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P<0.044) and emotional role limitation (OR: 8.1; P=0.042), while, patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P<0.049). Conversely, patients with a smoking history had less improvement in energy level (OR: 0.4; P=0.044) and patients with dialysis-dependence had less improvement in social function (OR: 0.2; P=0.034). Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Furthermore, study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.

A coordinated multipronged attack: integrated care is the future for gastroenterology

Historically, the field of gastroenterology has relied heavily on a medical model, in which the physician is primarily responsible for the entirety of a patient's clinical care. However, there has been a growing shift towards a model that centres on a multidisciplinary team working collaboratively to align with the patient's priorities. Integrated care has no unifying definition, but in the context of clinical gastroenterology it refers to the horizontal integration of clinical specialists (most often specialist nurses, psychologists, and dietitians) who work together to assess and provide a holistic treatment plan. This model should theoretically reduce fragmentation of health-care provision, improve efficiency, reduce duplication, and prioritise patient-centred care. However, enabling this type of integrated care approach requires effective systems and structures to facilitate collaboration and coordination, and despite the clear benefits within hepatology and disorders of gut–brain interaction the widespread adoption of integrated care across the breadth of gastrointestinal disorders remains poor. Standard gastroenterologist versus multidisciplinary treatment for functional gastrointestinal disorders (MANTRA): an open-label, single-centre, randomised controlled trialIntegrated multidisciplinary clinical care appears to be superior to gastroenterologist-only care in relation to symptoms, specific functional disorders, psychological state, quality of life, and cost of care for the treatment of functional gastrointestinal disorders. Consideration should be given to providing multidisciplinary care for patients with a functional gastrointestinal disorder. Full-Text PDF

Optimizing Multidisciplinary Treatment-Related Adverse Effects Detection and Reduction in Patients Undergoing Active Cancer Treatments in Ambulatory Infusion Centers.

The objective of this study was to describe the implementation of an interdisciplinary supportive care program for treatment-related adverse effects (TRAEs) of patients with cancer in two ambulatory infusion centers affiliated with a major health system. A management program of TRAEs was developed on the basis of the collaboration between oncologists, infusion center oncology nurses, and a board-certified oncology clinical pharmacist for patients with cancer in two outpatient infusion centers. Patients received multidisciplinary interventions or oncologist-driven interventions on the basis of their reported symptoms during their cancer treatments. They were followed prospectively at regular intervals for further symptom management interventions. To evaluate this program, a retrospective chart review was performed, and data were collected regarding the number and nature of these TRAEs. The outcomes of their interventions were assessed up to 3 months since initial encounters. Data for patient satisfaction were also collected before and after implementation of the program. A total of 308 patients received 469 interventions initiated either by the multidisciplinary team or by oncologists over a 3-year period. Compared with oncologist-led interventions, multidisciplinary interventions were statistically significant in the number of interventions (P = .004; 95% CI, 17.9 to 36.2) and in reducing occurrences of TRAEs (P = .03; 95% CI, 33.8 to 72.4) such as dermatological toxicities, diarrhea, immune-related adverse effects, mucositis, and nausea or vomiting after 1-month follow-up. Multidisciplinary team captured approximately 40% of TRAEs of all grades that were escalated to oncologists for further management, which led to an overall improvement in management of TRAEs. Multidisciplinary care for patients in infusion centers led to improvement in treatment-related toxicities.

Challenges in the Multidisciplinary Management of Pediatric Patients with Intestinal Failure During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic had profound effects on the management of pediatric patients with intestinal failure. Limitations in personal protective equipment and other necessary supplies led to changes in home care of central venous catheters. Limitations for in-person clinic visits led to changes in care delivery systems and contributed to delays in care and delays in the progression toward enteral autonomy. The emotional strain of living with chronic illness during a pandemic caused hardships that are still being felt. Delays in surgical care also potentially delayed children weaning from parenteral nutrition. The global pandemic of COVID-19 and its far-reaching effects on society contributed to challenges and changes in the multidisciplinary care of pediatric patients with intestinal failure, of which the full effect is still unknown. [Pediatr Ann. 2022;51(7):e277-e280.].

Care for oncological patients in primary health care

This article is the result of a research that aimed to analyze how the health care of cancer patients occurs in the sphere of Primary Care, in municipalities in the Far West Region of Santa Catarina. This is a qualitative study, where the interview technique was used, with the participation of 33 health professionals with higher education, who make up multidisciplinary teams from 25 municipalities with a population of less than five thousand inhabitants. Through the results obtained, there was an understanding in relation to the dynamics, flows and protocols for diagnosis and treatment in the multidisciplinary care of cancer patients. It was evidenced that, despite the existing health equipment and the realization of training, there are difficulties in the reference and in the counter-reference, highlighting fragmentations in the continuity of care.

Coordination Models for Cancer Care in Low- and Middle-Income Countries: A Scoping Review.

Background: The coordination of cancer care among multiple providers is vital to improve care quality and ensure desirable health outcomes across the cancer continuum, yet evidence is scarce of this being optimally achieved in low- and middle-income countries (LMICs). Objective: Through this scoping review, our objective was to understand the scope of cancer care coordination interventions and services employed in LMICs, in order to synthesise the existing evidence and identify key models and their elements used to manage and/or improve cancer care coordination in these settings. Methods: A detailed search strategy was conducted, aligned with the framework of Arksey and O’Malley. Articles were examined for evidence of coordination interventions used in cancer care in LMICs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension Guidelines for Scoping Reviews, which included a checklist and explanation. The PRISMA flow diagram was utilised to report the screening of results. Data were extracted, categorised and coded to allow for a thematic analysis of the results. Results: Fourteen studies reported on coordination interventions in cancer care in LMICs. All studies reported a positive impact of cancer coordination interventions on the primary outcome measured. Most studies reported on a patient navigation model at different points along the cancer care continuum. Conclusions: An evidence-based and culturally sensitive plan of care that aims to promote coordinated and efficient multidisciplinary care for patients with suspicion or diagnosis of cancer in LMICs is feasible and might improve the quality of care and efficiency.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety.

Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition. A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant. A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005). With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.

NFB-21. Neurofibromatosis Type I in the Setting of Neuro-Oncology

Neurofibromatosis Type I (NF1) is an autosomal dominant genetic syndrome that is inherited or sporadic. Neuro-Oncology nurses are experienced in the multidisciplinary care of NF1 patients due to an increased incidence of brain tumors and the treatment of plexiform neurofibromas with Mek inhibitors. However, these children are also at higher risk of rare solid tumors, specifically malignant peripheral nerve sheath tumors (MPNST). Most brain tumors in NF1 have a good prognosis. Conversely, MPNST has an extremely poor prognosis. While patients with MPNST are often cared for by solid tumor care teams, the identification and diagnosis of the tumors occur under the care of the neuro-oncology care team. Complex care coordination for patients with NF1 and cancer is required. Specifically, patients with NF1 are more sensitive to chemotherapy, have a higher incidence of radiation-induced secondary tumors, and need monitoring for NF1 related health impacts. Nurses and nurse practitioners with expertise in neuro-oncology, NF1, and solid tumors must collaborate to provide comprehensive care. Teaching tools and clinical strategies have been developed to maintain patients’ continuity with the primary oncology team while gaining the support of subspecialists. The genetic basis, inheritance pattern, and characteristics of Neurofibromatosis Type I will be discussed as well as rare oncologic diagnoses that are more prevalent in children/young adults with NF1. The multidisciplinary approach to the care of the patient with NF1 and a rare cancer diagnoses at a tertiary care center as well as the optimization of care of patients with NF1 and other underlying syndromes and rare cancers will be reviewed. Increased knowledge of NF1 and the associated health impacts and risk of cancers will improve the care of all patients with NF1.

The role of surgery (metastasectomy) in advanced BRAF positive melanoma during modern therapy.

e21512 Background: Improved overall survival in patients undergoing metаstasectomy for melanoma have been reported in several retrospective studies before era of modern therapy in melanoma. Rapid progress in BRAF and MEK targeted therapy (TT) and immunotherapy (IT) has led to significant improvements in objective response rates and survival rates in advanced melanoma patients. Unfortunately, part of patients have a resistance to modern therapy in one or more lesions. In 2019 Nelson DW et al published data when surgery followed by modern therapy in 47 matched pairs was associated with higher 5-year melanoma-specific survival (MSS) versus modern therapy alone (58.8% vs. 38.9%, p = 0.049). But data about modern therapy in BRAF + advanced melanoma with metastasectomy during therapy are limited. Methods: We conducted an observational retrospective chart review study and evaluated a subset of patients which underwent surgery (metastasectomy) with V600 BRAF-mutant advanced melanoma, who received therapy in a real-world setting in Russia. Survival analyses were performed using the Kaplan-Meier method, Log-rank, chi-square and Fisher exact tests were used for comparison between groups. Results: The observed population included 382 patients in Russia. The date of the first enrollment after all approvals was 8 October 2018, and the date of the last completed register was 27 April 2019. Among 382 patients, 107 (28%) patients received surgical treatment for advanced melanoma during modern therapy (removal of metastases from the brain, lungs, soft tissues and other organs). Surgery during first line therapy was performed in 60pts (56%), as second – in 25pts (23.4%) and third or higher line in 22pts (20.6%). Comparison of overall survival curves for all patients depending on the surgical treatment showed that the survival in the subgroup of patients with the presence of surgical treatment was higher than among patients who did not undergo metastasectomy: 24-months OS was 76.7 (95%CI, 65.6 – 84.6) and 53.7% (95%CI, 46.4-60.4), p = 0,0027). Conclusions: Our findings suggest that resection of distant metastases associated with improved overall survival despite all limitations in retrospective nature of the study. While modern systemic therapy have improved outcomes in advanced melanoma, metastasectomy remains associated with favorable survival. Surgery have to be a part of multidisciplinary care for patients with advanced melanoma.

Patient reported function and symptom burden in breast cancer patients with CNS metastases.

e18635 Background: Central nervous system (CNS) metastases are associated with decreased quality of life for patients with metastatic breast cancer (MBC). Collecting patient-reported outcome (PRO) data can identify patient needs and inform patient-focused interventions. IMPACT the Brain is a care coordination program that aims to improve access to multidisciplinary care for patients with MBC and CNS metastases. The purpose of this study is to report baseline PRO data obtained as part of this program. Methods: Patients with MBC and CNS metastases are referred for enrollment in the program. PROs and caregiver assessments are collected on a voluntary basis at baseline and every 3 months. We performed a retrospective review of the baseline PRO data to determine: (1) type and severity of cancer-related symptoms reported by patients and (2) degree of burden reported by caregivers. The PROMIS Cancer Function Brief 3D Profile measures physical function (PF), fatigue (Fat), and social participation (Soc) in patients with cancer; 50.0 is the population mean and higher scores indicate a greater degree of a trait. The MD Anderson Symptom Inventory Brain Tumor (MDASI-BT) measures severity of cancer-related symptoms including interference with daily life. A score &gt; 4 represents moderate symptoms and &gt; 6 severe symptoms. The mean of the interference items represents overall symptom distress. The Short Form Zarit Burden Interview (ZBI-12) evaluates caregiver burden; a score ≥ 10 suggests mild burden while &gt; 20 suggests high burden. PRO scores were summarized using descriptive statistics. Results: Sixty patients were referred and 54 (90%) enrolled; median age was 53 years (range 31-81). 47 questionnaires were collected at baseline from 32 participants. Average PROMIS T-scores were 37.0 for PF (31.9-51.2), 59.9 for Fat (48.9-66.8), and 42.3 for Soc (32.8-57.1). Participants reported greatest difficulty with performing heavy housework and completing usual work. The mean symptom severity score reported on the MDASI-BT (n = 20) was 2.82 (SD 1.56). Fatigue was the most severe symptom (mean 5.2, SD 2.7) and 25% of patients reported moderate symptoms. The mean interference score was 3.9 (SD 2.66), with 20% of patients reporting moderate and 30% reporting severe overall symptom distress. 65% of caregivers (n = 17) had at least mild caregiver burden on the ZBI-12. Of those, almost half (45.5%) had a score consistent with high burden. Conclusions: Collecting baseline PROs was feasible and provided valuable information about the patient experience. Symptoms experienced by patients with MBC and CNS metastases, particularly fatigue, interfere with ability to carry out usual activities. The distress caused by these symptoms may not correlate with the severity reported by the patient. Given the prevalence of burden experienced by caregivers, further work is needed to explore relationships among symptom distress, symptom severity, and caregiver burden.

PREECLAMPSIA COMPLICATED WITH PULMONARY EDEMA IN NEWLY DIAGNOSED PERIPARTUM DILATED CARDIOMYOPATHY: CASE REPORT

Objective: Pulmonary edema is one of the most serious complications of preeclampsia that should be ruled out in case of dyspnea in a pregnant woman. The prognosis is generally good, however it can indicate underlying unrecognized dilated cardiomyopathy. Design and method: We present a case of 30-year-old woman in 34 weeks of pregnancy was hospitalized at the Gynecology Clinic for preeclampsia. Results: This was the third pregnancy without any previous known cardiovascular disease or known hypertension. Cardiology examination was requested which showed conscious, severely dispnoic and tachycardic patient, with lower leg edema and bilateral pulmonary rales indicating acute pulmonary edema. Blood pressure was 170/100 mmHg, heart rate 130 bpm and saturation 89% with oxygen nasal mask. She reported the presence of headache. Patient was treated for three days with Metil dopa, Nifedipine and corticosteroid therapy of baby lung maturation. She received magnesium sulfate, Verapamil and intravenous Furosemide of 120 mg and the time of pulmonary edema. The patient was not in labor. The ultrasound revealed a monofetal pregnancy and amniotic fluid in normal quantity. Laboratory tests showed mild anemia with normal renal and liver function results. D-dimers were 1320 ng/ml. After stabilization of the patient, a C-section was performed, with the extraction of healthy newborn with an APGAR at 10/10th. There were no post-operative complications. There was marked disappearance of dyspnea within 72 hours, and stabilization of blood pressure. Patient was transferred to the cardiology clinic. Echocardiography showed signs of dilated cardiomyopathy with EF 30% and absent valvopathy. She was put on heart failure treatment with ACE inhibitor, beta blocker, MRA antagonist, furosemide, bromocriptine and LMWH. We received significant clinical improvement during the hospitalization. She was discharged after 6 days in NYHA class II. Conclusions: Acute pulmonary edema is a rare complication, but leading cause of death in women with pre-eclampsia. Diagnosis of peripartum cardiomyopathy requires heightened awareness among multidisciplinary patient care teams and a high degree of suspicion. Many patients with peripartum cardiomyopathy recover within 3 to 6 months of disease onset, but recovery might occur as late as 48 months postpartum