Multidisciplinary Team Assessment Research Articles

Moving pain management programmes into the digital age: development and evaluation of an online PMP for people with chronic pain.

In response to Coronovirus Disease (COVID-19) health care restrictions, the pain management programme delivered group treatment digitally (OPMP). We aimed to: 1) evaluate pain related outcomes of the OPMP, 2) evaluate patient satisfaction and qualitive feedback of the OPMP and 3) compare OPMP outcomes with the pre-pandemic face to face (F2F) PMP outcomes. Age, gender, pain duration, occupational status, referral information and patient satisfaction data were collected. Pre- and post-treatment pain related outcomes were compared by calculating mean difference, benchmarking with effect size (Cohen's d) and determining clinically significant change (CSC) for OPMP and F2F PMP. Two-hundred and thirty-seven patients provided outcome data, with 60 completing the OPMP and 177 completing the F2F PMP. OPMP patients were 10 years younger than the F2F PMP (44.8 vs 53.3), more were female (6.5:1 vs 2.8:1), more were working (45% vs 27%) and fewer were retired (3% vs 17%). The OPMP showed improvements comparable to the F2F PMP. Large effect size was reported across all outcome domains including objective physical outcomes. Eighty-one percent of OPMP patients were 'extremely likely' to recommend the programme but just over 50% of patients felt F2F would provide greater clinical benefits. The results support that OPMP is effective for carefully selected patients following a multidisciplinary team assessment however more complex cases still require F2F PMP.

A clinical consensus paper on jejunal tube feeding in children.

Feeding problems are common in children with complex medical problems or acute critical illness and enteral nutrition may be required. In certain situations, gastric tube feeding is poorly tolerated or may not be feasible. When feed intolerance persists despite appropriate adjustments to oral and gastric enteral regimens, jejunal tube feeding can be considered as an option for nutrition support. A multidisciplinary expert working group of the Australasian Society of Parenteral and Enteral Nutrition was convened. They identified topic questions and five key areas of jejunal tube feeding in children. Literatures searches were undertaken on Pubmed, Embase, and Medline for all relevant studies, between January 2000 and September 2022 (n = 103). Studies were assessed using National Health and Medical Research Council guidelines to generate statements, which were discussed as a group, followed by voting on statements using a modified Delphi process to determine consensus. A total of 24 consensus statements were created for five key areas: patient selection, type and selection of feeding tube, complications, clinical use of jejunal tubes, follow-up, and reassessment. Jejunal tube feeding is a safe and effective means of providing nutrition in a select group of pediatric patients with complex medical needs, who are unable to be fed by gastric tube feeding. Appropriate patient selection is important as complications associated with jejunal tube feeding are not uncommon, and although mostly minor, can be significant or require tube reinsertion. All children receiving jejunal tube feeding should have multidisciplinary team assessment and follow-up.

Immunotherapy Combined With Standard Therapies in Head and Neck Squamous Cell Carcinoma - A Meta-analysis.

Head and neck squamous cell carcinoma (HNSCC) is a deadly disease with a poor prognosis due to late diagnosis and limited treatment options. Immunotherapy (IT) is emerging as a promising approach, especially after the failure of standard of care therapies (STs). The objective of this systematic review and meta-analysis was to evaluate whether the addition of IT to STs improves outcomes for patients with HNSCC, including overall survival (OS), progression-free survival (PFS), and quality of life (QoL). This review employed the Population Intervention Comparison and Outcome (PICO) framework to identify relevant search terms in electronic databases, and also included supplementary hand searches. Six primary research articles were selected using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) flow chart, and were critically appraised. Data extraction from these studies was conducted, and a meta-analysis was performed to aid in the generation of forest plots. The addition of IT to standard anticancer therapies was found to enhance patient outcomes, such as OS, PFS, and QoL. The toxicity profile of IT was acceptable, with minimal treatment-related deaths. The most frequently observed adverse events (AE) were related to the skin, followed by hematological toxicities. Based on our analysis, the addition of IT to STs is a suitable treatment option and is supported by current research. However, further studies are needed to investigate factors that influence treatment effectiveness and to develop optimal therapies. To achieve this, we recommend a comprehensive treatment approach that involves the multidisciplinary team (MDT) and patient assessment tools.

A Multisource Process Evaluation of a Community-Based Healthy Lifestyle Programme for Child and Adolescent Obesity.

Whānau Pakari is a healthy lifestyle assessment and intervention programme for children and adolescents with obesity in Taranaki (Aotearoa/New Zealand), which, in this region, replaced the nationally funded Green Prescription Active Families (GRxAF) programme. We compared national referral rates from the GRxAF programme (age 5-15 years) and the B4 School Check (B4SC, a national preschool health and development assessment) with referral rates in Taranaki from Whānau Pakari. We retrospectively analysed 5 years of clinical data (2010-2015), comparing referral rates before, during, and after the Whānau Pakari clinical trial, which was embedded within the programme. We also surveyed programme referrers and stakeholders about their experiences of Whānau Pakari, analysing their responses using a multiple-methods framework. After the Whānau Pakari trial commenced, Taranaki GRxAF referral rates increased markedly (2.3 pretrial to 7.2 per 1000 person-years), while NZ rates were largely unchanged (1.8-1.9 per 1000 person-years) (p < 0.0001 for differences during the trial). Post-trial, Taranaki GRxAF referral rates remained higher irrespective of ethnicity, being 1.8 to 3.2 times the national rates (p < 0.001). Taranaki B4SC referrals for obesity were nearly complete at 99% in the last trial year and 100% post-trial, compared with national rates threefold lower (31% and 32%, respectively; p < 0.0001), with Taranaki referral rates for extreme obesity sustained at 80% and exceeding national rates for both periods (58% and 62%, respectively; p < 0.01). Notably, a referral was 50% more likely for referrers who attended a Whānau Pakari training half-day (RR = 1.51; p = 0.009). Stakeholders credited the success of Whānau Pakari to its multidisciplinary team, family-centred approach, and home-based assessments. However, they highlighted challenges such as navigating multidisciplinary collaboration, engaging with families with complex needs, and shifting conventional healthcare practices. Given its favourable referral trends and stakeholder endorsement, Whānau Pakari appears to be a viable contemporary model for an accessible and culturally appropriate intervention on a national and potentially international scale.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BackgroundInternational guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes.MethodsThis paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records.Main resultsA total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year.ConclusionsThis cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Abstract 13691: New Model for Prevention and Management of Venous Thromboembolism After Heart Valve Surgery

Introduction: Venous thromboembolism (VTE) is one of the possible complications that can occur after heart valve surgery. Exploring effective VTE prevention and management models for post-cardiac surgery is an important issue in perioperative management. Hypothesis: We hypothesized that a new model for VTE prevention and management can effectively reduce the incidence of VTE in patients undergoing heart valve surgery. Methods: A total of 1200 patients who underwent heart valve surgery were included in this study and randomized in a 1:1 ratio into the control group and new management group. The control group received basic VTE prevention measures, while the intervention group implemented a newly designed VTE prevention and management protocol in addition to the basic preventive measures. The protocol included multidisciplinary team training and assessment, a comprehensive VTE evaluation mechanism, proper execution of preventive measures, physical and mechanical prophylaxis, patient rehabilitation training, and education. The primary outcome measure was the incidence of perioperative VTE, and secondary outcome measures included the occurrence of postoperative pulmonary embolism and all-cause mortality after heart valve surgery. Results: The intervention group included a total of 600 patients, with 57.6% being male and an average age of 56.7 ± 13.4 years. The control group also included 600 patients, with 55.5% being male and an average age of 57.5 ± 12.8 years. There were no significant differences in general clinical data between the two groups. The incidence of in-hospital deep vein thrombosis (DVT) in the intervention group was significantly lower than that in the control group (0.3% vs 1.5%, P&lt;0.05). However, there were no significant differences between the two groups in terms of in-hospital pulmonary embolism and early postoperative all-cause mortality. The intervention group showed a significantly higher accuracy rate in VTE risk assessment compared to the control group (91.3% vs 87.9%, P&lt;0.05). Conclusions: The new model for VTE prevention and management can effectively reduce the incidence of VTE in patients undergoing heart valve surgery, providing important evidence for the prevention and management of VTE in cardiac surgery.

Abstract 15659: Bupropion Overdose Requiring Veno-Arterial Extracorporeal Membrane Oxygenation

Introduction: Bupropion is a monocyclic antidepressant that inhibits dopamine and norepinephrine reuptake, with significant risk cardiotoxicity in overdose cases. Case: A 32-year-old transgender man with a history of Human Immunodeficiency Virus (on anti-retroviral therapy), poly-substance use disorder, and depression presented with an intentional bupropion overdose. On arrival the patient was noted to have seizures and a decreased mental status. He was intubated and treated with anti-epileptic medication. Initial EKG was sinus tachycardia with a QTc of 456 milliseconds. Transthoracic echocardiogram (TTE) showed severely reduced left ventricular ejection fraction (LVEF) that worsened over a 6 hour period from 40% of 25%. Serial EKGs showed progressive QTc prolongation to 635 milliseconds. Cardiac catheterization demonstrated angiographically normal coronary arteries and a Cardiac Index of 2.5 L/min/m 2 . Due to the rapidly prolonging QTc and the significant risk of ventricular tachycardia (VT), the decision was to proceed with Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) cannulation after a multidisciplinary shock team discussion. A few hours after cannulation, patient suffered hemodynamically unstable VT, requiring electrical cardioversion (DCCV) with brief return to sinus rhythm (SR) and with subsequent VT recurrence, that responded to lidocaine and repeat DCCV. ECG normalized and the patient was decannulated from VA ECMO on hospital day 4. Repeat TTE showed recovery of LVEF to 60%. The patient was extubated and discharged to psychiatric rehabilitation. Conclusion: Cardiogenic shock and ventricular arrhythmias are well recognized complications from bupropion toxicity likely due to gap junction inhibition. VA ECMO cannulation should be considered as part of multidisciplinary team assessment for patients at high risk for hemodynamic or electrical collapse in toxidromes with marked cardiotoxicity.

Surgery in chronic pancreatitis after implementation of multidisciplinary team assessment - a single centre prospective study from Oslo

Surgery in chronic pancreatitis after implementation of multidisciplinary team assessment - a single centre prospective study from Oslo

Management Strategies for Congenital Heart Disease Comorbid with Airway Anomalies in Children

To assess management strategies for pediatric patients with the challenging combination of congenital heart diseases (CHD) and airway anomalies. Patients diagnosed with CHD and airway anomalies in the Pediatric Cardiac Surgery Centre of Fuwai Hospital from January 2016 to December 2020 were included in this retrospective study. Patients were divided into three groups based on different management, including the conservative group, the slide group (slide tracheoplasty), and the suspension group (suspension with external stenting). Patients' data and CT measurements from medical records were reviewed. A total of 139 patients were included in the cohort; 107 had conservative airway treatment (conservative group), 15 had slide tracheoplasty (slide group), and 17 had tracheal suspension operation (suspension group). The top three associated intracardiac anomalies were ventricular septal defect (N=34, 24%), pulmonary artery sling (N=22, 16%), and tetralogy of Fallot (N=15, 11%). Compared with patients with conservative airway management (100 minutes [median], 62-152 [interquartile range, IQR]), the extra airway procedure prolonged cardiopulmonary bypass (CPB) duration, with 202 minutes (IQR, 119-220) for the slide group and 150 minutes (IQR, 125-161) for the suspension group. Patients who underwent slide tracheoplasty required prolonged mechanical ventilation (129 minutes [median], 56-328 [interquartile range]). Of the total cohort, 6 in-hospital deaths, all in the conservative group, and 8 mid- to long-term deaths, with 6 in the conservative group, occurred. Both conservative and surgical management of CHD patients with airway anomalies have promising outcomes. Extra tracheobronchial procedures, especially the slide tracheoplasty, significantly prolonged CPB duration. Based on multi-disciplinary team assessment, individualized management strategies should be developed for these patients.

SP7.12 One stop multi-speciality Chronic Postoperative Inguinal Pain Clinic – implementation outcomes

Abstract Aim/Objective The aim on this presentation is to assess patients’ feedback as well as the outcomes of individualised treatment plans for patients assessed in the multidisciplinary team (MDT) clinic. The primary endpoint was quality of life and pain improvement 3 months after receiving treatment. Material and methods All patients reviewed in MDT CPIP clinic in the Comprehensive Hernia Centre between July 2021 and July 2022 were included in the study. Patients feedback as well as MDT individualised treatment plans were assessed. The outcomes, Visual Analogue Scale (VAS) and modified Activity Assessment Scale (mAAS) 3 months post intervention have been audited against data collected prior to intervention. Results We have received 57 referrals during the investigated period. 40 patients underwent MDT assessment with 55% receiving treatment and entering follow-up stage. In that group 26% had surgery, 35% had invasive non-surgical treatment (local injections and radiofrequency ablation), 39% were qualified for pharmacological treatment, together with physiotherapy and psychological support. Follow up data was collected for 19/22 patients. All patients had reported moderate to significant pain (VAS 4-10) on initial assessment and a significant reduction in pain (&amp;gt; 50% improvement in VAS) after treatment. Mean baseline mAAS score was 20.3± 7.3 (range 8 to 40). Mean change was - 10.6±2.6 with all patients reporting significant improvement (&amp;gt; 50%). Moreover, on a scale from 0 to 5, the average satisfaction score was 4.5. Conclusion Developing a multidisciplinary clinic to assess patients presenting with CPIP improved patients’ experiences and outcomes. Enhancing patient-centred care.

Robotic CT guided biopsy to aid histological confirmation of recurrent lymphoma in cases where tissue sample is challenging to obtain through conventional percutaneous methods.

e18796 Background: Histological confirmation of recurrent lymphoma, suspected on clinical history or imaging, enables the determination of an optimal treatment regimen. Conventional percutaneous biopsy methods often involve computed tomography to plan ‘freehand’ needle paths that will often require multiple in procedure adjustments which increases the risk of collateral damage. In cases where suspected recurrent disease is challenging to access using conventional methods, such as lesions close to major structures or located within the retroperitoneum, histological diagnosis can be delayed. Robotic CT guided biopsy allows precise lesion targeting, minimizing the risk of collateral injury, enabling minimally invasive tissue diagnosis in difficult to access lymphoproliferative disease. The aims of this analysis were to assess the safety of robot assisted biopsy by analyzing the related complications and the effectiveness of robotic CT guided biopsy via the sufficiency of histological specimens obtained. Methods: Retrospective consecutive analysis of 11 patients who underwent robotic CT guided biopsy between the months of January and October 2022 in the context of suspected recurrent lymphoproliferative disease. The decision for robotic guided biopsy was based on a multidisciplinary team assessment of the radiology and proposed target sites. Tissue sample adequacy and histological diagnosis were recorded from local histopathology reports. Biopsy related complications were recorded within a 4-month follow-up period from clinical documentation. Results: 11 patients underwent robotic CT guided biopsy. Sufficient samples consisting of at least 2 cores were obtained in all patients. 9 patients were identified with a recurrent form of lymphoma. 1 patient was negative for recurrence. In 1 case an insufficient sample was obtained. No biopsy related immediate or late complications were recorded. Conclusions: We find that, with careful case selection, robotic CT guided biopsy is allowing us to safely obtain a histological diagnosis in suspected recurrent lymphoma where conventional methods are deemed challenging. In the single case where an insufficient sample was obtained significant patient agitation was documented, highlighting that a static target remains of importance with robotic CT guided biopsy. The targeting accuracy the technique provides is allowing optimal treatment planning in a higher proportion of cases.

Informing a value care model: lessons from an integrated adult neurogenomics clinic.

Advances in genomics provide improved opportunities for diagnosis of complex neurogenetic disorders, yet the optimal approach to translate these benefits to the outpatient clinic is unclear. We retrospectively reviewed referral indications and outcomes of an integrated multidisciplinary team (MDT) clinic pathway for adults with suspected neurogenetic disorders. The associated cost implications were estimated. Consecutive patients who attended the neurogenomics clinic from January 2017 to April 2020 were included. The clinic comprised neurologists, clinical geneticists and genetic counsellors, who assessed each patient concurrently. Ninety-nine new patients were referred spanning 45 different clinical diagnoses. Following MDT clinical assessment, 23% (23/99) of referral diagnoses were revised prior to molecular testing. Eighty-one patients (82%) underwent genetic testing, including 43 exome-based panels, 15 whole-genome sequencing, 14 single gene tests, 27 repeat-primed polymerase chain reaction testing and two chromosomal microarrays. Overall, 33/99patients (33%) received a diagnosis, either a molecular diagnosis (n = 24, of which 22 were diagnostic and two were predictive) or a clinical diagnosis (n = 9). Of the clinical diagnosis cohort, five patients received a diagnosis without molecular testing and four patients whose negative testing (one diagnostic and three predictive) allowed exclusion of genetic differentials and, hence, confirmation of clinical diagnoses. The diagnostic rate following MDT and diagnostic testing was 30% (28/94), excluding the five predictive testing cases. MDT assessment aligned with eventual molecular diagnoses in 96% of cases. The estimated average costs were AU$1386 per patient undergoing MDT assessment and AU$4159 per diagnosis achieved. We present an integrated multidisciplinary neurogenomics clinic pathway providing a diagnostic yield of 33% (30% excluding predictive testing cases), with costing implications. The relatively high diagnostic yield may be attributed to multidisciplinary input integrating accurate phenotyping of complex disorders and interpretation of genomic findings.

OC-077 ONE STOP MULTI-SPECIALTY CHRONIC POSTOPERATIVE INGUINAL PAIN CLINIC - IMPLEMENTATION OUTCOMES

Abstract Aim/Objective The aim on this presentation is to assess patients’ feedback as well as the outcomes of individualised treatment plans for patients assessed in the multidisciplinary team (MDT) clinic. The primary endpoint was quality of life and pain improvement 3 months after receiving treatment. Material and methods All patients reviewed in MDT CPIP clinic in the Comprehensive Hernia Centre between July 2021 and July 2022 were included in the study. Patients feedback as well as MDT individualised treatment plans were assessed. The outcomes, Visual Analogue Scale (VAS) and modified Activity Assessment Scale (mAAS) 3 months post intervention have been audited against data collected prior to intervention. Results We have received 57 referrals during the investigated period. 40 patients underwent MDT assessment with 55% receiving treatment and entering follow-up stage. In that group 26% had surgery, 35% had invasive non-surgical treatment (local injections and radiofrequency ablation), 39% were qualified for pharmacological treatment, together with physiotherapy and psychological support. Follow up data was collected for 19/22 patients. All patients had reported moderate to significant pain (VAS 4–10) on initial assessment and a significant reduction in pain (&amp;gt; 50% improvement in VAS) after treatment. Mean baseline mAAS score was 20.3± 7.3 (range 8 to 40). Mean change was - 10.6±2.6 with all patients reporting significant improvement (&amp;gt; 50%). Moreover, on a scale from 0 to 5, the average satisfaction score was 4.5. Conclusion Developing a multidisciplinary clinic to assess patients presenting with CPIP improved patients’ experiences and outcomes. Enhancing patient-centred care.

A New Treatment Program: Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD).

Bipolar disorder (BD) is complicated by a dynamic, chronic course along with multiple comorbid psychiatric and medical conditions, making it challenging for clinicians to treat and patients to thrive. To efficiently manage the complexity of BD and help patients recover, we developed a Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). The purpose of this paper is to describe how we developed this clinic and the lessons we learned. We developed FITT-BD by integrating strategies from stepped care, collaborative care, and learning health care systems. We describe the rationale, details, and lessons learned in developing FITT-BD. By integrating stepped care, collaborative care, and a learning health care system approach, FITT-BD aims to reduce barriers to care, leverage the expertise of a multidisciplinary treatment team, ensure patient-centeredness, and use assessments to inform and continuously improve outcomes in real time. We learned that there are challenges in the creation of a web-based application that tracks the treatment of patients within a network of hospitals. The success of FITT-BD will be determined by the degree to which it can increase treatment access, improve treatment adherence, and help individuals with BD achieve their treatment goals. We expect that FITT-BD will improve outcomes in the context of ongoing clinical care. The treatment of BD is challenging and complex. We propose a new treatment model for BD: FITT-BD. We expect that this program will be a patient-centered approach that improves outcomes in the context of ongoing clinical care for patients with BD.

INTRODUCTION OF A MULTIMODAL PAIN REHABILITATION INTERVENTION IN PRIMARY CARE: A PILOT STUDY.

To evaluate patient-reported outcome measures in patients with chronic musculoskeletal pain 1 year after participation in a case manager-led multimodal rehabilitation intervention in a Finnish primary care centre. Changes in healthcare utilization (HCU) were also explored. A prospective pilot study with 36 participants. The intervention consisted of screening, multidisciplinary team assessment, a rehabilitation plan and case manager follow-up. Data were collected through questionnaires filled in after the team assessment and 1 year later. HCU data 1 year before and 1 year after team assessment were compared. At follow-up, satisfaction with vocational situation, self-reported work ability and health-related quality of life (HRQoL) had improved and pain intensity had diminished significantly for all participants. The participants who reduced their HCU improved their activity level and HRQoL. Early intervention by a psychologist and mental health nurse was distinctive for the participants who reduced HCU at follow-up. The findings demonstrate the importance of early biopsychosocial management of patients with chronic pain in primary care. Identification of psychological risk factors at an early stage may lead to better psychosocial wellbeing, improve coping strategy and reduce HCU. A case manager may free up other resources and thereby contribute to cost savings.

Liver Resection and Transplantation Following Yttrium-90 Radioembolization for Primary Malignant Liver Tumors: A 15-Year Single-Center Experience.

Patients diagnosed with HCC and ICC treated by RE with further liver resection (LR) or LT between 2005-2020 were included. All patients selected were discarded for the upfront surgical approach for not accomplishing oncological or surgical safety criteria after a multidisciplinary team assessment. Data for clinicopathological details, postoperative, and survival outcomes were retrospectively reviewed from a prospectively maintained database. A total of 34 patients underwent surgery following RE (21 LR and 13 LT). Clavien-Dindo grade III-IV complications and mortality rates were 19.0% and 9.5% for LR and 7.7% and 0% for LT, respectively. After RE, for HCC and ICC patients in the LR group, 10-year OS rates were 57% and 60%, and 10-year DFS rates were 43.1% and 60%, respectively. For HCC patients in the LT group, 10-year OS and DFS rates from RE were 51.3% and 43.3%, respectively. Liver resection after RE is safe and feasible with optimal short-term outcomes. Patients diagnosed with unresectable or high biological risk HCC or ICC, treated with RE, and rescued by LR may achieve optimal global and DFS rates. On the other hand, bridging or downstaging strategies to LT with RE in HCC patients show adequate recurrence rates as well as long-term survival.

Cognitive behaviour therapy (CBT) as a psychological intervention in the treatment of ARFID for children and young people

AbstractAvoidant Restrictive Food Intake Disorder (ARFID) is a condition characterised by a disturbance in eating behaviour that leads to a significant negative impact on physical, social and nutritional health. The diagnosis of ARFID relies on a comprehensive, multi-disciplinary assessment to understand the individual’s history, physical, social and mental health risk, and any co-occurring mental health difficulties. Consensus guidance suggests that psychological treatment, alongside medical and dietetic input is delivered with consideration of any appropriate adaptions to accommodate developmental stage and/or common co-occurring presentations. This paper has been authored by clinicians working in an out-patient setting for children and adolescents with ARFID, and focuses on the presentation and assessment of ARFID and cognitive behavioural therapy (CBT) approaches that can help children, young people and their families. After an introductory section, the paper is split into four sections: assessment of ARFID; drivers of avoidant restrictive eating behaviour; multi-disciplinary formulation and intervention planning; and treatment. The treatment section provides an overview of the available research on CBT for ARFID, and a brief summary of the broader evidence base for CBT in children and young people with anxiety. Following a review of the evidence base, three case descriptions are provided to illustrate the clinical application of CBT where fear-based avoidance is the main driver. The paper concludes with practice points for clinicians to take forward when working with children and young people with ARFID.Key learning aims(1)To be aware of the international consensus for the use of psychological interventions as a component of ARFID treatment alongside medical and dietetic input.(2)To understand that ARFID is characterised as a disturbance of eating behaviour, and as such, psychological intervention should target the drivers of this disturbance to promote behavioural change.(3)To gain an overview of the multi-disciplinary team assessment as an important tool to understand the contribution of each of the three drivers proposed to underpin an ARFID presentation.(4)To recognise when a CBT approach might be indicated, the current best evidence base for CBT for ARFID and how to adapt CBT to accommodate developmental stage and/or common co-occurring presentations.

Findings of a Multidisciplinary Assessment of Children Referred for Possible Neurodevelopmental Disorders: Insights from a Retrospective Chart Review Study.

Children with ASD have a wide spectrum of functional deficits in multiple neurodevelopmental domains. A multidisciplinary team assessment (MDT) is required to assess those deficits to help construct a multimodal intervention plan. This is a retrospective chart review of the assessment for children who were referred for an assessment of potential neurodevelopmental disorders. We reviewed 221 participants' charts from January 2019 to January 2020. The mean age of the children was 7.95 ± 3.69, while the mean age of the fathers and mothers was 37.31 ± 8.57 and 31.95 ± 6.93, respectively. Consanguinity was as high as 37.9% for the referred children with developmental delay who were first-degree related, and 13.2% of the parents were second-degree relatives. Approximately 26.6% of children had a family history of mental illness in first-degree relatives. ASD was the most commonly reported diagnosis post-assessment, and ADHD was the most common reported comorbidity at 64.3% and 88.5%, respectively. The MDT findings showed that 58% of children required moderate or higher assistance with toileting, 79.2% were unable to answer yes/no questions, and 86.8% were unable to understand "wh" questions. Only 26% of the nonverbal children had average IQ testing results, and 31% of verbal children did. In conclusion, the mean age of the children when assessed was above that recommended for early screening and intervention. An increased paternal and maternal age was noticeable. Consanguinity and a family history of mental disorders in first-degree relatives were high, attesting to a possible genetic risk.

The impact of hospital volume on survival in patients with locally advanced colonic cancer.

High hospital volume has been shown associated with improved survival in patients with several cancers. The aim of this nationwide cohort study was to investigate whether hospital volume affects survival in patients with locally advanced colonic cancer. All patients with non-metastatic locally advanced colonic cancer diagnosed between 2007 and 2017 in Sweden were included. Tertiles of annual hospital volume of locally advanced colonic cancer were analysed and 5-year overall and colonic cancer-specific survival were calculated with the Kaplan-Meier method. HRs comparing all-cause and colonic cancer-specific mortality rates were estimated using Cox models adjusted for potential confounders (age, sex, year of diagnosis, co-morbidity, elective/emergency resection, and university hospital) and mediators (preoperative multidisciplinary team assessment, neoadjuvant chemotherapy, radical resection, and surgical experience). A total of 5241 patients were included with a mean follow-up of 2.7-2.8 years for low- and high-volume hospitals. The number of patients older than 79 years were 569 (32.3 per cent), 495 (29.9 per cent), and 482 (26.4 per cent) for low-, medium- and high-volume hospitals respectively. The 3-year overall survival was 68 per cent, 60 per cent and 58 per cent for high-, medium- and low-volume hospitals, respectively (P < 0.001 from log rank test). High volume hospitals were associated with reduced all-cause and colon cancer-specific mortality after adjustments for potential confounders (HR 0.76, 95 per cent CI 0.62 to 0.93 and HR 0.73, 95 per cent CI 0.59 to 0.91, respectively). The effect remained after inclusion of potential mediators. High hospital volume is associated with reduced mortality in patients with locally advanced colonic cancer.

Speckle tracking echocardiography in plasma cell disorders: the role of advanced imaging in the early diagnosis of AL (Light Chain) cardiac amyloidosis

Abstract Introduction Cardiac involvement is described as the most important prognostic factor in light chain amyloidosis. An early diagnosis is mandatory to customize the follow-up timing and the best treatment. The aim of the study was to identify the role of advanced echocardiography in the diagnosis of amyloid light chain cardiac amyloidosis (ALCA). Material and methods Seventy-seven patients were prospectively included in the study: 22 patients with biopsy proven ALCA, 28 patients with multiple mieloma, and 27 with monoclonal gammopathy of undetermined significance. All patients underwent first and second level imaging including Speckle Tracking and complete biochemical profile. Univariate and Multivariate analysis was applied to the best multi-chamber predictor assessed with Receiver Operating Curve analysis. Continuous variables were discretized and compared with different subgroups based on multiparametric imaging assessment using available AL score. Results Biochemical indices have been confirmed as the best predictors of ALCA. More specifically, high sensitivity troponin (hsTn) and N-terminal pro brain natriuretic peptide (NT-pro-BNP) showed an AUC of 0.88 and 0.91 respectively. Among left ventricular systolic function parameters, left ventricular longitudinal strain (AUC: 0.92); apical sparing pattern (AUC: 0.75) and relative wall thickness (RWT) (AUC: 0.88) showed the best diagnostic accuracy. Atrial parameters such as left atrial volume index (LAVI) (AUC: 0.74), left atrial stiffness (LAS) (AUC: 0.82) and inter-atrial septum diameter (AUC: 0.75) showed a good diagnostic accuracy in ALCA (Figure 1). LAS and AL score maintained their diagnostic value in the multivariate model analysis (B=2,16; p=0,01 and B= 0,72; p&amp;lt;0.01 respectively). However, only LAS, with a cut off value of 0.65, was able to discriminate ALCA when AL score was not detrimental (P&amp;lt;0.001). Conclusion ALCA diagnosis often relies only on the biochemical profile. A comprehensive cardiac evaluation by a multiparametric imaging approach with LAS estimation is mandatory to ensure early diagnosis and a prompt treatment through a multidisciplinary team assessment. Funding Acknowledgement Type of funding sources: None.