Multidisciplinary Assessment Research Articles

Primary breast sarcomas: A 13 case-series study treated in university hospital in central Tunisia over a 25-year period.

To retrospectively study the therapeutic modalities of primary breast sarcomas in view of the data of a local Tunisian experience. It is a monocentric, descriptive, retrospective study including 13 cases of primary breast sarcoma treated over a period of 25 years (1995-2020) in the oncological radiotherapy department of a university hospital in Sousse, Tunisia. In our study, 13 cases of non-metastatic breast sarcomas that has been identified, divided into ten cases of phyllodes sarcomas and three cases of non-phyllodes sarcomas.Surgically, all our patients had a mastectomy. Among them, seven underwent a lymph node procedure: five underwent axillary lymph node dissection, and two others had primary axillary lymph node biopsy. For the adjuvant treatment, all the patients included in our study received radiotherapy and seven received chemotherapy. Local recurrence occurred on the operative scar in one patient after completion of radiation therapy. Metastatic relapse was described in five patients. The time to onset of metastases varied between two months and five years. Nevertheless, a complete remission was noted in 6 patients with a follow-up varying from four years to 20 years. Two patients were lost to follow-up. Breast sarcomas remain a very rare entity of aggressive tumors.The therapeutic approach is poorly codified. For this reason, the therapeutic decision should always be discussed in a multidisciplinary assessment.

Effect of a Billing Code to Reimburse Nurse-Supported Rheumatology Care on Health Care Costs and Access: An Interrupted Time Series Analysis.

This study was undertaken to evaluate the impact of a Multidisciplinary Care Assessment (MCA) billing code on health system costs and access to care in British Columbia (BC). Data on all people treated by rheumatologists in BC were obtained from five linked health administrative databases held by Population Data BC from April 1, 2006, to March 31, 2020. Rheumatologists were allocated to either the intervention (ever-billers) or control groups (never-billers). For the intervention group, the index date was the month of the first MCA code billing. For the control group the index dates were imputed from intervention index dates. Our analysis focused on a 48-month period (24 months before and after the index date). We evaluated the impact on two cost (costs related to rheumatoid arthritis [RA]; total health care costs) and access outcomes (rheumatology-related visits per rheumatologist; days between rheumatology visits for patients with RA) using an interrupted time series analysis. A total of 46 rheumatologists (31 intervention and 15 control) met our inclusion criteria. Introduction of the MCA was associated with a small but significant increase in RA-related costs that, at 2 years, translates to a net absolute change of $9.66 per patient per month, but no statistically significant changes in total health care costs. There was no statistically significant change in the number of rheumatology-related visits, but at 2 years there was a net absolute reduction in the median days between rheumatologist visits for patients with RA (6.3 days). The introduction of the MCA code was associated with a negligible increase in the RA-related costs and an improvement in access to ongoing care for patients.

Real-World Effectiveness of High-Dose Tafamidis on Neurologic Disease Progression in Mixed-Phenotype Variant Transthyretin Amyloid Cardiomyopathy.

Transthyretin amyloidosis (ATTR) is a progressive, heterogeneous rare disease manifesting as ATTR polyneuropathy (ATTR-PN), ATTR cardiomyopathy (ATTR-CM), or a mixed phenotype. Tafamidis meglumine (20mg po qd) is approved in some markets to delay neurologic progression in ATTR-PN, while high-dose tafamidis (80/61mg po qd) is approved worldwide to reduce cardiovascular mortality and cardiovascular-related hospitalization in ATTR-CM. The objective of this study was to assess the real-world benefit of high-dose tafamidis for delaying neurologic progression in patients with mixed-phenotype variant ATTR-CM (ATTRv-CM). This exploratory, retrospective, observational cohort study evaluated anonymized electronic medical records and included adult patients with mixed-phenotype ATTRv-CM treated with high-dose tafamidis for at least 6months. Neurologic assessments included the Medical Research Council (MRC) Scale for Muscle Strength, Neuropathy Impairment Score (NIS) muscle weakness subscale, and Polyneuropathy Disability (PND) instrument. Modified body mass index (mBMI) was also assessed. Patients (N = 10) started tafamidis treatment an average of 3.8months after diagnosis, with an average treatment duration of 20.8months. Seven of 10 patients demonstrated normal muscle strength on the MRC scale throughout the study, and 9 of 10 patients had no decline in muscle strength during the post-treatment period. The NIS muscle weakness subscale score was ≤ 60 for all patients in the study at all time points, suggesting normal function to mild impairment. Six of 10 patients had no change in walking capacity as measured by the PND instrument at pre- and post-assessments, while one-third of patients had a decrease in PND stage (signaling improvement) from pre- to post-assessment. mBMI remained relatively stable throughout the study. This is the first real-world study to demonstrate the potential value of high-dose tafamidis for delaying neurologic disease progression in patients with mixed-phenotype ATTRv-CM. The findings underscore the importance of multidisciplinary assessment for patients with ATTR amyloidosis. ClinicalTrials.gov: NCT05139680.

Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort

Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking. To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting. This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022. Reidentification with birth-registered sex. The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received. Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%). These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.

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.

Endometriosis and pain

Managing chronic pain in endometriosis requires multidisciplinary assessment and care. The aim is not complete disappearance of symptoms, but rehabilitation through medication, non-medication treatments and overall follow-up.

Multidisciplinary Decision-Making-ITAlian Consensus After Two Years of Real Practice on the Management of Severe Uncontrolled CRSwNP by Biologics (ITACA Study).

We aimed to reach an Italian multidisciplinary consensus on some crucial aspects of treatment decision making in CRSwNP, following 2years of clinical experience in order to support specialists in the management of CRSwNP in clinical practice. We addressed issues relating to therapeutic decision-making and shared criteria for the treatment choice, as well as appropriate timing and criteria for evaluating treatment response, and highlighted the need for repeated multidisciplinary assessments. A national survey has been conducted recently to understand how rhinology practice has changed in Italy with the advent of biologics and how this affects patients with uncontrolled, severe CRSwNP. Despite the many published consensus documents, practical recommendations, and protocols on the use of biologics in CRSwNP, heterogenous behaviors in practice are still observed mainly conditioned by the novelty of the topic. The consensus procedure followed a modified Delphi approach. The scientific board included 18 otorhinolaryngologists and 8 allergists, who selected the 4 main topics to be addressed and developed overall 20 statements. Consensus on these statements was sought by a larger group of 48 additional experts, through two rounds of voting, the first web-based, the second in presence with discussion and possible refinement of the statements. The statements reaching an average score ≥ 7 at the second voting round were approved. Five statements were proposed for each of the following topics: baseline evaluation of patients eligible for biologic therapy; choice between different therapeutic options; assessment of the response to biologic treatment; multidisciplinary management. At the first voting round, 19 out of the 20 statements reached a mean score ≥ 7. Following the discussion and a few consequent amendments, at the second round of voting all the 20 statements were approved.

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.

The Role of Greenhouse Gases, Aerosols, and Deforestation in Climate Change: a Multidisciplinary Assessment of the Interaction Mechanisms Between Human Activity and the Environment

Climate change can be caused by various anthropogenic or natural factors that influence atmospheric changes. The direct link between human activity and the environment is represented by the interaction mechanisms between anthropogenic factors such as urbanization, deforestation, hydrological changes, greenhouse gases and aerosols. These interaction mechanisms are assessed by the current state of knowledge in the climate change field. One of these mechanisms is related to greenhouse gases (GHGs), which increase surface level heating and lowers atmospheric temperature in the long term by increasing atmospheric GHG concentration. This heating reduces air density parcel and increases total evaporation to transfer excess heat from surface (latent heat) to atmosphere. Another mechanism is related to anthropogenic aerosols, which have direct and indirect effects on climate change with variable direct radiative forcing depending on the nature, density and composition of the aerosol particles. Anthropogenic sulphate is the main element that influences atmospheric conditions through its direct and indirect effects, which delay global warming by increasing the albedo and the lifetime of clouds formed by water droplets. A third mechanism is related to deforestation, which affects the environment according to the results of climate models based on deforestation scenarios. Deforestation alters the heat exchange between the oceans (relatively warm) and the atmosphere (relatively cold), generating a sensible heat flux (warming) that influences neighbouring regions. Deforestation also lowers surface temperature by changing coniferous vegetation to tundra and desert, causing a cooling of up to -4°C in North America and -6°C in Siberia. In Europe, deforestation scenarios show a decrease in surface temperature of -2°C to -3°C in spring and -1°C in summer in northern mid-latitudes, mainly due to the delayed melting of spring snow.

Understanding and supporting the diversity of the autistic spectrum

Autism is a neurodevelopmental disorder that affects people's communication, social interaction and behavior. This article aims to explore autism in detail, addressing its characteristics, causes, diagnosis and impact on people's lives. In developing the article, a comprehensive review of available literature was carried out, including scientific studies, reports from health organizations and personal experiences of autistic individuals and their families. The introduction presented an overview of autism, emphasizing the importance of understanding the complexity of the autism spectrum, which encompasses a wide variety of individual profiles and characteristics. The need to promote the inclusion and acceptance of people on the autism spectrum in society was also highlighted. In developing the article, the main characteristics of autism were discussed, including difficulties in verbal and non-verbal communication, challenges in social interaction, restricted and repetitive patterns of behavior, sensory sensitivities and variations in cognitive development. The importance of early diagnosis and multidisciplinary assessment to identify autism and initiate appropriate interventions was addressed. The possible causes of autism were also explored, such as genetic, environmental and neurobiological factors, highlighting the complexity and multifactorial nature of the disorder. Another point discussed in the development of the article were the approaches and interventions used to support people on the autism spectrum. Behavioral strategies, specialized therapies, educational support, environmental adaptations and social inclusion programs were mentioned as important components to promote the development and quality of life of autistic people. The importance of the teacher's role in the classroom was highlighted, emphasizing the need for an inclusive and individualized approach. Strategies such as adapting the environment, clear communication, individualized instruction and promoting social interaction were discussed as ways to support autistic students in the school environment. The conclusion reinforced the importance of promoting an inclusive society aware of the needs of autistic people. The need for greater awareness, acceptance and support to overcome the challenges and barriers faced by autistic people in society was highlighted. It was also highlighted that when provided with appropriate support and an inclusive environment, autistic people have the potential to flourish, contribute and achieve a full and meaningful life. Finally, bibliographic references were provided to support and validate the information presented in the article.

A288 ALCOHOL RELAPSE AND ADVERSE OUTCOMES IN EARLY VERSUS ROUTINE LIVER TRANSPLANT FOR ALCOHOL-ASSOCIATED LIVER DISEASE IN THE PROVINCE OF BRITISH COLUMBIA

Abstract Background Liver transplant is a life-saving treatment for patients with alcohol-associated liver disease (ALD) resulting in decompensated cirrhosis or severe alcoholic hepatitis, significantly reducing mortality compared to supportive treatment. Despite its previous wide acceptance, there is a lack of strong evidence to justify a 6-month abstinence period. In 2019, BC Transplant policies were updated to allow liver transplant within 6-months of alcohol use in carefully selected patients with limited life expectancy and favorable multidisciplinary psychosocial assessment. Aims This study aims to assess alcohol relapse rates and adverse outcomes in patients who received an early liver transplant for ALD. Methods A retrospective chart review was performed on all adult patients who underwent liver transplant in the province of British Columbia between January 1, 2020, and December 31, 2022. Follow up data was extracted until May 31, 2023. Patients were included if they had alcohol documented as a contributing factor to their liver disease prior to transplant. Early transplant was defined as alcohol abstinence of 179-days or less and routine transplant as 180-days or more. Alcohol use and time to alcohol use were determined by patient history, random biochemical testing, and health-care utilization for an alcohol-associated complication. Graft dysfunction or rejection resulting in a change in therapeutic management, noncompliance determined by clinician documentation, rehospitalization, and death were recorded as adverse events. Results 278 patients underwent liver transplant during the study period. 81 patients were classified as alcohol-related, and 15 received early transplant. The mean follow-up period was 20.5 months. Early transplant recipients were more likely to be younger (median 45 vs. 58 years, p = 0.003) and have a higher MELD score at the time of transplant (median 37 vs. 17, p ampersand:003C 0.001). There was no significant difference in post-transplant alcohol relapse (13 vs. 15%, hazard ratio = 0.78, 95% CI [0.17, 3.55], p = 0.74). Graft dysfunction was increased in patients who received early transplant (53 vs. 25%, relative risk = 2.17, 95% CI [1.15, 4.10]). There was no significant difference between rates of noncompliance (0 vs. 9%), rehospitalization (53 vs. 56%), or death (0 vs. 2%). Conclusions Alcohol relapse is similar between early and routine liver transplant. Graft dysfunction is increased in early transplant, although other adverse events including medication noncompliance, rehospitalization, and death are not significant different. These results are favorable for the continued use of early liver transplant for ALD, providing an effective treatment for ALD and significantly reducing mortality in patients with a limited life expectancy. Funding Agencies None

Weight suppression at lowest weight as an indicator of eating disorder clinical severity: A retrospective cohort study

ObjectivesWeight suppression (WS) defines the difference between the highest weight in adulthood and the current weight. WS at lowest weight is the difference between the highest and the lowest ever weight. Weight rebound is the difference between the past lowest weight and current weight. The distinction in the capacities of WS, weight rebound, and WS at the lowest weight remains unclear regarding their efficacy in forecasting clinical endpoints. This study assessed the relationship between WS, WS at lowest weight and/or weight rebound and eating disorder (ED) clinical severity. MethodsIn this retrospective cohort study, adult participants were selected at the Outpatient Unit for multidisciplinary assessment of ED, Montpellier, France, between February 2012 and October 2014 and May 2017 and January 2020. ED clinical severity was evaluated using the Eating Disorder Examination Questionnaire (EDE-Q). ResultsThe sample included 303 patients: 204 with anorexia nervosa (AN) and 99 with bulimia nervosa (BN). The EDE-Q total score was positively correlated with WS at lowest weight in patients with AN (Spearman's rho = 0.181, p = 0.015) and with BN (Spearman's rho = 0.377; p < 0.001). It was also positively correlated with weight rebound (Spearman's rho = 0.319; p = 0.003) in patients with BN. In the multivariate analysis, EDE-Q total score was associated with WS at lowest weight only in patients with BN (β = 0.265; p = 0.03). ConclusionWS at lowest weight seems to be a good measure of ED clinical severity. More research is needed for better understanding WS at lowest weight in assessment and treatment of patients with ED.

The Association of Rheumatologist Supply and Multidisciplinary Care With Timely Patient Access to Rheumatologists: Evidence From British Columbia, Canada.

The objective was to understand how the expansion of rheumatology supply and the introduction of multidisciplinary care was associated with access to rheumatology services. We accessed Population Data BC, a longitudinal database with de-identified individual-level health data on all residents of British Columbia, Canada, to analyze physician visits and prescribing from 2010-2011 to 2019-2020. We calculated access as the time from referral to first rheumatologist visit and, for people with rheumatoid arthritis (RA), time to first disease-modifying antirheumatic drug (DMARD). Associations between lag time, patient characteristics, and system variables were explored using quantile regression. Over the study period, there were 149,902 new rheumatologist visits, with 31% more visits in 2019-2020 than in 2010-2011. The proportion of first visits for patients with inflammatory arthritis increased from 28% to 51%. The median time from referral to first visit decreased by 22 days (35%) from 63 days (interquartile range 21-120 days) in 2010-2011. For people with RA, time from referral to DMARD decreased by 4 days (6%) to 62 days. Male sex, living in metropolitan areas, and having a rheumatologist who used a multidisciplinary care assessment code were associated with shorter times from referral to first DMARD. Access to rheumatology care improved, and the increased proportion of patients with IA in the first visits case-mix indicates that rheumatologist supply and incentives for multidisciplinary care may have improved referral patterns. However, time to DMARDs for people with RA remained long, and we found signals of unequal access for female patients and people living outside of metropolitan areas.

Analysis of feeding and eating disorders in 191 children according to psychiatric or gastroenterological recruitment: The PEDIAFED cohort study.

The DSM-5 classification introduced new Feeding and Eating Disorders (FED) diagnostic categories, notably Avoidant and Restrictive Food Intake Disorder (ARFID), which, like other FED, can present psychiatric and gastrointestinal symptoms. However, paediatric clinical research that focuses on children below the age of 12years remains scarce. The aim of this study was first to investigate the clinical features of FED in a cohort of children, second to compare them according to their recruitment (gastroenterology or psychiatry unit). This non-interventional retrospective cohort study analysed 191 patients in a French paediatric tertiary care centre (gastroenterology n=100, psychiatry n=91). The main outcome variables were clinical data (type of FED, BMI, nutritional support, chronic diseases, psychiatric comorbidities, sensory, sleep, language disorders, gastrointestinal complaints, adverse life events, family history). The outcome was defined by a Clinical Global Impression of Change-score. FED diagnoses were ARFID (n=100), Unspecified FED (UFED, n=57), anorexia nervosa (AN, n=33) and one pica/rumination. Mean follow-up was 3.28years (SD 1.91). ARFID was associated with selective and sensory disorders (p<0.001); they had more anxiety disorders than patients with UFED (p<0.001). Patients with UFED had more chewing difficulties, language disorder (p<0.001), and more FED related to chronic disease (p<0.05) than patients with ARFID and AN. Patients with AN were female, underweight, referred exclusively to the psychiatrist, and had more depression than patients with ARFID and UFED (p<0.001). The gastroenterology cohort included more UFED, while the psychiatry cohort included more psychiatric comorbidities (p<0.001). A worse clinical outcome was associated with ARFID, a younger age at onset (p<0.001), selective/sensory disorders and nutritional support (p<0.05). ARFID and UFED children were diagnosed either by gastroenterologists or psychiatrists. Due to frequently associated somatic and psychiatric comorbidities, children with FED should benefit from a multidisciplinary assessment and care.

“Great day! But now what?” Adolescents’ and foster carers’ experiences of a comprehensive health assessment for children in out-of-home care

Children in out-of-home care have extensive mental and physical health care needs. Best practice guidelines recommend comprehensive health assessments to all children entering out-of-home care, as their needs are often unidentified and unmet. The aim of this study was to explore adolescents’ and foster carers’ experiences and expectations after participating in a comprehensive multi-disciplinary health assessment. Within two weeks of the assessment day, nine adolescents (aged 11–17 years), and 12 foster carers were interviewed, and asked to share what they thought about the encounters and the tasks from the assessment day. Based on these experiences, further conversations explored relevant issues from contemporary life, and prospects for the future. Through Interpretative Phenomenological Analyses, three major themes were identified as the main findings. First, the participants felt seen and involved, taken care of and taken seriously throughout the assessment day. Adolescents and carers had concordant views on what made the environment feel safe, despite the potentially demanding comprehensiveness and topics of the assessment. Second, the assessment was perceived as relevant, and gave access to enhanced understanding, although the adolescents and the carers expressed divergent views on the perceived importance of the assessment and how it related to their daily lives. The third theme referred to feeling hopeful, but powerless facing the future, and the uncertainty regarding what would happen with the identified needs and recommendations for services. Our results suggest that the assessment day was manageable, understandable and acceptable, but the engagement and involvement from the assessment day did not transfer to the expectations for follow-up.

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.

A 10-year review on older patients undergoing colorectal cancer surgery: surgeon-led geriatric service and good quality surgery are drivers of good outcomes

BackgroundOlder age and frailty are associated with worse postoperative outcomes and prolonged length of stay (LOS). In this study, we aimed to analyze the long-term outcomes after the implementation of our geriatric surgical service (GSS). MethodsThis was a single-center retrospective study from July 2010 to December 2021 on patients aged ≥75 years or patients aged ≥65 years with frailty. Our GSS includes multidisciplinary assessment and optimization by specialized nurses, physiotherapists, anesthetists, dietitians, and geriatricians. Cumulative sum (CUSUM) analysis was used to assess the performance of our GSS. Our primary outcome was defined as the presence of 30-day mortality, prolonged LOS ≥ 14 days, and/or >10% decrease in the modified Barthel Index at 6 weeks, which depicts the failure of GSS. A downsloping CUSUM curve implies consecutive cases of success. ResultsThere were 233 patients with a mean age of 79.0 ± 4.9 years; of these, 73 patients (31.3%) were frail. The overall 30-day mortality (1.7%), Clavien-Dindo ≥ grade IIIA complications (12.0%), and LOS (median, 7.0 days) were low. The CUSUM analysis showed 3 phases with overall sustained improvement in outcomes. Transient inconsistency in the second phase (during midimplementation of GSS) may be due to the early adoption of laparoscopic surgery (44.6% vs 24.1%; adjusted P =.031) and expansion of service to include patients with higher perioperative risks (weighted Charlson Comorbidity Index score ≥4: 64.9% vs 38.0%; adjusted P =.002) in the second period compared with the first period. The outcomes subsequently improved in the third phase after overcoming the learning curve. ConclusionOur GSS showed sustained performance over the past decade. Good quality surgery and surgeon-led geriatric service are paramount for good postoperative outcomes.

A multidisciplinary assessment of disability in early medieval Culmen, Poland

This study bridges a gap between palaeopathology and the textual analysis, with the aim of investigating whichdiseases and pathological lesions could have been associated with disability in Early Mediaeval Culmen in Poland.We used palaeopathological methods to examine 661 skeletons, as well as reviewed Early Mediaeval hagiographiesand chronicles. The textual analysis revealed three types of disability: mobility difficulties, an abnormal posture, and blindness, which were also identified in the osteological materials from Culmen. Eight skeletons display lesions corresponding to Pott’s disease, poliomyelitis, leprosy, osteomyelitis, multiple myeloma, and amputation, which were identified as disabilities. The prevalence of disability depended on the age, with adults affected more frequently. This interdisciplinary study is the first to analyse people with disabilities on a population level, using textual sources and osteological materials from mediaeval Central Europe. The protocol forresearch on disability in archaeology presented by us may be applied to other archaeological contexts, also from sites outside Poland, from historical periods of time.

Polar climate change: a multidisciplinary assessment

The rapid environmental changes in polar regions have been attracting considerable political, public, and scientific attention in recent years. The polar amplification is recognized as a robust feature of the climate system in response to carbon dioxide (CO2) forcing, resulting in sea ice loss, ice sheet melting, and methane release from permafrost thawing. From a physical perspective, this paper examines the polar amplification and sea ice changes for past and future scenarios using satellite, reanalysis, and climate model datasets. From an interdisciplinary perspective, we discuss the potential environmental, socioeconomic, and political effects associated with these changes. The observational data showed enhanced warming and rapid changes in sea ice cover in polar regions. Under the largest future CO2 forcing, climate simulations indicate an unprecedented rise in air temperature and fast sea ice loss, even in low emission scenarios. This results in a number of physical, environmental, and social-economic effects that need to be carefully considered. Polar climate change, however, offers new opportunities, including the local increase in fisheries and the opening of new navigation routes, which substantially impact the world economy. At the same time, it also implies critical environmental consequences associated with many socioeconomic and ecological risks, such as migration or extinction of populations and species; sea level rise; an increase in frequency and intensity of extreme weather in mid-latitudes; and infrastructure damage from permafrost thawing. Even with the advances and improvements in climate modeling in recent decades, the exact nature of these nonlinear interactions is still in debate.

Biostimulation of indigenous microbes for uranium bioremediation in former U mine water: multidisciplinary approach assessment

Characterizing uranium (U) mine water is necessary to understand and design an effective bioremediation strategy. In this study, water samples from two former U-mines in East Germany were analysed. The U and sulphate (SO42−) concentrations of Schlema-Alberoda mine water (U: 1 mg/L; SO42−: 335 mg/L) were 2 and 3 order of magnitude higher than those of the Pöhla sample (U: 0.01 mg/L; SO42−: 0.5 mg/L). U and SO42− seemed to influence the microbial diversity of the two water samples. Microbial diversity analysis identified U(VI)-reducing bacteria (e.g. Desulfurivibrio) and wood-degrading fungi (e.g. Cadophora) providing as electron donors for the growth of U-reducers. U-bioreduction experiments were performed to screen electron donors (glycerol, vanillic acid, and gluconic acid) for Schlema-Alberoda U-mine water bioremediation purpose. Thermodynamic speciation calculations show that under experimental conditions, U(VI) is not coordinated to the amended electron donors. Glycerol was the best-studied electron donor as it effectively removed 99% of soluble U, 95% of Fe, and 58% of SO42− from the mine water, probably by biostimulation of indigenous microbes. Vanillic acid removed 90% of U, and no U removal occurred using gluconic acid.