Multidisciplinary Care Program Research Articles

7341 Establishing a Multidisciplinary Care Program for patients with Klinefelter Syndrome and other Aneuploidy X and Y Variations

Abstract Disclosure: C.J. Romero: None. N.R. Malhotra: None. A. Norris-Brilliant: None. C. Mintz: None. Objectives: Klinefelter syndrome (KS) is one of the most common genetic aneuploidies denoted by a XXY karyotype and affects up to 1 in 600 patients. Most patients are not diagnosed until adolescent years or adulthood. KS is one of the leading causes of male infertility and testosterone insufficiency. KS is also associated with developmental delays, particularly speech and language delay. Advances in genetics screenings has led to early identification of KS and other aneuploidy X and Y variations, access to neurodevelopmental screening and fertility preservation resources during adolescence and young adulthood. We believe a multidisciplinary program for KS can provide the necessary resources for patients and families at any age from infancy to young adulthood. Methods: A group of faculty from the divisions of pediatric endocrinology, genetics, urology and psychiatry assembled in 2023 to establish a multidisciplinary clinic (MDC) to provide comprehensive care to patients/parents; this ranged from prenatal diagnosis to young adulthood. Two major challenges of care are access to neuro-psychological evaluations and fertility preservation options. Testosterone supplementation requires appropriate referral to endocrinology and timing of treatment remains controversial. Our goals include: expertise guidance and planning after prenatal diagnosis or later in age; access to cost effective neuro-psychological testing during early childhood years; urological consultation beginning in early puberty to educate and prepare patients for choices of surgical and non-surgical options of fertility preservation. Results: Our current center cares for 12 patents ranging from ages 3 months to 21 years. Of this cohort, 3 (25%) of the patients had initial consultations with the parents during pregnancy. 7 (58%) of the patients were of pubertal age that one would consider testosterone replacement, but only 3 (43%) were taking testosterone. Only 1 patient of school age reported neuro-psychological evaluation that was completed at a different institution. No patients received testosterone supplementation during year one of life. Conclusions: A multidisciplinary team can offer simultaneous assessment, anticipatory guidance and management for KS patients and their families. It is a comprehensive resource to our community. Prenatal genetic screenings bring awareness to this diagnosis and therefore timely education toward understanding the lifelong management of KS. Identifying developmental delays early in childhood will help with scholastic success. Monitoring of pubertal development will ensure appropriate pubertal progression in addition to education and management of fertility preservation. Undoubtedly future urological advances will assist patients more effectively. We believe our model provides the access to resources that allow our patients and family to successfully thrive. Presentation: 6/2/2024

Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK)

IntroductionMulti-disciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care, but the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard. MethodsWe conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 mL/min per 1.73m2) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a pre-emptive kidney transplant. Secondary outcomes included home dialysis initiation, pre-emptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019. ResultsAmong 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 (62%) patients who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) peritoneal dialysis, 16 (5%) home hemodialysis, and 36 (12%) preemptive transplant. Of the 195 (65%) patients starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% CI 1.05 – 1.71, p = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor. ConclusionsPatients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.

Correlation between Palliative Performance Scale results and observed survival among Mexican patients with advanced cancer.

e24040 Background: Cancer is a common cause of death among Hispanics. Estimating patient survival is critical in cancer care since it allows better shared decision-making and avoids use of futile therapy. Palliative Performance Scale (PPS) has been widely used for survival prediction among patients with cancer. However, its performance has not been validated across populations in Latin America, which could have different outcomes. The aim of this study was to analyze the correlation between PPS score and observed survival among patients with advanced cancer to facilitate physician and patient decision-making near the end of life. Methods: We conducted a retrospective observational analysis of patients with advanced cancer included in “ Te Acompañamos” cohort, a multidisciplinary patient navigator-led supportive care program in a single center in Mexico City. We used descriptive statistics to analyze clinico-demographic variables, PPS score, observed survival in days (from recruitment to death). Pearson correlation coefficients were used for correlating observed survival in days and predicted survival using PPS. U de Mann Whitney was used for comparing survival days between PPS groups. Results: We analyzed 246 patients with advanced cancer included in “Te Acompañamos” who died between August 2017-January 2024. Among these patients, 143 (58%) were women. Mean age was 64 years (SD 13). 153 patients (62%) had gastrointestinal (GI), 43 (17%) gynecologic, 19 (7%) genitourinary, 5 (2%) lung, 5 (2%) thyroid, and 21 (8%) other solid malignancies. Pancreatic cancer was the most common cancer (n = 60, 24%). Patients with GI cancer more frequently reported pain (59%) and had an average PPS of 67.7%. Mean survival was 233 days (SD 247) and mean predicted survival in days according to PPS was 68 days (SD 20). Correlation between observed survival days and PPS-predicted survival was low (R = 0.29). Patients with PPS &lt; 50% had mean survival of 74.6 days while patients with PPS &gt; 50% of 243.2 days (p &lt; 0.05). Patients aged &lt; 60 years with GI tumors had a higher PPS score, while older patients had a lower score (74.6% vs 65%; p &lt; 0.05). No other significant differences were found in other subgroups. Conclusions: Our results show weak correlation between observed and predicted survival in days using PPS. However, lower PPS was associated with decreased survival. Among patients with GI cancers we observed that older patients had the lowest PPS scores. This study emphasizes the need to develop and validate more precise tools for survival prediction across patient populations, including minorities such as the Hispanics. Our study suggests that strategies to diagnose and alleviate pain promptly in patients with advanced cancer near the end of life are urgently required.

Post-recovery experience among COVID-19 patients: A population-based online survey in India.

Patients who recovered from the acute phase of COVID-19 experience several post-COVID-19 health and social problems. This study was therefore done to explore the living experiences and the various health problems experienced by people and their determinants during the post-recovery phase of COVID-19. This cross-sectional study was conducted in Mangalore in March 2022. Data were collected using a semi-structured questionnaire designed as a Google Doc. Post-COVID-19 conditions were defined as adverse health consequences returning, new, or persistent beyond 1 month after SARS-CoV-2 infection. The experiences in the post-recovery phase of COVID-19 were assessed based on a scoring system for the related items in the questionnaire. Out of 235 participants, 204 (86.8%) reported post-COVID-19 health problems between 1 and 6 months following SARS-CoV-2 infection. The majority of them reported fatigue [114 (55.9%)]. Self-perceived health status and social relationships were significantly poorer among participants in the post-COVID-19 phase than before infection. In the multivariable analysis, unmarried/divorced/widow status, staying within city limits, and history of being admitted to the hospital due to various COVID-19-related emergencies were independently associated with the presence of post-COVID-19 conditions among the participants. The living experience in the post-recovery phase was positive only among 22 (9.4%) participants and was found to be significantly associated with the severe status of COVID-19 at the time of disease presentation. Post-COVID-19 health problems were present among several participants. Those identified to be at risk of developing these conditions need to be periodically screened and managed with a multi-disciplinary care and rehabilitation program. There is also a need to address social problems and encourage positive living experiences among COVID-19 patients during the post-recovery phase of the disease.

Beyond vulvodynia: from a correct diagnosis to a multidisciplinary care program. A referral center experience.

Vulvodynia is a chronic pain condition without an identifiable cause. As such, it is a diagnosis of exclusion, and all other causes of vulvar pain should be excluded. Although a standard treatment for vulvodynia has not been established yet, multidisciplinary care programs appear to be effective. The aim of this retrospective monocentric study was to analyze the prevalence of vulvodynia among women referred to our institution for a suspected diagnosis and to evaluate the efficacy of a multidimensional treatment plan. The primary outcome was the prevalence of vulvodynia following differential diagnosis. Secondary outcomes included: prevalence of the differential diagnoses, symptom resolution rate following treatment, and the relation between persistence of symptoms and (a) patients' age; (b) coexisting chronic overlapping pain conditions (COPCs). After having ruled out all other causes of vulvar pain, only 40.1% of women were considered as affected by vulvodynia. The most frequent differential diagnoses included lower genital tract infections (25.3%), vulvar lichen sclerosus (17.6%) and vulvovaginal atrophy (8.2%). Following a multidisciplinary care program, resolution of symptoms was observed in 13.6% cases, improvement in 64.3% and persistence in 21.9%. We did not find a statistically significant association between persistence of symptoms and age > 38years (OR 2.10; p = 0.30). Women with one or more COPCs other than vulvodynia had a 75% increased risk of not obtaining a resolution of symptoms (OR 1.75; p = 0.44). A thorough differential diagnosis and a multidisciplinary care program may represent a first way out of the muddle in the management of these patients.

Clinician Awareness of Stickler Syndromes Among Australian Allied Health Care Professionals.

Stickler Syndromes are multisystem collagenopathies affecting 1 in 7500-9000 individuals and are associated with craniofacial, ocular, auditory, and musculoskeletal complications. Prophylactic retinopexy treatment reduces the risk of retinal detachment, emphasising the need for early detection and multidisciplinary referral. This study evaluated knowledge and awareness of Stickler Syndromes among allied health professionals and their perceived needs for targeted education to improve multidisciplinary care. A cross-sectional survey was undertaken among audiologists, speech pathologists, optometrists, orthoptists, and physiotherapists in Australia. Survey questions included practitioner demographics, awareness and knowledge of Stickler Syndromes, confidence managing Stickler Syndromes, and perception of multidisciplinary care needs for Stickler Syndromes. Of 180 healthcare professions who participated (79% female; 78% aged between 25 and 44 years), 55% indicated that they had heard of Stickler Syndrome, and 14% had directly worked with patients known to have Stickler Syndromes. Practitioners who had were either optometrists, orthoptists, or audiologists. The most recognised clinical sign of Stickler Syndromes was retinal detachment (selected by 66% of optometrists and orthoptists and 16% of other professions), but only 41% of optometrists and orthoptists (27% all respondents) selected cryopexy as a potential management strategy. Vitreous anomaly was recognised as a clinical feature by 20% of all respondents. Overall, 69% of allied health professionals did not feel confident managing Stickler Syndromes, and a similar number of practitioners (69%) indicated that they were willing to attend professional development courses for complex conditions such as Stickler Syndromes. This study provides meaningful insights on awareness and knowledge of Stickler Syndromes among allied healthcare professionals. Targeted clinician education, enhanced communication between healthcare entities, and multidisciplinary care programs can significantly improve the integrated care of Stickler Syndromes leading to better patient outcomes.

(347) A Single Center Review of Access to Gender Affirming Surgical Care: Analysis of Consultation to Surgery Conversion Rates and Patient Wait Times

Abstract Introduction The demand for gender-affirming surgical care has grown exponentially throughout the United States throughout the last decade. Even within gender care programs, patients face complex barriers to receiving multidisciplinary, gender-affirming care. The differences in access to care among different gender-affirming procedures remain understudied. Understanding the barriers that patients face within our multidisciplinary gender care program is imperative to addressing the needs of our population. Objective To assess the differences in wait times and successful completion of surgery following initial consultation across multiple gender-affirming surgical procedures. Methods Records of all patients seeking an initial consultation for gender-affirming surgical care at a single center from February 2018 to March 2022 were reviewed. Recorded demographic data of patients included age, sex assigned at birth, gender identity, insurance type, race, and ethnicity. We categorized gender-affirming surgical care into the following procedures: vaginoplasty, phalloplasty, mastectomy, breast augmentation, facial feminization, orchiectomy, hysterectomy, and other. The conversion rate was defined as the percentage of patients who completed surgery after an initial consult. Patients were followed until April 2023, a minimum of &amp;gt;365 days. Contact to consult was defined as the time between a patient’s initial contact for scheduling an appointment and a formal in-office consult, and consult to surgery was determined by the time from the first consult to the actual surgery. Comparisons were analyzed in SPSS with Pearson chi-square test or one-way ANOVA with post-hoc comparisons as appropriate. Results Our comprehensive gender care program conducted 621 consultations and 438 surgeries between February 2018 and March 2022. The difference between conversion rates among surgeries was statistically significant by Pearson chi-square test (p &amp;lt;0.001), with vaginoplasty and phalloplasty having the lowest conversion rate at 31%, with post-hoc adjusted residuals &amp;lt; -2. Facial feminization and mastectomy had a higher conversion rate (88% and 79%, respectively). Regarding time between major events, the time from patient contact to in-office consult was not statistically significant with one-way ANOVA between gender-affirming procedures at p= 0.53. However, the time from consult to surgery was statistically significant between groups at p= 0.002. Phalloplasty had a statistically longer consult to surgery time at 416 days (p&amp;lt;0.02) than any other surgery on post-hoc testing. Vaginoplasty had a statistically lengthier wait at 289 days (p&amp;lt;0.05) than mastectomy and breast augmentation. Conclusions Phalloplasty and vaginoplasty have the lowest conversion rates of all gender-affirming procedures. Among patients who undergo a phalloplasty, the consult to surgery wait time is statistically longer than any other surgery. For vaginoplasty patients, the consult to surgery wait is statistically longer than for mastectomy and breast augmentation. The differences in conversion rates and wait times from consult to surgery raise questions about disparities and access to care, particularly for more complex gender-affirming surgical procedures, that will be further explored in the dataset. Disclosure No.

Program-Based Lung Cancer Care: A Prospective Observational Tumor Registry Linkage Study

IntroductionLow-dose computed tomography screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordant care. The impact of such program-based care on “real-world” lung cancer survival is unquantified. We evaluated outcomes of lung cancer care delivered through structured programs in a community health care system. MethodsWe conducted a cohort study linking institutional prospective observational LDCT, LNP and MDC databases with Tumor Registry of Baptist Cancer Center facilities. We categorized all patients diagnosed with lung cancer between 2011 and 2021 into program-based care versus non-program-based care cohorts. We compared patient characteristics, stage distribution, treatment modalities, survival and mortality in each pathway of care. ResultsOf 12,148 patients, 237, 1,165, 1,140 and 9,606 were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96.3% to 66.5%, diagnosis through LDCT increased from 0.5% to 7.1%, LNP from 3.5% to 20.8%; and MDC alone decreased from a high of 12.8% in 2014 to 5.6% in 2021. Program-based care was associated with earlier stage (p < 0.001), higher surgical resection rates (p < 0.001), greater use of adjuvant therapy (p < 0.001), better aggregate and stage-stratified survival (p < 0.001), and lower all-cause and lung cancer-specific mortality (p < 0.001). Recipients of non-program-based care were considerably less likely to receive lung cancer treatment; results remained consistent when patients receiving no treatment were excluded. ConclusionsProgram-based care was associated with substantially better survival. Increasing access to program-based care should be explored as a matter of urgent public policy.

Day care program for older adults with dementia: A multidiscipilinary approach for patients and family caregivers from Argentina

AbstractBackgroundDay care programs for older adults with dementia is an effective strategy that allows prolonging the functionality of the elderly, their support and that of their family reducing home care costs and delaying the institutionalization of patients with cognitive impairment. The aim of the present work is to describe the main goals and the implementation of a multidisciplinary day care program for patients with dementia and their family caregivers in Argentina.MethodSubjects: 22 patients and their family caregivers, who attend a day care program in Argentina. Instruments: socio‐demographic and psychosocial questionnaire of both patient and caregiver (built ad hoc) Patient: MMSE, GDS, HAD‐A, PANAS‐VRARG, EQ‐5D and instrumental and basic habilites of daily living. Family caregiver: Zarit Burden Interview. Procedure: The intervention for patients consists of two different lines of work, one for the patient, and another for the family member. The activities are coordinated by a multidisciplinary group of professionals. Regarding the caregiver, individual orientation interviews and therapeutic group spaces and psycho‐educational material are offered.ResultPreliminary data of 22 patients and caregivers, who have taken part in the program so far, indicate that: Patient: median age was years 75,27 old (ds = 9,28), % 63,6 of which are woman. The values obtain in the instrument are: MMSE 22,45 (ds = 4,78) GDS 4,47 (ds = 3,73), HAD‐A 3,66 (ds = 3,39), (PANAS ‐E‐VRARG) Negative ítems 7,70 (ds = 3,11) (PANAS ‐E‐VRARG) Positive ítems 18,7 (ds = 3,13), EQ‐5D 77,35 (ds = 16,21) and BHDL 93,63 (ds = 13,10), IHDL 9,1 (ds = 3,31) . And for family caregivers the mean age was 65,27 old (ds = 11,37), % 66,71 of which are woman. Caregivers Zarit Burden Interview mean score was 40,18 (ds = 11,35).ConclusionOur findings concur with those presented in scientific literature and support the WHO recommendations regarding the need to implement multidisciplinary programs for patients with dementia and family caregivers, in order to moderate the impact that providing care for an elderly relative with a neurological disease has on them.

A single-center observational study on long-term neurodevelopmental outcomes in children with tuberous sclerosis complex

BackgroundTuberous sclerosis complex (TSC) is a rare multisystem disorder caused by mutations in the TSC1 or TSC2 gene. More than 90% of patients with TSC develop neurological and/or neuropsychiatric manifestations. The aim of the present study was to determine the developmental and cognitive long-term outcomes of pediatric TSC patients.MethodsThis cross-sectional, monocenter study included pediatric TSC patients who received multidisciplinary long-term care with a last visit between 2005 and 2019. Neurological manifestations and cognitive development (BSID, K-ABC) were analyzed in relation to age and type of mutation.ResultsThirty-five patients aged 13.5 ± 7.8 years were included in the study. Diagnosis was confirmed genetically in 65.7% of patients (TSC1, 26.1%; TSC2, 65.2%; NMI, 8.7%). Mean age at diagnosis was 1.3 ± 3.5 years; 74.3% of the patients had been diagnosed within the first year of life due to seizures (62.9%) or/and cardiac rhabdomyomas (28.6%). The most common TSC manifestations included structural brain lesions (cortical tubers, 91.4%; subependymal nodules, 82.9%), epilepsy (85.7%), and cardiac rhabdomyomas (62.9%). Mean age at seizure onset was 1.5 ± 2.3 years, with onset in 80.0% of patients within the first two years of life. Infantile spasms, which were the first seizure type in 23.3% of the patients, developed earlier (0.6 ± 0.4 years) than focal seizures (1.8 ± 2.5 years). Refractory epilepsy was present in 21 (70.0%) patients, mild or severe intellectual impairment in 66.6%, and autism spectrum disorders in 11.4%. Severe cognitive impairment (33.3%) was significantly associated with epilepsy type and age at seizure onset (p < 0.05).ConclusionsThe results emphasized the phenotypic variability of pediatric-onset TSC and the high rate of neurological and neuropsychiatric morbidity. Early-onset refractory epilepsy was associated with impaired cognitive development. Children of all ages with TSC require multidisciplinary long-term care and individual early-intervention programs.

Patient Polypharmacy use Following a Multi-Disciplinary Dementia Care Program in a Memory Clinic: A Retrospective Cohort Study.

Dementia increases the risk of polypharmacy. Timely detection and optimal care can stabilize or delay the progression of dementia symptoms, which may in turn reduce polypharmacy. We aimed to evaluate the change in polypharmacy use among memory clinic patients living with dementia who participated in a dementia care program compared to those who did not. We hypothesized that patients in the dementia care program would reduce their use of polypharmacy compared to those who were not in standard care. We retrospectively analyzed data extracted from electronic medical records from a university memory clinic. Data from a total of 381 patients were included in the study: 107 in the program and 274 matched patients in standard care. We used adjusted odds ratios to assess the association between enrollment in the program and polypharmacy use at follow-up (five or more concurrent medications), controlling for baseline polypharmacy use and stratified polypharmacy use by prescription and over-the-counter (OTC). The two groups did not differ in the use of five or more overall and prescription medications at follow-up, controlling for the use of five or more of the respective medications at baseline and covariates. Being in the program was associated with a three-fold lower odds of using five or more OTC medications at follow-up (adjusted odds ratio = 0.30; p <0.001; 95% Confidence interval = 0.15-0.58) after controlling for using five or more OTC medications at baseline and covariates. Dementia care may reduce polypharmacy of OTC medications, potentially reducing risky drug-drug interactions. More research is needed to infer causality and understand how to reduce prescription medication polypharmacy.

Synthèse des principes et schémas de prise en charge dans les troubles neurologiques fonctionnels

After more than twenty years of academic research on functional neurological disorders (FND) throughout the world, a standardized care management strategy has emerged to allow a more adapted care offer to patients with FND, as close as possible to their experience and their needs. With regard to this special issue on FND in collaboration with L’Encéphale and at the initiative of the Neuropsychiatry section of the AFPBN (French Association of Biological Psychiatry and Neuropsychopharmacology), we would like to suggest a summary of all topics discussed in more detail in each article of this special issue, in order to facilitate its reading. We therefore cover the following themes: the initial contact with a patient with FND, the diagnostic process in favor of a positive diagnosis, the physiological, neural and psychological basis of FND, the diagnostic announcement (and its intangibles), the therapeutic patient education in FND, the general principles of therapeutic management through a personalized and multidisciplinary care program, and the validated therapeutic tools available according to the symptoms identified. This article is designed to be of broad interest on FND, supported by tables and figures showing the key points of all these steps, to keep an educational purpose at most. We hope that through this special issue, each health professional will be able to grasp this knowledge and this framework of care as easily and quickly as possible, in order to participate in the standardization of the care offer.

HIP SURGERY IN GENETIC SKELETAL DISORDERS: RISKY BUSINESS?

Genetic skeletal disorders constitute a rare and heterogeneous bone diseases often leading to poor quality of life. Several surgical options are available. The surgeon must deal with specific features (bone deformity, previous procedures, abnormal bone quality, stiffness or instability, muscle weakness). The questions concern the feasibility of the procedures and the surgical strategy.55 patients (26 W, 29 M) were reviewed between 2016 and 2022. The mean age of the patients was 35 years (17–71). The diagnosis included 9 hereditary multiple exostoses, 8 osteogenesis imperfecta, 6 multiple epiphyseal dysplasia congenita, 6 achondroplasia, 4 osteopetrosis, 3 pycnodysostosis, 3 hypophosphatemic rickets, 3 fibrous dysplasia, 2 mucopolysaccharidosis, and 10 miscellaneous. 25 patients were referred for hip problems (40 hips). 4 patients (7 hips) requiring a THA have not been operated (4 planned). 4 patients (6 hips) had a proximal femoral fixation (2 osteotomies, 4 fracture fixations). 17 patients (27 hips) sustained a THA (25 primary, 2 revisions). All of them were operated by one operator, using a posterolateral approach and standard implants (including 7 dysplastic and 2 short stems). No customized implant has been used.As regard the 27 THAs, the mean follow up was 4.2 years (1–12). The early complications included 2 femoral cracks and 1 femur fracture. There were 2 revisions (1 cup loosening at 2 years, 1 stem loosening at 4 years). No infection nor dislocation occurred. All the patients were satisfied with their treatment and regain some autonomy. 3 THA were considered as unfeasible.Constitutional bone diseases need a multidisciplinary program of care. The indication for surgery is based on a mutual trust patient/surgeon, a careful evaluation of benefits/risks, and an accurate imaging to anticipate the difficulties. The expected results are a better function and quality of life, and a stability over time.

Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program.

Home-based primary care (HBPC) has shown promise in the management of multiple chronic conditions for patients who are homebound or who have limited mobility. The objective of this study was to implement and evaluate an HBPC program that integrates the services of clinical pharmacists and community aging services providers in a community-based setting. Mountain Area Health Education Center's (MAHEC) HBPC program brought together an interdisciplinary team including medical providers, pharmacists, and community aging services providers to conduct home visits with older adults (age 50+). A single-arm, prepost analysis was conducted to determine differences from the year before program enrollment to the year postenrollment. We examined the frequency of health care visits, high-cost health care utilization (emergency department [ED] utilization and hospitalizations), and health care costs. Descriptive statistics characterized the study population and outcomes. Fisher's Exact Tests were used to determine if there was a significant difference between years. There were 130 home visits with 62 patients enrolled in the program. The Medicare Annual Wellness Visit (AWV) was completed for 32 (51.6%) patients. There were 13 (21.0%) and 12 (19.4%) individuals who had at least 1 ED visit and hospitalization, respectively, pre-enrollment as compared with 8 (12.9%) and 9 (14.5%) individuals postenrollment (p-value = 0.05, p-value = 0.06). During the postenrollment year, patient enrollees had an average per-member-per-month (PMPM) cost of $1567.96 as compared with $3053.21 in the year prior. Pharmacist and community agency services-integrated HBPC was implemented in the community setting. There was a decrease in high-cost health care utilization and total health care expenditures for patients as compared with the previous year.

Real-world program-based lung cancer care.

6581 Background: Low dose CT screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordance. The impact of such program-based care on ‘real-world’ population-level lung cancer survival and mortality is uncertain. We evaluated program-based lung cancer care versus care outside structured programs in a large community healthcare system. Methods: We linked prospective observational databases for LDCT, LNP and MDC with the Tumor Registry of Baptist Cancer Center facilities across Mississippi, Arkansas and Tennessee, categorizing all lung cancer patients between 2011 and 2021, according to program- (LDCT, LNP, MDC) versus non-program-based care. We compared stage distribution, care patterns, survival and mortality by standard statistical methods. Results: Of 12,089 patients, 250 (2%), 1236 (10%), 1045 (7%) and 9558 (79%) were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96% in 2011 to 67% in 2021, diagnosis through LDCT increased from 0.3% to 7%, LNP from 0.9% to 21%; and MDC alone decreased from a high of 13% in 2015 to 5% in 2021. Black persons, 28% of the whole cohort, were 13% of LDCT, 25% of LNP, 31% of MDC, and 28% of non-program-based care recipients (p = 0.0005). Median (IQR) tumor size was 20mm (13 – 34), 25mm (17 – 44), 35mm (20 – 55) and 35mm (20 – 55), respectively (p &lt; 0.0001); 40-46% of patients across programs had adenocarcinoma; clinical stage was I or II in 58%, 48%, 38% and 29% and IV in 16%, 27%, 31% and 42% in the respective programs (p &lt; 0.0001). 2609 patients (21.6%) had surgery, including 49.2%, 37.7%, 36.1% and 17.2% in LDCT, LNP, MDC and non-program-based care respectively, among whom aggregate pathologic stage was I in 76%, 71%, 54% and 60% (p = 0.0005). Surgery was the sole treatment modality in 27.6%, 21.5%, 12.9% and 10.6%, respectively (p &lt; 0.0001). Despite higher proportions with more advanced pathologic stage, 30.8% of recipients of non-program-based care received adjuvant therapy, compared to 42% among recipients of program-based care, including 39.0%, 37.1% and 49.3% in LDCT, LNP and MDC, respectively (p &lt; 0.0001); 8.7% of patients in programs received no treatment, compared to 20.1% of non-program-based care. Aggregate 5-year overall survival rates were 60% (95% CI: 52% - 69%), 45% (95% CI: 42% - 49%), 30% (95% CI: 27% - 33%), and 18% (95% CI: 17% - 19%), respectively (p &lt; 0.0001). Adjusting for age, sex, race, patient-level rurality and histology, with non-program-based care as reference, the aHR were 0.3 (95% CI: 0.234 – 0.373), 0.51 (95% CI: 0.464 – 0.556, and 0.66(95% CI: 0.607 – 0.712). Results were consistent even without patients who received no treatment. Conclusions: Program-based care was associated with more favorable lung cancer characteristics, better quality of care and survival. Disseminating program-based care should be explored as a matter of urgent public policy.

Risk of malnutrition and predisposing factors among Mexican patients with advanced cancer.

12033 Background: Malnutrition is a predictor of cancer survival independent of cancer site. However, routine screening for malnutrition is underutilized. Advanced cancer accounts for 60% of cancer cases in developing countries of which approximately 52 % have malnutrition. This study aimed to describe factors associated with risk of malnutrition among patients with advanced cancer. Methods: We conducted a cross-sectional analysis of baseline data from patients with recently diagnosed advanced cancer included in a multidisciplinary patient navigator-led supportive care program in Mexico City (Te Acompañamos). At the time of enrollment in the program, patients completed a series of questionnaires including assessments of quality of life (FACT-G), various symptoms and the validated malnutrition screening tool (MST). Clinic and demographic characteristics were obtained from the patient chart. Descriptive statistics were used for analysis and factors associated with risk of malnutrition were analyzed by bivariate testing. Results: Between August 2017 and December 2022, a total of 601 patients were included. Mean age was 62 years (range 18-94), 57.2% were women, 56% had gastrointestinal and 28% gynecological malignancies. 72 % screened positive for malnutrition on the MST and 49 % reported nausea on FACT-G. Patients with an ECOG performance status ≥3 were more likely to screen positive for malnutrition (OR 5.9 95%CI 2.5- 13) as well as those with baseline nausea (OR 2.99; 95%CI 1.9-4.7). On the other hand, patients with active chemotherapy (OR 1.4 95%CI, 1.016-1.95) and those receiving antiemetic treatment with a single medication (OR 1.63 95%CI, 1.1-2.4) were more likely to have nausea. No other clinical or demographic characteristics were significantly associated with screening positive for malnutrition or reporting nausea, including gender, age, history of smoking or alcohol abuse, type of neoplasia, or oncologic treatment. Conclusions: Our results show that a high proportion of patients with advanced cancer are at increased risk for malnutrition and report nausea. Poor functional status and nausea were strongly associated with a higher risk of malnutrition, while receiving insufficient antiemetic medication was associated with increased odds of nausea. This suggests that appropriate treatment of nausea and nutritional interventions should be prioritized early in the management of patients with advanced cancer regardless of the type of cancer treatment in order to avoid malnutrition and improve patient well-being.

Multidisciplinary care for patients with HCC: a systematic review and meta-analysis.

Given the complexity of managing HCC, professional society guidelines advocate multidisciplinary care (MDC) for patients with HCC. However, implementation of MDC programs requires a significant investment of time and resources. We conducted a systematic review and meta-analysis to enumerate potential benefits of MDC for patients with HCC. We conducted a search of the PubMed/MEDLINE and EMBASE databases and national conference abstracts to identify studies published after January 2005 that reported early-stage presentation, treatment receipt, or overall survival among patients with HCC, stratified by MDC status. We calculated pooled risk ratios and HRs for clinical outcomes according to MDC receipt using the DerSimonian and Laird method for random effects models. We identified 12 studies (n = 15,365 patients with HCC) with outcomes stratified by MDC status. MDC was associated with improved overall survival (HR = 0.63, 95% CI: 0.45-0.88); however, its association with curative treatment receipt was not statistically significant (risk ratio = 1.60, 95% CI: 0.89-2.89) and pooled estimates were limited by high heterogeneity (I2 > 90% for both). Studies (n = 3) were discordant regarding an association between MDC and time-to-treatment initiation. MDC was associated with early-stage HCC (risk ratio = 1.60, 95% CI: 1.12-2.29), suggesting possible referral bias contributing to improved outcomes. Limitations of studies also included risk of residual confounding, loss to follow-up, and data preceding the availability of immune checkpoint inhibitors. MDC for patients with HCC is associated with improved overall survival, underscoring the likely benefit of managing patients with HCC in a multidisciplinary care setting.

Editorial introductions.

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into ten sections that are reviewed once a year. Each section is assigned one or more Section Editors. They are the leading authorities in their area, who identify the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Deirdre LyellDeirdre LyellDr Lyell is a Professor of Obstetrics and Gynecology in the Division of Maternal-Fetal Medicine at Stanford University, USA, where she serves as the Associate Division Director, Director of the Program in Placental Disorders, and Program Director of the Maternal-Fetal Medicine Fellowship. Dr Lyell is a member of the Child Health Research Institute at Stanford, the March of Dimes Prematurity Research Center at Stanford, and conducts research in clinical obstetrics. From 2013–2016 she served as an alternate P.I. to the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Unit (MFMU) Network, USA. In 2010 she formed the Program in Placental Disorders at Stanford, a multidisciplinary patient care and research program for women with placenta accreta and cofounded a Placenta Accreta Special Interest Group that meets annually at the Society for Maternal-Fetal Medicine meeting. Dr Lyell earned a Bachelors of Arts and Sciences in History and Biology from Stanford University and a Medical Degree from the George Washington University School of Medicine, USA. She completed residency training in Obstetrics and Gynecology at Brigham and Women's and Massachusetts General Hospitals, USA, and fellowship in maternal-fetal medicine at Stanford University. She is certified by the American Board of Obstetrics and Gynecology in obstetrics and gynecology and maternal-fetal medicine. Mark BoddyMark BoddyDr Mark Boddy received his bachelor's degree from Georgia State University, USA. He received his medical degree from the Medical College of Georgia prior to completing a residency in obstetrics and gynecology at Atlanta Medical Center, USA. He subsequently completed a fellowship in maternal fetal medicine at The George Washington University School of Medicine, USA. He practiced for 17 years in a hospital-based setting while also serving as a Regional Perinatal Director for the State of Georgia. Currently, Dr Boddy is an Associate Clinical Professor at Stanford University School of Medicine, USA and the Medical Director of the Stanford Children's Healthcare Perinatal Diagnostic Center in Salinas, California, USA. His interests include prenatal diagnosis, improving quality of care and patient safety. Martha RodeMartha RodeDr Martha Rode received her bachelor's degree in biology at Harvard University, USA, before attending medical school at the University of California, Los Angeles, USA. She then completed residency and a maternal-fetal medicine fellowship at the University of Pennsylvania in Philadelphia, USA. She has since worked in both academic and hospital-based practices on both the East Coast and Northern California Bay Area in USA. She is currently a Clinical Associate Professor at Stanford Medical School, USA, serving as the Medical Director of the Perinatal Diagnostic Center in Santa Cruz. Her interests include perinatal diagnosis and high-risk obstetrics as well as community physician outreach and continued education. Jane ChuehJane ChuehDr Jane Chueh received her bachelor's degrees in biology and humanities at Stanford University, USA. She attended medical school at University of California San Diego, USA and completed her residency at University of Washington, USA and her fellowships in maternal fetal medicine and clinical genetics at University of California San Francisco, USA. She has worked in both academic and hospital-based practices in the Northern California Bay Area. Currently she is a Clinical Professor at Stanford Medical School, serving as the Director of Prenatal Diagnosis and Therapy at Stanford Children's Health. She enjoys practicing prenatal diagnosis and high-risk obstetrics, collaborating in research projects related to ultrasound and simulation teaching, and mentoring Stanford undergraduates and medical students. Amy VoedischAmy VoedischAmy J Voedisch, MD, MSc, NCMP is a Clinical Associate Professor in the Division of Family Planning, in the Department of Obstetrics and Gynecology at Stanford University, USA. Dr Voedisch attended the Mayo Medical School in Rochester, Minnesota, USA, and completed her OB-GYN residency at Kaiser Permanente Santa Clara, USA. She then went on to a fellowship in family planning at Stanford University, becoming an expert in reproductive health services, with a focus on increasing access to contraception in underserved international areas. She also earned her master's degree in clinical sciences research during her fellowship. Dr Voedisch is an expert in perimenopause and menopause and is a North American Menopause Society Certified Menopause Practitioner (NCMP).

Illness-related parental stress and quality of life in children with kidney diseases.

This cross-sectional study investigated quality of life (QoL) and illness-related parental stress in children with kidney diseases by (1) comparing mean levels of these two variables between several kidney disease categories; (2) exploring correlations between QoL and parental stress; and (3) describing which disease category reports lowest QoL and highest parental stress. We included 295 patients with a kidney disease (0-18years) and their parents, followed at 6 reference centers for pediatric nephrology. Children's QoL was assessed by the PedsQL™ 4.0 Generic Core Scales, and illness-related stress by the Pediatric Inventory for Parents. All patients were divided into 5 kidney disease categories according to the multidisciplinary care program criteria prescribed by the Belgian authorities: (1) structural kidney diseases, (2) tubulopathies and metabolic diseases, (3) nephrotic syndrome, (4) acquired diseases with proteinuria and hypertension, and (5) kidney transplantation. Child self-reports showed no differences in QoL between kidney disease categories, in contrast to parent proxy reports. Parents of transplant patients reported lower QoL in their child and more parental stress compared with the 4 non-transplant categories. QoL and parental stress were negatively correlated. Lowest QoL and highest parental stress scores were mainly found in transplant patients. This study showed lower QoL and higher parental stress in pediatric transplant patients compared with non-transplants, based on parent reports. Higher parental stress is associated with worse QoL in the child. These results highlight the importance of multidisciplinary care for children with kidney diseases, with special attention to transplant patients and their parents. A higher resolution version of the Graphical abstract is available as Supplementary information.

Assessment of Patients With ARFID Presenting to Multi-Disciplinary Tertiary Care Program.

There are no standard assessment approaches for Avoidant Restrictive Food Intake Disorder (ARFID). We describe our approach to multidisciplinary assessment after assessing more than 550 patients with ARFID. We collected online survey (ARFID-specific instruments, measures of anxiety, depression) measures. Electronic medical record data (mental health and gastrointestinal diagnoses, micronutrient and bone density assessments, and growth parameters) were extracted for the 239 patients with ARFID seen between 2018 and 2021 with both parent and patient responses to online surveys. We identified 5 subtypes/combinations of subtypes: low appetite; sensory sensitivity; fear + sensory sensitivity; fear + low appetite; fear + sensory sensitivity + low appetite. Those with appetite-only subtype had higher mean age (14.0 years, P < 0.01) and the lowest average body mass index z score (-1.74, P < 0.01) compared to other subtypes. Our experience adds to understanding of clinical presentations in patients with ARFID and may aid in assessment formulation.