Multidisciplinary Clinic Setting Research Articles

A Quality Improvement Project to Improve After-visit Summary Patient Instructions in a Pediatric Multidisciplinary Neuromuscular Program.

Multidisciplinary clinics aim to coordinate care between multiple specialties for children with medical complexity yet may result in information overload for caregivers. The after-visit summary (AVS) patient instruction section offers a solution by summarizing visit details and recommendations. No known studies address patient instruction optimization and integration within a multidisciplinary clinic setting. This project aimed to improve the quality of patient instructions to support better postvisit communication between caregivers and providers in a multidisciplinary pediatric neuromuscular program. A multidisciplinary stakeholder team created a key driver diagram to improve postvisit communication between caregivers and providers in the clinic. The first specific aim was to achieve an 80% completion rate of AVS patient instructions within 6 months. To do so, a standardized electronic medical record "text shortcut" was created for consistent information in each patient's instructions. Feedback on AVS from caregivers was obtained using the Family Experiences with Coordination of Care survey and open-ended interviews. This feedback informed the next specific aim: to reduce medical jargon within patient instructions by 25% over 3 months. Completion rates and jargon use were reviewed using control charts. AVS patient instruction completion rates increased from a mean of 39.4%-85.0%. Provider education reduced mean jargon usage in patient instructions, from 8.2 to 3.9 jargon terms. Provider education and caregiver feedback helped improve patient communication by enhancing AVS compliance and diminishing medical jargon. Interventions to improve AVS patient instructions may enhance patient communication strategies for complex medical visits.

Integrating artificial intelligence techniques for advancements in colorectal cancer management: navigating past and predicting future direction.

Artificial Intelligence (AI) in the last few years has emerged as a valuable tool in managing colorectal cancer, revolutionizing its management at different stages. In early detection and diagnosis, AI leverages its prowess in imaging analysis, scrutinizing CT scans, MRI, and colonoscopy views to identify polyps and tumors. This ability enables timely and accurate diagnoses, initiating treatment at earlier stages. AI has helped in personalized treatment planning because of its ability to integrate diverse patient data, including tumor characteristics, medical history, and genetic information. Integrating AI into clinical decision support systems guarantees evidence-based treatment strategy suggestions in multidisciplinary clinical settings, thus improving patient outcomes. This narrative review explores the multifaceted role of AI, spanning early detection of colorectal cancer, personalized treatment planning, polyp detection, lymph node evaluation, cancer staging, robotic colorectal surgery, and training of colorectal surgeons.

Management advances for congenital diaphragmatic hernia: integrating prenatal and postnatal perspectives.

In congenital diaphragmatic hernia (CDH), abdominal organs are displaced into the chest, compress the lungs, and cause mediastinal shift. This contributes to development of pulmonary hypoplasia and hypertension, which is the primary determinant of morbidity and mortality for affected newborns. The severity is determined using prenatal imaging as early as the first trimester and is related to the laterality of the defect, extent of lung compression, and degree of liver herniation. Comprehensive evaluation of fetal CDH includes imaging-based severity assessment, severity assessment, and evaluation for structural or genetic abnormalities to differentiate isolated from complex cases. Prenatal management involves multispecialty counseling, consideration for fetal therapy with fetoscopic endoluminal tracheal occlusion (FETO) for severe cases, monitoring and intervention for associated polyhydramnios or signs of preterm labor if indicated, administration of antenatal corticosteroids in the appropriate setting, and planned delivery to optimize the fetal condition at birth. Integrated programs that provide a smooth transition from prenatal to postnatal care produce better outcomes. Neonatal care involves gentle ventilation to avoid hyperinflation and must account for transitional physiology to avoid exacerbating cardiac dysfunction and decompensation. Infants who have undergone and responded to FETO have greater pulmonary capacity than expected, but cardiac dysfunction seems unaffected. In about 25-30% of CDH neonates extracorporeal life support is utilized, and this provides a survival benefit for patients with the highest predicted mortality, including those who underwent FETO. Surgical repair after initial medical management for the first 24-48 hours of life is preferred since later repair is associated with delayed oral feeding, increased need for tube feeds, and increased post-repair ventilation requirement and supplemental oxygen at discharge. With overall survival rates >70%, contemporary care involves management of chronic morbidities in the context of a multidisciplinary clinic setting.

First Nations Patients’ Experience Receiving Care for Cleft Lip and Palate in a Multidisciplinary Clinic Setting

Purpose: Our small-scale qualitative study sought to explore the experiences of Indigenous patients receiving care for cleft lip and/or palate at a multidisciplinary clinic. There currently are no published studies that demonstrate the experiences of cleft lip and/or palate patients receiving care in multidisciplinary clinics in Canada. This work is foundational to informing future care in a way that is reflective and cognizant of Indigenous ways of life and lived experiences. Method: Participants were recruited via purposive and snowball sampling through community networks and public advertising in relevant healthcare spaces. Semi-structured interviews were completed; transcribed verbatim and descriptive codes were generated using Indigenist research methodologies through the Blackfoot medicine wheel. Results: Five participants that included patients, parents of patients with cleft lip and/or palate, and Indigenous health liasions were interviewed. Participants indicated a lack of spiritual health, the physical demands of having a cleft lip and/or palate on a patient and their families, the fear and unknown associated with a new cleft lip and/or palate diagnosis, and lack of cultural support, awareness and racism may negatively impact mental health. Conclusion: Indigenous patients must receive cleft lip and/or palate care that is cognizant of both their cultural needs identified in our study but also reflective of the ways in which health may be conceptualized for Indigenous patients. The following models of care suggested in our study must also seek to address historic mandates that include UNDRIP and the Truth and Reconciliation Commission's Calls to Action.

BEEC psychosocial screening at Royal Manchester Children's Hospital

Bladder Exstrophy and Epispadias Complex (BEEC) is associated with psychosocial difficulties. Screening questionnaires, alongside consultation with a clinical psychologist, can help identify children/young people for further assessment and track trends over time to improve service delivery. To screen paediatric BEEC patients for a range of general psychosocial difficulties in a multi-disciplinary out-patient clinic setting and compare these results with our previous study and against published norms. The current service evaluation collected data at outpatient BEEC clinic appointments between 2016 and 2022 (2016-2022 sample). Children aged 4-5, 10-11 and 14-15 years and their parents/proxy were asked to complete two standardised psychosocial questionnaires: Paediatric Quality of Life Inventory (PedsQL 4.0 Generic Core and Family Impact Module) and the Strengths and Difficulties Questionnaires (SDQ). 79 children (CYP) and 93 parent/proxy (P/P) responses were recorded. The sample included paired CYP and P/P responses for the PedsQL (n=67) and SDQ (n=35). The mean age for CYP was 9.9 years (SD 3.99, range 2-17), 69.8% (n=120) of responses for male children. The percentage of total CYP scores falling within the 'At Risk' category on the PedsQL increased in the 2016-2022 sample compared to our 2015 sample, indicating the prevalence of greater difficulties. Differences between P/P and CYP responses on both the PedsQL and SDQ favoured CYP. Age, gender, and diagnosis appeared to influence certain questionnaire responses, depending on respondent (CYP or P/P). A significant difference between P/P and CYP in the emotional domain of the PedsQL for those aged 13-18 was observed (p=0.020), with P/P reporting greater difficulties, but this was not seen in the younger age ranges. Physical Health on the PedsQL were significantly lower for children with a cloacal exstrophy diagnosis, in comparison to bladder exstrophy and epispadias. P/P SDQ scores for boys were significantly higher in several domains. The results demonstrate the need for psychosocial screening, providing benchmarking for psychosocial difficulties within this patient group. Results indicate that patients accessing our clinic are reporting a higher level of challenge across psychosocial domains in recent years reflected by the percentage within the 'At Risk' category for psychosocial difficulty. Linked questionnaire data with condition specific information and surgical history would improve service evaluations. CYP reaching clinical thresholds are offered further psychological assessment within the service.

Airway Clearance Strategies and Secretion Management in Amyotrophic Lateral Sclerosis.

Amyotrophic lateral sclerosis (ALS) is a rare, neurodegenerative motor neuron disease that affects voluntary muscle movement. Often, difficulty in coughing, breathing, and swallowing are sequela associated with the condition, and the presence of bulbar muscle predominant weakness results in deleterious effects on airway clearance and secretion management. This narrative review will provide practical guidance for clinicians treating this population. Cough insufficiency in this population typically manifests as a prolonged, slow, weak cough effort that impedes the clearability of secretions and airway protection. Dystussia and dysphagia frequently occur simultaneously in bulbar dysfunction, subsequently impacting respiratory health. Measures of respiratory strength should be obtained and monitored every 3-6 months, preferably in a multidisciplinary clinic setting. Cough augmentation, whether manual or mechanical techniques, should be sought as early in the disease progression as possible to adequately control secretions in the proximal airways. This airway clearance strategy can aid in the prevention and treatment of respiratory tract infections (RTIs), which can pose a significant clinical hurdle to those with ALS. The use of mechanical insufflation-exsufflation may be complicated by severe bulbar dysfunction rendering this technique ineffective. Though peripheral airway clearance strategies, such as high-frequency chest-wall compression, have the advantage of being less impacted by bulbar dysfunction, it is only recommended this modality be used in conjunction with, versus in lieu of, proximal strategies. Salivary secretion management includes the use of anticholinergics, botulinum toxin, and radiation therapy depending on severity and desire for relief.

Early detection of the risk of cognitive disorders

BACKGROUND: Cognitive disorders are a relevant problem in an aging population. Research shows a wide range of data on the prevalence of cognitive disorders in the general population. Thus, more studies on the prevalence of cognitive disorders and assessment of the risks of their development are necessary, which will determine the burden on the regional healthcare system.
 AIM: To examine the prevalence of cognitive impairment in an outpatient multidisciplinary clinic setting and determine the risk ratios for cognitive deficits in different age groups.
 MATERIALS AND METHODS: The Montreal Cognitive Assessment Scale was used in the screening of people aged 4590 years.
 RESULTS: Cognitive dysfunction was noted in 20.0% of patients in the group aged 4559 years, 33.1% in the group aged 6074 years, and 79.6% in the group aged 7590 years. The average results on the assessment of cognitive functions of persons aged 4559 (27.10.3) and 6074 (26.20.2) years corresponded to the norm, and the value in persons aged 7590 (23.60.3) years was below the norm. In groups aged 6074 and 7590 years, the prevalence of cognitive dysfunction was comparable between men and women. Cognitive impairments in men aged 4559 years were recorded 2.5 times more often than that in women. The risk of cognitive disorders in the second group (aged 6074 years) relative to that in the first group (aged 4559 years) is insignificant (relative risk [RR], 1.21). In the third group (aged 7590 years), the probability of cognitive disorders is significantly higher than that in the second group (RR=2.40) and nearly five times higher than that in the first group (RR=4.86).
 CONCLUSION: Sex- and age-stratified screening indicators for assessing cognitive functions and the RRs of developing cognitive disorders in older age groups make it possible to plan for diagnostic, therapeutic, and preventive measures in mental health.

The Impact of Head and Neck Multidisciplinary Clinic on Treatment Package Time During the COVID-19 Pandemic: A Single Institutional Experience

Purpose/Objective(s)The onset of the COVID-19 pandemic in the United States has had a profound impact on the delivery of medical care in this country, particularly in the outpatient clinical setting. A result of the pandemic has been the introduction of delays in the diagnosis and treatment of head and neck cancer which are strongly associated with inferior oncologic outcomes. Efforts to minimize these delays are therefore a high priority in this patient population. Here, we report the results from one particular intervention taken at our institution - the formation of a multidisciplinary clinic (MDC) - on treatment times.Materials/MethodsIn July 2020, our institution initiated a pilot program establishing a MDC combining otolaryngology and radiation oncology visits. Clinics were held on a half-day every two weeks and consisted of both new patient consults and follow-up patients who had received radiation as part of their treatment course. We measured and compared treatment package time of the MDC patients with those seen at our institution in the standard clinic setting.ResultsA total of 25 new patients requiring radiation were seen in our MDC between 7/31/2020 and 9/3/2021. This included 8 patients who underwent definitive radiation, 12 patients who underwent adjuvant radiation, and 5 patients who underwent palliative radiation. A total of 54 patients received radiation through standard clinics during this time frame, with 21 definitive cases, 28 adjuvant cases, and 5 palliative cases. There was no difference in median radiotherapy duration between the patients seen in MDC vs standard clinics (41 vs 41 days, p = NS). In comparison, however, the patients seen in MDC started adjuvant radiotherapy sooner (median 34 vs 41.5 days, p=0.002) and had a more compact treatment package times (median 76.5 vs 84.5 days, p=0.002). Three patients in the standard clinics cohort had treatment package times exceeding 100 days while no patient seen in MDC had a treatment package time exceeding 84 days.ConclusionDespite the many challenges associated with the ongoing COVID-19 pandemic, we found that patients seen in our MDC setting maintained timely treatment package times that were significantly better than those seen in our standard clinics. This is potentially due to the identification of patients likely to require adjuvant radiotherapy earlier in their clinical presentation. This in turn allowed for more advanced planning and minimization of delays in initiation of adjuvant radiotherapy. While previous studies have demonstrated improved oncologic outcomes when head and neck multispecialty care is delivered at tertiary care facilities, we found a further improvement in care delivery with colocalization of clinic visits by the treatment team.

High Local Control Following Pre-Operative Radiotherapy for Adult Deep Soft Tissue Sarcoma of the Head and Neck

<h3>Purpose/Objective(s)</h3> Local control (LC) of head and neck (HN) soft tissue sarcoma (STS) is generally lower than the > 90% rate expected in extremity STS. We report outcomes of high-risk adult HN STS [defined as requiring surgery and radiotherapy (RT) after joint in-person assessment by a HN surgeon and radiation oncologist with expertise in sarcoma management] using pre-operative (Pre-op) RT to reduce target volumes adjacent to optic or other vulnerable anatomy. <h3>Materials/Methods</h3> A prospective series of newly diagnosed adult HN STS patients who underwent Pre-op RT between 1989-2019 was analyzed. Angiosarcoma, fibromatosis, and embryonal/alveolar rhabdomyosarcoma were not included due to natural history requiring different management paradigms; other histologies were excluded due to the anticipated favorable control rates in these subtypes (i.e., dermatofibrosarcoma protuberans, HN sinonasal solitary fibrous tumor/hemangiopericytoma). Actuarial rates of LC, distant control (DC), and overall survival (OS) were analyzed by resection margin status. Important wound complications, defined according to a published randomized trial evaluating Pre-op RT in extremity STS, were also reported. <h3>Results</h3> Eligibility comprised 59 cases arising from neck/supraclavicular (n = 23), sinonasal (n = 16), oral (n = 11), parapharyngeal (n = 7), and scalp (n = 2) regions. UICC/AJCC TNM-8 cT-categories were: T1 (n = 10), T2 (n = 20), T3 (n = 20), and T4 (n = 9). Neoadjuvant chemotherapy was given to 3 patients (2 rhabdomyosarcomas and 1 synovial sarcoma). Pre-op RT included: 50 Gy in 25 fractions over 5 weeks (n = 53) or 60 Gy in 30 fractions over 6 weeks (n = 6). Median interval from pre-op RT to surgery was 7.3 weeks (range: 2.9-19.6). Four patients (6.7%) had wound complications considered important according to the defined criteria. One healed following flap debridement and the remainder only required conservative management. Resection margins were grossly positive (gross+) in 4 (7%), microscopically positive (micro+) in 16 (27%), and negative in 39 (68%) patients. Six received a post-op boost of 10 Gy in 5 fractions (1 for micro+ and 5 for < 10 mm resection margins). Median follow-up was 6.5 years (0.8-28.6 years). Local failure occurred in 1/39 negative, 2/16 micro+, and 4/4 gross+ resection margin groups. Five-year LC, DC and OS for negative vs micro+ vs gross+ resection margin groups were: 97% vs 93% vs 25% (<i>P</i> < 0.001, micro+ vs negative: <i>P</i> = 0.083); 78% vs 75% vs 75% (<i>P</i> = 0.97), 83% vs 87% vs 25% (<i>P</i> < 0.001). No patient developed significant toxicity (e.g., blindness) related to RT. <h3>Conclusion</h3> HN STS patients requiring combined modality local management with moderate dose Pre-op RT in a sarcoma-focused multidisciplinary clinic setting have excellent LC and functional outcomes that parallel extremity cases, but with less wound complications. Micro+ margins without postop boost RT does not seem to compromise LC when managed within a collaborative environment.

Integration and feasibility of symptom burden assessment and early palliative care into an adolescent and young adult leukemia clinic.

10052 Background: Patients (pts) diagnosed with hematologic malignancies during adolescence &amp; young adulthood (AYA) are a uniquely challenging population who are understood to have robust supportive care needs. Here, we describe their symptom burdens and the feasibility of integrating palliative care into an outpatient, multi-disciplinary AYA leukemia clinic at an academic medical center. Methods: Palliative care was introduced into the AYA clinic in 8/2020 to provide symptom-focused care. Pre-existing clinic services included psychologists, pharmacists, and social workers. All established pts receiving routine follow up were referred by the oncology team to the Supportive Care team, which provided same-day palliative care consultation in the same clinic space with a telehealth option and as needed follow-up. To describe baseline symptom burdens, a random cross-sectional sample of pts completed a multi-domain symptom assessment (SA) using validated self-report instruments including physical (Edmonton Symptom Assessment Scale [ESAS]); emotional (Brief Symptom Inventory-18 [BSI-18]); financial (FACIT-COST); cognitive (Childhood Cancer Survivor Study – Neurocognitive Questionnaire); spiritual (FACIT -Spiritual Well-being Scale); and quality of life (QOL) (FACT-General) measures. All pts have a diagnosis of acute or chronic leukemia and were on active treatment or in survivorship. Results: Over 6 months, 30 pts (median age 29 years at assessment, range 18-45 years) received symptom-focused palliative care over 16 combined clinics with 81 total encounters averaging 5 pts (range 1-8) per clinic. 47% were female. No pts declined palliative care. Pts received on average 2.7 follow up visits (range 1-6), with 50% of encounters resulting in adjustments to medical management. Common issues addressed included pain, muscle cramps, neuropathy, anxiety, insomnia, depression, nausea, and non-pharmacological symptom control remedies. Of 46 pts, 31 (67%) completed the SA (median age 30 years at assessment, range 18-43 years); 48% were female; 84% were on treatment. 100% of pts reported fatigue, and 48% reported &gt; = 1 severe symptom (range 0-7) based on the ESAS with “poor feeling of well-being” as the most common (23%). 45% met criteria for BSI-18 emotional distress, and 45% reported some neurocognitive impairment. Emotional distress (p &lt; 0.01), financial toxicity (p = 0.03), low spiritual well-being (p &lt; 0.01), and presence of pain, nausea, or depression (p &lt; 0.05) were all associated with lower QOL. Conclusions: AYA pts with leukemia undergoing treatment and in survivorship experience high symptom burden with poor QOL. It is feasible to both assess symptom burden and provide early palliative care focused on symptom management in an outpatient, multi-disciplinary clinic setting.

Patient reported outcomes in ALS: characteristics of the self-entry ALS Functional Rating Scale-revised and the Activities-specific Balance Confidence Scale

Objective: This study characterized two patient-reported outcome measures (PROMs): a patient-facing adaptation of the revised amyotrophic lateral sclerosis (ALS) Functional Rating Scale (“self-entry ALSFRS-R”) and the Activities-specific Balance Confidence (ABC) Scale. Methods: ALS patients presenting to clinic completed PROMs that included (1) the self-entry ALSFRS-R, (2) the Activities-specific Balance Confidence Scale (ABC Scale), and (3) a question about falls. PROM data were compared to one another and to the traditional ALSFRS-R collected by trained evaluators in clinic (“standard ALSFRS-R”). Results: Over the data collection period, 449 ALS patients completed at least one of the three PROMs. Self-entry vs. standard ALSFRS-R total scores (n = 183) had high agreement (intraclass correlation (ICC)=0.81, 95% CI = 0.67, 0.88). Self-entry ALSFRS-R total scores were significantly higher than standard ALSFRS-R total scores (2.3 points, p < 0.001). In a subset of participants who contributed data at two timepoints, the average ALSFRS-R decline was not significantly different between methods (n = 49). ABC scores correlated highly with self-entry and standard ALSFRS-R Gross Motor subdomain scores (Pearson’s r = 0.72, p < 0.001 and Pearson’s r = 0.76, p < 0.001, respectively; n = 130). ABC score was negatively correlated with the number of reported falls within the last month (Spearman’s r=–0.40; p < 0.001; n = 130). A 10-point decrease in ABC score increased odds of a reported fall by 16%. Conclusions: In a multidisciplinary clinic setting, self-entry and standard ALSFRS-R scores were similar, but not interchangeable. Self-entry scores were higher than standard ALSFRS-R scores but declined at a similar rate to the standard ALSFRS-R. ABC scores correlated with self-reported fall history and thus may provide useful data for clinical care.

Routine Use of Swallowing Outcome Measures Following Head and Neck Cancer in a Multidisciplinary Clinic Setting.

Introduction Chemoradiotherapy treatment for head and neck cancer (HNC) can have a major impact on swallowing function and health-related quality of life. The use of outcome measures in early detection of patients with swallowing problems provides the opportunity for targeting speech and language therapy (SLT) interventions to aid adaption and promote better clinical outcomes. Objective The purpose of the present study was to assess relationships between four outcomes measures over time, in a cohort of HNC patients, treated by (chemo-)radiotherapy. Methods Data were collected at 3 months and 12 months, on 49 consecutive patients with primary squamous cell cancer of the oropharynx, nasopharynx or hypopharynx stage T1–4, N0–2b, M0 disease. Results Out of 49 eligible patients, 45 completed assessment at 3 months and 20 at 12 months. The 3-month outcomes gave a strong indication of performance at 1 year. There were several strong correlations found between measures. The strongest was between the 3-month Performance Status Scale for Head and Neck Cancer (PSSHN) and the 12-month PSSHN (rs = 0.761, n = 17), the 12-month PSSHN and the 12-month Functional Oral Intake Scale (FOIS) (rs = 0.823, n = 20), and the 12-month University of Washington Head and Neck Quality of Life (UWQoL) swallow and the 12-month Water Swallow Test (WST) capacity (rs = 0.759, n = 17). Conclusion The UW-QoL swallow item and WST are easy to incorporate into routine care and should be used as part of a standard assessment of swallow outcome. These measures can serve to help screen patients for dysfunction and focus allocation of resources for those who would benefit from more comprehensive assessment and intervention by SLT.

Interest in cessation treatment and survival among smokers in a community-based multidisciplinary thoracic oncology program.

2028 Background: Tobacco cessation is essential to high quality oncology care. Many patients smoke when diagnosed and continue to smoke during treatment, which adversely affects treatment response and survival. Although most patients are motivated to quit, few receive effective cessation therapy. The multidisciplinary clinic (MDC), where patients, their caregivers, and key specialists coordinate care, is an ideal setting to integrate a cessation program. To assess the need for cessation services within a MDC setting, we surveyed incoming patients about their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program. Methods: The study was conducted in the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN. We evaluated sociodemographic/clinical characteristics, smoking status, and tobacco dependence of consecutive new patients diagnosed with lung cancer from 2014-2019, who completed a social history questionnaire. Current smokers reported their interest in quitting and their willingness to participate in a cessation program. Chi square tests and logistic regression models were used to compare characteristics of those who would participate vs. those who would not/were unsure. Kaplan-Meier curves and multivariable Cox regression were used to evaluate the association between willingness to participate in a cessation program and overall survival, adjusted for age, sex, race, and total pack-years of smoking. Results: Of 641 patients, the average age was 69 years (range: 32-95), 47% were men, 64% white/34% black, and 17% college graduates; 90% had ever smoked, 34% currently smoked, and 24% quit smoking within the past year. Among current smokers, 60% were very interested in quitting and 37% would participate in a clinic-based cessation program. Willingness to participate was associated with greater interest in quitting (p = 0.0010) and greater overall survival (log rank p = 0.01;HR: 0.48, 95% CI: 0.24-0.95) but was not associated with any sociodemographic, clinical, or smoking-related characteristics. Conclusions: Over half (58%) of patients in a community-based MDC program were current smokers/recent quitters. Willingness to participate in a cessation program was associated with improved survival, suggesting patients with favorable prognoses are especially interested in receiving cessation support. There is considerable need for cessation services and relapse-prevention support within a coordinated, MDC lung cancer care setting.

Using Participatory Methods to Engage Multidisciplinary Clinical Staff in the Embedding of Trauma-Informed Care and Practice Principles in a Sub-Acute Mental Health Inpatient Unit.

Changing multidisciplinary team practice is difficult, even in circumstances where the staff support such change. This methodology paper describes the successful use of respectful and participatory methods and processes to engage multidisciplinary clinical staff in practice change. These methods are described and discussed in relation to a clinical practice change project that sought to embed trauma-informed care and practice (TICP) in a sub-acute mental health unit. TICP is a critical new paradigm for multidisciplinary mental health services that involves the recognition of the high rates of abuse and trauma suffered by those with mental illness and the need to both understand the effects of this abuse and trauma and to respond to them appropriately. The principles of the paradigm need to be introduced throughout mental health services, but especially in inpatient units where a predominantly biomedical perspective can preclude a more holistic approach. This paper outlines the background of TICP and describes in detail the four TICP-compatible, participatory methods and processes used to engage staff in the embedding of TICP principles in their everyday practice. The participatory approaches employed reflected TICP principles and addressed issues including the engagement of staff in the change project, the identification of TICP-compatible care practices currently used in the unit, the identification of issues related to the further embedding of TICP in everyday care, and the generation of solutions to the issues raised. The processes undertaken were underpinned by a heuristic framework to maintain staff engagement. This paper is not intended to be a recipe for TICP change. However, the methods and processes described may be adapted to be of practical use in the design of TICP and other practice change initiatives in multidisciplinary clinical settings.

When do athletes benefit from cardiac genetic testing?

Genetic testing has had a major impact in many areas of medicine, including sports cardiology. Here we discuss cardiac genetic testing not as a screening tool but rather as an...

Concordant Validity of a Digital Peak Cough Flow Meter to Assess Voluntary Cough Strength in Individuals with ALS

Peak cough flow represents an important metric directly related to the physiologic ability of an individual to defend the airway or expel tracheal aspirate. Given the high prevalence of dysphagia and dystussia in individuals with amyotrophic lateral sclerosis (ALS) and recent findings that the expiratory phase of voluntary cough is significantly impaired in ALS individuals, we aimed to determine the reproducibility of an affordable, portable peak cough flow (PCF) meter for the assessment of cough production in individuals with ALS. 109 individuals with ALS completed voluntary cough testing using both the research cough spirometry equipment and a digital peak cough flow meter. Maximum peak expiratory cough flow rates were obtained from each device. Analyses included paired t test, Pearson's correlation, and Lin's concordance correlation to determine the degree of agreement and reproducibility between cough measurement devices (alpha = 0.05). Mean differences between peak cough flow test values (L/min) across instruments were not statistically significant (mean difference = - 2.93; 95% CI - 18.67, 12.82; p = 0.713). PCF values obtained from the digital peak cough flow meter and the research cough spirometry equipment were strongly associated (r = 0.826, p < 0.000) and demonstrated a high level of agreement and reproducibility (ρc = 0.824, 95% CI 0.754, 0.876). These data validate the use of an inexpensive and portable digital peak cough flow device to index peak cough flow strength in individuals with ALS. This assessment could easily be incorporated into a multidisciplinary ALS clinical setting to index the physiologic ability of an individual to protect the airway.

Combined evaluation of genotype and phenotype of thiopurine S-methyltransferase (TPMT) in the clinical management of patients in chronic therapy with azathioprine.

Background The thiopurine S-methyltransferase (TPMT)/azathioprine (AZA) gene-drug pair is one of the most well-known pharmacogenetic markers. Despite this, few studies investigated the implementation of TPMT testing and the combined evaluation of genotype and phenotype in multidisciplinary clinical settings where patients are undergoing chronic therapy with AZA. Methods A total of 356 AZA-treated patients for chronic autoimmune diseases were enrolled. DNA was isolated from whole blood and the samples were analyzed for the c.460G>A and c.719A>G variants by the restriction fragment length polymorphism (RFLP) technique and sequenced for the c.238G>C variant. The TPMT enzyme activity was determined in erythrocytes by a high-performance liquid chromatography (HPLC) assay. Results All the patients enrolled were genotyped while the TPMT enzyme activity was assessed in 41 patients. Clinical information was available on 181 patients. We found no significant difference in the odds of having adverse drug reactions (ADRs) in wild-type patients and variant allele carriers, but the latter had an extra risk of experiencing hematologically adverse events. The enzyme activity was significantly associated to genotype. Conclusions TPMT variant allele carriers have an extra risk of experiencing hematologically adverse events compared to wild-type patients. Interestingly, only two out of 30 (6.6%) patients had discordant results between genotype, phenotype and onset of ADRs.

Abstract ID: 365 MR spectroscopy and multiparametric imaging of the breast

Purpose To focus on the current status of MR spectroscopy (MRS) and multiparametric MR imaging (mMRI) of breast lesions, from the standpoint of the medical physicist in a multidisciplinary clinical setting. Methods A meta-analysis of the available literature on the subject has been performed. Studies at 1.5 T as well as at 3.0 T were considered. Higher magnetic fields were also included for the sake of completeness. Results MRS of breast lesions has not yet entered the field of routine examinations due to technical difficulties and confounding factors that limit its sensitivity. Major limitations include patient motion, strong lipid signals in MR spectra, and suboptimal performances of dedicated breast coils. In a recent meta-analysis [1], pooled sensitivity and specificity were reported as 73% and 88%, respectively. On the other hand, mMRI shows increased sensitivity and specificity compared to single MRI modalities. A study on mMRI at 7 T has recently reported a sensitivity of 100% and a specificity of 88.2% when dynamic studies and DWI were simultaneously taken into account [2]. In another study, MRS was shown to improve the performance of a machine-learning classifier when added to mMRI based on morphology, dynamic imaging and DWI [3]. Conclusions MR spectroscopy of breast lesions might finally find its role in the clinical practice. Multiparametric MRI has shown promising results in the characterization of suspicious breast lesions and in the correlation to molecular subtypes of breast tumors. The role of the medical physicist in a multidisciplinary clinical setting is increasingly recognized as a key factor in order to guarantee the quality of the information provided by quantitative MRI imaging techniques.

Validation of French upper limb Erasmus modified Nottingham Sensory Assessment in stroke.

Somatosensory impairment of the upper limb (UL) occurs in approximately 50% of adults post-stroke, associated with loss of hand motor function, activity and participation. Measurement of UL sensory impairment is a component of rehabilitation contributing to the selection of sensorimotor techniques optimizing recovery and providing a prognostic estimate of UL function. To date, no standardized official French version of a measure of somatosensory impairment has been established. To develop and validate a French version of the Erasmus modified Nottingham Sensory Assessment somatosensory (EmNSA-SS) and stereognosis (EmNSA-ST) component for evaluating the UL among adults with stroke. This study is a single-center observational cross-sectional study. A French version of the EmNSA for UL was developed by forward-backward translation and cross-cultural adaptation. Fifty stroke patients were recruited to establish concurrent-criterion-related validity, internal consistency, intra- and inter-rater reproducibility with intracorrelation coefficients (ICCs) for reliability and the minimal detectable change with 95% confidence interval (MDC95) for agreement, as well as ceiling and floor effects. Criterion validity was assessed against the Fugl-Meyer Assessment-Sensory (FMA-S) for the UL. The median (range) EmNSA-SS score was 41.5 (1-44). The Spearman rank correlation coefficient between EmNSA-SS and FMA-S total scores was moderate (rho=0.74, P<0.001). The EmNSA-SS/ST internal consistency was adequate across subscales; with Cronbach α ranging from 0.82-0.96. For the EmNSA-SS total score, intra- and inter-rater reliability was excellent (ICC=0.92 in both cases), with MDC95 of 12.3 and 14.6, respectively. EmNSA-SS/ST total scores demonstrated no ceiling or floor effects. The French EmNSA is a valid and reproducible scale that can be used for comprehensive and accurate assessment of somatosensory modalities in adults post-stroke. Taking less than 30min to administer, the instrument has clinical utility for use in patients with cognitive comorbidities and at various stages of recovery in multidisciplinary clinical practice and research settings.

Subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management.

At our tertiary medical center, multidisciplinary subspecialists meet twice a week during a CME-accredited conference to discuss oncologic and non-oncologic patients with pancreatic diseases at which time a subspecialized abdominal staff radiologist reinterprets the patient's relevant imaging studies. This study assesses the changes in patient management due to imaging reinterpretation during multidisciplinary pancreas conference (MPC). In this retrospective, IRB-approved, HIPAA-compliant study, imaging studies of all patients discussed at MPC between July 1 and December 31, 2015 were assessed for technical adequacy, and original reports analyzed for congruency with reinterpretation. Management measures included change in diagnosis, clinical stage, treatment, or workup. Additional data were obtained on referring services affected and their resultant change in practice. Changes in surgical resectability, surgical approach, or delayed operative dates were noted for surgeons. Changes in chemotherapeutic or radiation oncology regimens as well as decisions for additional imaging, laboratory workup, or histologic evaluation were also recorded. A total of 252 patients were included (54.4% males, 45.6% females, mean age 63.71years). Relevant imaging consisted of 142 abdominal CT scans, 112 abdominal MRI scans, 1 abdominal ultrasound, and 1 nuclear medicine octreotide study of which 69.4% were performed in-house. Image quality was deemed appropriate in 95.2%. Cases presented included solid pancreatic malignancies (n = 140; 55.6%), cystic pancreatic lesions (n = 41; 16.3%), acute and chronic inflammatory conditions (n = 52; 20.6%), and miscellaneous entities (n = 10; 4.0%); 9 (3.6%) cases were normal. Image reinterpretation was congruent with original reports in 56.7%, with minor, moderate, and major discrepancies occurring in 9.5, 26.2%, and 7.5% of cases, respectively. Incongruent reinterpretation was predominantly due to perceptional errors (false-negative reports due to missed findings) and interpretative errors (false-positive results due to over-reporting or misclassification of diagnoses). Services most commonly affected included surgical oncology, radiology, and gastroenterology at 16.7%, 13.1%, and 12.7% of cases, respectively. Management changes included a change in diagnosis in 8.7%, change in clinical stage in 8.7%, change in treatment in 17.9%, and further workup needed in 19.0% of patients, respectively. No change in management occurred in the remaining 61.5% of cases. Subspecialized abdominal radiologist reinterpretation in the context of more comprehensive patient information heavily impacts the multidisciplinary management of patients with pancreatic disorders. Further efforts are needed to solidify the abdominal radiologist's role in the multidisciplinary clinical setting.