Multidisciplinary Medical Team Research Articles

The role of plastic surgery in sarcoma treatment

Sarcomas are low-incidence tumours, but their poor prognosis and complex treatment require the work of a multidisciplinary medical team. The Plastic Surgery Service forms part of the Sarcoma Functional Unit in our centre, performing tumour exeresis as well as immediate reconstruction. We present a retrospective study on the experience of the Plastic Surgery Service of the Hospital Universitario de Bellvitge in the treatment of 133 sarcomas over 20 years. The surgical treatment was based on local radical surgery supported by primary reconstructive surgery in 42.9% of the cases, with an amputation rate in limb sarcomas of 9.7%. Radiotherapy and chemotherapy were used in the high-grade sarcomas as adjuvant treatment. The anatomical location of the head and neck was associated with the need for reconstructive procedures. Survival free from local recurrence was 84.72% at 5 years. Disease-specific survival was 81.22% at 5 years. The only prognostic factor for survival in our series was histological grade. Primary reconstructive surgery has a fundamental role in sarcoma treatment enabling radical surgical resection, avoiding amputations and facilitating adjuvant treatments.

Factores de riesgo para las complicaciones postoperatorias en cirugía mayor de cabeza y cuello

Background and objectiveTumor extension is the factor that usually determines the choice of radiotherapy or surgery for head and neck cancers. The choice of surgery carries with it certain specific risks that must be assessed jointly by the maxillofacial surgeon and the anesthetist so that they can agree on the best course of action to choose. We aimed to identify risk factors for complications after major head and neck surgery. Patients and methodsRetrospective descriptive analysis of data for patients who underwent oncologic head and neck surgery with graft reconstruction. The main candidate predictors gathered from records were age, sex, ASA physical status classification, time under anesthesia, and intra- and postoperative events. The main dependent variables were records of early and delayed complications, time until extubation, and related mortality. ResultsWe identified 61 interventions in 56 patients (mean duration of surgery, 9 hours). Early complications developed in 57.4% while they were in the critical care area. Age>60 years was associated with longer hospital stays. Short-term mortality was higher in current smokers (P=.01). Survival was significantly higher in patients classified ASA 1 or 2 in comparison with those classified as ASA 3 or 4, in whom long–term mortality was higher (P<.05). ConclusionsThe incidence of postoperative complications was associated with comorbidity and risk behaviors found in this type of patient. We feel that a multidisciplinary medical team should assess the surgical and postoperative care of these patients.

Improving management of patients with advanced cancer

Development of bone metastases in patients with advanced cancer is associated with skeletal-related events (SREs) such as pathologic fractures, spinal cord compression, the requirement for surgery or palliative radiotherapy to bone, and hypercalcemia of malignancy. Skeletal morbidity may reduce patient mobility, limit functional independence, and impair quality of life (QOL). Proactive management of new or worsening bone pain or motor impairment is crucial because of the potential for rapid progression of symptoms. Administration of bisphosphonate therapy as a monthly infusion to patients with bone metastases prevents or delays the onset and reduces the frequency of SREs and provides clinically meaningful improvements in bone pain and QOL. In addition to administration of therapy, the monthly infusion visit allows a dedicated team of healthcare professionals to regularly assess SREs, response to therapy, adverse events (AEs), QOL, and adherence to oral medications and supplements. The continuity of care that occurs during the monthly infusion visit provides oncology nurses with an opportunity to educate patients about effective strategies to manage SREs and AEs. In addition, regular interaction provides oncology nurses with an opportunity to recognize and proactively address subtle changes in the patients’ medical condition. Using a multidisciplinary medical team also eliminates barriers between the various healthcare professionals involved in patient management. Consequently, the monthly infusion visit can result in effective patient management and improved clinical outcomes in patients with malignant bone disease.

How Cleveland Clinic managed communications and media relations for the nation's first near-total face transplant

On December 8th, 2008, Cleveland Clinic performed the first near-total face transplant in the USA on a patient who was severely disfigured from a gunshot wound to her face. At the time, it was the most complex face transplant in the world. Cleveland Clinic's Corporate Communications Office and a multidisciplinary medical team worked side-by-side to announce this milestone for the organization. Together, the team managed all communication, including the announcement of the first Institutional Review Board (IRB) approved protocol, two extensive media events, complex and ongoing messaging related to the transplants in France and China, and thousands of media requests over a five-year period, from all over the world. The media attention and coverage continues more than a year after the transplant occurred.

Sedation, Analgesia, and Delirium in the Critically Ill Patient

Most critically ill patients receive a myriad of psychoactive medications during their hospital stay. An understanding of the pharmacology of the more commonly used sedative and analgesic therapies enables the clinician to aptly utilize these medications and limit toxicity. A key to the appropriate provision of sedative and analgesic pharmacotherapy is a thorough patient assessment, use of validated monitoring tools, and defined therapeutic goals. Limiting these therapies while optimizing patient comfort has been shown to reduce the duration of mechanical ventilation and reduce intensive care unit (ICU) and hospital length of stay and should be the aim of the multidisciplinary medical team. This review is intended to provide the reader with a fundamental understanding of how to facilitate comfort of the mechanically ventilated critically ill adult patients and how to minimize medication-related toxicities.

Collaboration Within Different Settings: A Study of Co-located and Distributed Multidisciplinary Medical Team Meetings

This paper reports our findings from a study of multidisciplinary team meetings for the treatment and ongoing management of breast cancer patients. The focus of the fieldwork was the meetings within and between a large group of multidisciplinary health professionals from two hospitals in Sydney, a large public teaching hospital and a much smaller private hospital. The paper examines the common work of the meetings and the variation within and between local practices and sites in the doing of this work, both in the local settings of each hospital and in the video-mediated setting when the local meetings are linked. Variations in the physical setup of the meetings, the presentation of the patient cases and the preparation of images used in patient discussion are identified, traced to their various sources and examined within their particular sociotechnical context. This is followed by a discussion of how local variation contributed to the particular challenges of the video-mediated meetings as experienced by the participants and how they might be addressed. Our motivations are to contribute both to the growing case studies of multidisciplinary team meetings within healthcare settings and to the important work being done to generate conceptual and design approaches that can support the development and successful use of CSCW technologies across highly variable local settings.

Haiti tragedy shakes up SA’s emergency response planning

The tragic Haitian earthquake that claimed at least a quarter of a million lives this January and devastated that island has provided a sobering wake-up call for volunteer South African emergency medics who pitched in to help. South Africa’s response was fragmented, with two NGOs operating separately and independently. The lessons learnt have led to a joint initiative between the largest emergency academic medicine divisions in the country. Six of South African’s top disaster and emergency medics propose creating a single, all-inclusive, cross-sector, multi-disciplinary medical team that is properly trained, equipped and prepared to respond to local and international disasters. The main weaknesses identified in South Africa’s bid to help Haitians were the use of commercial flights, limiting the timely arrival of essential tools (including medical oxygen not being permitted on such flights), the lack of pre-departure briefings, no emergency evacuation plan or formal trauma debriefing sessions, and inappropriate food and clothing. The experts insist that a prerequisite for ‘deploy-ability’ to any disaster area in future is that all volunteers complete the new International Search and Rescue Advisory Group (INSARAG) course. The group, who penned an original article for the August edition of the SAMJ (‘Haiti: The South African perspective’),1 consists of some of the country’s most respected and experienced working emergency medics. They question the efficacy of responding to disasters ‘halfway across the world’, arguing that as a developing country South Africa’s contribution to settings such as Haiti, where the 12 January earthquake left 1.1 million homeless and 300 000 severely injured, was ‘often miniscule when compared with that of Western countries’.

Chimioprophylaxie de longue durée à la méfloquine : étude des effets indésirables

To estimate the relative frequency of reported adverse drug reactions during the malaria chemoprophylactic period of the Moroccan contingent in Democratic Republic of Congo (DRC). The transversal survey involved all military personnel of the Moroccan contingent and was carried out using a questionnaire to be filled out by a multidisciplinary medical team. It was performed in all the military sites and the advanced posts accessible during the period of the study. The study involved 362 male military subjects. Ninety-four adverse drug reactions were described: neuropsychiatric (anxiety, irritability, dizziness...) [n=76], digestive (anorexia, diarrhea, nausea...) [n=42], cardiovascular (tachycardia, palpitation, precordialgia...) [n=5], musculoskeletal (arthralgia, cramps) [n=4], cutaneous (redness, purpura) [n=2], and other (n=13). No "unexpected" or "serious" adverse drug reaction was reported. The causality assessment score was determined in 94 cases. Two of these reports were rated "likely", 12 "possible" and 80 doubtful. More adverse drug reactions were reported by subjects having medical and paramedical functions. During our study, mefloquine induced adverse drug reactions in a quarter of the treated subjects. Most of the adverse drug reactions were neuropsychiatric. No "serious" adverse drug reactions were reported underlying the interest of its use, even for long-term chemoprophylaxis.

Plastic Surgeonsʼ Performance during the February 27 Earthquake in Chile

Plastic Surgeonsʼ Performance during the February 27 Earthquake in Chile

Kidney and Sports

Several renal function modifications can be related to sports activity, as pre-existing renal dysfunction can influence the assessment of sports practice capability. The multiplicity of aetiologies requires an accurate diagnosis to correctly define the treatment approach and feasible activities. Previous nephrectomy or chronic renal failure are conditions that complicate the sport exercise fitness assessment and every patient should be assessed individually by a multidisciplinary medical team.

Complexity of health care needs and interactions in multidisciplinary medical teams

By using an information processing and social identity approach, this study examines the relationships between the complexity of the health care needs of a patient and (1) the interactions among physicians during team meetings and (2) how the meeting participants evaluate the discussion. Three dimensions of the complexity of the health care needs are related to the interactive behaviour of medical specialists during meetings of multidisciplinary medical teams. Three medical teams from a Dutch university hospital, each discussing a total of 40 patients, were observed. The results show that component complexity was positively related to the amount of information team members exchanged, to positive reactions, and to the positive evaluation of the discussion. Two other dimensions (interrelatedness of needs and ambiguity) have to be considered in concert: interrelatedness was positively related to negative reactions but only if ambiguity was low; and, further, ambiguity was positively related to evaluative behaviour and to positive reactions, and negatively to the evaluation of the discussion, but only if interrelatedness was low.

Medical and non-medical considerations for the outpatient management of children with pulmonary arterial hypertension

Outpatient management of children with pulmonary arterial hypertension (PAH) requires unique and practical considerations, especially for those who require prostacyclin therapy. Currently, subcutaneous, inhaled, and intravenous forms of prostacyclin are available. Although intravenous prostacyclin delivery poses risks, such as catheter-related bloodstream infections, this form of therapy may be preferred due to the inherent issues associated with subcutaneous treprostinil therapy (incidence of site pain with delivery) and inhaled iloprost therapy (prescribed 6-9 treatments daily). Management of the child requiring intravenous prostacyclin therapy must include consideration of drug choice (epoprostenol or treprostinil), and patient and caregiver readiness to support and manage this therapy at home. Further management decisions regarding chronic anti-coagulation therapy, exercise recommendations, and school and travel considerations must also be addressed for each child. A dedicated, multi-disciplinary medical team, attuned to the specific needs of children with PAH, is required to provide the safest and most effective medical treatment as well as essential psycho-social support for these children and their families.

Consequences of Participating in Multidisciplinary Medical Team Meetings for Surgical, Nonsurgical, and Supporting Specialties

This study examines the consequences for medical specialists of participating in multidisciplinary medical team meetings in terms of perceived clinical autonomy, domain distinctiveness, and professional accountability. These consequences may influence their willingness to cooperate and the quality of teamwork. The authors hypothesized that multidisciplinary medical team meetings would be more of a threat to the professional identity of surgical specialists than to the professional identity of nonsurgical and supporting specialists. A survey among 1,827 Dutch medical specialists supported the authors' hypotheses. However, a few specific specialties had response patterns that deviated from our expectations. The results are related to specialty choice, to the training of medical specialties, and to having a role in leading team meetings.

Information Sharing at Multidisciplinary Medical Team Meetings

Results of a study of multidisciplinary medical team meetings (MDTMs) are presented, with focus on information presentation, collaboration, sharing and decision-making issues. The MDTM forum is shown to be an important juncture in the patient care pathway where prior work is reviewed, future work is planned, and decisions are made by consensus. It is shown that while all participants perceive that they benefit from their attendance, the benefit for most active participants is directly proportional to their contribution. Record keeping of the decision agreed and the basis for that decision poses a challenge, particularly in the context of electronic patient record (EPR) keeping. This study also reveals the multi-faceted nature of the event and the fact that new knowledge is generated during the meetings. In addition to its main function in patient management, the MDTM has an educational role and fulfils hospital functions in planning and co-ordination of service delivery. These findings are analysed in terms of their implications for the information sharing needs of participants according to their roles; and requirements for technology support at individual, group and organisational levels are discussed.

Assessment of the capacity to consent to treatment in patients admitted to acute medical wards

BackgroundAssessment of capacity to consent to treatment is an important legal and ethical issue in daily medical practice. In this study we carefully evaluated the capacity to consent to treatment in patients admitted to an acute medical ward using an assessment by members of the medical team, the specific Silberfeld's score, the MMSE and an assessment by a senior psychiatrist.MethodsOver a 3 month period, 195 consecutive patients of an internal medicine ward in a university hospital were included and their capacity to consent was evaluated within 72 hours of admission.ResultsAmong the 195 patients, 38 were incapable of consenting to treatment (unconscious patients or severe cognitive impairment) and 14 were considered as incapable of consenting by the psychiatrist (prevalence of incapacity to consent of 26.7%). Agreement between the psychiatrist's evaluation and the Silberfeld questionnaire was poor (sensitivity 35.7%, specificity 91.6%). Experienced clinicians showed a higher agreement (sensitivity 57.1%, specificity 96.5%). A decision shared by residents, chief residents and nurses was the best predictor for agreement with the psychiatric assessment (sensitivity 78.6%, specificity 94.3%).ConclusionPrevalence of incapacity to consent to treatment in patients admitted to an acute internal medicine ward is high. While the standardized Silberfeld questionnaire and the MMSE are not appropriate for the evaluation of the capacity to consent in this setting, an assessment by the multidisciplinary medical team concurs with the evaluation by a senior psychiatrist.

Traitement orthodontique des enfants atteints du trouble déficit de l'attention avec hyperactivité (TDAH)

Successful orthodontic treatment requires the child's cooperation. Yet how can this be achieved when this cooperation is compromised by a neurobehavioural disorder: the attention deficit hyperactivity disorder (ADHD)? This disorder, slightly tracked down, common in children, leads to hyperactivity, impulsiveness and a short attention span. The objective of this survey is to compare the challenges of conducting orthodontic treatment on children who have or have not been diagnosed and treated by a multi-disciplinary medical team. The data of this survey was collected from orthodontists in Paris and Strasbourg, and from graduate orthodontics students. The orthodontic treatment of 30 children (25 males and 5 females) between 8 and 15 years, affected by ADHD (half have been diagnosed and treated by a multi-disciplinary team) are compared to 30 control subjects. The results highlight the therapeutic difficulties (with behavior, attention span, cooperation, hygiene and dental trauma) encountered with children affected by ADHD (especially those who did not benefit from multidisciplinary follow up) compared to control population. In conclusion, hyperactive children present more challenges during an orthodontic treatment compared to a control population. Nevertheless, the treatment is easier when children are diagnosed and treated multimodally. Further studies are required on a wider population to confirm the differences in therapeutic difficulties.

The surgical pathology of skeletal metastases

In this review, we aim to (1) outline the nature and scale of metastatic skeletal disease; (2) describe the role of the multidisciplinary musculoskeletal medical and surgical team; and (3) discuss and illustrate the diagnostic pathology approach with emphasis on its clinical relevance. The employment of immunohistochemistry in helping to establish the occult primary site of metastatic skeletal tumours is reviewed.

Social Work in the Department of Defense Hospital: Impact, Role, and Interventions

For the social worker in the Department of Defense hospital numerous challenges are faced and met while serving the nation's wounded. As an integral part of the multidisciplinary medical team, social workers perform vital services and function in diverse roles. The survey research reported in this article details some of the roles and functions performed by social workers, noting the impact, challenges, and rewards they identified when considering their work. In addition, various intervention modalities that the social workers utilize on a regular basis were identified. One hundred forty-one social workers in over 26 treatment facilities were surveyed in settings across the United States. A large percentage of those surveyed work at least 50% of their time with OEF/OEF soldiers and their families.

Achieving Diagnosis by Consensus

This paper provides an analysis of the collaborative work conducted at a multidisciplinary medical team meeting, where a patient’s definitive diagnosis is agreed, by consensus. The features that distinguish this process of diagnostic work by consensus are examined in depth. The current use of technology to support this collaborative activity is described, and experienced deficiencies are identified. Emphasis is placed on the visual and perceptual difficulty for individual specialities in making interpretations, and on how, through collaboration in discussion, definitive diagnosis is actually achieved. The challenge for providing adequate support for the multidisciplinary team at their meeting is outlined, given the multifaceted nature of the setting, i.e. patient management, educational, organizational and social functions, that need to be satisfied.

Évaluation de la prise en charge des patients atteints d'accident vasculaire cérébral (AVC) dans un centre hospitalier

The aim of this study was to evaluate the quality of care provided in a university hospital to stroke patients with the use of an evaluation of practice carried out by comparing results to the recommendations of the High Authority of Health (HAS). The study period covered two years (2005 and 2006). The study was retrospective based on patients' medical records (n=154), and it compared local medical practices to national guidelines. Significant gaps with the recommended practices were noted, in particular in the prescription of additional examinations and their delay in being carried out. There were also noticeable deficiencies in therapeutic care. Furthermore, there was a certain element of heterogeneity of care in the acute phase of stroke attack within the same hospital service. Establishment of a multidisciplinary medical team including at least two neurologists who are aware of and motivated by evaluation would be an opportunity for this hospital to improve services. In addition, the referral of stroke patients to a specialized service and the implementation of a standardized template card to collect clinical criteria are also proposed.