Multidisciplinary Specialist Research Articles

Adherence to published guidelines for perioperative care of the elderly: a survey of Scottish anaesthetic departments

BackgroundIn 2010, a national enquiry into elderly patient outcomes after surgery identified that only 36% received ‘good’ care. Guidance was subsequently published by the Association of Anaesthetists of Great Britain and Ireland regarding perioperative care of the elderly and those with dementia; this study aims to assess current adherence to these guidelines in anaesthetic departments across Scotland.MethodsA web-based survey was sent to all Scottish departments. The questions assessed department patient demographic, access to specialist pre-assessment services, availability of multidisciplinary input, perioperative care of patients with cognitive impairment and departmental training on geriatric perioperative care.ResultsResponses were collected from November-December 2020 with a 92.6% response rate. A total of 64% of departments stated that > 50% of their workload involved patients over 75. One department had a lead clinician for geriatric anaesthesia, whilst 20% could access a geriatric specialist when coordinating perioperative care. Specialist geriatric pre-assessment services operate in 20% of centres. A total of 60% of respondents used a clinical frailty score when pre-assessing patients over 75, with 48% specifically screening for cognitive impairment. The vast majority of centres, 76%, did not routinely provide information regarding post-operative delirium and 24% ‘never or very rarely’ invite caregivers to accompany patients with dementia into the department. Education sessions regarding perioperative elderly care had occurred in 56% of departments.ConclusionsElderly patients represent a significant proportion of anaesthetic workload in Scotland. Despite this, adherence to recommended practice is low. The vast majority of centres lack access to specialist multidisciplinary input or specialist pre-assessment services which are essential to providing good care. Reported screening for frailty and cognitive impairment is variable, with opportunities for improvement in communication and education (patient and clinician) surrounding these conditions.

MO15-5 A proposal of efficient operation of expert panel for genomic medicine by pre-review meeting (pre-EP)

Under the National Health Insurance system in Japan, the cancer genome core hospitals must hold expert panels (EP) which consist of multidisciplinary specialists to evaluate the indication of treatments and possibilities of secondary findings (SFs). After August 2021, serum-based cancer comprehensive genomic profiling test was also reimbursed by National Health Insurance system. This situation will increase the number of cases which must be evaluated by EP. However, some cases have obvious druggable genomic alterations or some cases have neither recommended treatment nor SFs.

Představení projektu Transgenerační přenos traumatu holocaustu – prevence a péče

The project focuses on connecting multidisciplinary specialists interested in research and healing of the transgenerational transmission of Holocaust trauma. A lot of untreated traumas from the collective catastrophe have been passed to the next generations. The aim is to exchange information and experience about this issue within the V4 countries and to bring new insights about healing of trauma for Jewish communities and for the specialists who work with this issue.

Elexacaftor-Tezacaftor-Ivacaftor Treatment Reduces Abdominal Symptoms in Cystic Fibrosis-Early results Obtained With the CF-Specific CFAbd-Score.

Background: The novel and highly effective CFTR modulator combination of elexacaftor-tezacaftor-ivacaftor (ETI) has been shown to improve lung function and body weight in people with Cystic Fibrosis (pwCF) carrying a F508del mutation. However, the impact of these modulators on gastrointestinal (GI) symptoms is relatively unknown. Therefore, the CFAbd-Score was developed and validated following FDA recommendations for development of a PROM including focus groups, multidisciplinary CF specialists, people with CF and their families. The aim of this study was to assess effects of ETI on GI symptoms using the CFAbd-Score. Methods: Gastrointestinal symptoms were prospectively assessed in pwCF using the CFAbd-Score before and up to 26 weeks during therapy. The CFAbd-Score was also administered to a healthy control (HC) group. The one-sided questionnaire includes 28 items grouped in five domains. Data analysis included calculation of scores with a weighting tool, developed according to FDA recommendations. Results: A total of 107 pwCF attended in four CF centres in Germany and four centres in the UK completed the CFAbd-Score on at least two occasions. Results were compared to those obtained from the questionnaire of 45 HCs. Despite differences in demographics, age and proportion of pancreatic insufficiency between German and UK patients, analyses based on linear mixed-effects models at week 24 of ETI therapy revealed that estimated marginal means (EMMs) of total CFAbd-Scores significantly reduced (mean ± SE: 14.9 ± 1.2→10.6 ± 1.4; p < 0.01). Also EMMs of all five domains significantly declined (“pain” 16.3 ± 1.6→10.2 ± 2.3, “GERD” 15.8 ± 1.8→8.2 ± 1.9, “disorders of bowel movement” 20.9 ± 1.5→16.0 ± 1.7, “disorders of appetite” 7.9 ± 1.1→2.6 ± 1.1 and “quality of life impairment” 10.1 ± 1.92→3.9 ± 1.9). However, during 24 weeks, CF participants’ symptoms mostly still did not reach the reference levels of HCs. Discussion: Using the CFAbd-Score, the first PROM specifically developed for assessment of CF-related abdominal symptoms, we demonstrate comprehensive improvements in GI symptoms after initiation of the highly effective modulator therapy ETI.

Surgical inter‐hospital transfers: life saver or resource drainer?

As to diseases, make a habit of two things – to help, or at least to do no harm. The Hippocratic Corpus1 IHTs may be necessary for multiple reasons. These include lack of appropriate resources at the index hospital, higher acuity of care requirement, or need for complex multidisciplinary specialist care to ensure adequate patient management.4, 9 The process of IHT is complicated, requiring effective dialogue between the referring and receiving teams to ensure pertinent clinical information is communicated and patient-specific needs relayed.8, 10 Each transfer requires individualized shared decision making with patient safety and medical stability foremost in mind, taking into consideration the indication for transfer, capabilities of the health-care settings, distance and mode of transportation.10 The inherent intricate nature of the transfer process highlights the importance of having a robust, repeatable and dependable system to ensure optimal patient outcomes. This need has become increasingly apparent in recent years due to the trend of increasing preoperative IHT of surgical patients.11 This is likely due to increasing specialization of urban hospitals and the increased resource demands associated with sophisticated preoperative and intraoperative care.4, 12 However, there is limited evidence on the widespread benefits of surgical IHTs. Many groups of transferred surgical patients have poorer outcomes compared to their non-transferred counterparts, including increased hospital admission length, healthcare costs and in-hospital mortality.9, 13 Transferred patients have twice the associated health-care costs and three times the in-hospital mortality compared with their non-transferred counterparts.9, 13 These poorer outcomes have been demonstrated in a range of surgical pathologies and specialties.5-9 Proposed contributing factors relate to patients (e.g. older age, lower SES), disease (e.g. life-threatening illness) and transportation (e.g. mode of transport, distance travelled).9 Postponement of surgery due to delay in transfer or increased preoperative transfer time due to remoteness of the referring hospital is a major contributor to poorer surgical outcomes.5-7 There are several proposals to address and overcome the barriers associated with effective IHTs. Utilizing an appropriate mode of transportation concordant with the distance needing to be traversed, the geography of the region, the equipment and expertise of available transfer crew, and the medical stability of the patient have been shown to improve survival.10 Developing a systematic and rigorous health information exchange and handover system between facilities improve patient outcomes by ensuring accurate and up-to-date patient clinical data and diagnosis is available.10 The presence of specialized and experienced staff during transfer has also been shown to reduce transport morbidity.4 Patients with myocardial infarction or stroke experience improved outcomes following IHTs, likely due to standardized transfer protocols and expedited interventions.9 These success stories demonstrate the potential positive consequences of effective IHTs. Particularly in the dynamic climate of COVID-19, an evidence-based approach must be utilized to improve IHTs in Australia.14 There remains a need for further investigation into factors affecting the negative trajectory of surgical patients that undergo IHTs. It is imperative that factors resulting in futile transfers are identified to ensure best patient care and that scarce regional resources are not squandered. A national surgical audit database, such as the Australian and New Zealand Audit of Surgical Mortality, captures data from all surgical mortality in Australia and may play a key role in discovering relevant avoidable factors contributing to patient mortality during IHT.15 Recent reviews of this data identified that IHTs were involved in up to 30% of cases of surgical mortality11. IHTs to provide necessary patient care is inevitable due to the unique challenges of the Australian geography, population density and health-care system. Current evidence demonstrates that IHTs are an independent risk factor for mortality in surgical presentations. Avoidable transport-associated factors have been identified, however the current rate of mortality in IHT suggest further research into attributable factors should be performed to minimize patient harm and reduce surgical mortality. IHTs have the potential to be a lifeline for the unwell surgical patient, and careful planning is imperative to ensure it is not an unintended resource drainer. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. Ishraq Murshed: Conceptualization; investigation; writing – original draft; writing – review and editing. Aashray K. Gupta: Conceptualization; investigation; writing – review and editing. Joshua G. Kovoor: Conceptualization; investigation; writing – review and editing. Guy J. Maddern: Conceptualization; investigation; supervision; writing – review and editing.

COVID-19 infection and liver damage in children. Clinical case study.

Introduction. COVID-19 is currently considered a systemic disease affecting the immune system, primarily, lungs, heart, central nervous system, kidneys, intestines, liver and spleen. Impaired liver function and the presence of biochemical changes in liver can be found in approximately 14-53% of adults infected with SARS-CoV-2. Impaired liver function in patients infected with COVID-19 may occur due to a direct effect of the virus on hepatocytes, as well as being secondary to factors such as a systemic inflammatory response of the infected host, the onset of hypoxia (associated with lung damage), multiple organ failure, or due to abusive treatment using overlapping and hepatotoxic drugs. The purpose of this article is to describe a clinical case study regarding the clinical and paraclinical manifestations of liver damage in a 12-year-old child infected with SARSCoV-2, hospitalized at the Municipal Children’s Clinical Hospital „Valentin Ignatenco”, Republic of Moldova. Material and methods. The epidemiological, clinical and paraclinical data were used to highlight this study, followed by the conclusions of multidisciplinary specialists, retrieved from the inpatient medical records of the 12-yearold child with moderate COVID-19 infection, who was admitted for emergency treatment. Results. A 12-year-old patient F. was admitted to the „Covid-19” subunit, complaining of severe general malaise, fever up to 39°C, cough, rhinorrhea. The objective clinical examination revealed hepatomegaly and lack of splenomegaly. Laboratory findings determined leukocytosis 15.88 x109 /l, neutrophilia 72.2%, lymphopenia 26.1%, increased ESR (Erythrocyte Sedimentation rate) – 20 mm/h, increased CRP (C-reactive protein) &gt;12.0 mg/l, increased ALT (alanine aminotransferase) by 16 (50.9-487-764 U/l) values compared to the normal reference and a 3-fold increase in AST (aspartate aminotransferase) that is higher than the normal range (55.8 - 113 - 181 U/l), an increased fibrinogen - 5.3 g/l, increased ferritin - 2834 pmol/l and D-dimer levels - 762 ng/ml. Hepatomegaly was detected on abdominal ultrasound. Covid-19 infection was confirmed by a rapid test of nasopharyngeal exudate for SARS-CoV-2 antigens. Conclusions. Patients with the novel coronavirus (COVID-19) show varying degrees of liver dysfunction, especially those with increased levels of AST and ALT. A question arises within the clinical practice, as whether the liver damage occurred due to direct viral hepatotoxicity or due to the drugs used in COVID-19 treatment.

Using real-world data to assess variations in cost and healthcare utilization for patients diagnosed with bladder cancer.

e18815 Background: Disparities in diagnosis, treatment, and outcomes for bladder cancer in underserved patient populations persist in the United States. High out-of-pocket costs can prevent patients from seeking or continuing treatment, which can worsen existing disparities in care. The Association of Community Cancer Centers (ACCC) conducted a claims analysis of Medicare beneficiaries diagnosed with bladder cancer to assess differences in healthcare utilization and costs and to inform future provider education initiatives. Methods: ACCC convened an expert steering committee of multidisciplinary specialists and patient advocates to guide the development of the claims analysis methodology and code sets used to identify study cohorts and model variables. Using the CMS Medicare 100% Innovator Administrative Claims Data Set, incident patients were defined as those newly diagnosed in 2018 using a 24-month lookback to confirm no prior bladder cancer diagnosis. Claims for incident patients incurred in the time-period between 24 months prior to and 24 months following diagnosis date were analyzed to generate descriptive summaries of cohorts by severity of disease at diagnosis. Classification is defined by treatment observed within 6 months of diagnosis: No treatment, Early Stage-treated (intravesical chemotherapy), and Late-stage (one or more claims of non-intravesical systemic therapy, radiation therapy, or major bladder surgery). Results: 4,356 incident patients were identified: average age 77.7, 71% male, 56% no treatment, 15% early-stage treated, 28% late-stage. Patients diagnosed at late-stage incur 128% more allowed costs (total amount paid by Medicare and patients) on all-cause healthcare in the first year after diagnosis than early-stage patients who receive treatment ($76,483 vs $33,530) and 101% higher cumulative costs two years following diagnosis ($112,178 vs $55,814). Patients diagnosed at late-stage incur 90% more out-of-pocket costs (copays, coinsurance, deductibles) in the first year following diagnosis than early-stage treated patients ($9,970 vs $5,225) and 81% higher cumulative out-of-pocket costs two years following diagnosis ($15,145 vs $8,390). For both early- and late-stage patients, the month of diagnosis is the most expensive. 53% of all costs incurred in the month of diagnosis are for cystoscopy/TURBT procedures. Elevated costs persist at levels higher than pre-diagnosis levels for at least 20 months. Among late-stage patients, treatments (surgery, radiation therapy, and systemic therapy) sum to 34% of all costs incurred in 6 months following diagnosis. Conclusions: Patients diagnosed with late-stage bladder cancer experience higher financial burden and need more resource-intensive services than those diagnosed at an earlier stage. Earlier diagnosis of bladder cancer is needed to improve patient outcomes and reduce financial burden.

Type 1 diabetes management and hospitalisation in the over 25’s at an Australian outer urban diabetes clinic

AimsTo describe clinic management and referral pathways among adults with type 1 diabetes (T1D) aged > 25 years attending a public outpatient diabetes service.MethodsRetrospective cohort study of people with T1D aged > 25 years seen by endocrinologists in one Australian urban public outpatient in 2017. Electronic and paper medical records were reviewed using a dataset adapted from the UK National Institute for Health and Care Excellence 2015 guidelines.ResultsAmong the 111 people with T1D (mean age 41 ± 13 years, 55% men, mean body mass index 27.1 ± 5.6 kg/m2), mean HbA1c was 8.1 ± 1.9% (66 ± 19 mmol/mol) (lower than the Australian National Diabetes Audit: 8.5%/69 mmol/mol) with 25.5% meeting the guideline target of < 53 mmol/mol (7.0%). Most people had seen a diabetes educator (80.2%) or dietitian (73.0%) and had complication screening. Complication rates were high (nephropathy 20.4%, retinopathy 27.4%, peripheral neuropathy 30.1%, ischaemic heart disease/acute infarction 10.5%). Overall, 27% of referrals occurred following an acute inpatient admission or emergency department presentation and 13% for management of diabetes in pregnancy.ConclusionsA high proportion of people with T1D accessed public specialist care either during pregnancy or after a largely avoidable acute glycaemia-related hospital presentation. Subsequent care was in line with national specialist standards. This area has a “wait for acute event” rather than “complication prevention” model of care, associated with under-referral to the local multidisciplinary specialist service. Understanding how widespread this model of care is, and ways to reduce its prevalence, are urgently required.

Diagnosis and treatment of systemic mastocytosis in Brazil: Recommendations of a multidisciplinary expert panel

Introduction: Systemic Mastocytosis comprises a group of neoplastic diseases characterized by clonal expansion and infiltration of mast cells into several organs. The diagnosis and treatment of this disease may be challenging for non-specialists. Objective: Make suggestions or recommendations in Systemic Mastocytosis based in a panel of Brazilian specialists.Method and results: An online expert panel with 18 multidisciplinary specialists was convened to propose recommendations on the diagnosis and treatment of Systemic Mastocytosis in Brazil. Recommendations were based on discussions of topics and multiple-choice questions and were graded using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence Chart.Conclusion: Twenty-two recommendations or suggestions were proposed based on a literature review and graded according to the findings.

Experiences of Families Caring for Children with Newborn Screening-Related Conditions: Implications for the Expansion of Genomics in Population-Based Neonatal Public Health Programs.

With the expansion of newborn screening conditions globally and the increased use of genomic technologies for early detection, there is a need for ethically nuanced policies to guide the future integration of ever-more comprehensive genomics into population-based newborn screening programs. In the current paper, we consider the lived experiences of 169 family caregivers caring for 77 children with NBS-related conditions to identify lessons learned that can inform policy and practice related to population-based newborn screening using genomic technologies. Based on caregiver narratives obtained through in-depth interviews, we identify themes characterizing these families’ diagnostic odyssey continuum, which fall within two domains: (1) medical management implications of a child diagnosed with an NBS-related condition and (2) psychological implications of a child diagnosed with an NBS-related condition. For Domain 1, family caregivers’ experiences point to the need for educational resources for both health care professionals that serve children with NBS-related conditions and their families; empowerment programs for family caregivers; training for providers in patient-centered communication; and access to multi-disciplinary specialists. For Domain 2, caregivers’ experiences suggest a need for access to continuous, long-term counseling resources; patient navigator resources; and peer support programs. These lessons learned can inform policy recommendations for the benefit of the child, the family, the healthcare system, and society.

Features of Gastrointestinal Malformations in Children with Autism Spectrum Disorders: Literature Review

Autism spectrum disorders (ASDs) are common neurodevelopmental disorders characterized by heterogeneity and high variability in severity of mental, neurological, and somatic symptoms. Such gastrointestinal malformations as abdominal pain, constipation, diarrhea, gastroesophageal reflux, nutritional disorders, intestinal microbiota disorders are common in autistic children. The association between the severity of gastrointestinal malformations and the severity of behavioral symptoms in ASDs was revealed. Early diagnosis and assessment of gastrointestinal malformations in ASDs is crucial for their further correction to optimize nutrition, to develop individual complex treatment and management with the involvement of multidisciplinary specialists.

Developing a Virtual Equity Hub: Adapting the Tumor Board Model for Equity in Cancer Care.

We define cancer equity as all people having as the same opportunity for cancer prevention, treatment, and survivorship care. However, marginalized populations continue to experience avoidable and unjust disparities in cancer care, access to clinical trials, and cancer survival. Racial and ethnic minorities, and individuals with low socioeconomic status, Medicaid insurance, limited health literacy, disabilities, and mental health disorders are more likely to experience delays to cancer diagnosis and less likely to receive guideline-concordant cancer care. These disparities are impacted by the social determinants of health including structural discrimination, racism, poverty, and inequities in access to healthcare and clinical trials. There is an urgent need to develop and adapt evidence-based interventions in collaboration with community partners that have potential to address the social determinants of health and build capacity for cancer care for underserved populations. We established the Virtual Equity Hub by developing a collaborative network connecting a comprehensive cancer center, academic safety net hospital, and community health centers and affiliates. The Virtual Equity Hub utilizes a virtual tumor board, an evidence-based approach that increases access to multi-specialty cancer care and oncology subspecialty expertise. We adapted the tumor board model by engaging person-centered teams of multi-disciplinary specialists across health systems, addressing the social determinants of health, and applying community-based research principles with a focus on populations with poor cancer survival. The virtual tumor board included monthly videoconferences, case discussion, sharing of expertise, and a focus on addressing barriers to care and trial participation. Specifically, we piloted virtual tumor boards for breast oncology, neuro-oncology, and individuals with cancer and serious mental illness. The Virtual Equity Hub demonstrated promise at building capacity for clinicians to care for patients with complex needs and addressing barriers to care. Research is needed to measure the impact, reach, and sustainability of virtual equity models for patients with cancer.

Primary lymphomas of the central nervous system. Questions of epidemiology and treatment. Clinical example of multidisciplinary approach in therapy

Background. Currently, the frequency of occurrence of neoplasms is emerging in the world. Under conditions of a general tumor, brain tumors are rare (0.7–1.5 %). However, high mortality, disability, limited life expectancy of patients, high economic and social inferiority, raise concerns about the medical organization of care, development and social adaptation. Of particular importance among the causes of primary brain tumors is the congenital or acquired growth of immunodeficiency. The growth in the number of drug addicts led to the elimination of the annual epidemic at the end of the 70s and the increase in the number of patients with immunodeficiency syndrome (AIDS), due to which the growth of a brain tumor began to develop in this population group. The number of Russian patients with lymphoma is also steadily increasing.Objective. Consider an illustrative clinical case that reflects the expected continuity in patients with ordinary CNS lymphoma.Design and methods. A 50-year-old patient with moderate memory loss was examined using various methods: MRI, PET-CT and etc.Results. Based on histological and immunohistochemical studies, diffuse large B-cell lymphoma of the CNS was diagnosed. There was a positive trend in the reduction of tumor size after radiation therapy.Conclusion. Primary CNS lymphoma is becoming an active epidemiological problem of society, requiring comprehensive multidisciplinary monitoring. Only high vigilance in terms of lymphoma and well-coordinated work of multidisciplinary specialists can help to perform the correct diagnostics and patient management.

Pearls from the First Gulf Cardiac Amyloidosis Summit 2021

Abstract: These proceedings from the First Gulf Cardiac Amyloidosis Summit held in June 2021 aimed to increase awareness of cardiac amyloidosis among the wider medical community in the region. Although the clinical presentation of cardiac amyloidosis is highly variable, a number of ‘red flags’ have been identified to raise suspicion of the disease and prompt further investigation. Accurate diagnosis of cardiac amyloidosis is challenging and relies on the integration of clinical, imaging and laboratory investigations. Recent imaging techniques, including bone scintigraphy together with a complete serum and urine workup, allow, in the majority of patients, accurate non-invasive diagnosis without the need for confirmatory endomyocardial biopsies. Early differential diagnosis between light-chain (AL) amyloidosis and amyloid transthyretin amyloidosis (ATTR) is critical for timely delivery of appropriate therapy. AL amyloidosis is a medical emergency requiring chemotherapy and supportive care. Treatment for ATTR-amyloidosis is most effective when administered early, before development of significant symptoms or cardiac dysfunction. Optimal management of patients involves close collaboration between multidisciplinary specialists, which may include hematologists, cardiologists, and other subspecialists, ideally at a designated specialty center with interest and expertise in amyloidosis.

Enhancing the management of long COVID in general practice: a scoping review.

Long COVID is a multifaceted condition, and it has impacted a considerable proportion of those with acute COVID-19. Affected patients often have complex care needs requiring holistic and multidisciplinary care, the kind routinely provided in general practice. However, there is limited evidence regarding GP interventions. This study aimed to identify key concepts and knowledge gaps around long COVID by conducting a scoping review of literature on the condition's management by GPs. Arksey and O'Malley's six-stage scoping review framework, with recommendations by Levac et al, was used. PubMed, Google Scholar, the Cochrane Library, Scopus, and Google searches were conducted to identify relevant peer reviewed and grey literature, and study selection process was conducted according to the PRISMA Extension for Scoping Reviews guidelines. Braun and Clarke's 'Thematic Analysis' approach was used to interpret data. Nineteen of 972 identified articles were selected for review. These included peer reviewed articles and grey literature spanning a wide range of countries. Six themes were identified regarding GP management of long COVID, these being: (1) GP uncertainty, (2) listening and empathy, (3) assessment and monitoring of symptoms, (4) coordinating access to appropriate services, (5) facilitating provision of continual and integrated multidisciplinary care and (6) need to provide or facilitate psychological support. The findings show that GPs can play and have played a key role in the management of long COVID, and that patient care can be improved through better understanding of patient experiences, standardised approaches for symptom identification and treatment, and facilitation of access to multidisciplinary specialist services when needed. Future research evaluating focused GP interventions is needed.

Positive Microbiological Cultures in the Respiratory Tract of High Model for End-Stage Liver Disease (MELD) Liver Transplant Recipients With and Without Pneumonia

Pneumonia in liver transplant recipients is one of the most common infections in the early phase after transplantation. The diagnosis is based on clinical signs combined with positive microbiological samples taken from the lower respiratory tract. However, the role of bacterial colonization is not clear, nor is its association with pneumonia or its long-term consequences. The aim of this study was to investigate the association between positive microbiological findings and clinically relevant pneumonia and analyze different clinical and laboratory parameters for their association with pneumonia in liver transplant recipients. This was a retrospective analysis of 266 adult orthotopic liver transplantations between January 2008 and December 2013. A multidisciplinary in-house specialist panel established and confirmed the diagnosis of clinically relevant pneumonia in microbiologically positive patients. Of the 266 transplantations analyzed, 54 patients (20%) showed microbiologically positive trachea-bronchial cultures during the first 21 days after liver transplantation. Of those 54 patients, 24 (44.4%) had pneumonia as rated by the multidisciplinary specialist panel. Presence of gram-negative Enterobacteriaceae (P=.013) and positive chest radiologic findings (P=.035) were associated with pneumonia in microbiological-positive patients. Although patients with pneumonia had the lowest long-term survival, those without pneumonia but with positive microbiological cultures had still worse survival compared with the Model for End-Stage Liver Disease-matched control group without positive cultures (P=.012). Gram-negative Enterobacteriaceae and positive radiologic findings were associated with pneumonia in liver transplant recipients with positive microbiological trachea-bronchial cultures. Recipients with bacterial colonization without pneumonia also showed decreased long-term survival.

Re-evaluating paraganglioma surgery – towards optimising patient care

Abstract Background Phaeochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumours of chromaffin cells that secrete catecholamines. The understanding of their aetiology and management is evolving. This study aimed to examine aspects in the management of PCC and PGL over the last decade. Methods Patients undergoing surgery for PCC/PGL over an eleven-year period were studied using a prospectively maintained database and electronic hospital clinical portal. Appropriate statistics were then employed. Results Sixty-nine patients underwent surgery (35 female, median age 52 years (12–82) to treat 57 PCC (inc. 2 bilateral) and 14 PGLs (inc. 2 recurrences). Although PCC and PGL patients were matched for gender and tumour-size, those with PGL were younger (median 40 (12–75) versus 54 (23–82), p = 0.044). PGL patients were also more likely to have a genetic abnormality identified (58.3% versus 16.1%, p = 0.002) and to have a malignant tumour (38.5% vs 6.8%, p = 0.002). Peri-operative blockade regimes were similar, but PGLs more frequently had an open procedure (42.9% vs 5.3% p&amp;lt;0.001). However, when laparoscopic surgery was undertaken, the conversion rate was not significantly different (PGL: 7.1%, PCC 5.2% p = 0.785). Distant and local recurrences were more common in the paraganglioma group (PGL: 25.0%, PCC 1.8%, p=0.002). Conclusions PGLs represent an even rarer subset of an already rare tumour-type. Access to multi-disciplinary specialists and appropriate decision-making are critical. High incidence of inherited disease, increased malignancy and recurrence rates along with the increased operative complexity favour greater use of open surgery and specialised follow-up to ascertain recurrence, as well as access to high quality genetic counselling services.

Precision Medicine in Adult Obstructive Sleep Apnea and Home Diagnostic Testing: Caution in Interpretation of Home Studies Without Clinician Input Is Necessary

PurposeTo assess the validity of home sleep apnea test directed diagnosis and treatment of obstructive sleep apnea (OSA) in a real-life clinical setting and establish the extent to which clinical evaluation alters diagnosis and therapeutic intervention, in the context of the evolving realm of precision medicine.MethodsRetrospective consecutive cohort study of 505 patients referred to a single center between 15th September 2015 to 14th September 2016, multidisciplinary specialist sleep clinic presenting with a home sleep apnea test prior to referral. We evaluated the effect of sleep medicine practitioner (SMP) and ear, nose, and throat surgeon (ENTS) review on patient diagnoses, disease severity, and management options in OSA.ResultsHundred and fifteen patients were included. Repeat evaluation with in-lab polysomnogram (PSG) was required in 46/115 (40.0%) of patients, of which 20/46 (43.5%) had OSA severity changed. Sleep medicine practitioner review decreased the need for repeat testing with formal in-lab PSG (p < 0.05) and increased patient acceptance of continuous positive airway pressure (CPAP) as a long-term management option for OSA. Sleep medicine practitioner/ENTS review resulted in discovery of a non-OSA related sleep disorder or change in OSA severity in 47.8% (55/115). Ear, nose, and throat surgeon review resulted in additional or changed diagnosis in 75.7% (87/115) of patients.ConclusionIn the clinical assessment and diagnosis of OSA, patients should be reviewed by medical practitioners with an interest in sleep disorders to better navigate the complexities of assessment, as well as the identification of co-morbid conditions.

Conceptualising effective symptom management in palliative care: a novel model derived from qualitative data

BackgroundPain, breathlessness and fatigue are some of the most challenging symptoms to manage in patients with advanced disease. Specialist palliative care leads to better symptom management, but factors contributing to successful symptom management in this context have not been explored. Our aim was to understand what facilitates effective symptom management in specialist palliative care within UK hospices and investigate what barriers are experienced.MethodsThis was a grounded theory study using qualitative semi-structured focus groups and interviews. Participants were recruited from multidisciplinary specialist palliative care teams (doctors, nurses, healthcare assistants, physiotherapists, occupational therapists, complementary therapists, social workers and chaplains) working in inpatient, outpatient and community services provided by five hospices in the United Kingdom.ResultsWe present a novel qualitative data-derived model of effective symptom management in specialist palliative care. We describe a co-ordinated, multi-faceted, sequential approach involving a process of engagement, partnership, decision-making, and delivery. Interventions to manage symptoms are less effective in psychologically distressed patients. Our data highlights that families of patients have a key role in determining effectiveness of symptom management interventions A holistic approach by a co-ordinated, multi-disciplinary team, including support to recognise and minimise psychological distress might facilitate more effective symptom management. Barriers to symptom management include team discordance and lack of understanding about symptom management by patient and families.ConclusionsShared decision-making between patients and professionals and co-ordination of care by a multi-disciplinary team are key components of effective symptom management. Actions to address psychological distress and evaluate the understanding and expectations of patients and their families would enable more effective symptom management. A more effective multi-disciplinary approach would be facilitated by discussion within teams about role competencies and boundaries.

Long-Term Outpatient Care and Rehospitalizations in Patients after Cardiac Electrotherapy Device Implantation.

Background and Objectives: Cardiovascular implantable electronic device (CIED) treatment is widely used in modern cardiology. Indications for this type of treatment are increasing. However, a significant proportion of CIED implantation patients require subsequent hospitalization for cardiovascular reasons. Older age and the associated complex clinical picture necessitate multidisciplinary outpatient specialist care for these patients. The aim of this study was to analyze the reasons for subsequent hospitalizations in the cardiology department and the impact of outpatient specialty care on these hospitalizations. To the best of our knowledge, there are no such studies in the available literature. Materials and Methods: This study was conducted on a population of patients treated with CIED. Reasons for subsequent hospitalizations were divided into clinically and statistically valid groups according to the main diagnosis. Using an electronic database, causes of hospitalization were determined based on this diagnosis. Using data on consultations at outpatient specialty clinics, a logistic regression model was created for the probability of subsequent hospitalization for cardiovascular causes according to the specialty of the clinic. Results: The 9-year follow-up included a population of 2071 patients treated with CIED. During the follow-up period, 508 patients (approximately 24.5%) required subsequent hospitalization for cardiovascular reasons. The most common leading causes were heart failure, atrial fibrillation, and coronary artery disease. The need for consultation at outpatient specialty clinics increased the likelihood of hospitalization. Moreover, the need to consult patients in nephrology outpatient, pulmonary disease outpatient, and orthopedic outpatient clinics was the most significant. Conclusions: The use of electronic implantable cardiovascular devices is a very important part of therapy in modern cardiology. The methods for their use are constantly being improved. However, they represent only one stage of cardiac treatment. After CIED procedures, patients require further care in both inpatient and outpatient specialty care settings. In this paper, we outline the reasons for subsequent hospitalizations and the importance of outpatient specialty care in this context. Effective organization of care after CIED procedures may be important in reducing the most expensive component of this care, that is, inpatient treatment.