Management Pathway Research Articles

Assessing the impact of a dedicated referral and management algorithm in maternal hypothyroidism.

The significant risks of hypothyroidism during pregnancy can be mitigated through timely diagnosis and initiation of thyroxine to achieve a maternal euthyroid state. This study aimed to evaluate the efficiency of hospital endocrine services by assessing the rate of thyroxine commencement before the initial clinic appointment, the median gestational age at the first consultation, the rate of guideline-appropriate investigations, perinatal outcomes, and the proportion of referred patients who achieved their target thyroid-stimulating hormone (TSH) levels before and after implementing a dedicated referral and management pathway. A retrospective clinical audit was conducted using electronic medical records for the first fifty consecutive patients with hypothyroidism referred to the hospital clinic during two-time intervals: from April 1 to September 1, 2020 (pre-intervention) and from April 1 to September 1, 2021 (postintervention). Following the pathway implementation, there was no significant difference in the proportion of women with initially raised TSH who were prescribed thyroxine prior to the first clinic appointment (P=0.83). However, the first TSH measurement occurred earlier (median 5.5 vs. 6.5 weeks, P=0.011), and specialist reviews were conducted sooner (median 19 vs. 22 weeks, P=0.032). Significantly more women with elevated TSH underwent thyroid autoantibody testing postintervention (78% vs. 55.5%, P=0.035). There was no significant difference in perinatal outcomes. All women achieved their target TSH levels, with a median final TSH of 1.6 mIU/L (IQR: 1.2 to 2.3). While the proportion of referred patients achieving target TSH levels during pregnancy remained unchanged, certain measures of service efficiency improved. These included earlier TSH measurement, earlier endocrinologist review, and increased detection of thyroid autoantibodies.

Can a chest pain virtual ward be used to safely manage patients with low-risk acute coronary syndrome?

Abstract Background Acute coronary syndrome (ACS) accounts for approximately 2-6% of emergency department (ED) presentations and contributes at least 20% of the overall acute hospital admissions(1-3). Patients presenting with low-risk ACS may be suitable for remote monitoring(4) while awaiting angiogram in chest pain virtual ward(CPVW) thereby improving patient flow and resource utilisation. Purpose We aimed to assess outcomes for patients with low-risk ACS admitted in a district general hospital with a view to establish an onboarding pathway for CPVW whilst ensuring a safe monitoring without effecting the readmission rate or all-cause mortality. Methods We retrospectively analysed the Myocardial Ischaemia National Audit Project (MINAP) registry of from March 2022 to April 2023 for patients who presented to ED with a diagnosis of confirmed ACS. Patients were stratified into low-risk (GRACE score <140, HEART score <4, non-dynamic ECG, non-dynamic troponin, without ongoing chest pain), all other patients were deemed intermediate-to-high-risk ACS. Baseline demographics, the total length of acute admission days, waiting time before and after coronary investigation ,adverse events (escalation of therapy, death)whilst awaiting for invasive inpatient angiogram were calculated. The primary endpoint was 30-day readmission and all-cause mortality. Results 1077 patients were coded as ACS diagnosis in ED. 561(52.1%) had a confirmed diagnosis of ACS. Data to allow stratification was available for 538 patients, included in final analysis. 377(70.1%) were male with a mean age of 66.8 ± SD 13.1 years. A significant number of patients had other comorbidities, including hypertension (66.1%), diabetes (45.3%), hyperlipidaemia (51.3%), and previous history of IHD (46.5%). Total number of patients stratified into low-risk ACS was 55(10.2%), intermediate-to-high-risk group contained 483(89.8%) patients. The median total-length-of-stay (LOS) for low-risk ACS patients was 4 days(IQR 2-7), waiting time to have an inpatient angiogram was 3 days(IQR 0-5), and discharge time post-angiogram was 1 day(IQR 0-2). 4 patients(7.3%) in low-risk cohort required CCU admission for GTN infusion due to ongoing chest pain, among them 3 patients(5.5%) had abnormal coronary angiogram. 5 patients(9.1%) in low-risk cohort were readmitted due to chest pain post-angiogram and no patients had 30-days or 1-year all-cause mortality. The result depicts 51 patients from low-risk cohort would have been eligible for CPVW reducing the LOS from median 4 days to 1-2 days, this is a saving of 102-153 acute bed days per year. Assuming the costing of a bed day is £320 this equates to £32,640 - £48,960 cost saving without any adverse outcomes. Conclusion Our data suggests that there is a large cost saving with minimal risk in managing patients with low-risk ACS via a CPVW. This pathway of management is likely to have benefit in patient flow and resource utilisation in our district general hospital trust.Comparison of different ACS cohortsCPVW flow-diagram

Multidisciplinary management of gastroesophageal reflux disease: an italian retrospective study

Abstract Background Millions of individuals are affected by gastroesophageal reflux disease (GERD) that causes significant discomfort negatively affecting patients’ overall quality of life. For a collaborative approach of continuous improvement in public health we wanted to know the real-world perspectives in the multidisciplinary and multimodal management pathway. Methods We aimed to interview a sample of gastroenterologists (GE), primary care physicians (GP), and otolaryngologists (ENT) to investigate the management of the intake and treatment of patients reporting symptoms of GERD. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life was explored with the GERD Impact Scale (GSI) and Reflux Symptom Index (RSI). Results A total of 6211 patients were analyzed of whom with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p < 0.0001). GSI was highest in patients followed by GE (9 points) and GP (9 points) than ENT specialists (8 points), while the RSI was higher in the ENT group (14.3 ± 6.93) than in the groups of GP and GE, respectively (10.36 ± 6.36 and 10.81 ± 7.30, p < 0.0001). Chest pain had the greatest negative impact on quality of life (p < 0.0001). Of the 3,025 patients who used (proton pump inhibitors) PPIs, non-responders had a lower GSI when treated with a combination of adjunctive drug treatments and bioadhesive compounds, compared with single-component drugs. Conclusions The multidisciplinary and multimodal approach to the management pathway of GERD patients reveals variations in patient profiles by physician specialty, directing toward more appropriate and targeted treatments. In addition, the combination of adjunctive drug treatments and bioadhesive compounds appears to be effective in the management of patients refractory to PPIs. Key messages • The presentation of GERD symptoms is different in accordance with the physician’s speciality: the patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. • The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

Topical delivery of baricitinib-impregnated nanoemulgel: a promising platform for inhibition of JAK -STAT pathway for the effective management of atopic dermatitis.

Baricitinib, an inhibitor of Janus kinase 1/2 receptors majorly involved in the dysregulation of immune responses in atopic dermatitis, is currently approved for managing atopic dermatitis in Europe. The delivery of baricitinib through oral route is associated to several adverse effects due to off-target effects. Therefore, the current study is aimed at formulation of baricitinib loaded nanoemulgel for evaluation of topical delivery potential in the treatment of atopic dermatitis. The baricitinib-loaded nanoemulsions (0.05 and 0.1% w/w) revealed an average globule size of 162.86 ± 0.37 and 173.66 ± 4.88nm respectively with narrow PDI. The optimized batch of baricitinib nanoemulsion was converted to nanoemulgel by the addition of the mixture of gel bases SEPINEO™ DERM and SEPINEO™ P 600 along with propylene glycol, resulting in pseudoplastic shear thinning behaviour. The optimized nanoemulgels have shown prominent retention of baricitinib in the skin along with permeation. The skin distribution study of coumarin-6 loaded nanoemulgel demonstrated high fluorescence in the epidermal layer. The western blot analysis revealed significant inhibition of phosphorylated signal transducers and activators of transcriptions 1 (##p < 0.01) and 3 (#p < 0.05) by application of 0.05 and 0.1% baricitinib nanoemulgel. The baricitinib nanoemulgels have shown anti-inflammatory activity by significantly reducing expressions of various inflammatory markers. Histopathological analysis of skin tissues treated with baricitinib nanoemulgel has demonstrated a marked reduction in acanthosis, hyperkeratosis, and intact outer epidermis. These results supported the potential role of baricitinib-loaded nanoemulgel in reducing the inflammation and disease severity associated with atopic dermatitis.

The identification, referral and management of patients with cardiac-related distress: a new model to support psychological recovery after a cardiac event

Abstract Background Identification, referral and management of patients with psychological distress is an important component of cardiac rehabilitation (CR). We developed a protocol to identify patients in hospital, CR and primary care settings, and refer them to a specialist psychocardiology clinic. Using the newly developed Cardiac Distress Inventory (CDI), we demonstrated that counselling resulted in reduced rates of cardiac-related distress. This study demonstrates the importance of having a clear pathway from screening to referral to intervention to support cardiac patients in their recovery. Purpose The team identified a dearth of high-quality research on distress in cardiac patients, including a lack of data on the resolution of cardiac-related distress after psychotherapeutic intervention. This was due to the lack of appropriate measurement of cardiac distress, and the absence of clear pathways for identification, referral and management of cardiac distress. Methods The Cardiac Emotions Study is a multi-site, multi-component study of cardiac-related distress. The team first developed the 55-item Cardiac Distress Inventory (CDI), a comprehensive clinical assessment tool. A brief screening version, the 12-item Cardiac Distress Inventory Short Form (CDI-SF), was then developed. Patients referred to the specialist psychocardiology clinic over a 6-month period (N=113) were administered the CDI-SF, together with the Generalised Anxiety Disorder 7 (GAD7) and the Patient Health Questionnaire (PHQ9), with all measures re-administered at discharge. Results More than half the clients presented to the Clinic within the first 3 months post-event (58%), while 84% presented within the first year. At presentation, over half the clients were anxious (GAD7&amp;gt;10; 53%), depressed (PHQ9&amp;gt;10; 57%), or distressed (CDI-SF&amp;gt;13; 56.4%). Levels of particular aspects of cardiac distress are shown in the Figure. On completion of counselling, distress had resolved for the majority of clients, with the distress rate of 18.6% at discharge equivalent to that seen in a normative sample of cardiac patients. Rates of anxiety and depression also significantly decreased after counselling. Conclusion This study demonstrated that distressed cardiac patients could be appropriately identified in settings such as hospital, CR and primary care and referred for counselling, and that counselling resulted in significant reductions in rates of cardiac distress, anxiety and depression. Undergoing counselling through a specialist psychocardiology clinic assisted clients in obtaining normative rates of post-cardiac event distress. The analysis showed the necessity of having a clear clinical pathway from screening to psychological treatment, and the utility of having a validated measure of cardiac distress that is sensitive to change after intervention.

Real-world evaluation of a lipid transformation project in primary care settings

Abstract Background The National Health Service England Long-Term Plan (2019) highlights the need to optimise lipid management to reduce cardiovascular disease (CVD) risk. A collaborative project was funded between a local health service and an industry partner to review current practice and improve outcomes in a UK region through introduction of lipid management pathways, primary care education and patient-focused reviews to optimise lipid-lowering therapies among high-risk patient groups. Purpose The project aimed to increase prescribing of CVD risk reduction therapies such as high-intensity statins (HIST), escalation of therapy to achieve lipid-lowering treatment targets, to improve clinician knowledge and confidence in lipid management and provide benefits for local populations in reducing CVD risk. Methods Systematic patient searches across six Primary Care Networks (PCNs) prioritised high-risk patients for review. Community of Practice sessions were held to facilitate shared learning and problem-solving. A pragmatic, real-world evaluation was conducted to explore the impact of the new pathways and tools on prescribing outcomes and optimisation of lipid-lowering therapies. To examine the changes in HIST prescriptions, a statistical analysis of open-source prescribing data was undertaken between baseline (December 2021) and follow-up (December 2022) on over 39,000 eligible patient records. Qualitative interviews with clinicians from all participating PCNs and a thematic analysis of emerging themes was conducted in 2023. Results A paired sample t-test demonstrated a significant increase in the percentage of HIST prescribed, of the total number of statins prescribed, across the six PCNs between baseline and follow-up t(5) = -3.38, p = 0.01. Table 1 illustrates the changes at individual PCN level. Four of the six PCNs reached the National Institute for Health and Care Excellence minimum threshold of 65% target for HIST prescribing in statin prescriptions and three of these PCNs exceeded the optimal target of 75% HIST. An additional 600 patients were prescribed Ezetimibe (as therapy escalation or for statin intolerance). Through qualitative data, clinicians reported development of new skills and knowledge, leading to increased confidence in optimising lipid management with medication and lifestyle interventions. Conclusion The lipid transformation project demonstrated significant improvements in prescribing of lipid-lowering therapies and improved clinician competence in lipid management pathways and guidance. This has enabled sustainable improvements in lipid management and cardiovascular disease reduction in local populations.

Sonographic anatomy of surgically acquired abdominal pseudohernia—A guide to the documentation of anterolateral integument denervation with ultrasound

AbstractIncisional hernia is a common clinical diagnosis when a patient presents with a post‐surgical abdominal wall bulge. Herniation is a complication that can result from a disruption to the anterior abdominal wall, however other differentials need to be considered to account for a localized prominence of the abdominal integument. One such differential is a pseudohernia; a bulging of an intact abdominal integument without protrusion of abdominal contents. This can occur as a direct consequence of operative trauma and subsequent denervation injury to abdominal wall musculature. Although surgical techniques have been refined to reduce the potential of segmental neuropathy, atrophy of the abdominal wall can be a long term sequalae that clinically mimics that of a hernia. Such an outcome can result from surgical approaches with a particular location and orientation leaving little option to avoid damage to nerves inherent to the area. Damage to these nerves can not only result in abdominal wall laxity but also to the development of further complications that can affect a patient's quality of life. The aim of this article is to increase sonographer awareness of postsurgical pseudohernia of the anterolateral abdominal wall as a differential to incisional hernia, and as such provide guidance on how to demonstrate this anomaly. Considering that pseudohernia and incisional hernia have differing management techniques, the sonographer can play a pivotal role in influencing patient management, negating the need for surgical hernia repair and advocate for a conservative management pathway.

Chinese Expert Consensus on the Whole-Course Management of Hepatocellular Carcinoma (2023 Edition)

Background: Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. Most HCC patients have the complication of chronic liver disease and need overall consideration and whole-course management, including diagnosis, treatment and follow-up. To develop a reasonable, long-term, and complete management plan, multiple factors need to be considered, including the patient's general condition, basic liver diseases, tumor stage, tumor biological characteristics, treatment requirements and economic cost. Summary: To better guide the whole-course management of HCC patients, the Chinese Association of Liver Cancer and the Chinese Medical Doctor Association has gathered multidisciplinary experts and scholars in relevant fields to formulate the “Chinese Expert Consensus on The Whole-Course Management of Hepatocellular Carcinoma (2023).” Key Messages: This expert consensus, based on the current clinical evidence and experience, proposes surgical and nonsurgical HCC management pathways and involves 18 recommendations, including perioperative treatment, systematic treatment combined with local treatment, conversion treatment, special population management, symptomatic support treatment, and follow-up management.

Comparison of clinical presentation and management of children and adolescents with ARFID between paediatrics and child and adolescent psychiatry: a prospective surveillance study

ObjectiveTo compare the clinical presentations, management and outcomes of avoidant/restrictive food intake disorder (ARFID) across paediatric and child and adolescent (C&A) psychiatric settings.Study designProspective surveillance study.MethodsData were collected during a...

Preparing for responsive management versus preparing for renal dialysis in multimorbid older people with advanced chronic kidney disease (Prepare for Kidney Care): Study protocol for a randomised controlled trial.

BackgroundChronic kidney disease (CKD) prevalence is steadily increasing, in part due to increased multimorbidity in our aging global population. When progression to kidney failure cannot be avoided, people need unbiased information to inform decisions about whether to start dialysis, if or when indicated, or continue with holistic person-centred care without dialysis (conservative kidney management). Comparisons suggest that while there may be some survival benefit from dialysis over conservative kidney management, in people aged 80 years and over, or with multiple health problems or frailty, this may be at the expense of quality of life, hospitalisations, symptom burden and preferred place of death. Prepare for Kidney Care aims to compare preparation for a renal dialysis pathway with preparation for a conservative kidney management pathway, in relation to quantity and quality of life in multimorbid, frail, older people with advanced CKD.MethodsThis is a two-arm, superiority, parallel group, non-blinded, individual-level, multi-centre, pragmatic trial, set in United Kingdom National Health Service (NHS) kidney units. Patients with advanced CKD (estimated glomerular filtration rate < 15 mL/min/1.73 m2, not due to acute kidney injury) who are (a) 80 years of age and over regardless of frailty or multimorbidity, or (b) 65–79 years of age if they are frail or multimorbid, are randomised 1:1 to ‘prepare for responsive management’, a protocolised form of conservative kidney management, or ‘prepare for renal dialysis’. An integrated QuinteT Recruitment Intervention is included. The primary outcome is mean total number of quality-adjusted life years during an average follow-up of 3 years. The primary analysis is a modified intention-to-treat including all participants contributing at least one quality of life measurement. Secondary outcomes include survival, patient-reported outcomes, physical functioning, relative/carer reported outcomes and qualitative assessments of treatment arm acceptability. Cost-effectiveness is estimated from (i) NHS and personal social services and (ii) societal perspectives.DiscussionThis randomised study is designed to provide high-quality evidence for frail, multimorbid, older patients with advanced CKD choosing between preparing for dialysis or conservative kidney management, and healthcare professionals and policy makers planning the related services.Trial registrationISRCTN, ISRCTN17133653 (https://doi.org/10.1186/ISRCTN17133653). Registered 31 May 2017.

Co-creation of a step-by-step guide for specifying the test-management pathway to formulate focused guideline questions about healthcare related tests

BackgroundGuideline development on testing is known to be difficult for guideline developers. It requires consideration of various aspects, such as accuracy, purpose of testing, and consequences on management and people-important outcomes. This can be outlined in a test-management pathway. We aimed to create and user-test a step-by-step guide for guideline developers for designing a test-management pathway.MethodsDevelopmental design with a co-creative strategy. We created a draft step-by-step guide, that was user tested in a workshop with 19 experts, and by interviewing 7 guideline panel members.ResultsOur proposed guide consists of five blocks of signalling questions: patients/population, index test(s), current practice/comparison/control, people-important outcomes, and the link between testing and outcome(s). The user testing led to refinement of the signalling questions, the use of inclusive terminology, and addition of a test-management pathway figure with detailed explanation.ConclusionsThe step-by-step guide for formulating focused guideline questions regarding healthcare related testing can help in identifying relevant characteristics of the population, tests, and outcomes and to create a test management pathway. This should facilitate the formulation of evidence-based guideline recommendations about healthcare related testing.

ANTERIOR CRUCIATE LIGAMENT RUPTURE DISGUISED AS PATELLAR INSTABILITY: A COMMON MISS

Patellar dislocation is a common presentation with a clear management pathway. Sometimes, however, what a patient experiences as the patella dislocating may, in fact, be ACL insufficiency.We reviewed case notes and imaging of 315 consecutive ACL reconstructions, collecting data on the date and mechanism of injury, time to MRI, and reconstruction. We noted cases initially diagnosed as patellar dislocation.25 of 315 (7.9%) patients were initially diagnosed with a patellar dislocation. Subsequently, however, MRI scans revealed no evidence of patellar dislocation and instead showed ACL rupture with pathognomonic pivot-shift bony oedema. The false patella dislocation group were 32% female and had an average age of 25; the rest of the group average age was 27.1 and there were a lower proportion of females; 21%. The false patella instability patients had a median waiting time of 412 days from injury to operation (range: 70-2445 days), compared to 392 days (range: 9 – 4212 days) for rest of the patients. 5 of the remaining 290 had MRIs showing patella oedema with medial patello-femoral ligament injury in addition to their ACL rupture.From our literature search this is a new finding which shows that ACL rupture can present with symptoms suggestive of patellar dislocation. These findings raise the risk that there are a group of people who have been diagnosed with patellar instability who instead have ACL insufficiency and so are at risk of meniscal and chondral damage. Further research should analyse those diagnosed with patellar instability to quantify missed ACL injuries.

Resource Utilization of Rare-Earth-Rich Biomass and Ammonia Nitrogen Effluent from Mining

The post-treatment of heavy metal-enriched plants in mining areas and the purification of ammonia and nitrogen pollution in water bodies are significant for the ecological environment of ionic rare earth mining areas. Herein, we focused on the biochar production potential of Dicranopteris pedata, characterizing biochar prepared by an oxidative modification process and an iron modification process. We conducted adsorption experiments to comparatively investigate the adsorption performance of biochar on NH4+ and studied the fertilizer application and migration toxicity of the adsorbed biochar for rare earth elements (REEs). Results indicated that ~332.09 g of biochar could be produced per unit area of D. pedata under 100% clipping conditions. The Brunauer–Emmett–Teller (BET) specific surface area of oxidized biochar (H2O2BC) increased, and the pore size of iron-modified biochar increased. The adsorption behavior of biochar toward NH4+ was well represented by the pseudo-second-order and Langmuir models. H2O2BC demonstrated the strongest adsorption of NH4+ with maximum theoretical equilibrium adsorption of 43.40 mg·g−1, 37.14% higher than that of pristine biochar. The adsorption process of NH4+ on biochar is influenced by various physicochemical mechanisms, including pore absorption, electrostatic attraction, and functional group complexation. Furthermore, the metal ions in the biochar did not precipitate during the reaction process. The adsorbed NH4+ biochar promoted the growth of honey pomelo without risking REE pollution to the environment. Therefore, it can be applied as a nitrogen-carrying rare earth fertilizer in low rare earth areas. This study provides a theoretical basis and technical support for the phytoremediation post-treatment of rare earth mining areas and the improvement of ammonia nitrogen wastewater management pathways in mining areas.

Step-by-step: A clinical pathway for stepped care management of fear of cancer recurrence-results of a three-round online delphi consensus process with Australian health professionals and researchers.

Fear of cancer recurrence (FCR) is not routinely addressed in clinical practice, meaning many cancer survivors forego effective interventions. We established expert consensus on a clinical pathway to help health professionals identify and manage FCR in early-stage cancer survivors. Australian health professionals and researchers working with adult cancer survivors participated in a three-round Delphi study promoted via oncology professional bodies and social media. The Round 1 online survey presented 38 items regarding FCR screening, triage, assessment, referral, and stepped care, based on a literature review, related pathways/guidelines, and expert input. Participants rated how representative of best-practice items were on a 5-point scale (strongly disagree-strongly agree), with optional qualitative feedback. Consensus was defined as ≥ 80% of participants strongly/agreeing with items. Items not reaching consensus were re-presented to Round 1 participants in two subsequent rounds with new items, derived from content analysis of qualitative feedback. From 94 participants in Round 1 (89% health professionals), 26/38 (68%) items reached consensus. By round 3, 35/38 (92%) items, including 8 new items, reached consensus. Routine FCR screening and triage conversations and stepped care management (i.e. tailored and staged treatment) were endorsed. However, the timing of FCR screening/triage did not reach consensus. This world-first FCR clinical pathway incorporating contemporary evidence and expert opinion recommends routine screening and triage to stepped care management of FCR. Some pathway components, such as screening or triage timing, may need tailoring for different contexts. Implementation of the pathway could aid routine identification and management of FCR, reducing its burden on cancer survivors and the healthcare system.

Recruitment and retention of new doctors in remote and Aboriginal medical services through the Remote Vocational Training Scheme's Targeted Recruitment Strategy: a focus group study.

To explore the results of a targeted recruitment strategy designed to attract and retain new doctors in remote and Aboriginal medical services where they can access Remote Vocational Training Scheme (RVTS) training and support to qualify as general practitioners. Two 2-hour purposeful online focus groups on the RVTS' Targeted Recruitment Strategy. Five participants and nine stakeholders with knowledge and experience of the strategy. Data were transcribed and deductively and inductively coded for themes including insights from separate project reference and stakeholder advisory groups. Perspectives of the strategy. The overarching theme was that the strategy is useful for attracting and retaining new general practitioners in areas of high need and is potentially scalable. Since 2018, 20 new doctors were recruited via the Targeted Recruitment Strategy and six of them completed the RVTS program. The strategy could better differentiate target locations because increasing communities are experiencing major general practice workforce shortages. The package of employment and training could also be more clearly defined for participants, nationally marketed and collaboratively implemented. Further, more site accreditation and ongoing risk and quality review is needed, along with intense early supports for participants who are new to both the community and general practice work. The Targeted Recruitment Strategy is still maturing but the early results suggest it is a unique and proactive model for attracting and improving access to general practitioners in places with high needs. It could be strengthened through formal agreements between communities and agencies, ensuring coordinated implementation, clarifying roles and responsibilities, and developing clear pathways for risk and quality management.

7756 Gonadectomy in Individuals with Differences of Sex Development - A Prospective I-DSD Registry Study

Abstract Disclosure: M.A. O'Connell: None. A.K. Lucas-Herald: None. J. Bryce: None. M. Chen: None. J.H. Davies: None. M. Shnorhavorian: None. N. Atapattu: None. I. Bachynska: None. N. Birkebaek: None. M. Cools: None. K. Demir: None. L. de Vries: None. H. Elsedfy: None. M.A. Fahmy: None. E. Globa: None. R. Grinspon: None. G. Guaragna-Filho: None. G. Guerra-Junior: None. D. Janus: None. Z. Kolesinska: None. I. Mazen: None. S.M. O'Connell: None. S.N. Seneviratne: None. M. Stancampiano: None. G. Verkauskas: None. S.F. Ahmed: None. O. i-DSD gonadectomy surveillance consortium: None. Introduction: Gonadectomy may be indicated in people with differences of sex development (DSD), but variation in practice is reported. This study aims to determine, through prospective surveillance, the frequency of gonadectomy and associated care pathways in individuals with DSD internationally. Methods: All I-DSD centres were invited to participate; the study commenced in December 2022. Participating centres receive a monthly email asking whether a gonadectomy has been performed in an individual with DSD. Where informed consent for inclusion in the I-DSD Registry has been obtained in a reported case, a secondary survey captures additional clinical information. Results: Of 208 centres invited, 74 have responded to monthly email surveys. Over the first 12 months of surveillance, gonadectomies were reported in 71 individuals from 34 centres in 19 countries (median [range]: 1[1, 5]); 40 centres reported no gonadectomy. Secondary survey data are available for 30/65 (46%) of reported cases to date. Twenty-four (80%) individuals are female; median (range) age at gonadectomy was 9.2 (2.1,20.0) years. All had specialist multidisciplinary team involvement prior to gonadectomy: endocrinology (97%), genetics (77%) and psychology (67%) were most frequently involved. Gonads were intra-abdominal in 25/30 (83%). Differences of gonadal development (13/30 [43%]) and Turner syndrome (8/30 [27%]) were the most frequent underlying DSD. Pre-gonadectomy investigations included: hormonal testing (28/30 [93%]), imaging (23/30 [77%] - US alone n=14; US + MRI n=7; MRI alone n=2), direct visualisation at laparoscopy (7/30 [23%]) and gonadal biopsy (2/30 [7%]). Bilateral gonadectomy was undertaken in 25/30 (83%). Mitigation of future malignancy risk in the context of gonadal insufficiency was the most common primary indication for gonadectomy (19/30, [63%]); additional indications were concerning changes on biopsy/imaging (3/30 [10%]), hormone production incongruent with sex assigned (4/30 [13%]) or gender identity (2/30 [7%]) and parental choice (2/30 [7%]). Histopathology confirmed neoplastic change in 7 individuals (23%). Gonadectomy was intentionally deferred in 8/30 (27%) individuals, most commonly to allow their involvement in decision making. Twelve individuals (40%) were 12yrs or older at gonadectomy; all were involved in the pre-operative decision-making process. Conclusions: This study offers important contemporary insights into the practice of gonadectomy in individuals with DSD internationally. Multidisciplinary care provision prior to gonadectomy is standard; however, management pathways vary, likely reflecting diversity of clinical presentations and lack of consensus regarding optimal approach. The I-DSD platform shows clear utility for performing prospective surveillance of rare procedures; such studies are essential for care quality improvement. Presentation: 6/2/2024

Quelle réponse au trouble somatique fonctionnel : la filière ACSEPT

BackgroundFunctional somatic disorder (FSD) is a prevalent disorder that can be severely disabling for the patient and is associated with major health costs. There are few formalized care programs for these disorders in the country, and their management encounters various difficulties, both in the diagnosis and its announcement and the treatment. Cognitive-behavioural and emotional therapy (CBT) is the standard on psychiatry care, and its efficacy has been demonstrated through several randomised controlled studies on the intensity of physical and psychological symptoms. InterventionAt Lille's University Hospital Center, we have established the “ACSEPT” care pathway for TSF management which consists of a psychiatric consultation followed by an individual referral, including a treatment using repeated transcranial magnetic stimulation (rTMS) or the integration of a CBT-based psychoeducation group. This group had the particularity of caring for all patients presenting FSD regardless of the associated physical symptoms. Educating medical professionals and conducting FSD research were other goals of ACSEPT. Discussion/conclusionACSEPT allows an improvement in the care offered to these patients with a defined orientation and interdisciplinary, early, organized cares that are repeatable. Our goal is to study the effectiveness of these different interventions in subsequent studies, to continue the development of ACSEPT and to be able to distribute this intervention at the regional level to establish a clear care program allowing early management of these patients.

Regional Sustainable Management Pathways to Carbon Neutrality

With the background of global climate change and rapid economic growth, there are increasing problems threatening regional sustainable development [...]

The inter-rater reliability of emergency department and paramedic frailty screening in older patients following a fall

BackgroundScreening for frailty in the emergency setting may be useful in directing patients to appropriate management pathways. The main aim of this study was to assess the inter-rater reliability of the Clinical Frailty Scale between paramedics and emergency department staff (doctors and allied heath) for patients after a fall. Secondarily, to assess how these scores correlate with patient outcomes. MethodsA prospective study of older patients arriving by ambulance to a single hospital in Western Australia following a fall. The inter-rater reliability was assessed using a weighted Cohen’s κ. The relationship between Clinical Frailty Scale and secondary outcomes were assessed using chi-squared and Kruskal-Wallis tests. ResultsData from 94 patients were included, the mean age was 82 years and 64 % were female.The inter-rater reliability between paramedics and emergency department staff using the Clinical Frailty Scale was moderate (κ 0.48 (95 % CI 0.36–0.59)). ConclusionsThere is only moderate agreement between emergency department staff and paramedics when screening for frailty in patients who present after a fall. The findings indicate the need to improve reliability as a pre-requisite to the use of frailty screening in emergency settings.

Nasal Extranodal NK/T Cell Lymphoma with Orbital Involvement: A Rare Entity of Common Presentations.

Nasal Extranodal NK/T Cell Lymphoma is an aggressive tumour affecting the nasal and midline structures, causing surrounding tissue destruction as the result of its progression. The initial presentations are similar to symptoms of benign nasal polyps, such as nasal obstruction, hyposmia and nasal discharge. As the disease progresses, the involvement of the palate, paranasal sinuses, orbit and skin become alarming symptoms. We report a case of a young male with Nasal ENKTL who presented with symptoms similar to acute on chronic rhinosinusitis with orbital complications. The challenges of diagnosing and getting to the correct management pathway are discussed.