Specialist Management Research Articles

INTEGRATING ALLIED HEALTH PROFESSIONALS DURING THE ONCOLOGICAL TREATMENT PHASE FOR GLIOBLASTOMA PATIENTS: A CASE STUDY AT A UK CANCER CENTRE

Abstract AIMS Primary brain tumour patients should be offered neurological rehabilitation assessment at diagnosis and every stage of follow With only 5% of glioblastoma patients surviving more than 5 years, specialist management that spans across all phases of the Dietz rehabilitation model is required to optimise function, treatment tolerance and Quality-of-life. At Guy’s cancer centre an Allied health multi-disciplinary team (Physiotherapy, Occupational therapy and Speech and language therapy) work alongside the oncologist-led clinic to support this patient group. METHOD Case history A 54-year-old, male, was diagnosed with right parietal Glioblastoma, WHO grade 4, IDH wildtype, MGMT 5.47% methylated (August 2023) on biopsy only. He underwent chemo/radiotherapy - 60gy/90 fractions with Temozolmide (TMZ) on 3/11/2023 Currently C4 of adjuvant TMZ. Dexamethazone 2mg was discontinued on 29/11/2023, he continues with Keppra 500mg twice daily. RESULTS Dietz Intervention approach in phases: PREVENTATIVE Fatigue management was introduced prior to radiotherapy including a physical activity review, advice on pacing, sleep hygiene and relaxation techniques. Given the patient’s history of shift work and altered sleep patterns, managing risks of treatment-related fatigue was of particular importance. Restorative & Supportive: A targeted and periodised exercise programme was initiated, comprising 1:1 gym based physiotherapy sessions. The aims included enhancing exercise confidence, improve balance, endurance, maintain strength, pain management and weight maintenance during chemo/radiotherapy and adjuvant TMZ. Education was deployed on adjusting activity levels based on chemotherapy cycle and day to day side effects, alongside ongoing fatigue management advice around pacing and sleep hygiene. CONCLUSION Learning and Recommendations Implementing tailored rehabilitation interventions early in the patient’s treatment pathway, enables proactive management to mitigate the impact of treatment-related side effects on their QOL. Based on our experience, early engagement with a dedicated therapy team is recommended to foster strong rapport with both the patient and their caregivers. This facilitates timely rehabilitation planning for optimal outcomes.

(158) UTILITY OF PRIMARY CARE PHYSICIANS IN A UROLOGY MEN’S HEALTH CLINIC

Abstract Introduction Urology clinics may receive consultation referrals for clinical issues which do not require surgical specialist management. Additionally, with ongoing expansion of therapeutic options in men’s health, referring family medicine physicians may not be aware of all potential treatment modalities. Delayed time from referral to specialist consultation represents a significant issue in Canadian healthcare. Common referrals from general practice for urology assessment includes erectile dysfunction and testosterone deficiency. Multidisciplinary clinics enable access to care for various men’s health concerns where some may not require urologic surgeon specialist intervention. Objective We aim to assess whether men’s health trained primary care providers (PCPs) with foundational training in men’s health working within a multidisciplinary clinic can address common urologic referrals and reduce the need for specialist management of urology clinic referrals. Methods A retrospective chart review was performed involving all patients referred by personal primary care providers to urology who were screened by a urologist as appropriate for initial consultation by a PCP at a multidisciplinary men’s health clinic from January 2022 to January 2023 in Winnipeg, Canada. Patient demographics, medical concern, management, time from referral to treatment, and need for urologist follow-up was captured. There were no inclusion or exclusion criteria. Results A total of 419 patients were identified. Treatment data for all were collected. 331 patients (79%) were managed by an in-house PCP alone and 88 (21%) required urologist consultation following PCP assessment. De novo erectile dysfunction, low testosterone and orchalgia were the most common issues triaged to PCP initial management. Issues managed by PCP also included penile curvature, functional sexual concerns and lower urinary tract symptoms. Male infertility, penile curvature, and orchalgia were the most prevalent conditions requiring subsequent urologist referral. PCPs were able to initiate non-surgical therapies in a majority of patients. In analysis of treatment by primary referral medical concern, 100% of low testosterone, 96% of erectile dysfunction, and 82% of orchalgia were managed at the PCP level alone and did not require urologic surgeon assessment. Conclusions PCPs in a multidisciplinary clinic can provide care for a range of urologic issues and reduce need for urologist consultation. This study demonstrates the utility of PCPs in optimization of urologist consultation. Presenting issues may be predictive of the need for urologist referral. Disclosure No.

Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour

BackgroundChronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs’ experiences diagnosing and managing pOUD in their chronic pain patients.MethodsThis qualitative research used semi-structured interviews and a case study to investigate GPs’ experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual’s perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed.ResultsTwenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions.ConclusionsNegative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

IMPACT OF DISCHARGE FROM A CARDIOLOGY UNIT ON OUTCOMES IN NON–ST ELEVATION MYOCARDIAL INFARCTION: AN ANALYSIS OF A NATIONWIDE ADMINISTRATIVE DATABASE

Abstract Background Current data on the prognostic impact of a specialist management of patients with acute coronary syndromes are scarce. Aim To evaluate the impact of the discharge of revascularized patients with Non–ST elevation myocardial infarction (NSTEMI) from a cardiology unit on their 1–year prognosis and to evaluate the differences in terms of effectiveness between discharge from a cardiology and non–cardiology unit and the whole management of the index hospitalization in a cardiology unit. Methods Retrospective nationwide cohort study enrolling consecutive patients older than 18 years admitted in 2019–2020 in Italy for a NSTEMI and undergoing percutaneous coronary intervention (PCI) within 48 hours from the index admission. Patients died within 30 days from the index admission were excluded from the analysis. Enrolled patients were classified based on the management department into: patients not discharged from a cardiology unit (group 1); patients not admitted but discharged from a cardiology unit (group 2); patients completely managed (admitted and discharged) in a cardiology unit (group 3). The outcome of interest was 1–year all–cause mortality. A Cox multivariate regression model was used to evaluate the impact of the management department on 1–year mortality. Results The study cohort consisted of 31950 NSTEMI events. Among them, 534 (1.6%) were allocated in group 1, 1160 (3.6%) in group 2 and 30256 (94.7%) in group 3. Patients completely managed by a cardiology unit were younger and less likely to be female than patients in other groups. The 1–year mortality was 14.4%, 8.4% and 3.8% (p<0.001) for group 1, group 2 and group 3, respectively (Figure). After adjustment for age, sex, and comorbidities, the hazard ratio (HR) for 1–year mortality was 2.4 (p<0.0001) and 1.7 (p<0.0001), in patients in group 1 and group 2, respectively, as compared with patients completely managed in a cardiology unit (group 3). Conclusion Complete management of index hospitalization or hospital discharge from a specialist unit alone improves the one–year prognosis of patients hospitalized with a diagnosis of NSTEMI in Italy.

Development of a Multivariable Model to Predict the Need for Bone Marrow Sampling in Persons With Monoclonal Gammopathy of Undetermined Significance : A Cohort Study Nested in a Clinical Trial.

Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) are asymptomatic precursor conditions to multiple myeloma and related disorders. Smoldering multiple myeloma is distinguished from MGUS by 10% or greater bone marrow plasma cells (BMPC) on sampling, has a higher risk for progression, and requires specialist management. To develop a multivariable prediction model that predicts the probability that a person with presumed MGUS has 10% or greater BMPC (SMM or worse by bone marrow criteria) to inform the decision to obtain a bone marrow sample and compare its performance to the Mayo Clinic risk stratification model. iStopMM (Iceland Screens, Treats or Prevents Multiple Myeloma), a prospective population-based screening study of MGUS. (ClinicalTrials.gov: NCT03327597). Icelandic population of adults aged 40 years or older. 1043 persons with IgG, IgA, light-chain, and biclonal MGUS detected by screening and an interpretable bone marrow sample. Monoclonal gammopathy of undetermined significance isotype; monoclonal protein concentration; free light-chain ratio; and total IgG, IgM, and IgA concentrations were used as predictors. Bone marrow plasma cells were categorized as 0% to 4%, 5% to 9%, 10% to 14%, or 15% or greater. The c-statistic for SMM or worse was 0.85 (95% CI, 0.82 to 0.88), and calibration was excellent (intercept, -0.07; slope, 0.95). At a threshold of 10% predicted risk for SMM or worse, sensitivity was 86%, specificity was 67%, positive predictive value was 32%, and negative predictive value was 96%. Compared with the Mayo Clinic model, the net benefit for the decision to refer for sampling was between 0.13 and 0.30 higher over a range of plausible low-risk thresholds. The prediction model will require external validation. This accurate prediction model for SMM or worse was developed in a population-based cohort of persons with presumed MGUS and may be used to defer bone marrow sampling and referral to hematology. International Myeloma Foundation and the European Research Council.

Plasma neurofilament light chain is increased in Niemann-Pick Type C but glial fibrillary acidic protein remains normal.

Niemann-Pick Type C (NPC) is a genetic neurodegenerative lysosomal storage disorder commonly associated with psychiatric symptoms and delays to accurate diagnosis and treatment. This study investigated biomarker levels and diagnostic utility of plasma neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) in NPC compared to healthy controls. Patients with NPC were recruited from a specialist assessment and management service. Data was available from an age and sex-matched healthy control group. NfL and GFAP were measured on Quanterix Simoa HD-X analysers and groups compared using generalised linear models. NfL levels were compared to, and percentiles derived from, recently developed NfL reference ranges. Plasma NfL was significantly elevated in 11 patients with NPC compared to 25 controls (mean 17.1 vs. 7.4 pg/ml, p < 0.001), and reference ranges (all >98th percentile). NfL distinguished NPC from controls with high accuracy. GFAP levels were not elevated in NPC (66.6 vs. 75.1 pg/ml). The study adds important evidence on the potential diagnostic utility of plasma NfL in NPC, extends the literature of NfL as a diagnostic tool to differentiate neurodegenerative from primary psychiatric disorders, and adds support to the pathology in NPC primarily involving neuronal, particularly axonal, degeneration.

Endo the line: stricturing terminal ileum endometriosis

Endometriosis is the implantation and proliferation of endometrial tissue outside the uterus, and while involvement of the small bowel is rare, it is particularly unusual for it to present with terminal ileum stricture mimicking Crohn’s ileitis. We present the case of a 38-year-old female with recurrent mechanical small bowel obstruction with transition point in the terminal ileum. She was struggling with infertility issues and was not previously known to have endometriosis. The presumptive diagnosis was Crohn’s disease due history of previous anal fissure, high faecal calprotectin level, and imaging findings of terminal ileitis with stricture, despite lacking tissue confirmation from colonoscopy. She underwent laparoscopic ileocolic resection with histology showing endometrial stricture and secondary mucosal inflammation, without any established features of Crohn’s disease. This case demonstrates the potential diversity in presentation of endometriosis, including small bowel manifestations that can mimic Crohn’s ileitis. If endometrioma can be confidently diagnosed based on characteristic imaging features or tissue sample, unnecessary treatment may be avoided, whilst appropriate specialist management improves endometriosis symptoms and fertility outcomes.

A Delphi consensus on clinical features, diagnosis and treatment of major depressive disorder patients with anhedonia amongst psychiatrists in the Asia-Pacific.

Anhedonia, a core diagnostic feature for major depressive disorder (MDD), is defined as the loss of pleasure and interest in daily activities. Its prevalence in MDD patients vary from 35 to 70%. Anhedonia in MDD negatively impacts functioning and is associated with treatment resistance and poorer prognosis for various clinical outcomes. Owing to its complexity, there remains considerable heterogeneity in the conceptualization, diagnosis and clinical management of anhedonia in MDD. This modified Delphi panel was conducted to elicit expert opinion and establish consensus on concepts relating to clinical features, diagnosis and treatment of MDD with anhedonia (MDDwA) amongst psychiatrists in the Asia-Pacific region. Seven themes were covered. A three-stage process was adopted for consensus generation (two online survey rounds, followed by a moderated consensus meeting). Statements were developed based on a literature review and input from a steering committee of six regional experts. The panel included 12 psychiatrists practicing in Australia, China, Hong Kong, Japan, South Korea and Taiwan with ≥5 years of specialist clinical experience, including assessment or management of patients with MDDwA. Overall, consensus was achieved (median ≥8) on 89/103 statements (86%). About half of the statements (55/103, 53%) achieved consensus in Round 1, and 29/36 modified statements achieved consensus in Round 2. At the moderated consensus meeting, five modified statements were discussed by the steering committee and consensus was achieved on all statements (5/5). The findings highlighted a lack of clear and practical methods in clinical practice for assessing anhedonia in MDD patients and limited physician awareness of anhedonia in Asia-Pacific. Insights from this Delphi consensus provide a reference point for psychiatrists in Asia-Pacific to optimize their strategies for personalized diagnosis and management of patients with MDDwA. Identification of distinct and clinically relevant subtypes in MDD may be valuable for guiding personalized diagnosis and management approaches, including type-specific therapies.

The Characteristics of Epitaxis Patients at Sumedang Regional Public Hospital Emergency Departement in 2021-2022

Epitaxis is a term from Greek, epistaizein, which means bleeding from the nose. Epitaxis is common problem ranging from minor traces of blood or clot to isolated massive bleeds that may be life-threatening and one of the common ear, nose, throat emergencies that present to emergency department or the primary care clinic . From an epidemiological of view, the lifetime incidence of epitaxis has been reported to be as high as 60% people worldwide during their lifetime. However, a real number is difficult to be estimated as only a very small proportion requires specialist management and therefore many cases escape to evaluation. Only 10% of patients with epitaxis will present to a physician. This study aims the characteristics of epitaxis patients in Emergency Departement of Sumedang Regional Public Hospital from January 2021 to December 2022. This study was designed as a retrospective descriptive study. Research used medical records on patients diagnosed with epitaxis. The research's results showed that there are 74 patients in that period with 7 patients experiencing recurrent epitaxis, 2 patients with hypotension and 27 patients with anemia. The incidence in male is higher than female. Patients with epitaxis more common in the age group &gt;45 years. The most common cause of epitaxis is by systemic cause.

Sustaining work ability amongst female professional workers with long COVID.

Long COVID (LC) compromises work ability (WA). Female worker WA has been more adversely impacted than WA in men. Exploration of lived experiences could elucidate the WA support required. To explore the working conditions and circumstances experienced as affecting sustained WA amongst female workers with LC, to help mitigate worklessness risks. Online semi-structured qualitative interviews were conducted with 10 female workers self-reporting or formally diagnosed with LC who had made some attempt to return to work (RTW). Interviews were analysed using template analysis to map themes informing WA enablers and obstacles onto a biopsychosocial model of rehabilitation. All participants were professionals working in an employed or self-employed capacity. Key themes reflecting circumstances that afforded sustained WA included the autonomy over where, when and how to work indicated as facilitated by a professional role, rapid health care access, predominantly sedentary work, competent colleagues able to cover for transient reduced WA, a strong interface between specialist health and management support, and accessible organizational policies that steer health management according to equity rather than equality. Highly flexible, iterative, co-produced RTW planning, tolerant of fluctuating symptom expression appears vital. In return for providing such flexibility, participants felt that employers' workforce diversity and competence would be protected and that workers would need to reciprocate flexibility. These qualitatively derived findings of workers' lived experiences add to existing guidance on supporting WA for people struggling with LC. Moreover, the same principles seem appropriate for tackling worklessness amongst working-age adults with complex long-term health conditions.

Turnover intention of foreign trained physicians in German rehabilitation facilities

Abstract Germany's medical specialist shortage is an acute challenge, especially in the rehabilitation segment. One countermeasure is to recruit foreign trained physicians (FTP), but high turnover of FTP is a burden on the departments that train them and integrate them professionally. Preliminary research showed that currently one in three physician positions in German Pension Insurance (DRV) contract facilities is filled by FTP. This paper examines the turnover intention of FTP in German rehabilitative departments. In spring 2022, we conducted an online survey of FTP that captured sociodemographic and professional biographical data, turnover intention, satisfaction, difficulties with professional integration and structural characteristics. The data was evaluated in a subgroup analysis using chi-square tests. The sample includes n = 145 FTP, 119 stating no turnover intention and 27 with turnover intention. More than half of FTP with turnover intention wished to move to an acute care hospital. They are significantly (p &amp;lt; 0.05) younger, have worked in Germany and in the institutions for a shorter time, and have studied in more countries than FTP without turnover intention. The latter are proportionally more likely to have a German specialist title and management responsibilities. FTP with turnover intention are far less satisfied, particularly with career prospects and institution location. Structurally, FTP with turnover intention are proportionately more likely to be based in peripheral regions than conurbations, which are where all FTP without turnover intention are based. FTP with turnover intention have reported a much higher rate of discrimination by non-physician colleagues. Key messages • The results reveal a group of ‘established FTP’ whose professional integration has been successfully completed. • FTP with turnover intention are comparatively younger, career-oriented physicians for whom work in the rehabilitation facility is a career springboard to gain a foothold in acute care clinics.

Burden and unmet need for specialist care in poorly controlled and severe childhood asthma in a Danish nationwide cohort

BackgroundAsthma is a common disease in childhood and adolescence with lifelong consequences particularly among those at risk of severe disease, poor control and/or frequent exacerbations. Specialist care is recommended for at-risk children and adolescents, yet access to specialist management in free-to-access healthcare settings remains poorly understood.MethodsA Danish nationwide cohort of children and adolescents aged 2–17 years with persistent asthma, defined as repeated redemption of inhaled corticosteroids (ICS) during 2015, were followed for two years, to identify at-risk children and adolescents comprising those with severe asthma (classified according to GINA 2020 guidelines), poor control (defined as use of 400/600 (ages 2–11/12 +) annual doses of short-acting bronchodilators), or frequent exacerbations (defined as use of oral steroids or hospitalization), and access to specialist care. The population is chosen due to detailed medical records in the setting of universal health care.ResultsThe cohort comprised of 29,851 children and adolescents (59% boys), with a median age of 9 years. While 17% of children were on high dose ICS, 22% were on daily ICS below GINA low dose cut-off. Prevalence of severe asthma (3.0–6.5%) was lower than poor asthma control (6.4–25%); both declined from childhood to adolescence. Exacerbations occurred in 7.1–9.0% of children, with median number of exacerbations being 1 (IQR 1–1). Despite being classified as having mild-to-moderate asthma, 15% had poor asthma control and 3.8% experienced exacerbation(s), respectively. While 61% of children with severe asthma and 58% with exacerbation-prone disease were in specialist care, only 24% with uncontrolled disease were receiving specialist care. Of children and adolescents using high-dose ICS, 71% were managed in primary care, while the use of additional controllers was more common in specialist care.ConclusionsThroughout childhood and adolescence, there was a high prevalence of severe asthma and poor control, although their prevalence declined with age. We demonstrate a large unmet need for specialist care among children with at-risk asthma, particularly among those with poorly controlled asthma, even in a system with free-to-access, tax-funded healthcare.

P382 Cystic fibrosis and disordered eating behaviour: a collaborative approach to improve care

Cystic Fibrosis (CF) and Eating Disorders (ED) are both complex conditions requiring specialist management. A collaborative project between two adult CF centres and an ED team aimed to better understand and meet the needs of CF patients with body image concerns and/or disordered eating.

P437 HEART AND RHEUMATOLOGICAL DISEASE: A PICTURE OF ACUTE HEART FAILURE

Abstract Systemic sclerosis is a connective tissue disease characterized by endothelial dysfunction, hyper reactivity of fibroblasts and immunity abnormality in both humoral and mediated cells. Clinically, in addition to the typical skin involvement, mainly the face and fingers, is frequent involvement of lungs, heart and kidneys. Cardiac involvement, in combination with lung involvement, is considered to be the most important determinant of the prognosis of these patients. Cardiac involvement occurs in 15– 35% of cases but in autopsy surveys the incidence reaches 80%. The case we present concerns a woman of 65 years, admitted in December at the Department of Cardiology of our AOU for an episode of low–output heart failure with epigastralgia, sweating, and breathlessness. The cardiological history was almost silent; instead, it presented a history of chronic thyroiditis and a recent infection with SARS COV 2. The objective examination presented hypokinesis of basal pulmonary fields and pitting edema. The blood tests showed an increase in myocardial necrosis, BNP, creatininemia and inflammatory indices (VES, PCR, beta 2 microglobulin, ferritin, fibrinogen), normocytic normochromic anemia, hypogammaglobulinemia, hyperuricemia and proteinuria and hematuria. The echocardiogram showed severe biventricular dysfunction and moderate–grade mitral insufficiency. A coronary examination was performed that showed epicardial coronary vessels free from significant injury. The cardiac magnetic resonance showed a widespread late enhancement subendocardial of the ventricular and atrial chambers with non–vascular distribution suggestive of pathology on an autoimmune basis. Upon closer examination, multiple small telangiectasias were observed in the face, slight hyperpigmentation of the chest and back, and swelling of the hands. The antibody panel showed positivity of ANA and anti Scl70. The patient was thus addressed to a multi–specialist management in which therefore cardiologist and rheumatologist compare and support the treatment of this pathology with the goal of reducing the high mortality and morbidity that characterizes systemic scleroderma with cardiac involvement.

An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients.

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting. From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed. Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care. A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

Extending the role of the dental professional in the management of non-melanoma skin cancer

Non-melanoma skin cancer is the most frequently diagnosed malignancy worldwide and regularly presents in the head and neck region. As a result, dental professionals are in a key position to identify suspected cases and provide an onward referral. The specialist management of these patients requires a team approach. Although surgery is the mainstay of treatment, radiotherapy may be employed as a definitive or adjuvant treatment modality. This article provides an overview of the epidemiology, presentation and management of non-melanoma skin cancer as well as the interdisciplinary work between the restorative consultant and radiotherapy department to provide an innovative custom-made radiotherapy bolus. CPD/Clinical Relevance: To raise awareness of the presentation and management of non-melanoma skin cancer and the role of the restorative dentist within the multidisciplinary team.

Identifying advanced MAFLD in a cohort of T2DM and clinical features.

MAFLD is the most common cause of chronic liver disease, affecting 25% of the global population. Patients with T2DM have an increased risk of developing MAFLD. In addition, patients with T2DM have a higher risk of advanced forms of steatohepatitis and fibrosis. Identifying those patients is critical in order to refer them to specialist and appropriate management of their disease. To estimate advanced fibrosis prevalence in a cohort of patients with T2DM and to identify possible predictors. subjects with T2DM during regular health check-up were enrolled. Demographic and general characteristics were measured, including metabolic parameters and homeostasis model assessment of insulin resistance (HOMA2-IR). Four non-invasive fibrosis scores (NAFLD fibrosis scores, FIB-4, APRI, Hepamet fibrosis score) were measure and compared with transient elastography (TE). 96 patients (21%) presented risk of significant fibrosis (≥F2) measured by TE and 45 patients (10%) presented with risk of advanced fibrosis F3-F4. Liver fibrosis was related to BMI, AC, HOMA2-IR. The results of the non-invasive fibrosis scores have been validated with the results obtained in the TE. It is observed that the index with the greatest area under the curve (AUC) is APRI (AUC=0.729), with a sensitivity of 62.2% and a specificity of 76.1%. However, the test with better positive likelihood ratio (LR+) in our study is NAFLD fibrosis score. Our results show that in a general T2DM follow up, 10% of patients were at risk of advanced fibrosis. We found a positive correlation between liver fibrosis and BMI, AC and HOMA2-IR. Non-invasive fibrosis markers can be useful for screening, showing NAFLD Fibrosis score a better LHR+ compared to TE. Further studies are needed to validate these results and elucidate the best screening approach to identify those patients at risk of advanced MAFLD.

1357 THE ‘CONSULTATION COMMUNICATION’ PROFORMA: ENHANCING EFFECTIVE COMMUNICATION BETWEEN OUTPATIENTS AND INTERMEDIATE CARE

Abstract Introduction The Norman Power Centre (NPC) is a 32 bedded Intermediate Care Unit, run by an acute hospital trust in Birmingham, UK, for patients who require ongoing 24-hour care, rehabilitation or further assessment, but do not need to be in an acute hospital setting. These frail patients attend numerous outpatient hospital appointments, but rarely do staff receive communication back from these outpatient reviews. This can lead to delays in implementing specialist management plans, with potential for adverse outcomes for patients and increased staff workload in seeking out the required information. A ‘Consultation Communication’ proforma was designed, to be filled in at the appointment and brought back to NPC with the patient. Method Patients and escorts took proformas to outpatient appointments between March and June 2022. The information on the forms was then analysed to assess completeness and usefulness. Results Appointments were in surgical and medical specialities, as well as imaging in three hospitals within one trust. Proformas were taken to 19/20 appointments. 100% of these were at least partially completed, with only two forms being largely incomplete. 17/19 provided information about the assessment carried out. 12/19 included recommendations relevant to admission at NPC. 13/19 had information on medication changes. 14/19 stated whether follow up was required. Eight out of nine required follow-ups had specific details included. 13/19 had the professional’s details, 11 with contact numbers. Of those without details, two were imaging appointments where contact details were not relevant. Conclusions This easy to implement, simple intervention, with an excellent engagement rate from both NPC and outpatient appointment staff, has led to improved continuity of care for patients. The proforma has scope to be improved based on staff feedback, and its use could be expanded across other off-site facilities such as community hospitals or care homes.

Pain specialist management of sexual pain—I: foundations

Abstract Introduction The biopsychosocial model of care for women with sexual pain is a widely endorsed approach melding the expertise of multiple professional disciplines. Interventional pain management provides specialized diagnosis and treatment of chronic pain as part of the interdisciplinary care team. Diagnosis and treatment strategies are built on the foundational knowledge of the causes of female sexual pain, appreciation of the intrapersonal, interpersonal, and sociocultural contexts which shape pain, and the psychological and neurophysiological effect of chronic pain. This first paper in a series of four lays the groundwork for applying the perspectives, approaches, and therapeutic treatment options inherent in the specialty of pain management. Objectives To provide a current summary of the neurobiology, intrapersonal and interpersonal aspects of female sexual pain within a chronic pain paradigm. Describe the role of an interventional pain specialist as part of an interdisciplinary sexual pain team. Methods Internet search engines, PubMed and Cochrane Library were searched for relevant articles on female sexual pain within the scope of practice of pain management. Results A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case-reports. The neurobiological and psychological aspects of sexual pain were described within a chronic pain paradigm. The perspective of a pain specialist on female sexual pain was presented. Conclusion The care of women with sexual pain is highly complex and must be individualized based on the characteristics of the pain, its chronicity, and all the ways the condition impacts each woman. Physiological changes seen in chronic pain are likely to be present in most women with sexual pain. Awareness of the replete biopsychosocial dimensions of sexual pain promotes the goals of interdisciplinary care and provides a foundation for each specialty in the team. The way pain management specialists employ that knowledge for women with sexual pain will be examined in subsequent papers.

Renal medicine in the intensive care unit: a narrative review.

Kidney disease, both acute and chronic, is commonly encountered on the intensive care unit. Due to the role the kidneys play in whole body homeostasis, it follows that their dysfunction has wide-ranging implications and can affect prescribing and therapeutic management. This narrative review discusses the pathophysiology of acute kidney injury and chronic kidney disease, and how this relates to critically unwell patients. We cover several aspects of the management of renal dysfunction on the critical care unit, exploring some of the recurrent themes within the literature, including type and timing of kidney replacement therapy, management of acute kidney injury, as well as discussing how novel biomarkers for acute kidney injury may help to identify patients suffering from acute kidney injury as well as risk stratifying these patients. We discuss how early involvement of specialist nephrology services can improve outcomes in patients with kidney disease as well as offer valuable diagnostic and specialist management advice, particularly for patients with established end stage kidney disease and patients who are already known to nephrology services. We also explore some of the ongoing research questions that need to be answered within this arena.