Team Conference Research Articles

Multimodal treatment strategies for colorectal liver metastases.

Colorectal cancer is the third most common cancer worldwide. Half of CRC patients develop liver metastases during the course of the disease, with a 5-year survival rate close to zero in the absence of therapy. Surgical resection remains the only possible curative option, and current guidelines recommend adjuvant chemotherapy, resulting in a 5-year survival rate exceeding 50%. Neoadjuvant systemic therapy is not indicated in cases with simple resection but should be offered to all patients with extensive bilobar disease. Personalised systemic treatment is essential to convert upfront non-resectable lesions to resectable ones. Anatomical resections, non-anatomical resections and two-stage hepatectomies can be performed though open or minimally invasive (laparoscopic or robotic) surgery. The extent of a hepatic resection is limited by the risk of postoperative liver failure due to a too small liver remnant, inflow or outflow obstruction or insufficient biliary drainage. About 75% of patients are diagnosed with non-resectable liver metastases not amenable to a standard upfront resection. In recent years, effective therapeutic approaches have revolutionised liver surgery and new strategies have enabled the conversion of primarily non-resectable metastatic disease for resection. These strategies include oncological and surgical therapies, as well as combinations of the two. From an oncological perspective, colorectal liver metastases  may be treated by systemic chemotherapy or immunotherapy, or selective intra-hepatic arterial infusion chemotherapy, depending on the extent of the disease and the mutational status. In surgery, we often apply two-stage strategies using portal vein occlusion, such as portal vein embolisation or ligation, or complex two-stage hepatectomy such as associating liver partition and portal vein ligation for staged hepatectomy. Other additive tools to reach curative resection are tumour ablations (electroporation, microwave or radiofrequency). The role of stereotactic radiation of liver metastases is not yet well defined. Modern radiation techniques, including image guidance, breath hold and gating, were only introduced for a larger patient population in recent years. Therefore, prospective studies with larger patient cohorts are still pending. Over the last decade, liver transplantation has gained increasing attention in selective cases of non-resectable colorectal liver metastases, with promising cohort studies, but definitive recommendations must await the results of ongoing randomised controlled trials. The optimal treatment of patients with colorectal liver metastases requires the timely association of various strategies, and all cases must be discussed at multidisciplinary team conferences. While colorectal liver metastases was a uniformly lethal condition a few decades ago, it has become amenable to curative therapies, with excellent quality of life in many scenarios. This review reports on up-to-date treatment modalities and their combinations in the treatment algorithm of colorectal liver metastases.   &nbsp.

Multi-disciplinary team conference clarifies bosniak classification of complex renal cysts

Objectives The aims of this study are to determine the progression rate of Bosniak IIF cysts, the malignancy rates of complex renal cysts in patients undergoing surgery and explore the influence of multi-disciplinary team conference (MDT) on re-classification of Bosniak cysts. Materials and Methods All CT scans from January 2010 to 2017 were pooled into a database. Initially, 167 patients were identified with possible Bosniak IIF, III or IV cysts. Patients with follow up of less than 24 months, without progression or regression were excluded. Results Thirty-one (18.6%) cysts of the initial 167 cysts were either up or downgraded at a MDT. Twenty-six of the 31 cysts were up or downgraded at the primary MDT, 13 cysts (50%) were downgraded, five cysts (19.2%) were upgraded and eight cysts (30.8%) were re-classified as solid tumors. Of those 19/26 (73.1%) were primary interpreted by a periphery radiologist and re-classified centrally. The last five patients 5/120 cysts (4.2%) were re-classified during follow up. 116 patients with a total of 120 cysts met the inclusion criteria, 79 (65.8%) Bosniak IIF, 28 (23.3%) Bosniak III and 13 (10.8%) Bosniak IV cysts represented. Median follow up of Bosniak IIF cysts were 46 months. One Bosniak IIF cyst progressed to a solid tumor at 15 months from diagnosis, progression rate 1.3%. Histopathology was papillary renal cell carcinoma. Malignancy rates of Bosniak III and IV cysts were 50% and 78%, respectively. Conclusion Multi-disciplinary team conference may have an important role in correct classification of Bosniak cysts. Trial registration None

A Collaborative Effort to Define Classification Criteria for ATM Variants in Hereditary Cancer Patients.

Gene panel testing by massive parallel sequencing has increased the diagnostic yield but also the number of variants of uncertain significance. Clinical interpretation of genomic data requires expertise for each gene and disease. Heterozygous ATM pathogenic variants increase the risk of cancer, particularly breast cancer. For this reason, ATM is included in most hereditary cancer panels. It is a large gene, showing a high number of variants, most of them of uncertain significance. Hence, we initiated a collaborative effort to improve and standardize variant classification for the ATM gene. Six independent laboratories collected information from 766 ATM variant carriers harboring 283 different variants. Data were submitted in a consensus template form, variant nomenclature and clinical information were curated, and monthly team conferences were established to review and adapt American College of Medical Genetics and Genomics/Association for Molecular Pathology (ACMG/AMP) criteria to ATM, which were used to classify 50 representative variants. Amid 283 different variants, 99 appeared more than once, 35 had differences in classification among laboratories. Refinement of ACMG/AMP criteria to ATM involved specification for twenty-one criteria and adjustment of strength for fourteen others. Afterwards, 50 variants carried by 254 index cases were classified with the established framework resulting in a consensus classification for all of them and a reduction in the number of variants of uncertain significance from 58% to 42%. Our results highlight the relevance of data sharing and data curation by multidisciplinary experts to achieve improved variant classification that will eventually improve clinical management.

Мультидисциалинарное обсуждение в онкологии

The multidisciplinary team (MDT) conference has evolved as an essential instrument in the optimal management of a complex patient in the era of ever-changing medical knowledge. MDT discussions may improve the quality of diagnosis and treatment as well as provide an additional formal opportunity for collaboration among colleagues. MDT conference has become the standard of care and decision making tool in oncology. Such meetings include medical staff from all oncology-related services, and the decision is encouraged to be supported by the principles of evidence-based medicine. This paper provides an overview of the goals, pitfalls, and general recommendations for holding a productive MDT discussion.

Launching of the accreditation system for rehabilitation facility in Korea

Rehabilitation is one of the five vital components of the healthcare system, along with prevention, promotion, treatment, and palliation. In Korea, inpatient rehabilitation service is inadequately supplied based on the low fee system for rehabilitation services and an absence of a standard for inpatient rehabilitation facility. Consequently, the length of hospital stays increases and the rate of successful post-rehabilitation return to the community is low. To provide intensive rehabilitation, US established ‘inpatient rehabilitation facility’ system and Japan established ‘restorative rehabilitation hospital system’. In 2020, a new accreditation system has been launched in South Korea with the aim to improve the country’s intensive inpatient rehabilitation services. This new system defines the standards of workforce management, facility, diagnostic category, comprehensive functional measure, onset and duration of inpatient rehabilitation, and fees for team conferences and social services for a successful return to the community. The system aims to achieve an effective and efficient inpatient rehabilitation system in Korea.

Using a group development framework to maximize leadership strategies in the inaugural session of the Society of Behavioral Medicine Leadership Institute.

The 2016-2017 Inaugural Class of the Society of Behavioral Medicine Leadership Institute (SBM LI) debuted to an eager team of 36 mid-career fellows led by energetic mentors, professional coaches, and career development experts. Fellows were divided into learning communities of eight participants for deeper engagement. Our "Green Team" learning community bonded quickly and actively committed to our collective progress and projects. Upon returning home from the in-person sessions, our activities included monthly team conference calls and consultation with our mentors and selected coaches. The Green Team regularly communicated throughout the year, giving feedback to each other about our projects to be presented at the 2017 SBM Annual Meeting. We also discussed our mentoring and coaching experiences, leadership skills put to use at our institutions, and personal development. Contact continued via social media, email, teleconferencing, and collaborations at other professional meetings. The Green Team utilized the Tuckman and Jensen model of small group development to describe how we developed into a high-functioning group that maximized the resources afforded by the SBM LI to yield successful leadership outcomes. This commentary will offer an example of how a productive SBM LI team works collaboratively to utilize its mentors and resources for professional development.

Does parent engagement enhance children’s emotional well-being in family team conference? Not a panacea for families with intimate partner violence

In child welfare, the Family Team Conference (FTC) model is designed to develop an individualized case plan to promote children’s safety, permanency, and well-being through active parent engagement and community partnerships. However, no consensus has emerged regarding whether FTC is beneficial for families with Intimate Partner Violence (IPV). This study examined the role of IPV in the association between parent engagement in FTC and children’s emotional well-being. Results showed that children’s emotional well-being significantly increased when both parents engaged actively in FTC as equal partners who played a leading role in collaborative decision-making. Although IPV was not directly associated with children’s emotional well-being, it significantly moderated the positive association between parent engagement in FTC and children’s emotional well-being. More specifically, active parent engagement did not significantly enhance children’s emotional well-being when parents experienced IPV. Findings suggest that careful preparation and effective strategies to address IPV are required to ensure parents’ active engagement in FTC and enhance children’s emotional well-being. Strong partnerships among families, child welfare caseworkers, and service providers are critical for developing safety and support plans for families with IPV during FTC utilization.

The impact of multidisciplinary team conferences in urologic cancer in a tertiary hospital.

Multidisciplinary team (MDT) conferences are currently the standard of care in cancer patients' management. Despite evidence supporting benefits to the majority of malignancies, a paucity of data exists examining the impact in urinary and male genital cancers. This study aims to evaluate the impact of MDT conferences in urologic cancer practice. Clinical plans discussed in urologic MDT conferences in Centro Hospitalar Universitário de Lisboa Central between January 2019 and December 2019 were retrospectively analysed. Clinical plans were categorized as accepted, changed, rejected (cases that had to be re-presented to the MDT because of insufficient staging or administrative issues) or no plan. MDT conferences' impact was assessed according to type of consultation, referral medical specialty and primary tumour type. 710 clinical plans were discussed at the MDT conferences. 61.8% were accepted, 10.6% were changed, 16.5% were rejected and 11.1% of cases referred to MDT discussion had no defined clinical plan. First consultations had a higher rate of accepted clinical plans (63.4%) versus subsequent consultations (56.4%). Referrals by the urology specialty had the highest rate of acceptances (64.3%). On the stratification by primary tumour site, testicular cancer had the highest acceptance rate (70.3%), whereas bladder cancer had the lowest (47.8%). MDT conferences had an important impact in the management of 38.2% of cases. Therefore, all patients with urologic malignancies should be referred to MDT review to ensure optimal clinical care.

The results of pancreatic operations after the implementation of multidisciplinary team conference (MDT): A quality improvement study.

Centralization has improved the outcome of complex operations including cancer surgery. Moreover, the implementation of multidisciplinary team conferences (MDT) has ameliorated the decision making, but the impact on patient outcome is controversial. The aim of the study was to investigate the outcome of pancreatic surgery in the setting of centralization and upfront multidisciplinary decision making. The decisions of MDT from 2010 to 2016 and the outcome of operations were compared with operations from 2003 to 2009 before centralization of pancreatic surgery and implementation of MDT. Data were drawn from the department's database and from hospital's electronic patient files. From 2010 to 2016, 7.015 patients were evaluated at the MDT. In 72.6% of patients a treatment plan followed the first evaluation, the referral diagnosis was changed in 12.4% of cases. Of 3.362 solid neoplasms, 1.680 (50.0%) were evaluated as resectable and 1.080 (32.1%) patients were operated. The annual resection rate of operated patients was78.3%-88.5% (median 80.0%) compared to 21.4% to 80.% (median 68.6%, p=0.0001) from 2003 to 2009 with 279 operated patients. The post-operative 30 - and 90-days mortality from 2003 to 2009 and 2010 to 2016 was 3.4% vs. 1.8% (NS) and 5.0% vs 3.6% (NS). In the same periods explorative laparotomies and palliative resections decreased from 18.3% to 3.6% (p=0.0001) and 18.6%-10.2% (p=0.0002). The median survival of radically resected pancreatic adenocarcinoma (PAC) from 2003 to 2009 and from 2010 to 2016 was 20.2 and 21.9 months, respectively (p=0.687). The MDT increased patient flow, improved quality of decision-making and offered more patients surgical treatment without increasing morbidity or mortality. But an impact on the long-term survival of patients with PAC was not found.

Electromagnetic navigation bronchoscopy for lung nodule evaluation. Patient selection, diagnostic variables and safety.

Electromagnetic navigation bronchoscopy (ENB) is a relatively new technique to diagnose pulmonary lesions in patients with reduced lung function. Several parameters have been shown to affect diagnostic yield including patient selection. We performed a prospective registration of data on one hundred patients who consecutively underwent electromagnetic navigation bronchoscopy. Selection criteria, patient characteristics, lesion size, distance to pleura, location of the lesion and presence of bronchus sign on computed tomography were registered. Navigation was performed using the superDimension hardware and software system. Patients were referred to ENB from a multidisciplinary team conference. We did not use fluoroscopy, endobronchial ultrasound equipment, rapid onsite evaluation or general anesthesia during the procedure. All patients in whom no malignant diagnose was found were subsequently followed for two years in order to verify a benign nature of the pulmonary lesion. One hundred and nine ENB procedures were performed between September 2009 and November 2014. Overall diagnostic yield was 68%. Twenty seven of 49 malignant tumors were found by ENB leading to a sensitivity for malignancy of 55%. The sensitivity for malignancy was significantly higher for lesions in the upper and middle lobes compared to the lower lobes (P = 0.01). Lesions size, distance to pleura and presence of bronchus sign did not affect sensitivity. ENB is a safe diagnostic procedure in an everyday setting with an acceptable diagnostic yield even without addition of supportive diagnostic methods and offers a possibility to diagnose pulmonary nodules in patients for whom other diagnostic procedures are too hazardous or have proven unsuccessful.

The Results of Pancreatic Operations After the Implementation of Multidisciplinary Team Conference (MDT):

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The Johns Hopkins Neurosciences Intensive Care Nursery Tenth Anniversary (2009-2019): A Historical Reflection and Vision for the Future.

Since 2009, the Neurosciences Intensive Care Nursery at Johns Hopkins Children’s Center has provided a multidisciplinary approach toward the care of newborns with neurological disorders. The program’s cornerstone is an interdisciplinary approach that involves the primary neonatology team plus experts from more than 10 specialties who convene at a weekly team conference at which newborns with neurological problems are discussed in detail. This interdisciplinary approach fosters in-depth discussion of clinical issues to optimize the management of neonates with neurological problems as well as the opportunity to generate research ideas and provide education about neonatal neuroscience at all levels (faculty, nurses, and trainees). The purpose of this article is to provide a 10-year reflection of our Neurosciences Intensive Care Nursery with a view toward expanding efforts in the 3 areas of our mission: clinical care, research, and education. We hope that our experience will enhance the spread of neonatal neuroscience education, care, and research as widely as possible.

Reporting colon cancer staging using a template

PurposeThe purpose of this study was to evaluate the effect of completeness of the radiological reports in primary local staging colon cancer when using a template. MethodsThe study used primary staging reports retrieved from the departments RIS/PACS. Five key tumour descriptors were evaluated within each report: tumour morphology (polypoid or annular), information on tumour breach of the colon wall (≥ T3), tumour out-growth in mm, nodal status and TNM in conclusion. The failure to provide a description of the presence or absence of a feature in a report counted as ‘not reported’. To allow comparisons between reporting styles, the template or free-text style of reporting was also recorded. ResultsDuring a two year period, a total of 666 patients CT reports were evaluated at the colorectal center multidisciplinary team (MDT) conference. In 200 of these reports a template was used. Information on tumour morphology (polypoid or annular) was present in 81% of the template reports vs 9% in free-text style. The figures in percentage for information on tumour breach of the colon wall (≥ T3) were 93% vs 48 %, tumour out-growth in mm: 51% vs 17%, nodal status: 99% vs 86% and TNM in conclusion: 98% vs 51%. P < 0.0001. ConclusionThe present study provides additional support for the routine use of template reports to improve imaging reporting standards in colonic cancer.

Inter-Professional Communication Between Nursing Therapists and other Therapeutic Professions (Physio-, Occupation and Speech Therapy) in Neurological Early Rehabilitation

A comparison of inter-professional communication within the core therapeutic teams including nurses in 5 neurological early rehabilitation hospitals of one non-profit organization was supposed to indicate factors facilitating and impairing cooperation. Data collection was conducted through analysis of architecture plans, passive participating observation in 10 wards and through partly standardized interviews (N=39). Participants were nurses, physio-, occupational and speech therapists. Data analysis used the method of Thick Description [1]. A permanent team, daily team conferences, treatments in cooperation, ward based training and informal talks influence interprofessional communication. Organizational and structural preconditions have effects on the quality of communication. Daily inter-professional briefings and the organization of training sessions within the team improve inter-professional communication, a confrontation nurses vs. therapists impairs it.

Clinical impact of pre‐treatment FDG‐PET/CT staging of primary ovarian, fallopian tube, and peritoneal cancers in women

To assess the clinical impact of preoperative fludeoxyglucose (FDG) with positron emission tomography (PET) and computed tomography (CT) in women with ovarian, fallopian tube, or peritoneal cancer with focus on consequences of added findings (AFs). FDG-PET/CT was implemented as a standard imaging modality for women with newly diagnosed ovarian, fallopian tube, or peritoneal cancer at our institution in 2008. After full implementation, all preoperative scans were reviewed and AFs were evaluated from January 2011 to December 2012. Decisions regarding further examination made at the first multidisciplinary team conference were recorded. Subsequent procedures were tracked via medical records, and the impact of AFs on additional examinations, delay, and change in treatment plans was evaluated. Forty-four (21.1%) of 209 women presented with AFs. Further examination was performed in 35/44 (79.5%). Malignancy was identified in 15/35 (42.9%), revealing metastases from ovarian, fallopian tube, or peritoneal cancer in 11, a synchronous primary cancer in 3, and recurrence of a previous cancer in 1 woman. The ovarian, fallopian tube, or peritoneal cancer metastases were localized in the lungs, uterus, colon, vagina, and breasts. The remaining 20 AFs revealed 2 benign lesions and 1 pre-malignant lesion, whereas no abnormality was found in 17. Further examination of AFs resulted in a significant time delay until treatment start of median 4days (range 1-83days, P<0.004). Further examinations of AFs by FDG-PET/CT delayed time to start of treatment by median 4days in women with newly diagnosed ovarian, fallopian tube, or peritoneal cancer in a contemporary institution with fast-track access to additional diagnostics. The clinical implications of this must be balanced against the gain of detecting unrecognized malignancy in 15 of 209 women (7.2%).

The impact of comprehensive geriatric assessment for optimal treatment of older patients with cancer: A randomized parallel-group clinical trial

ObjectivesThe aim was to investigate if oncologic treatment decision based on G8 screening followed by comprehensive geriatric assessment (CGA) and a multidisciplinary team conference in patients with G8 ≤ 14 was better than treatment decision based on standard assessment. ClinicalTrials.gov Identifier: NCT02671994. Materials and MethodsFrom January 2016 to June 2018, 96 patients with cancer, aged ≥70 years, were included. Patients were randomized to treatment decision based on the oncologist's clinical judgement (control) or based on screening with G8. If G8 > 14 treatment decision was made as in the control group and if G8 ≤ 14, patients were referred to CGA including intervention as needed and treatment decision after a multidisciplinary team conference (MDT). ResultsThe study was closed early. 47 patients were randomized to the control group and 49 to the intervention group; 28 had a G8 ≤ 14, 24 of whom attended CGA. In the intervention group 48% completed treatment as planned compared to 54% in the control group (p = .208). Thirty-eight percent experienced grade 3–4 toxicity in the control group compared with only 20% in the intervention group (p = .055). Median overall survival (OS) was 14.2 months in the control group and 19.1 months in the intervention group (p = .911). Median progression-free survival (PFS) was 9.0 months in the control group and 7.8 months for the intervention group (p = .838). ConclusionTreatment decision based on G8 screening followed by CGA had no impact on completion rate of planned oncologic treatment, OS or PFS, but resulted in a borderline significant lower incidence of grade 3–4 toxicity.

Competency of aMCI patients to consent to cholinesterase treatment.

In medical practice, a patient's loss of competency is a major obstacle when choosing a treatment and a starting treatment program smoothly. A large number of studies have revealed the lack of medical competency in patients with dementia. However, there have been only a few reports focusing on the capacity of patients with mild cognitive impairment (MCI) to make a medical choice. In this study, we evaluated the competency of 40 patients with amnestic MCI (aMCI) and 33 normal subjects to make a medical choice using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). We compared the judgement of a team conference using the recorded semi-structured interview with the clinical judgement of a chief clinician. A team conference concluded that 12 aMCI patients had no competency, and the clinical judgement, without any special interview, judged that five aMCI patients had no competency. All subjects in the control groups were judged to be competent to consent to treatment by both clinicians and the team conference. Without supplementary tools such as explanatory documents, not a few patients with aMCI were judged by a team conference to have no competency to consent to therapy even in a relatively simple and easy case. In contrast, clinical physicians tended to evaluate the competency of aMCI patients in a generous manner.

Upfront PET/CT affects management decisions in patients with recurrent head and neck squamous cell carcinoma

PurposeTo compare multidisciplinary team conference (MDTC) decisions regarding treatment intent based on either chest X-ray + MRI of the head and neck (CXR/MRI) or 18F-FDG-PET/CT (PET/CT) in patients with recurrent head and neck squamous cell carcinoma (HNSCC). MethodsProspective blinded cohort study based on paired data. Consecutive patients with suspected recurrent HNSCC were invited to participate. All included patients underwent CXR/MRI and PET/CT before diagnostic biopsy. An ordinary MDTC using all available imaging data was conducted as per standard practice. After at least three months (to eliminate recall bias in the team), the first project MDTC, based on either CXR/MRI or PET/CT, was conducted, and the tumor board made conclusions regarding treatment. After an additional three months, a second project MDTC was conducted using the complementary imaging strategy. The separate treatment strategies were compared using McNemar’s test. ResultsA total of 110 patients (90 males and 20 females, median age 66 years, range 40–87) were included. The initial primary tumor originated from the pharynx in 56 (51%) patients, oral cavity in 17 (15%) patients, and larynx in 37 (34%) patients. Based on CXR/MRI, 87 patients (79%) were recommended curative treatment and 23 (21%) palliative treatment. Based on PET/CT, the MDTC decided that 52 (47%) patients were suitable for curative treatment and 58 (53%) for palliative treatment. The absolute difference of 32% was statistically significant (95% CI: 22–42%, p < 0.001). ConclusionsPET/CT affected MDTC decisions in patients with recurrent HNSCC towards less curative and more palliative treatment.

Abstract 103: Clinical Process and Outcome Improvements Based on Within Site Communication: Insights from the Patient Navigator Acute Myocardial Infarction and Heart Failure Program

Background: Team communication about hospital quality efforts in acute myocardial infarction and heart failure (AMI-HF) may affect compliance with hospital transitional care metrics. Methods: At 2 years, hospitals (n=35) participating in the Patient Navigator Program completed surveys on 5 types of communication (sharing meeting minutes, regular team meetings or conference calls with team leaders, a shared checklist, and electronic medical record (EMR)-directed communication) supporting program implementation. Results were assessed for association with 3 outcomes (30-day unadjusted AMI-HF readmission and in-hospital risk adjusted AMI death) and 14 processes: left ventricular systolic dysfunction evaluation, prescription of renin-angiotensin system and beta-blocker medications; identifying HF cases pre-discharge; medication reconciliation documentation on admission, discharge and both times [AMI-HF); planned follow-up in 7 days [HF]; documentation of self-care education and when to call healthcare providers [AMI-HF] and documentation of medication instructions, timing, and changes [AMI-HF]). In STEMI and NSTEMI, performance composites, overall defect free care and referral to cardiac rehabilitation were assessed. Univariate analyses were completed. Results: There were no differences in process or outcome metrics for sharing meeting minutes, regular team meetings or conference calls with leaders or using a shared checklist. EMR-directed communication was associated with a greater likelihood of discharge medication reconciliation (100% vs 68.4%, p =.027) and prescribed medication documentation, 100% vs 66.7%, p =.024). Sites that used 2-5 vs 0-1 communication types were more likely to identify patients with HF pre-discharge (100% vs 60%, p =.018), perform discharge medication reconciliation (100% vs 66.7%, p =.021), complete education documentation (93.3% vs 58.8%, p =.041) and medication instruction documentation (100% vs 64.7%, p=.019); but they were less likely to improve STEMI performance composite scores (37.5% vs 76.5%, p =.036). Conclusion: Team communication via EMR and using 2+ communication methods promoted some process metric improvements. Some communication methods may have had low use and process and outcome metrics that were unchanged may have been underpowered to detect differences.

A case report of OPLL patient with psychiatric problems managed with liaison team conference

A case report of OPLL patient with psychiatric problems managed with liaison team conference