Therapeutic Treatment Plan Research Articles

THE IMPACT OF NURSE–LED EDUCATION, ON QUALITY OF LIFE IN PATIENTS WITH HEART FAILURE DURING CARDIAC REHABILITATION: A REVIEW OF THE LITERATURE

Abstract Introduction The complex mosaic of cardiac rehabilitation (CR) in heart failure (HF) is composed of several "pieces": adherence to the rehabilitation program (Mazza & Paneroni, 2019), therapeutic education, improvement of perceived QoL and self–care (Deek et al., 2017). To improve the patient‘s QoL, however, it is imperative to position them at the focal point of the care process. Several studies, have documented the favorable impact of CR on QoL in HF patients (Conway et al., 2015). Although variations in therapeutic and rehabilitative treatment plans vary according to each stage of the disease, adopting lifestyle changes is a recommended strategy regardless of the stage of HF from which the person is affected (ACC/AHA 2005; Yancy et al., 2005). However, despite the evidence–based benefits of post–discharge interventions combined with patient education in HF patients, the specific impact and benefits of nurse–led patient education alone, independent of the broader health care system, remain still unclear. Objective This review aims to investigate the influence of the nurse‘s educational role on the quality of life of patients with HF in the setting of cardiac rehabilitation. Materials and Methods A comprehensive literature review was conducted using databases such as PubMed, Scopus, CIHNAL Complete and EMBASE. The review followed the PICO methodology, with the formulation of a research question. MeSH terms and keywords were combined using Boolean operators and inclusion criteria. The primary outcome of interest was improved QoL. Relevant articles were subjected to preliminary analysis on the Rayyan platform. They were first evaluated by title and abstract, then selected for full–text reading, and finally subjected to "quality appraisal". Results, Discussion and Conclusions Individuals with HF experience a decline in QoL and are at increased risk of poor prognosis, characterized by exacerbation episodes leading to frequent re–hospitalizations and increased mortality rates (Heo et al., 2009; Rechenberg et al., 2020; Freedland et al., 2021). Therefore, improving QoL in patients with HF is a priority from both care and organizational perspectives (Ades et al., 2013; Darkins et al., 2015). Notably, a tailored CR educational program helps to improve self–care management and, consequently, improve QoL. That highlights the importance of nurse–led CR for HF patients in improving health behaviors and adherence to therapeutic practices.

Data-driven Stochastic Model for Quantifying the Interplay Between Amyloid-beta and Calcium Levels in Alzheimer's Disease.

The abnormal aggregation of extracellular amyloid- in senile plaques resulting in calcium dyshomeostasis is one of the primary symptoms of Alzheimer's disease (AD). Significant research efforts have been devoted in the past to better understand the underlying molecular mechanisms driving deposition and dysregulation. Importantly, synaptic impairments, neuronal loss, and cognitive failure in AD patients are all related to the buildup of intraneuronal accumulation. Moreover, increasing evidence show a feed-forward loop between and levels, i.e. disrupts neuronal levels, which in turn affects the formation of . To better understand this interaction, we report a novel stochastic model where we analyze the positive feedback loop between and using ADNI data. A good therapeutic treatment plan for AD requires precise predictions. Stochastic models offer an appropriate framework for modelling AD since AD studies are observational in nature and involve regular patient visits. The etiology of AD may be described as a multi-state disease process using the approximate Bayesian computation method. So, utilizing ADNI data from 2-year visits for AD patients, we employ this method to investigate the interplay between and levels at various disease development phases. Incorporating the ADNI data in our physics-based Bayesian model, we discovered that a sufficiently large disruption in either metabolism or intracellular homeostasis causes the relative growth rate in both and , which corresponds to the development of AD. The imbalance of ions causes disorders by directly or indirectly affecting a variety of cellular and subcellular processes, and the altered homeostasis may worsen the abnormalities of ion transportation and deposition. This suggests that altering the balance or the balance between and by chelating them may be able to reduce disorders associated with AD and open up new research possibilities for AD therapy.

A View of an Adult Person with ADHD from the Standpoint of Transactional Analysis

The article examines attention deficit hyperactivity disorder from The point of view of Transactional Analysis, namely: what injunctions, drivers, script processes and adaptations adults with ADHD can possibly have. We considered how the symptoms of ADHD manifest themselves in childhood and transform in adulthood; what we, as therapists, will observe in our office, and how it will help to make the correct diagnosis.
 The article touches on the topic of the complexity of the diagnosis of ADHD due to its comorbidity. The question is raised whether a standard therapeutic treatment plan is suitable for neuroatypical (neurodiverse) people.The question is also raised about how the therapist and the client may not feel “OK” if both do not know that the client may have a neuroatypical brain, and as a result of this ignorance, they focus on the therapy of other disorders. In this case, the results of therapy may be insignificant, or symptoms may return again. In the presence of such markers, it is possible to make an assumption about the client’s neurodiversity and recommend that he or she undergo a diagnosis for ADHD, which will significantly increase the results of working with him or her.

P183 Disease activity, comorbidities and functional status predict treatment response to biologic and targeted synthetic disease-modifying anti-rheumatic drugs in psoriatic arthritis

Abstract Background/Aims Much discussion surrounds the optimal therapeutic treatment plan for biologic and targeted synthetic disease modifying anti-rheumatic drugs (bDMARDs/tsDMARDs) when treating psoriatic arthritis (PsA). The current study aims to identify predictors of treatment response among PsA patients initiating bDMARD/tsDMARD treatment, focusing on disease activity, functional status (Health Assessment Questionnaire, HAQ), and comorbidities. Methods The systematic review of clinical trials and observational studies used Medline, Embase and Cochrane databases. Eligible studies included full text papers with quantitative estimates of effect (or data to allow these to be computed). Papers also required a validated assessment of treatment response i.e., Minimal Disease Activity (MDA), or some other marker of treatment response such as treatment continuation. Case reports and conference abstracts were excluded. Results From 2824 articles identified, 27 were included. Across these, >15 different outcomes were used, and measured at > 10 different timepoints. There was consistent evidence to suggest that higher baseline disease activity was associated with a reduction in the likelihood of treatment response, see Table 1. Some studies reported up to 20% reduction in odds of LDA at 6 months associated with each 1 unit increase in DAPSA. Others demonstrated that patients with a high DAS28 (>3.2) experienced over a 90% reduction in the odds of MDA at 12 weeks. Eleven studies (from 15) demonstrated a significant association between baseline function and odds of treatment response. Each 1 unit increase in HAQ-DI decreased the odds of a good EULAR response at 3 months by up to 66%. The presence of comorbidities was also consistently associated with a decrease in treatment response. Studies showed that the presence of comorbidities at baseline lessened the odds of MDA at 6 months by up to 80%. Others reported that comorbidities were associated with a reduction in the odds of 5 year treatment persistence by up to 40%. Conclusion This review shows clear evidence of reduced bDMARD/tsDMARD response in PsA among patients with disease activity, poor function, and comorbidities. Clinicians should be aware of the reduced chances of treatment success and should consider early review of therapy, to consider whether treatment escalation or switching is required. Disclosure C. Addae-Kyereme: None. S. Lembke: None. G.J. Macfarlane: None. G.T. Jones: None.

Dentigerous cyst: proposal for a therapeutic algorithm and combined treatment plan

Included dental organs are associated with various jaws pathologies, among the most frequent are cysts, which are benign lesions that develop around the crowns from permanent teeth. The aim of this research is to propose a therapeutic algorithm and a treatment plan combined with two known techniques, in addition to describe clinical and radiographic findings and conservative therapeutic management. For this, gender and clinical diagnosis data were obtained from a series of 3 cases of dentigerous cyst, in which clinical, histological, radiographic characteristics and treatments used were described. In each case conservative surgical treatment was given accompanied by gauze soaked in nitrofurantoin. Because dentigerous cysts are the most common pathology associated with included dental organs, which can be detected in routine radiographic examinations, this must be corroborated with the histopathological study, allowing less invasive techniques, this work is based on a therapeutic algorithm and combined treatment plan, not only in children but also in adults, regardless of their size.

Establishment and Image based evaluation of a New Preclinical Rat Model of Osteoblastic Bone Metastases.

Bone remodeling is disrupted in the presence of metastases and can present as osteolytic, osteoblastic or a mixture of the two. Established rat models of osteolytic and mixed metastases have been identified changes in structural and tissue-level properties of bone. The aim of this work was to establish a preclinical rat model of osteoblastic metastases and characterize bone quality changes through image-based evaluation. Female athymic rats (n = 22) were inoculated with human breast cancer cells ZR-75-1 and tumor development tracked over 3-4 months with bioluminescence and in-vivo µCT imaging. Bone tissue-level stereological features were quantified on ex-vivo µCT imaging. Histopathology verified the presence of osteoblastic bone. Bone mineral density distribution was assessed via backscattered electron microscopy. Newly formed osteoblastic bone was associated with reduced mineral content and increased heterogeneity leading to an overall degraded bone quality. Characterizing changes in osteoblastic bone properties is relevant to pre-clinical therapeutic testing and treatment planning.

Posttraumatic Cognitions and Posttraumatic Stress Symptoms Among Young People Who Have Experienced Commercial Sexual Exploitation and Trafficking.

The impact of posttraumatic cognitions on the development and maintenance of posttraumatic stress symptoms (PTSS) is understudied among children and adolescents who have experienced commercial sexual exploitation/trafficking (CSE/T). The objectives of this study were to (1) explore posttraumatic cognitions among help-seeking young people aged 11-19 who have experienced CSE/T; (2) determine whether experiencing direct violence, witnessing violence, polyvictimization (ie, multiple exposures to different categories of potentially traumatic events), or demographic characteristics differentially affect whether these young people meet clinical criteria for posttraumatic cognitions using established cutoffs; and (3) explore associations between posttraumatic cognitions and PTSS among young people who have experienced CSE/T. This study is a secondary analysis of a baseline cross-sectional survey of 110 young people with substantiated CSE/T experiences who started trauma-focused cognitive behavioral therapy (mean [SD] age = 15.8 [1.5]) from August 1, 2013, through March 31, 2020, in a southeastern US state. We used descriptive statistics, adjusted modified Poisson regression, and adjusted linear regression to test study objectives. Fifty-seven of 110 (51.8%) young people aged 11-19 met clinical criteria for posttraumatic cognitions. Increased age and a greater number of trauma categories experienced were significantly associated with meeting clinical criteria for posttraumatic cognitions. On average, higher posttraumatic cognition scores were associated with higher PTSS scores, controlling for demographic characteristics (β = 0.95; 95% CI, 0.64-1.26). These findings underscore the importance of assessing comprehensive trauma history and PTSS of young people who have experienced CSE/T, with added usefulness of measuring cognitive appraisals to inform a therapeutic treatment plan. Measuring cognitive appraisals that may influence PTSS and therapeutic success can ensure an effective public health response for this population.

Croatian Models and Experience in First-Episode Psychosis Treatment

We have witnessed a significant push towards staging in medicine. That trend has not bypassed psychiatry, with realization that early phases of various disorders present the window for early intervention that is most likely to result in preserving every-day functionality and achieving favourable outcomes. First-episode psychosis programs have been developed in order to ensure adequate early interaction with psychiatric services, help achieve faster and quality remission, prevent relapses and ensure better long-term outcomes. There is still, however, no consensus on the format or the most appropriate intervention in the early-course psychosis. Patients in Zagreb, Croatia, are offered a number of first-episode psychosis programs, one of which is housed in the largest Croatian psychiatric institution, University Psychiatric Hospital Vrapce. Specialized early-course treatment model in Vrapce stemmed from first-episode inpatient unit established in 2004, and grew to present in its core integration of care across different organizational units, acuity levels, and specific patient needs. Recognizing that a significant number of first-episode patients first interact with psychiatric services through emergency units, Vrapce’s model fostered early interaction with specialized services staff starting with intensive and emergency care units, allowing for continuity of care and early recruitment into specialized services. Vertical integration meant inpatient acute and subacute units seamlessly linked with day hospital and outpatient services, creating the setting for earlier formation of therapeutic alliance and treatment plans, but also allowing for flexible entry points for users. COVID-19 pandemic, in addition to challenging the initial integrations of services, facilitated transfer of certain services into virtual space.DisclosureNo significant relationships.

Therapeutic Treatment Plan Optimization during the COVID-19 Pandemic: A Comprehensive Physicochemical Compatibility Study of Intensive Care Units Selected Drugs

Background: The SARS-CoV-2 pandemic has resulted in a dramatic rise of the demand for medical devices and drugs. In this context, an important shortage of programmable syringe pumps, used to administrate different drugs in intensive care units, was seen. The opportunity of administrating combinations of five intensive care units selected drugs (Sufentanil, Clonidine, Loxapine, Midazolam, and Ketamine) was considered. Methods: The drug mixtures were studied in a pure form or diluted in NaCl 0.9% or G5%. Twenty-six possible combinations of the five drugs were produced in glass vials or polypropylene syringes and stored at 25 °C for 14 days. The LC method was implemented to study drugs combinations in the presence of the degradation products. The clearness and pH were also monitored. Results: All the 26 possible combinations displayed adequate physicochemical stability at 25 °C: at least 3 days and 7 days, respectively, for the dilution in 0.9% NaCl or glucose 5%, and the pure drug products mixtures. Conclusions: The study provided sufficient stability results, covering the medication administration period of at least three days. The combination of more than two drugs offers the advantage of minimizing the individual doses and reduces unwanted side-effects. Hence, this study opens up the possibility of combining the five drugs in one single syringe, which is useful especially under the current circumstances associated with an important shortage of programmable syringe pumps and pharmaceuticals.

Aminoglycoside Therapy for Tuberculosis: Evidence for Ototoxicity among Tuberculosis Patients in Ghana.

Background: Hearing impairment (HI) is a major problem in Ghana; however, the few attempts at shedding light on its causes appear to overlook the adverse effects of some medications—a gap that this study sought to fill. Aminoglycoside therapy for tuberculosis (TB) treatment is one of these medications. Aim: The aim of this study was to establish the potential of aminoglycoside as a cause of hearing impairment among patients on anti-TB treatment. Method: This was a case–control study, involving patients receiving treatment for TB with aminoglycoside at the chest clinic of the Tema General Hospital and a control group of age- and gender-matched healthy volunteers. A structured questionnaire was administered to obtain the demographic data and case history of the participants. The hearing sensitivity of the participants was assessed using conventional pure tone audiometry and transient evoked otoacoustic emission tests. Results: A hearing loss prevalence of 20% (12/60) was found among patients receiving treatment for TB, with the intensity of impairment ranging from mild to severe. Hearing thresholds of patients receiving anti-TB medications were significantly elevated (p < 0.05) in comparison to the thresholds of the control group, especially at the high frequencies. Conclusion: This study shows that aminoglycoside therapy for tuberculosis may contribute to hearing impairment among tuberculosis patients in Ghana. Audiological management of these patients should therefore be an essential part of their therapeutic treatment plan.

Patient Monitoring Replacement Forecast

Patient monitors and monitoring systems are a staple for all healthcare facilities and healthcare delivery organizations. The continuous monitoring of patient parameters such as heart rate, heart electrical activity, oxygen saturation (Spo 2), blood pressure, temperature, and other specialty measurements is a common feature for the care and safety of patients. Patient monitoring systems must record, collect, and display physiological data accurately and in real time to support clinical decision making during treatment. Patient monitoring can be rigorously defined as “repeated or continuous observations or measurements of the patient, his or her physiological function, and the function of life support equipment, for the purpose of guiding management decisions, including when to make therapeutic interventions, and assessment of those interventions [Michael SM, Gardner RM. Decision Support Systems in Critical Care. Springer; 1994].” The data provided by patient monitors are used for a multitude of applications: it directly affects the diagnostic and therapeutic treatment plans for a patient, alerts care providers to potential life-threatening incidents, and provides insight on the control of connected life-support medical devices. Physiological monitors can be found everywhere within a hospital. Depending on the acuity of a department or their intended application, the complexity of the device can vary as to how many parameters are monitored, whether it is bedside (fixed), portable, or telemetry, and what other medical equipment directly communicate with the monitor. The most commonly known application of physiological monitoring is for unstable/critically ill patients in intensive care units and medical/surgical units. Monitoring is needed on patients in these areas who have compromised homeostatic systems, are suspected to have a life-threatening condition, or are at a high risk of developing a life-threatening condition. Outside the more common environments where patient monitors reside, they are also used during more specialized practices including labor and delivery, operating room procedures, and interhospital and intrahospital patient transport.

Abstract P009: A shared nearest neighbors approach for integrated, multi-platform networks and its application to the exploration of multiomics data from early-stage non-small cell lung cancers

Abstract Background: The ImmunogenomiC prOfiling of Non-small cell lung cancer (NSCLC) Project (ICON) represents an ambitious undertaking to comprehensively characterize immuno-genomic diversity in NSCLC across diverse platforms. The depth and breadth of this cohort presented a unique opportunity to develop a specialized method for multi-platform data integration and exploration, which can be broadly applied to forthcoming large-scale patient profiling studies. Such a holistic approach can unlock insights for therapeutic targets, biomarkers, and treatment plans by providing a more complete view of phenomena driving disease pathogenesis and evolution. Purpose: We developed a novel shared nearest neighbors (SNN) approach to create an integrated network of ICON’s multi-platform data and identified collections of closely related measurements within the resulting network tied to noteworthy patient characteristics, including recurrence and oncogenotype. Methods: The ICON dataset is derived from tumor and normal lung tissue samples collected from 150 patients at time of resection as well as blood samples collected then and at intervals during the year following. Tissue samples underwent RNA-sequencing (RNA-seq), whole exome sequencing, T-cell receptor sequencing, multiplex immunofluorescence for immune cells, and reverse phase protein array profiling; flow cytometry for immune cells was performed on tissue and blood samples. From these data, the ICON data network was built using an integrative approach based on the SNN algorithm in which genes were linked on the basis of their shared top correlates in orthogonal datasets. Results: The ICON data network currently includes over 20,000 genes linked by over 500,000 connections derived from correlations between RNA-seq and orthogonal platforms. We captured established associations between cancer-related genes and examined these along with new ones in the network. To do so, we used the InfoMap algorithm to extract more interpretable sub-networks, termed modules, from the ICON data network. Single sample gene set enrichment scores for each module were used in multivariate analysis to highlight modules linked to clinical characteristics of interest. As an example, we found modules significantly tied to disease recurrence. The most notable of these was strongly associated with metabolic pathways, and other modules associated with platelets and ion channels were also identified. The metabolic pathway module is being explored as a prognostic biomarker, underscoring the opportunites enabled by mining the network. Conclusions: Through the framework developed, we identified modules in the ICON data network significantly associated with important patient characteristics like recurrence and oncogenotype. We are validating the gene sets identified as potential biomarkers and are developing an interactive application to facilitate further mining of the network. Taken together, our SNN network-building approach enables the integration and exploration of patient data from diverse platforms. Citation Format: Stephanie T. Schmidt, Neal Akhave, Alexandre Reuben, Tina Cascone, Jianhua Zhang, Jun Li, Junya Fujimoto, Lauren A. Byers, Beatriz Sanchez-Espiridion, Lixia Diao, Jing Wang, Lorenzo Federico, Marie-Andree Forget, Daniel J McGrail, Annikka Weissferdt, Shiaw-Yih Lin, Younghee Lee, Natalie Vokes, Carmen Behrens, Ignacio I. Wistuba, Andrew Futreal, Ara Vaporciyan, Boris Sepesi, John V. Heymach, Chantale Bernatchez, Cara Haymaker, Jianjun Zhang, Christopher A. Bristow, Timothy P. Heffernan, Marcelo V. Negrao, Don L. Gibbons. A shared nearest neighbors approach for integrated, multi-platform networks and its application to the exploration of multiomics data from early-stage non-small cell lung cancers [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P009.

Therapeutically Targeting Cancers That Overexpress FOXC1: A Transcriptional Driver of Cell Plasticity, Partial EMT, and Cancer Metastasis.

Metastasis accounts for more than 90% of cancer related mortality, thus the most pressing need in the field of oncology today is the ability to accurately predict future onset of metastatic disease, ideally at the time of initial diagnosis. As opposed to current practice, what would be desirable is that prognostic, biomarker-based detection of metastatic propensity and heightened risk of cancer recurrence be performed long before overt metastasis has set in. Without such timely information it will be impossible to formulate a rational therapeutic treatment plan to favorably alter the trajectory of disease progression. In order to help inform rational selection of targeted therapeutics, any recurrence/metastasis risk prediction strategy must occur with the paired identification of novel prognostic biomarkers and their underlying molecular regulatory mechanisms that help drive cancer recurrence/metastasis (i.e. recurrence biomarkers). Traditional clinical factors alone (such as TNM staging criteria) are no longer adequately prognostic for this purpose in the current molecular era. FOXC1 is a pivotal transcription factor that has been functionally implicated to drive cancer metastasis and has been demonstrated to be an independent predictor of heightened metastatic risk, at the time of initial diagnosis. In this review, we present our viewpoints on the master regulatory role that FOXC1 plays in mediating cancer stem cell traits that include cellular plasticity, partial EMT, treatment resistance, cancer invasion and cancer migration during cancer progression and metastasis. We also highlight potential therapeutic strategies to target cancers that are, or have evolved to become, “transcriptionally addicted” to FOXC1. The potential role of FOXC1 expression status in predicting the efficacy of these identified therapeutic approaches merits evaluation in clinical trials.

Drug Repurposing for COVID-19 Treatment by Integrating Network Pharmacology and Transcriptomics.

Since coronavirus disease 2019 (COVID-19) is a serious new worldwide public health crisis with significant morbidity and mortality, effective therapeutic treatments are urgently needed. Drug repurposing is an efficient and cost-effective strategy with minimum risk for identifying novel potential treatment options by repositioning therapies that were previously approved for other clinical outcomes. Here, we used an integrated network-based pharmacologic and transcriptomic approach to screen drug candidates novel for COVID-19 treatment. Network-based proximity scores were calculated to identify the drug–disease pharmacological effect between drug–target relationship modules and COVID-19 related genes. Gene set enrichment analysis (GSEA) was then performed to determine whether drug candidates influence the expression of COVID-19 related genes and examine the sensitivity of the repurposing drug treatment to peripheral immune cell types. Moreover, we used the complementary exposure model to recommend potential synergistic drug combinations. We identified 18 individual drug candidates including nicardipine, orantinib, tipifarnib and promethazine which have not previously been proposed as possible treatments for COVID-19. Additionally, 30 synergistic drug pairs were ultimately recommended including fostamatinib plus tretinoin and orantinib plus valproic acid. Differential expression genes of most repurposing drugs were enriched significantly in B cells. The findings may potentially accelerate the discovery and establishment of an effective therapeutic treatment plan for COVID-19 patients.

FDG PET Hybrid Imaging.

Molecular imaging with positron emission tomography (PET) using tumour-seeking radiopharmaceuticals has gained wide acceptance in oncology with many clinical applications. The hybrid imaging modality PET/CT (computed tomography) allows assessing molecular as well as morphologic information at the same time. Therefore, PET/CT represents an efficient tool for whole-body staging and re-staging within one imaging modality. In oncology, the glucose analogue 18-F-fluorodeoxyglucose (FDG) is the most widely used PET/CT radiopharmaceutical in clinical routine. FDG PET and FDG PET/CT have been used for staging and re-staging of tumour patients in numerous studies. This chapter will discuss the use and the main indications of FDG PET/CT in oncology with special emphasis on lung cancer, lymphoma, head and neck cancer, melanoma and breast cancer (among other tumour entities). A review of the current literature is given with respect to primary diagnosis, staging and diagnosis of recurrent disease. Besides its integral role in diagnosis, staging and re-staging of disease in oncology, there is increasing evidence that FDG PET/CT can be used for therapy response assessment (possibly influencing therapeutic management and treatment planning) by evaluating tumour control, which will also be discussed in this chapter.

Developing a Black Feminist Analysis for Mental Health Practice: From Theory to Praxis

The use of a Black feminist therapeutic perspective represents an intellectual and practical effort to use racial consciousness to place the authentic reality of Black women at the center of the therapeutic process. From this space, participants formulate the therapeutic assessment, treatment plan, and goals. The ethos of therapy is shaped toward one that is more self-reflective about the limitations of one’s knowledge and ultimately more acknowledging of diversity. This article outlines a blueprint for the use of Black feminism in therapy by providing culturally congruent recommendations for therapists to develop their skills in practice with Black women.

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review.

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.

Multidisciplinary Approach to HCC Management: How Can This Be Done?

Multidisciplinary tumor boards have evolved to address the increasing complexity of cancer care management. Given that hepatocellular carcinoma (HCC) often arises in the setting of underlying cirrhosis, expert input from hepatologists alongside hepatobiliary and transplant surgeons, radiation oncologists, interventional and body radiologists, and medical oncologists has become increasingly important in order to offer patients appropriate cancer treatments. The MDLTB structure has evolved since the early 2000s to bring these specialists together at regularly scheduled meetings to develop a therapeutic treatment plan for HCC management. MDLTBs have reduced the time to treatment and improved patient satisfaction. Standardized documentation with common data elements has been recommended to ensure adequate communication from MDLTB to referring healthcare providers. Retrospective studies consistently highlight the frequency of changes in treatment plans after MDLTB review to better adhere to guideline recommended care. Despite several decades of MDLTBs implementation, few studies describe clinical outcomes associated with MDLTBs such as patient survival and cost benefits. More research is needed in this area to further justify the heavy use of resources that are needed to maintain MDLTBs. Development and use of a centralized database to store such information may assist with future studies of clinical outcomes and inform quality improvement projects.

The Role of Speech-Language Pathology in an Interdisciplinary Care Model for Persistent Symptomatology of Mild Traumatic Brain Injury.

The Marcus Institute for Brain Health (MIBH) provides interdisciplinary care for adults struggling with persistent effects of mild traumatic brain injury and accompanying changes in behavioral health, with specific emphases on Veterans and retired elite athletes. The cognitive, physical, and behavioral symptoms associated with mild traumatic brain injury are interrelated, with neurobiopsychosocial modeling encompassing the factors related to recovery from a traumatic brain injury. The diffuse impacts of chronic concussive injuries require multiple clinical providers to address the breadth of symptoms, facilitating both interdisciplinary and transdisciplinary care models. By implementing integrated practice units, patients receive advanced medical care, imaging, speech-language pathology, physical therapy, behavioral health, neuropsychology, and clinical pharmacy for a cohesive diagnostic and intervention plan. Nationally, speech-language pathologists report challenges with best-practice options for concussion, particularly in the domain of assessment practices. At the MIBH, speech-language pathologists begin their assessment with a structured clinical interview that focuses on patients' needs and concerns. Evaluation modalities focus on hearing, communication, and functional cognition to guide therapeutic treatment planning. The intensive outpatient care program at MIBH incorporates both individual sessions targeting patient-centered goals and group care, where speech-language pathologists work transdisciplinarily to generalize care from all disciplines out into the community. Care practices for concussive injuries continue to evolve rapidly; speech-language pathology at the MIBH offers one such vision for excellence in clinical care.

Novel presentations of periodic fever syndromes: Discrepancies between genetic and clinical diagnoses.

ObjectiveThe Periodic fever syndromes (PFS) are a group of disorders of the innate immune system. We investigated patients diagnosed with PFS at the Dartmouth Hitchcock Pediatric Rheumatology Clinic.MethodsCase acquisition was performed by reviewing ICD 9/10 coded records for familial Mediterranean fever (ICD 9 277.31), laboratory test records for PFS genetic screening, and clinic records between 1/1/2011 and 12/31/2017.ResultsTwenty-seven cases had clinical evaluations including PFS genetic screening. Clinical diagnoses included familial Mediterranean fever (FMF) (10 cases), Muckle-Wells (2 cases), tumor necrosis factor receptor associated periodic syndrome (TRAPS) (4 cases), hyper IgD syndrome (HIDS) (1 case), Crohn’s Disease (1 case), systemic onset juvenile idiopathic arthritis (SoJIA) (1 case), fever of unknown origin (FUO) (1 case), periodic fever adenitis pharyngitis aphthous ulcer (PFAPA) (6 cases), and cold-induced urticaria (1 case). Fifteen cases were associated with a genetic cause. Seven of the 10 FMF cases were confirmed genetically and were either heterozygous or compound heterozygotes. Both cases of Muckle-Wells had either a compound heterozygote for CIAS 1 or a NOD gene mutation. Both TRAPS cases presented atypically with patients developing systemic lupus erythematosus (SLE) or being asymptomatic. Two patients had novel syndromes. One FMF patient had a TRNT1 gene mutation who responded to intravenous immunoglobulin (IVIg) and colchicine after failing multiple treatments. The other had SoJIA with a LPIN 2 gene mutation but responded to colchicine. Only one of the 15 genetically proven cases had classical presentation and genetics (HIDS secondary to a mevalonate kinase (MVK) gene mutation).ConclusionPFS screening was helpful in over half of the cases to develop therapeutic treatment plans. Given the atypical clinical presentations seen with genetically determined PFS, extensive genetic testing is indicated for all patients presenting with a PFS, excluding classical PFAPA syndrome.