Multidisciplinary team meetings and their impact on workflow in radiology and pathology departments

<p>Abstract</p> <p>Background</p> <p>The development of multidisciplinary team meetings (MDTMs) for radiology and pathology is a burgeoning area that increasingly impacts on work processes in both of these departments. The aim of this study was to examine work processes and quantify the time demands on radiologists and pathologists associated with MDTM practices at a large teaching hospital. The observations reported in this paper reflect a general trend affecting hospitals and our conclusions will have relevance for others implementing clinical practice guidelines.</p> <p>Methods</p> <p>For one month, all work related to clinical meetings between pathology and radiology with clinical staff was documented and later analysed.</p> <p>Results</p> <p>The number of meetings to which pathology and radiology contribute at a large university teaching hospital, ranges from two to eight per day, excluding grand rounds, and amounts to approximately 50 meetings per month for each department. For one month, over 300 h were spent by pathologists and radiologists on 81 meetings, where almost 1000 patients were discussed. For each meeting hour, there were, on average, 2.4 pathology hours and 2 radiology hours spent in preparation. Two to three meetings per week are conducted over a teleconferencing link. Average meeting time is 1 h. Preparation time per meeting ranges from 0.3 to 6 h for pathology, and 0.5 to 4 for radiology. The review process in preparation for meetings improves internal quality standards. Materials produced externally (for example imaging) can amount to almost 50% of the material to be reviewed on a single patient. The number of meetings per month has increased by 50% over the past two years. Further increase is expected in both the numbers and duration of meetings when scheduling issues are resolved. A changing trend in the management of referred patients with the development of MDTMs and the introduction of teleconferencing was noted.</p> <p>Conclusion</p> <p>Difficulties are being experienced by pathology and radiology departments participating fully in several multidisciplinary teams. Time spent at meetings, and in preparation for MDTMs is significant. Issues of timing and the coordination of materials to be reviewed are sometimes irreconcilable. The exchange of patient materials with outside institutions is a cause for concern when full data are not made available in a timely fashion. The process of preparation for meetings is having a positive influence on quality, but more resources are needed in pathology and radiology to realise the full benefits of multidisciplinary team working.</p

Multidisciplinary cancer care in Spain, or when the function creates the organ: qualitative interview study

Background The Spanish National Health System recognised multidisciplinary care as a health priority in 2006, when a national strategy for promoting quality in cancer care was first published. This institutional effort is being implemented on a co-operative basis within the context of Spain's decentralised health care system, so a high degree of variability is to be expected. This study was aimed to explore the views of professionals working with multidisciplinary cancer teams and identify which barriers to effective team work should be considered to ensure implementation of health policy. Methods Qualitative interview study with semi-structured, one-to-one interviews. Data were examined inductively, using content analysis to generate categories and an explanatory framework. 39 professionals performing their tasks, wholly or in part, in different multidisciplinary cancer teams were interviewed. The breakdown of participants' medical specialisations was as follows: medical oncologists (n = 10); radiation oncologists (n = 8); surgeons (n = 7); pathologists or radiologists (n = 6); oncology nurses (n = 5); and others (n = 3). Results Teams could be classified into three models of professional co-operation in multidisciplinary cancer care, namely, advisory committee, formal co-adaptation and integrated care process. The following barriers to implementation were posed: existence of different gateways for the same patient profile; variability in development and use of clinical protocols and guidelines; role of the hospital executive board; outcomes assessment; and the recording and documenting of clinical decisions in a multidisciplinary team setting. All these play a key role in the development of cancer teams and their ability to improve quality of care. Conclusion Cancer team development results from an specific adaptation to the hospital environment. Nevertheless, health policy plays an important role in promoting an organisational approach that changes the way in which professionals develop their clinical practice

Multidisciplinary cancer care in Spain, or when the function creates the organ: qualitative interview study

Background The Spanish National Health System recognised multidisciplinary care as a health priority in 2006, when a national strategy for promoting quality in cancer care was first published. This institutional effort is being implemented on a co-operative basis within the context of Spain's decentralised health care system, so a high degree of variability is to be expected. This study was aimed to explore the views of professionals working with multidisciplinary cancer teams and identify which barriers to effective team work should be considered to ensure implementation of health policy. Methods Qualitative interview study with semi-structured, one-to-one interviews. Data were examined inductively, using content analysis to generate categories and an explanatory framework. 39 professionals performing their tasks, wholly or in part, in different multidisciplinary cancer teams were interviewed. The breakdown of participants' medical specialisations was as follows: medical oncologists (n = 10); radiation oncologists (n = 8); surgeons (n = 7); pathologists or radiologists (n = 6); oncology nurses (n = 5); and others (n = 3). Results Teams could be classified into three models of professional co-operation in multidisciplinary cancer care, namely, advisory committee, formal co-adaptation and integrated care process. The following barriers to implementation were posed: existence of different gateways for the same patient profile; variability in development and use of clinical protocols and guidelines; role of the hospital executive board; outcomes assessment; and the recording and documenting of clinical decisions in a multidisciplinary team setting. All these play a key role in the development of cancer teams and their ability to improve quality of care. Conclusion Cancer team development results from an specific adaptation to the hospital environment. Nevertheless, health policy plays an important role in promoting an organisational approach that changes the way in which professionals develop their clinical practice

Most bowel cancer symptoms do not indicate colorectal cancer and polyps: a systematic review

<p>Abstract</p> <p>Background</p> <p>Bowel symptoms are often considered an indication to perform colonoscopy to identify or rule out colorectal cancer or precancerous polyps. Investigation of bowel symptoms for this purpose is recommended by numerous clinical guidelines. However, the evidence for this practice is unclear. The objective of this study is to systematically review the evidence about the association between bowel symptoms and colorectal cancer or polyps.</p> <p>Methods</p> <p>We searched the literature extensively up to December 2008, using MEDLINE and EMBASE and following references. For inclusion in the review, papers from cross sectional, case control and cohort studies had to provide a 2×2 table of symptoms by diagnosis (colorectal cancer or polyps) or sufficient data from which that table could be constructed. The search procedure, quality appraisal, and data extraction was done twice, with disagreements resolved with another reviewer. Summary ROC analysis was used to assess the diagnostic performance of symptoms to detect colorectal cancer and polyps.</p> <p>Results</p> <p>Colorectal cancer was associated with rectal bleeding (AUC 0.66; LR+ 1.9; LR- 0.7) and weight loss (AUC 0.67, LR+ 2.5, LR- 0.9). Neither of these symptoms was associated with the presence of polyps. There was no significant association of colorectal cancer or polyps with change in bowel habit, constipation, diarrhoea or abdominal pain. Neither the clinical setting (primary or specialist care) nor study type was associated with accuracy.</p> <p>Most studies had methodological flaws. There was no consistency in the way symptoms were elicited or interpreted in the studies.</p> <p>Conclusions</p> <p>Current evidence suggests that the common practice of performing colonoscopies to identify cancers in people with bowel symptoms is warranted only for rectal bleeding and the general symptom of weight loss. Bodies preparing guidelines for clinicians and consumers to improve early detection of colorectal cancer need to take into account the limited value of symptoms.</p

The effectiveness of psychosocial interventions for anxiety in children and adolescents with autism spectrum disorder:a systematic review and meta-analysis

Anxiety is a common problem in children and adolescents with autism spectrum disorder (ASD). This meta-analysis aimed to systematically evaluate the evidence for the use of psychosocial interventions to manage anxiety in this population. Cognitive behavioural therapy (CBT) was the primary intervention modality studied. A comprehensive systematic search and study selection process was conducted. Separate statistical analyses were carried out for clinician-, parent-, and self-reported outcome measures. Sensitivity analyses were conducted by removing any outlying studies and any studies that did not use a CBT intervention. A subgroup analysis was performed to compare individual and group delivery of treatment. Ten randomised control trials involving a total of 470 participants were included. The overall SMD was d = 1.05 (95 % CI 0.45, 1.65; z = 3.45, p = 0.0006) for clinician- reported outcome measures; d = 1.00 (95%CI 0.21, 1.80; z = 2.47, p = 0.01) for parent-reported outcome measures; and d = 0.65 (95%CI -0.10, 1.07; z = 1.63, p = 0.10) for self-reported outcome measures. Clinician- and parent-reported outcome measures showed that psychosocial interventions were superior to waitlist and treatment-as-usual control conditions at post-treatment. However, the results of self-reported outcome measures failed to reach significance. The sensitivity analyses did not significantly change these results and the subgroup analysis indicated that individual treatment was more effective than group treatment. The main limitations of this review were the small number of included studies as well as the clinical and methodological variability between studies

Role of anatomical sites and correlated risk factors on the survival of orthodontic miniscrew implants:a systematic review and meta-analysis

Abstract Objectives The aim of this review was to systematically evaluate the failure rates of miniscrews related to their specific insertion site and explore the insertion site dependent risk factors contributing to their failure. Search methods An electronic search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Knowledge, Scopus, MEDLINE and PubMed up to October 2017. A comprehensive manual search was also performed. Eligibility criteria Randomised clinical trials and prospective non-randomised studies, reporting a minimum of 20 inserted miniscrews in a specific insertion site and reporting the miniscrews’ failure rate in that insertion site, were included. Data collection and analysis Study selection, data extraction and quality assessment were performed independently by two reviewers. Studies were sub-grouped according to the insertion site, and the failure rates for every individual insertion site were analysed using a random-effects model with corresponding 95% confidence interval. Sensitivity analyses were performed in order to test the robustness of the reported results. Results Overall, 61 studies were included in the quantitative synthesis. Palatal sites had failure rates of 1.3% (95% CI 0.3–6), 4.8% (95% CI 1.6–13.4) and 5.5% (95% CI 2.8–10.7) for the midpalatal, paramedian and parapalatal insertion sites, respectively. The failure rates for the maxillary buccal sites were 9.2% (95% CI 7.4–11.4), 9.7% (95% CI 5.1–17.6) and 16.4% (95% CI 4.9–42.5) for the interradicular miniscrews inserted between maxillary first molars and second premolars and between maxillary canines and lateral incisors, and those inserted in the zygomatic buttress respectively. The failure rates for the mandibular buccal insertion sites were 13.5% (95% CI 7.3–23.6) and 9.9% (95% CI 4.9–19.1) for the interradicular miniscrews inserted between mandibular first molars and second premolars and between mandibular canines and first premolars, respectively. The risk of failure increased when the miniscrews contacted the roots, with a risk ratio of 8.7 (95% CI 5.1–14.7). Conclusions Orthodontic miniscrew implants provide acceptable success rates that vary among the explored insertion sites. Very low to low quality of evidence suggests that miniscrews inserted in midpalatal locations have a failure rate of 1.3% and those inserted in the zygomatic buttress have a failure rate of 16.4%. Moderate quality of evidence indicates that root contact significantly contributes to the failure of interradicular miniscrews placed between the first molars and second premolars. Results should be interpreted with caution due to methodological drawbacks in some of the included studies

Antiangiogenic therapy for breast cancer

Angiogenesis is an important component of cancer growth, invasion and metastasis. Therefore, inhibition of angiogenesis is an attractive strategy for treatment of cancer. We describe existing clinical trials of antiangiogenic agents and the challenges facing the clinical development and optimal use of these agents for the treatment of breast cancer. Currently, the most promising approach has been the use of bevacizumab, a humanized monoclonal antibody directed against the most potent pro-angiogenic factor, vascular endothelial growth factor (VEGF). Small molecular inhibitors of VEGF tyrosine kinase activity, such as sorafenib, appear promising. While, the role of sunitinib and inhibitors of mammalian target of rapamycin (mTOR) in breast cancer has to be defined. Several unanswered questions remain, such as choice of drug(s), optimal duration of therapy and patient selection criteria