Implementation of malignant bowel obstruction multidisciplinary case conferences (MCCs) to improve clinical decision making in malignant bowel obstruction (MBO) in gynecologic oncology.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18322-e18322
Author(s):  
Gita Bhat ◽  
Ainhoa Madariaga ◽  
Luisa Bonilla ◽  
Yeh Chen Lee ◽  
Neesha C. Dhani ◽  
...  
Keyword(s):  
Decision Making ◽  
Interventional Radiology ◽  
Bowel Obstruction ◽  
Clinical Management ◽  
Clinical Decision Making ◽  
Gynecologic Oncology ◽  
Clinical Decision ◽  
Management Plan ◽  
Malignant Bowel Obstruction ◽  
Cancer Centre

e18322 Background: Though patients (pts) with gynecological cancer are at higher risk of MBO, clinical management is not well defined. We implemented a coordinated team approach to evaluate MBO at Princess Margaret Cancer Centre. The Princess Margaret Cancer Centre inter-professional MBO management program includes nurse led ambulatory symptom management, inpatient treatment algorithm, patient directed bowel management education & MCCs. This study evaluates the utility of MBO MCC on clinical decision making in gynecologic oncology. Methods: Monthly MBO MCCs are conducted to discuss complex clinical management issues. A clinical summary is presented prior to the discussion with each case incorporating radiology review followed by interdisciplinary discussion. In this study, the initial management plan was compared to post-MCC consensus. A change in plan was defined as a consensus plan different from the pre-MCC plan or no definite plan prior to MCC. Barriers to implementation of the consensus were analyzed. Results: From December 2016 to November 2018, 90 pts were discussed in 22 MCCs. Of these, 60 had high grade serous ovarian carcinoma (67%) & 64 had small bowel obstruction (71%). Discussion in MCCs lead to a change in management plan in 49 cases(54%). These changes included recommendations for palliative surgery (25%) or radiation (10%), interventional radiology (23%), pharmacologic management alone (14%), imaging studies (4%) & total parenteral nutrition (TPN) (4%). Chemotherapy continuation, break or regimen changes were recommended in 20%. MCC consensus plan could not be implemented in 11 cases (23%). The barriers were refusal of surgery (8%), interventional radiology procedures (2%), TPN (4%) by patients, functional decline (6%) & inability to create a colostomy due to dense adhesions (2%). During MCC referrals to the dietitian & palliative care team were planned for 16 (18%) & 22 (24%) pts respectively. Conclusions: Interdisciplinary MBO MCCs have a significant impact on decision making in complex MBO cases. Radiology review & group discussion facilitates greater clarity in formulation of a management plan.

scholarly journals P418 Does capsule endoscopy impact clinical management in established Crohn’s Disease?

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S423-S424
Author(s):  
A Elosua Gonzalez ◽  
M Rullan Iriarte ◽  
S Rubio Iturria ◽  
S Oquiñena Legaz ◽  
C Rodríguez Gutiérrez ◽  
...  
Keyword(s):  
Decision Making ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Capsule Endoscopy ◽  
Clinical Management ◽  
Clinical Decision Making ◽  
Real Life ◽  
Clinical Decision ◽  
Mucosal Inflammation ◽  
Therapeutic Impact

Abstract Background Capsule endoscopy (SBCE) has developed a relevant role in different indications in patients with established Crohn’s Disease (CD). However, evaluation of its impact in clinical management in CD specific modification strategies has been scarce. The purpose of our study was to question therapeutic impact of SBCE in an 11-year real-life cohort of established CD patients. Methods Retrospective single center study including all consecutive patients with CD submitted to SBCE from January 2008 to December 2019. Small bowel patency was evaluated with patency capsule in selected patients. A conclusive procedure was defined as the one that allowed clinical decision-making. Mucosal inflammation was graded as mild (few aphtoid ulcers), moderate (multiple aphtoid ulcers/isolated deep ulcers) or severe (multiple deep ulcers/stenosis). Therapeutic impact was defined as a change in CD related treatment including escalation, de-escalation, dose adjustment or referral to surgery recommended based on SBCE results within the next 3 months after the SBCE. Patients were assigned to four groups regarding CE indication: staging, flare, post-op and remission (fig 1). Results From the 432 CE performed, 378 (87.5%) were conclusive and allowed clinical decision-making. SBCE results guided changes in 51.3% of patients: 199 (46.1%) with escalation and 23 (5.3%) with de-escalation of treatment. Active disease was present in 310 (71.8%) patients; 131 (30.3%) presented mild, 126 (29.2%) moderate and 53 (12.3%) severe activity. Disease activity demonstrated by SBCE correlated with therapeutic changes. With mild activity 24.1% increased therapy, whereas 77.8% and 84.9% increased therapy with moderate or severe disease, respectively (p<0.001). De-escalation was conducted in 12.8% patients with mucosal healing and 6.1% with mild disease but not in moderate or severe activity (p<0.001). Treatment before and after SBCE is shown in the table. Conclusion SBCE is a safe and useful tool when approaching established CD patients guiding therapeutic management in a real-life setting. Its positive impact does not limit to treatment escalation but also helps to de-escalate in patients who can benefit from it.

Molecular Diagnostics in Pediatric Brain Tumors: Impact on Diagnosis and Clinical Decision-Making — A Selected Case Series

2018 ◽  
Vol 230 (06) ◽  
pp. 305-313 ◽  
Author(s):  
Heidi Bächli ◽  
Jonas Ecker ◽  
Cornelis van Tilburg ◽  
Dominik Sturm ◽  
Florian Selt ◽  
...  
Keyword(s):  
Decision Making ◽  
Molecular Diagnostics ◽  
Clinical Management ◽  
Clinical Decision Making ◽  
Case Series ◽  
Clinical Decision ◽  
Cns Tumors ◽  
Molecular Testing ◽  
Cancer Predisposition Syndrome ◽  
Pediatric Cns Tumors

AbstractCentral nervous system (CNS) tumors account for the highest mortality among pediatric malignancies. Accurate diagnosis is essential for optimal clinical management. The increasing use of molecular diagnostics has opened up novel possibilities for more precise classification of CNS tumors. We here report a single-institutional collection of pediatric CNS tumor cases that underwent a refinement or a change of diagnosis after completion of molecular analysis that affected clinical decision-making including the application of molecularly informed targeted therapies. 13 pediatric CNS tumors were analyzed by conventional histology, immunohistochemistry, and molecular diagnostics including DNA methylation profiling in 12 cases, DNA sequencing in 8 cases and RNA sequencing in 3 cases. 3 tumors had a refinement of diagnosis upon molecular testing, and 6 tumors underwent a change of diagnosis. Targeted therapy was initiated in 5 cases. An underlying cancer predisposition syndrome was detected in 5 cases. Although this case series, retrospective and not population based, has its limitations, insight can be gained regarding precision of diagnosis and clinical management of the patients in selected cases. Accuracy of diagnosis was improved in the cases presented here by the addition of molecular diagnostics, impacting clinical management of affected patients, both in the first-line as well as in the follow-up setting. This additional information may support the clinical decision making in the treatment of challenging pediatric CNS tumors. Prospective testing of the clinical value of molecular diagnostics is currently underway.

Integration of germline multigene panel testing into breast and gynecologic oncology clinics.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 164-164
Author(s):  
Mariella Tejada ◽  
June YiJuan Hou ◽  
Katherine D. Crew ◽  
Melissa Kate Accordino ◽  
Kevin Kalinsky ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Decision Making ◽  
Genetic Testing ◽  
Clinical Decision Making ◽  
Genetic Test ◽  
Gynecologic Oncology ◽  
Clinical Decision ◽  
Test Results ◽  
Panel Testing ◽  
Genetic Test Results

164 Background: Germline genetic testing plays an important role in informing cancer screening and risk-reducing strategies, as well as treatment decisions with PARP inhibitors for BRCA-associated malignancies. Referrals to clinical genetics for pre-test counseling and results disclosure can be delayed due to financial and logistical barriers, which may ultimately delay clinical decision-making. Our study objective was to understand patient attitudes, knowledge, and anxiety/distress with point-of-care (POC) genetic testing in breast and gynecologic oncology clinics. Methods: We enrolled patients with early-stage breast cancer undergoing neoadjuvant treatment, metastatic breast cancer, ovarian cancer, or endometrial cancer undergoing POC multigene panel testing with their primary oncologist, rather than a genetic counselor. Pre-test counseling came from discussion with their primary oncologist. Participants completed a survey at time of genetic testing and one after return of genetic test results. Validated measures of genetic testing knowledge, cancer-related distress, and attitudes towards genetic testing were included. Descriptive statistics were generated for all data collected and paired t-tests were conducted for baseline and follow-up comparisons. Results: We enrolled 106 subjects, of which 97 completed the baseline survey. All participants were female with a mean age of 61.5 years (SD 13.5). The cohort consisted of participants with the following tumor types: 80 breast, 2 ovarian, and 16 endometrial. Almost 44% of women identified as Hispanic/Latina, 55% had highest level of education of community/technical college or less, and 51.2% reported annual incomes of less than $50,000. Forty-seven percent of participants had adequate baseline genetic testing knowledge scores (defined as at least 50% correct responses). A majority of participants (86.6%) had positive attitudes toward undergoing genetic testing. Results of genetic testing revealed 11 participants (11.3%) with pathogenic or likely pathogenic variants (of which 36.3% were in BRCA1/2), 25 (25.8%) with variants of unknown significance (VUS), and 61 (62.9%) with benign or likely benign results. The mean cancer-related distress score (scale from 15 to 60, higher score indicates higher levels of distress) was 32.78 (SD 9.74) at baseline and 26.5 (SD 8.9) after receiving genetic testing results (p = 0.002). Genetic test results informed cancer treatment decisions regarding medications and surgery in 15% and 13% of patients, respectively, the majority of which were breast cancer patients. Conclusions: As genetic testing is more frequently used for clinical decision-making it is important to develop ways to efficiently integrate POC testing in the oncology clinics. We demonstrated that POC genetic testing for breast and gynecologic cancers is feasible and can inform clinical decision-making.

The junior doctor's virtual consulting room

2007 ◽  
Vol 13 (1_suppl) ◽  
pp. 65-67 ◽  
Author(s):  
Eleanor Wood ◽  
Alexandra Rankin ◽  
Pasquale Berlingieri ◽  
Owen Epstein
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Management Plan ◽  
Direct Access ◽  
Knowledge Use ◽  
Patient Journey ◽  
Web Based ◽  
Final Destination ◽  
Specialist Knowledge

We assessed the usability of the Virtual Consulting Room (VCR), a Web-based guidance application providing direct access to specialist knowledge. The VCR guides the user through the patient journey from first presentation to final destination. Four pre-registration house officers (PRHOs) were informed of the availability of the VCR which was accessible from all ward computers at the Royal Free Hospital. During a six-week study, 52 patients were assessed by four PRHOs. The VCR was accessed for all 52 patients. A questionnaire was completed in 49 cases (94%). In 43 of the 49 cases (88%), the PRHOs reported that the VCR supported clinical decision-making, and in 46 cases (94%) it improved their knowledge. Use of the VCR altered the PRHOs investigations in 24 cases (49%), changed the management plan in 18 cases (37%) and the decision to refer in 10 cases (20%). The present study showed that the VCR was easy to use, educational, supported clinical decision-making and affected patient management.

scholarly journals Impact on Clinical Decision Making of Next-Generation Sequencing in Pediatric Epilepsy in a Tertiary Epilepsy Referral Center

2019 ◽  
Vol 51 (1) ◽  
pp. 61-69 ◽  
Author(s):  
Hannes Hoelz ◽  
Christian Herdl ◽  
Lucia Gerstl ◽  
Moritz Tacke ◽  
Katharina Vill ◽  
...  
Keyword(s):  
Decision Making ◽  
Genetic Testing ◽  
Next Generation Sequencing ◽  
Clinical Management ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Pediatric Epilepsy ◽  
Next Generation ◽  
The Impact ◽  
Generation Sequencing

Background. Next-generation sequencing (NGS) describes new powerful techniques of nucleic acid analysis, which allow not only disease gene identification diagnostics but also applications for transcriptome/methylation analysis and meta-genomics. NGS helps identify many monogenic epilepsy syndromes. Pediatric epilepsy patients can be tested using NGS epilepsy panels to diagnose them, thereby influencing treatment choices. The primary objective of this study was to evaluate the impact of genetic testing on clinical decision making in pediatric epilepsy patients. Methods. We completed a single-center retrospective cohort study of 91 patients (43 male) aged 19 years or less undergoing NGS with epilepsy panels differing in size ranging from 5 to 434 genes from October 2013 to September 2017. Results. During a mean time of 3.6 years between symptom onset and genetic testing, subjects most frequently showed epileptic encephalopathy (40%), focal epilepsy (33%), and generalized epilepsy (18%). In 16 patients (18% of the study population), “pathogenic” or “likely pathogenic” results according to ACMG criteria were found. Ten of the 16 patients (63%) experienced changes in clinical management regarding their medication and avoidance of further diagnostic evaluation, that is, presurgical evaluation. Conclusion. NGS epilepsy panels contribute to the diagnosis of pediatric epilepsy patients and may change their clinical management with regard to both preventing unnecessary and potentially harmful diagnostic procedures and management. Thus, the present data support the early implementation in order to adopt clinical management in selected cases and prevent further invasive investigations. Given the relatively small sample size and heterogeneous panels a larger prospective study with more homogeneous panels would be helpful to further determine the impact of NGS on clinical decision making.

Multidisciplinary cancer care

2016 ◽  
pp. 196-208
Author(s):  
David N. Church ◽  
Rachel Kerr ◽  
David J. Kerr
Keyword(s):  
Decision Making ◽  
Patient Outcomes ◽  
Multidisciplinary Team ◽  
Cancer Care ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Healthcare Systems ◽  
Management Plan ◽  
Therapeutic Options ◽  
Western World

Over the last two decades, multidisciplinary team (MDT) working has become an integral part of cancer care in many healthcare systems in the Western world. MDT meetings were established as part of an effort to reduce the fragmented provision of cancer care, and to ensure that each patient receives a management plan based on expert consensus following consideration of all appropriate therapeutic options. Although limited, the available evidence indicates that MDT working is associated with improved patient outcomes, though the associated costs are significant. MDTs are likely to evolve over the coming years through the development of specific software tools to aid clinical decision-making, and through the incorporation of tumour genomics and the personalization of therapy this enables.

scholarly journals Real-World Use of Azathioprine Metabolites Changes Clinical Management of Inflammatory Bowel Disease

2020 ◽  
Author(s):  
Laura Wilson ◽  
Stephanie Tuson ◽  
Lufang Yang ◽  
Dustin Loomes
Keyword(s):  
Decision Making ◽  
Clinical Management ◽  
Chart Review ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Routine Care ◽  
Therapeutic Drug ◽  
Toxicity Monitoring ◽  
Inflammatory Bowel ◽  
Poor Efficacy

Abstract Background Thiopurines such as 6-mercaptopurine and azathioprine have complex metabolism, resulting in significant inter-individual differences in clinical efficacy and risk of drug toxicity, making conventional weight-based dosing inaccurate and potentially unsafe. Therapeutic drug monitoring (TDM) of thiopurine metabolites improves clinical outcomes through dose optimization and toxicity monitoring. Despite evidence for TDM, use is limited, due in part to test availability and awareness. The objectives of this study were twofold: (1) to investigate how thiopurine TDM impacts clinical management of IBD patients and (2) to evaluate proportion of patients outside therapeutic 6TGN levels or exhibiting signs of toxicity Methods Patients who received thiopurine TDM as part of routine care underwent chart review of demographics, disease activity, medication dosing, metabolite levels, and adverse events. Changes in clinical management following TDM were measured. Additionally, we conducted a retrospective review of clinical decision making blinded and unblinded to TDM result. Results A total of 92 IBD patients were included. Levels of 6TGN were therapeutic in 29% of patients. 6TGN levels correlated weakly with weight-based dosing (r2 = 0.057, P = 0.02). Adverse reactions were observed in 6.5%. TDM informed clinical management in 64%. Significantly more changes to clinical management occurred in those with active disease than in remission (73% versus 48%; P = 0.02) and in those on mono- versus combination therapy (48% versus 27.5%; P = 0.03). Conclusions TDM informs clinical decision making in over two-thirds of patients. The demonstrated poor efficacy of weight-based dosing and impact of TDM on clinical management contributes to the evidence supporting the need for greater availability and uptake of thiopurine TDM.

Debates in Dysphagia Management: How Do You Use Evidence-Based Practice in Your Dysphagia Patient Care?

2011 ◽  
Vol 20 (4) ◽  
pp. 121-123
Author(s):  
Jeri A. Logemann
Keyword(s):  
Decision Making ◽  
Patient Care ◽  
Clinical Outcomes ◽  
Clinical Judgment ◽  
Clinical Decision Making ◽  
Evidence Based Practice ◽  
Clinical Decision ◽  
Evidence Based ◽  
Clinical Method ◽  
Do So

Evidence-based practice requires astute clinicians to blend our best clinical judgment with the best available external evidence and the patient's own values and expectations. Sometimes, we value one more than another during clinical decision-making, though it is never wise to do so, and sometimes other factors that we are unaware of produce unanticipated clinical outcomes. Sometimes, we feel very strongly about one clinical method or another, and hopefully that belief is founded in evidence. Some beliefs, however, are not founded in evidence. The sound use of evidence is the best way to navigate the debates within our field of practice.

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