Providers' experiences collaborating with child welfare workers: The good, the bad, and the impacts

BACKGROUND

Successful interprofessional collaborations have been identified as a potential solution to mitigate problems associated with negative outcomes for clients involved with the child welfare system. The barriers to collaborative relationships need to be better understood and effectively addressed.

OBJECTIVE

To understand the characteristics, barriers, and facilitators of collaborations between different types of providers and child welfare workers, as well as their impacts.

PARTICIPANTS AND SETTING

Mental health professionals, foster and kinship parents, legal professionals, and other providers responded to an online survey distributed in a Northeastern State of the United States of America.

METHOD

Participants (n = 208) completed the Quality of Collaboration with Child Welfare survey. Qualitative responses were analyzed by three coders using three levels of axial coding with constant comparison.

RESULTS

Participants identified different aspects of communication, relationships, and follow-through as key elements of successful collaborations, as well as the items most likely to interfere with their formation. Providers differed somewhat in how concerned they were with various aspects of collaborations in accordance with their professional roles. Barriers to successful collaborations included both individual and systemic factors which often resulted in negative outcomes. Overall, more negative experiences were offered than positive ones.

CONCLUSIONS

Strategies are needed to improve communication, promote positive relationships, and address systemic barriers to enhance collaboration and, in turn, improve outcomes for child welfare-involved clients.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

POS1547-HPR CREATION OF A MULTI-DISCIPLINARY TEAM (MDT) RHEUMATOLOGY CLINIC AT UNIVERSITY COLLEGE LONDON HOSPITAL (UCLH) TO TACKLE THE BACKLOG OF PATIENTS WAITING FOR TREATMENT AS A RESULT OF THE COVID-19 PANDEMIC

Background

Covid-19 has consumed hospital resources since January 2020. In the UK, routine care has been disrupted with an estimated 30 million fewer outpatient attendances (2020/21) and over 6 million patients waiting for consultant led care (1). The British Society for Rheumatology ‘Rheumatology Workforce: a crisis in numbers (2021)’ highlights the challenges facing National Health Service rheumatology departments in managing rising caseloads (2). In 2021, UCLH wait time for follow up rheumatology appointments was 9 months. We were inundated with patients requiring urgent treatment. Innovative ways of running outpatients were required which led to the formation of an MDT clinic.

Objectives

Create a Rheumatology MDT clinic to:

Reduce follow up time

Increase clinic capacity

Reduce number of hospital attendances

Add value to each clinic encounter

Methods

The consultant lead identified an existing clinical nurse specialist (CNS) interested in supporting the MDT. With a UCLH Outpatient Transformation grant of £15,000 we recruited an advanced physiotherapy practitioner (APP) and administrator for a 6 month trial period. Managerial support was provided by the board. We met weekly to agree aims and allocate responsibilities. We did the following:

•Reviewed clinic lists for 6 months to identify duplicate appointments.

•Identified patients with CNS and consultant follow up scheduled in a short time frame and cancelled unnecessary appointments.

•Reviewed the clinic list weekly to identify patients suitable for APP management. This allowed overbooking of urgent cases.

•Embedded hand ultrasound appointments in the clinic template.

•Created CNS ‘Zoom’ virtual drop-ins for routine enquiries to reduce the administrative burden of patient emails/phone calls occurring outside the clinic.

•Organised patient participation sessions to help shape the service and collected patient feedback questionnaires.

Results

We reduced our waiting time for follow up appointments from 9 months to 2 months. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service i.e. pain management, hand therapy, APP-led hypermobility programme. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision making resulting in fewer appointments. Patients welcomed the Zoom sessions as an efficient, reliable method of raising concerns/queries. Our administrator helps to facilitate communication between patients and clinicians and streamline MDT processes. Embedding point of care ultrasound reduces hospital visits and enhances treatment decision making thereby reducing follow up attendances.

Conclusion

Our MDT model has reduced waiting lists, decreased treatment delays and cut the number of hospital visits. Performing ultrasound in clinic helped prevent patients being sent for scans at private providers. This cost saving likely covers the APP, ensuring the project is close to cost neutral. Shared decision making added value to outpatient attendances, reflected in patients positive feedback. The MDT enhances the role of APP and CNS, utilising their unique skill set. Administrative support is crucial, enhances team working and places added value on this often underappreciated role. We encourage other Rheumatology departments to adopt an MDT approach to tackle the backlog of patients awaiting treatment, add value to clinic encounters and maximise the skill set of clinicians involved in patient care.

References

[1]NHS backlog data analysis. British Medical Association. Online; NHS backlog data analysis (bma.org.uk)

[2]Rheumatology workforce: a crisis in numbers. British Society for Rheumatology. Workforce Policy Report 2021. BSR-workforce-report-crisis-numbers.pdf (rheumatology.org.uk)

Acknowledgements

I would like to thank the UCLH Outpatient Transformation Team for their support and funding to carry out this pilot project.

Disclosure of Interests

None declared

Aspirin in the primary prevention of cardiovascular disease in individuals with chronic kidney disease: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in individuals with chronic kidney disease (CKD). Aspirin is widely used in secondary prevention of cardiovascular disease. Its use in primary prevention, particularly in CKD, is less clear. Previous reviews have offered inconclusive findings for the benefit of aspirin in CKD. Recent trials have been completed that may help provide more conclusive answers in CKD.

Purpose

This study aimed to assess the role of aspirin in the primary prevention of CVD and its associated adverse events in individuals with CKD.

Methods

A pre-defined protocol registered with PROSPERO (CRD42014008860) was used. The OVID Medline and EMBASE databases were searched for studies from 1996 to the 15th September 2020. Abstracts and full-texts were screened independently by two reviewers. Randomised controlled trials that compared aspirin to placebo in individuals with non-endstage CKD without CVD nor primary renal disease were included. The primary outcomes of interests were: CVD, major and minor bleeding events. Secondary outcomes of interest were: all-cause mortality, coronary artery disease and stroke. A meta-analysis was conducted using a random-effects model to calculate a pooled relative risk (RR).

Results

Five trials were included with 434 CVD events in 7,825 individuals with CKD. Aspirin offered no statistically significant benefit in reduction of CVD events (RR = 0.79, 95%CI: 0.57, 1.09) but significantly increased both minor (RR = 2.62, 95%CI: 1.64, 4.20) and major bleeding (RR= 1.51, 95%CI: 1.13, 2.02) events compared to placebo. Aspirin conferred no benefit for all-cause mortality (RR= 0.89, 95%CI: 0.64, 1.22), coronary heart disease (RR= 0.66, 95%CI: 0.27, 1.63) and stroke (RR= 0.94, 95%CI: 0.55, 1.58).

Conclusion

Aspirin cannot be recommended for the primary prevention of CVD in individuals with CKD as it offers no conclusive benefit and increases the risk of bleeding. Other strategies to optimise CVD primary prevention in individuals with CKD should be prioritised.

P90 PERCEIVE: PrEdiction of Risk and Communication of outcome following major lower limb amputation - a collaboratIVE study

Introduction

Major Lower Limb Amputation (MLLA) is a life changing event with significant morbidity and mortality. Inaccurate risk prediction can lead to poor decision making, resulting in delay to definitive surgery, or undertaking amputation when not in the patient’s best interest. We aim to answer: In adult patients undergoing MLLA for chronic limb threatening ischaemia or diabetes, how accurately do health care professionals prospectively predict outcomes after MLLA, and how does this compare to existing prediction tools?

Methods

A multicentre prospective observational cohort study is being delivered through the Vascular and Endovascular Research Network. Dissemination was via an existing network of contacts and social media.

Consecutive data will be collected for seven months from site launch date, including demographic data and pre-operative outcome predictions from surgeons, anaesthetists, and allied healthcare professionals. Follow-up data will comprise 30-day (mortality, morbidity, MLLA revision, surgical site infection, and blood transfusion) and 1-year (mortality, MLLA revision and ambulation). The accuracy of surgeons’ predictions will be evaluated and compared to pre-existing risk prediction scoring tools.

Results

PERCEIVE launched on 01/10/2020 with 23 centres (16 UK, 7 international) registered to collect data. 50 other centres (27 UK, 23 international) have expressed interest/are pursuing local audit/ethical approval. We aim to collect data on clinicians estimate of outcomes for over 500 patients.

Discussion

This study will utilise a trainee research network to provide data on the accuracy of healthcare professionals’ predictions of outcomes following MLLA and compare this to the utility of existing prediction tools in this patient cohort.

Preoperative Cognitive Abnormality, Intraoperative Electroencephalogram Suppression, and Postoperative Delirium: A Mediation Analysis

BACKGROUND

Postoperative delirium is a common complication that hinders recovery after surgery. Intraoperative electroencephalogram suppression has been linked to postoperative delirium, but it is unknown if this relationship is causal or if electroencephalogram suppression is merely a marker of underlying cognitive abnormalities. The hypothesis of this study was that intraoperative electroencephalogram suppression mediates a nonzero portion of the effect between preoperative abnormal cognition and postoperative delirium.

METHODS

This is a prespecified secondary analysis of the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized trial, which enrolled patients age 60 yr or older undergoing surgery with general anesthesia at a single academic medical center between January 2015 and May 2018. Patients were randomized to electroencephalogram-guided anesthesia or usual care. Preoperative abnormal cognition was defined as a composite of previous delirium, Short Blessed Test cognitive score greater than 4 points, or Eight Item Interview to Differentiate Aging and Dementia score greater than 1 point. Duration of intraoperative electroencephalogram suppression was defined as number of minutes with suppression ratio greater than 1%. Postoperative delirium was detected via Confusion Assessment Method or chart review on postoperative days 1 to 5.

RESULTS

Among 1,113 patients, 430 patients showed evidence of preoperative abnormal cognition. These patients had an increased incidence of postoperative delirium (151 of 430 [35%] vs.123 of 683 [18%], P < 0.001). Of this 17.2% total effect size (99.5% CI, 9.3 to 25.1%), an absolute 2.4% (99.5% CI, 0.6 to 4.8%) was an indirect effect mediated by electroencephalogram suppression, while an absolute 14.8% (99.5% CI, 7.2 to 22.5%) was a direct effect of preoperative abnormal cognition. Randomization to electroencephalogram-guided anesthesia did not change the mediated effect size (P = 0.078 for moderation).

CONCLUSIONS

A small portion of the total effect of preoperative abnormal cognition on postoperative delirium was mediated by electroencephalogram suppression. Study precision was too low to determine if the intervention changed the mediated effect.

Circulating Agonist Autoantibody to 5-Hydroxytryptamine 2A Receptor in Lean and Diabetic Fatty Zucker Rat Strains

AIMS

Circulating neurotoxic autoantibodies to the 5-hydroxytryptamine 2A receptor were increased in older adult type 2 diabetes in association with certain neurodegenerative complications. The male Zucker diabetic fatty (ZDF) rat is a model system for studies of obese, type 2 diabetes mellitus. The aim of the current study was to test for (and compare) circulating neurotoxic autoantibodies to the 5-hydroxytryptamine 2A receptor in the Zucker diabetic fatty rat and age-matched lean Zucker rat strains.

METHODS

Plasma from lean and Zucker diabetic fatty rat (obtained at different developmental stages) was subjected to protein G affinity chromatography. The resulting immunoglobulin G fraction was tested for neurotoxicity (acute neurite retraction, accelerated neuron loss) in N2A mouse neuroblastoma cells and for binding to a linear synthetic peptide corresponding to the second extracellular loop of the 5-hydroxytryptamine 2A receptor.

RESULTS

The male Zucker diabetic fatty rat (fa/fa) and two Zucker lean strains (+/?) and (fa/+) harbored autoantibodies to the 5-hydroxytryptamine 2A receptor which appeared spontaneously around 7-8.5 weeks of age. The circulating autoantibodies persisted until at least 25 weeks of age in the Zucker diabetic fatty rat and in the Zucker heterozygote (fa/+), but were no longer detectable in 25-week-old lean (+/?) Zucker rats. Autoantibody-induced acute neurite retraction and accelerated loss in mouse neuroblastoma N2A cells was dose-dependently prevented by selective antagonists of the 5-hydroxytryptamine 2A receptor. It was also substantially prevented by co-incubation with antagonists of RhoA/Rho kinase-mediated signaling (Y27632) or Gq11/phospholipase C/inositol triphosphate receptor-coupled signaling.

CONCLUSIONS

These data suggest that neurotoxic 5-hydroxytryptamine 2A receptor-targeting autoantibodies increase in the aging male Zucker diabetic fatty rat and in male Zucker lean rats harboring a heterozygous mutation, but not in age-matched, older Zucker lean rats lacking a known leptin receptor mutation. The Zucker genetic strain may be useful in studies of the role of humoral and/or innate immunity in late neurodegeneration.

Fine sediment and particulate organic matter: A review and case study on ridge-to-reef transport, transformations, fates, and impacts on marine ecosystems

Studies documenting the effects of land-derived suspended particulate matter (SPM, i.e., particulate organic matter and mineral sediment) on marine ecosystems are typically disconnected from terrestrial studies that determine their origin, transport and fate. This study reviews sources, transport, transformations, fate and effects of SPM along the 'ridge-to-reef' continuum. We show that some of the SPM can be transported over long distances and transformed into large and easily resuspendible organic-rich sediment flocs. These flocs may lead to prolonged reductions in water clarity, impacting upon coral reef, seagrass and fish communities. Using the Great Barrier Reef (NE Australia) as a case study, we identify the latest research tools to determine thresholds of SPM exposure, allowing for an improved appreciation of marine risk. These tools are used to determine ecologically-relevant end-of-basin load targets and reliable marine water quality guidelines, thereby enabling enhanced prioritisation and management of SPM export from ridge-to-reef.

A visible-light photocatalytic thiolation of aryl, heteroaryl and vinyl iodides

A method for the light-driven synthesis of aryl and vinyl alkyl thioethers from a range of C(sp²)–I bonds is reported.

Psychological Outcomes of Living Liver Donors From a Multicenter Prospective Study: Results From the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2)

Although single-center and cross-sectional studies have suggested a modest impact of liver donation on donor psychological well-being, few studies have assessed these outcomes prospectively among a large cohort. We conducted one of the largest, prospective, multicenter studies of psychological outcomes in living liver donors within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2) consortium. In total, 271 (91%) of 297 eligible donors were interviewed at least once before donation and at 3, 6, 12, and 24 mo after donation using validated measures. We found that living liver donors reported low rates of major depressive (0-3%), alcohol abuse (2-5%), and anxiety syndromes (2-3%) at any given assessment in their first 2 years after donation. Between 4.7% and 9.6% of donors reported impaired mental well-being at various time points. We identified significant predictors for donors' perceptions of being better people and experiencing psychological growth following donation, including age, sex, relationship to recipient, ambivalence and motivation regarding donation, and feeling that donation would make life more worthwhile. Our results highlight the need for close psychosocial monitoring for those donors whose recipients died (n=27); some of those donors experienced guilt and concerns about responsibility. Careful screening and targeted, data-driven follow-up hold promise for optimizing psychological outcomes following this procedure for potentially vulnerable donors.

The impact of a high magnitude flood on metal pollution in a shallow subtropical estuarine embayment

Drought-breaking floods pose a risk to coastal water quality as sediments, nutrients, and pollutants stored within catchments during periods of low flow are mobilized and delivered to coastal waters within a short period of time. Here we use subtidal surface sediment surveys and sediment cores to explore the effects of the 2011 Brisbane River flood on trace metals zinc (Zn), lead (Pb), copper (Cu), nickel (Ni), chromium (Cr), manganese (Mn), and phosphorus (P) deposition in Moreton Bay, a shallow subtropical bay in eastern Australia. Concentrations of Zn, Cu, and Pb in sediments in central Moreton Bay derived from the 2011 flood were the highest yet observed in the Bay. We suggest flushing of metal rich sediments which had accumulated on the Brisbane River floodplain and in its estuary during the preceding 10 to 40years of low flows to be the primary source of this increase. This highlights the importance of intermittent high magnitude floods in tidally influenced rivers in controlling metal transport to coastal waters in subtropical regions.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Investigating the energy harvesting capabilities of a hybrid ZnO nanowires/carbon fiber polymer composite beam

Hybrid piezoelectric composite structures that are able to convert mechanical energy into electricity have gained growing attention in the past few years. In this work, an energy harvesting composite beam is developed by growing piezoelectric zinc oxide nanowires on the surface of carbon fiber prior to forming structural composites. The piezoelectric behavior of the composite beam was demonstrated under different vibration sources such as water bath sonicator and permanent magnet vibration shaker. The beam was excited at its fundamental natural frequency (43.2 Hz) and the open circuit voltage and the short circuit current were measured to be 3.1 mV and 23 nA, respectively. Upon connecting an optimal resistor (1.2 kΩ) in series with the beam a maximum power output 2.5 nW was achieved.

In vitro-to-in vivo correlation of the skin penetration, liver clearance and hepatotoxicity of caffeine

This work illustrates the use of Physiologically-Based Toxicokinetic (PBTK) modelling for the healthy Caucasian population in in vitro-to-in vivo correlation of kinetic measures of caffeine skin penetration and liver clearance (based on literature experiments), as well as dose metrics of caffeine-induced measured HepaRG toxicity. We applied a simple correlation factor to quantify the in vitro and in vivo differences in the amount of caffeine permeated through the skin and concentration-time profiles of caffeine in the liver. We developed a multi-scale computational approach by linking the PBTK model with a Virtual Cell-Based Assay to relate an external oral and dermal dose with the measured in vitro HepaRG cell viability. The results revealed higher in vivo skin permeation profiles than those determined in vitro using identical exposure conditions. Liver clearance of caffeine derived from in vitro metabolism rates was found to be much slower than the optimised in vivo clearance with respect to caffeine plasma concentrations. Finally, HepaRG cell viability was shown to remain almost unchanged for external caffeine doses of 5-400 mg for both oral and dermal absorption routes. We modelled single exposure to caffeine only.

Flow cytometric characterization and clinical outcome of CD4+ T-cell lymphoma in dogs: 67 cases

Background

Canine T‐cell lymphoma (TCL) is conventionally considered an aggressive disease, but some forms are histologically and clinically indolent. CD4 TCL is reported to be the most common subtype of TCL. We assessed flow cytometric characteristics, histologic features when available, and clinical outcomes of CD4+ TCL to determine if flow cytometry can be used to subclassify this group of lymphomas.

Objective

To test the hypothesis that canine CD4+ T‐cell lymphoma (TCL) is a homogeneous group of lymphomas with an aggressive clinical course.

Animals

Sixty‐seven dogs diagnosed with CD4+ TCL by flow cytometry and treated at 1 of 3 oncology referral clinics.

Methods

Retrospective multivariable analysis of outcome in canine CD4+ TCL including patient characteristics, treatment, and flow cytometric features.

Results

The majority of CD4+ TCL were CD45+, expressed low class II MHC, and exhibited an aggressive clinical course independent of treatment regimen (median survival, 159 days). Histologically, CD4+ TCL were classified as lymphoblastic or peripheral T cell. Size of the neoplastic lymphocytes had a modest effect on both PFI and survival in this group. A small number of CD4+ TCL were CD45− and class II MHC high, and exhibited an apparently more indolent clinical course (median survival not yet reached).

Conclusions and Clinical Importance

Although the majority of CD4+ TCL in dogs had uniform clinical and flow cytometric features and an aggressive clinical course, a subset had a unique immunophenotype that predicts significantly longer survival. This finding strengthens the utility of flow cytometry to aid in the stratification of canine lymphoma.

Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures

BACKGROUND AND PURPOSE

Osteoporotic fractures are an increasing problem in the world due to the ageing of the population. Different models of orthogeriatric co-management are currently in use worldwide. These models differ for instance by the health-care professional who has the responsibility for care in the acute and early rehabilitation phases. There is no international consensus regarding the best model of care and which outcome parameters should be used to evaluate these models. The goal of this project was to identify which outcome parameters and assessment tools should be used to measure and compare outcome changes that can be made by the implementation of orthogeriatric co-management models and to develop recommendations about how and when these outcome parameters should be measured. It was not the purpose of this study to describe items that might have an impact on the outcome but cannot be influenced such as age, co-morbidities and cognitive impairment at admission.

METHODS

Based on a review of the literature on existing orthogeriatric co-management evaluation studies, 14 outcome parameters were evaluated and discussed in a 2-day meeting with panellists. These panellists were selected based on research and/or clinical expertise in hip fracture management and a common interest in measuring outcome in hip fracture care.

RESULTS

We defined 12 objective and subjective outcome parameters and how they should be measured: mortality, length of stay, time to surgery, complications, re-admission rate, mobility, quality of life, pain, activities of daily living, medication use, place of residence and costs. We could not recommend an appropriate tool to measure patients' satisfaction and falls. We defined the time points at which these outcome parameters should be collected to be at admission and discharge, 30 days, 90 days and 1 year after admission.

CONCLUSION

Twelve objective and patient-reported outcome parameters were selected to form a standard set for the measurement of influenceable outcome of patients treated in different models of orthogeriatric co-managed care.

Retrospective evaluation of doxorubicin-piroxicam combination for the treatment of transitional cell carcinoma in dogs

OBJECTIVES

To determine whether doxorubicin-piroxicam combination is safe and has activity against transitional cell carcinoma in dogs.

METHODS

Data was collected retrospectively from 34 dogs from two institutions over a 6-year period. Signalment, clinical presentation, treatment specifics, adverse events, response, progression-free survival and overall survival time were evaluated.

RESULTS

Dogs received doxorubicin every 3 weeks and daily piroxicam; 17 dogs (50%) had surgery. Clinical presentations were those typically reported for transitional cell carcinoma. Mean number of doses administered was 3·5. Of the 23 dogs with measurable disease, 14 (60·5%) had stable disease, 7 (30·5%) had progressive disease and 2 (9%) a partial response. Adverse events were generally manageable, and gastrointestinal in origin; one dog died of treatment-related complications. Overall median progression-free survival and overall survival were 103 and 168 days, respectively. Cytoreductive surgery did not result in prolongation of progression-free survival, but significantly prolonged overall survival. All dogs but one died as a result of disease progression.

CLINICAL SIGNIFICANCE

Doxorubicin-piroxicam combination therapy is well-tolerated in dogs with transitional cell carcinoma although progression-free survival, overall survival and biological response rates appear modest. Combination with surgery appears to offer a survival advantage; however, this may reflect tumour location and volume. Prospective studies are necessary to compare activity of combination doxorubicin-piroxicam to currently applied therapies.