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In the UK, approximately 5820 new cases of multiple myeloma (MM) are diagnosed each year. This number has increased by a third since the early 1990s. Considerable progress has been achieved in our ability to treat MM as a result of the development of new chemotherapeutic agents. MM is a disease more commonly seen in elderly individuals who frequently have pre-existing co-morbidities and are subject to social pressures that impact adversely on their quality of life (QOL). As their lives are extended by more effective treatment of MM, there is a greater need to address such issues. This review will focus on the holistic needs of a patient with MM, and how all members of the multidisciplinary team have a role. The aim is to advocate for centres to support MM patients to live well with their condition.

Pathology is important in training to become a medical doctor but as curricula become more integrated, there is a risk that key aspects of pathology may be excluded. Following a survey of the current delivery of teaching in Ireland under the auspices of the Faculty of Pathology at the Royal College of Physicians of Ireland, suggested components of a core curriculum in pathology have been developed to be delivered at some stage during the medical course. These have been based on key principles and themes required by the Medical Council in Ireland. Professionalism is one of the core principles emphasised by the Medical Council. It includes the role of the pathologist in patient care and other professional values such as patient-centred care, clinical competencies and skills, e.g. explaining results, and knowledge under the various sub-disciplines, i.e. histopathology (including neuropathology), clinical microbiology, haematology, chemical pathology and immunology. In each of these, we suggest key aspects and activities that the medical graduate should be comfortable in carrying out. The methods of delivery of teaching and assessment across pathology disciplines have evolved and adapted to recent circumstances. Lessons have been learned and insights gained during the COVID-19 pandemic as educators have risen to the challenge of continuing to educate medical students. Integrated and multi-disciplinary teaching is recommended to reflect best the professional environment of the medical graduate who works as an integral part of a multi-disciplinary team, with the minimum dependence on the traditional lecture, where at all possible. Finally, options on assessment are discussed, e.g. multiple-choice questions, including their respective advantages and disadvantages. Supplementary information The online version contains supplementary material available at 10.1007/s11845-021-02774-1.

Long COVID (LC) symptoms can be long standing, diverse and debilitating; comprehensive multidisciplinary rehabilitation programs are required to address this. A 10-week LC Virtual Rehabilitation Program (VRP) was developed to provide early education and self-management techniques to address the main symptoms of LC and was delivered to a group of persons with Long COVID (PwLC) online, facilitated by members of the multi-disciplinary rehabilitation team. This paper describes an evaluation of this VRP. Questionnaires completed by Healthcare Professionals (HCP) delivering the VRP were thematically analyzed to gain a priori themes and design semi-structured telephone interview questions for PwLC. Template analysis (TA) was used to analyze interview data. Routinely collected patient demographics and service data were also examined. Seventeen HCP survey responses were obtained and 38 PwLC telephone questionnaires were completed. The HCP interviews generated three a priori themes (1. Attendance and Availability, 2. Content, 3. Use of Digital Technology). TA was applied and three further themes emerged from the combined HCP and PwLC responses (4. Group Dynamics, 5. Individual Factors, 6. Internal Change). Key outcomes demonstrated that: the VRP was highly valued; digital delivery enabled self-management; barriers to attendance included work/life balance, use of technology, health inequalities; and LC was poorly understood by employers. Recommendations are provided for the design of VRPs for LC.

Central nervous system (CNS) tumors represent the most deadly cancer in pediatric age group. In China, thousands of children are diagnosed with CNS tumors every year. Despite the improving socioeconomic status and availability of medical expertise within the country, unique challenges remain for the delivery of pediatric neuro‐oncology service. In this review, we discuss the existing hurdles for improving the outcome of children with CNS tumors in China. Need for precise disease burden estimation, lack of intra‐ and inter‐hospital collaborative networks, high probability of treatment abandonment, along with financial toxicities from treatment represent the key challenges that Chinese healthcare providers encounter. The tremendous opportunities for advancing the status of pediatric neuro‐oncology care in and beyond the country are explored.

Purpose Severe inflammatory colitis as a consequence of inflammatory bowel disease (IBD) may not be amenable to medical management, and surgery is often required. The optimal timing of surgery and perioperative therapeutic care requires a formal link between surgical department and gastroenterology which is often lacking. In this study, we assess the impact of adopting a multidisciplinary care bundle on complication rates of subtotal colectomy in IBD patients. Methods This is a single-centre retrospective observational study. Patients were identified through clinical discharge ICD10 codes. Clinical notes of patients who underwent subtotal colectomies from 1 January 2006 to 31 December 2019 were analysed. Socio-demographics, diagnosis, and medical and surgical management data were collected. A multimodule bundle, including weekly MDT discussions, was started in our unit on 1 April 2014. Multivariable logistic regression analysis was performed on these data. Results A total of 296 patients were identified with 113 patients of these (38.2%) experiencing a complication post operation. The overall complication rate improved over time (p = 0.023). Those patients treated after the initiation of the MDT bundle had reduced complication rates (44.6% versus 33.7%, p = 0.045). On multivariate analysis, increasing age (1.023 OR; 95% CI 1.004, 1.041) and procedure performed before MDT bundle (3.1 OR; 95% CI 1.689, 5.723) were independent predictors for post-operative complications. Conclusions Closer links between gastroenterology and colorectal specialties have improved patient outcomes in our unit. Whilst IBD MDTs have previously been shown to improve outcomes for patients managed medically, we demonstrate that this interaction, implemented as a multidisciplinary care bundle, also improves surgical outcomes.

Background: The COVID-19 pandemic has disproportionately affected people from more deprived communities. The experience of Long Covid is similarly distributed but very few investigations have concentrated on the needs of this population. The aim of this project was to co-produce an acceptable intervention for people with Long Covid, living in communities recognised as more deprived. Methods: The intervention was based on a multi-disciplinary team using approaches from sport and exercise medicine and functional rehabilitation. The co-production process was undertaken with a stakeholder advisory group and patient public involvement representation. This study identified participants by postcode and the indices of multiple deprivation (IMD); recruitment and engagement were supported by an existing health and wellbeing service. A virtual ‘clinic’ was offered with a team of professional practitioners who met participants three times each; to directly consider their needs and offer structured advice. The acceptability of the intervention was based on the individual’s participation and their completion of the intervention. Results: Ten participants were recruited with eight completing the intervention. The partnership with an existing community health and wellbeing service was deemed to be an important way of reaching participants. Two men and six women ages ranging from 38 to 73 were involved and their needs were commonly associated with fatigue, anxiety and depression with overall de-conditioning. None reported serious hardship associated with the pandemic although most were in self-employment/part-time employment or were not working due to retirement or ill-health. Two older participants lived alone, and others were single parents and had considerable challenges associated with managing a household alongside their Long Covid difficulties. Conclusions: This paper presents the needs and perspectives of eight individuals involved in the process and discusses the needs and preferences of the group in relation to their support for self- managed recovery from Long Covid.

Workplaces that provide services and deal with abuse cases are often associated with high levels of work stress, burn out, and high expressed affect. The current intervention aimed at a more effective management of stress and affect in the workplace. EMDR therapy is an evidence-based treatment for PTSD and anxiety disorders. A Group EMDR protocol was applied to professionals working at “the House of the Child”, an innovative specialized Mental Health Unit that provides multi-disciplinary assessment, diagnosis and treatment services for children and adolescents survivors of abuse and neglect operated by the Association “The Smile of the Child”. The intervention included two sessions. The stabilization session took place for purposes of screening and preparation (self-regulation) and lasted 45 minutes. In the second session, which lasted 90 minutes, participants processed a recent stressful event that occurred in the workplace. The stressful event was not shared in the group. There were twenty participants and two facilitators, all of whom working at the unit. The Job Affect Scale, the Impact of Event Scale–R, the State-Trait Anxiety Inventory and the Subjective Units of Distress (SUD’s) were administered. The dependent (paired) t test showed significant reduction of the SUDs related to the stressful event, decrease in the avoidance, intrusion and hyperarousal symptoms. Moreover, reduction in the negative affect in the workplace was noted. The current pilot intervention provided indications for the usefulness of workplace interventions aiming at more effective stress management and better communication among the members of the multi-disciplinary team. Further research is needed to evaluate the efficacy of Group EMDR in workplace stress management and the prevention or processing of vicarious/secondary trauma.

Objectives: The COVID-19 pandemic impacted food systems, health systems and the environment globally, with potentially greater negative effects in many lower-middle income countries (LMICs) including Indonesia. The purpose of this qualitative study was to investigate the potential impacts of the COVID-19 pandemic on diets, health and the marine environment in Indonesia, based on the perspectives of a multidisciplinary group of informants. Methods: We conducted remote in-depth interviews with 27 key informants from many regions of Indonesia, who are either healthcare providers, nutrition researchers or environmental researchers. Interview question guides were developed based on a socio-ecological framework. We analyzed the data using a qualitative content analysis approach. Results: Informants suggested that while the COVID-19 brought increased awareness about and adherence to good nutrition and health behaviors, the impact was transitory. Informants indicated that healthy food options became less affordable, due to job losses and reduced income, suggesting a likely increase in food insecurity and obesity. Environmental researchers described higher levels of marine pollution from increase in hygienic wastes as well as from plastic packaging from food orders. Conclusions: Our findings reveal perceptions by informants that the increased awareness and adherence to health behaviors observed during the pandemic was not sustained. Our results also suggest that the pandemic may have exacerbated the double-burden paradox and marine pollution in Indonesia. This study offers information for generating hypotheses for quantitative studies to corroborate our findings and inform policies and programs to mitigate the long-term impacts of the COVID-19 on diets, health, and the marine environment in Indonesia.

Objective: This preliminary review was conducted to inform the design of a new service to support families with children with Prader-Willi Syndrome. Families were invited to attend a pilot clinic at a hospital outpatient department, comprising of appointments with a multi-disciplinary team.Method: Following the clinic, families (n=6) were invited to partake in semi-structured qualitative interviews that were audio-recorded, transcribed and analysed using thematic analysis.Results: Families reported that the clinic offered enhanced support within the following categories; integrated care; professional input; signposting to social support (respite and financial); connection with the wider PWS community; and behavioural support.Conclusion: This is the first paper that documents the parental perspective of a multi-disciplinary team (MDT) clinic for children with Prader-Willi syndrome. The families felt an MDT led clinic was superior to current care, offering more convenient access to an enhanced service, which would provide integrated and consistent care for their children's diverse, changing needs.

Major lower extremity amputations have been an area of much concern in the Caribbean population. Hence, the purpose of this research was to investigate the current trends in major lower-extremity amputations. Data regarding all major lower-extremity amputations performed at a tertiary care institution in Trinidad and Tobago, from January 2010 to December 2016 were reviewed. The variation of yearly trends, gender, type of amputation and reason for amputation were analysed. The yearly amputation rate demonstrated a progressive increase from 2010 to 2016, the average for the seven years was 28 per 105/year. Males accounted for 59% of cases, and 60% of amputations were done above the level of the knee joint. The most common reason for amputation was control of sepsis in 71.5% of cases. A strong association between major amputations and prior intervention for a foot-related problem was observed, as 52% of the sample had a pre-existing wound or a prior minor amputation (32%). Overall, 14.5% of all amputees were able to acquire a prosthesis. Diabetes mellitus was the most consistently associated co-morbidity occurring in 91% of the study population. Major limb amputations continue to affect our population significantly, with a rise in the amputation rate despite the introduction of a Vascular Surgical Unit. Diabetes and its foot-related complications are one of the leading causes of major lower extremity amputations. Prosthetic limb acquisition for our amputee population continues to be lacking, reflected by the low prosthetic acquisition rate observed.

It is currently unknown how post-COVID-19 syndrome (PCS) may affect those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This longitudinal study includes healthcare staff who tested positive for SARS-CoV-2 between March and April 2020, with follow-up of their antibody titers and symptoms. More than half (21 of 38) had PCS after 7-8 months. There was no statistically significant difference between initial reverse-transcription polymerase chain reaction titers or serial antibody levels between those who did and those who did not develop PCS. This study highlights the relative commonality of PCS in healthcare workers and this should be considered in vaccination scheduling and workforce planning to allow adequate frontline staffing numbers.

Doug Cronie,1,2 Marlies Rijnders,3 Suze Jans,3,4 Corine J Verhoeven,5,6 Raymond de Vries7–9 1Department of Midwifery, OLVG (West) Hospital, Amsterdam, The Netherlands; 2Department of Midwifery Science, Faculty of Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands; 3Department of Child Health, TNO, Leiden, The Netherlands; 4Editorial Department, Dutch Journal for Midwives (KNOV), Utrecht, The Netherlands; 5Department of Midwifery Science, AVAG, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands; 6Department of Obstetrics and Gynecology, Maxima Medical Centre, Veldhoven, The Netherlands; 7Faculty of Midwifery Education & Studies, Zuyd University, Maastricht, The Netherlands; 8CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; 9Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA Aims: To examine the experiences of inter-professional collaboration of maternity service providers in the Netherlands and to identify potential enhancing and inhibiting factors for inter-professional collaboration within maternity care in the Netherlands. Background: Good collaboration between health care professionals is a key element of safe, effective care, but creating a collaborative culture can be challenging. Good collaboration requires, among other things, negotiating different professional orientations and the organizational constraints of hierarchies and scheduling. Good collaboration is especially important in maternity care. In the Netherlands, suboptimal collaboration has been cited as a significant factor in maternal deaths and in adverse incidents occurring in hospitals during evenings, nights, and weekends. In spite of its importance for effective maternity care, little is known about the nature and quality of collaboration between maternity care professionals. In order to fill this gap, we examined the inter-professional collaboration within multi-disciplinary teams (MDTs) providing maternity services in the Netherlands. Methods: Online survey of MDTs (consisting of hospital and PCMs, doctors, and carers) involved in the provision of maternity services in the Netherlands. We used a validated measure of collaboration (the Leiden Quality of Work Questionnaire) to analyze the attitudes of those involved in the provision of maternity services about multi-disciplinary collaboration in their work. We used descriptive and inferential statistics to assess differences between the groups. Results: 40% of all respondents were not satisfied with collaboration within their MDT. Overall, mean collaboration scores (MCS) were low. We found significant differences in MCS between professional groups. Midwives – community and hospital based – were pessimistic about collaboration in future models of maternity care. Discussion: In the Netherlands, collaboration in maternity care is less than optimal. Poor collaboration is associated with negative consequences for patient safety and quality of care. Strategies to address suboptimal collaboration exist; however, no one-size-fits-all approach is identified in the literature. Conclusion: Suboptimal collaboration exists within the midwifery model of care in the Netherlands and the relationship between care providers is under pressure. This could affect patient safety and quality of care, according to the literature. Précis: This paper presents an in-depth examination of the nature of, and attitudes about, collaboration between members of the MDT involved in the provision of maternity services in the Netherlands. Keywords: interprofessional communication, communication, multi-disciplinary team, interprofessional teamwork, interprofessional collaboration survey, questionnaire hospital midwife, primary care midwife, midwifery, carer, doctor, nurse, maternity care assistant, integrated-care

The current epidemic situation of coronavirus disease 2019 (COVID-19) still remains severe. As the National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital of the Zhejiang University School of Medicine is the primary medical care center for COVID-19 in Zhejiang Province. Based on the present expert consensus carried out by the National Health Commission and National Administration of Traditional Chinese Medicine, our team summarized and established an effective treatment strategy centered on “Four-Anti and Two-Balance” for clinical practice. The “Four-Anti and Two-Balance” strategy includes antivirus, anti-shock, anti-hypoxemia, and anti-secondary infection, and maintaining of water, electrolyte and acid/base balance and microecological balance. Simultaneously, an integrated multidisciplinary personalized treatment is recommended to improve therapeutic effects. The importance of early viral detection, dynamic monitoring of inflammatory indexes, and chest radiographs has been emphasized in clinical decision-making. Sputum was observed with the highest positive rate by reverse transcription-polymerase chain reaction (RT-PRC). Viral nucleic acids could be detected in 10% of the patients’ blood samples at the acute phase and 50% of patients had positive RT-PCR results in their feces. We also isolated live viral strains from feces, indicating potential infectiousness of feces. Dynamic cytokine detection was necessary to timely identify cytokine storms and for the application of the artificial liver blood purification system. The “Four-Anti and Two-Balance” strategy effectively increased cure rates and reduced mortality. Early antiviral treatment alleviated disease severity and prevented illness progression. We found that lopinavir/ritonavir combined with abidol showed antiviral effects against COVID-19. Shock and hypoxemia were usually caused by cytokine storms. The artificial liver blood purification system was able to rapidly remove inflammatory mediators and block the cytokine storm. Moreover, it also contributed to the balance of fluids, electrolytes, and acids/bases and thus improved treatment efficacy during critical illness. For cases of severe illness, early and also short periods of moderate glucocorticoid administration was supported. Patients with an oxygenation index below 200 mm Hg were transferred to the intensive care unit. Conservative oxygen therapy was preferred and noninvasive ventilation (NIV) was not recommended. Patients with mechanical ventilation were strictly supervised with cluster ventilator-associated pneumonia prevention strategies. Antimicrobial prophylaxis was prescribed rationally and was not recommended, except for patients with a long course of disease, repeated fever, and elevated procalcitonin, similarly secondary fungal infections were of concern. Some patients with COVID-19 showed intestinal microbial dysbiosis with decreased genus such as Lactobacillus and Bifidobacterium. Nutritional and gastrointestinal function should; therefore, be assessed for all patients. Nutritional support and application of prebiotics or probiotics were suggested to regulate the balance of intestinal microbiota and reduce the risk of secondary infections due to bacterial translocation. Anxiety and fear were common in patients with COVID-19. Therefore, we established a dynamic assessment and warning for psychological crises. We also integrated Chinese medicine in the treatment to promote rehabilitation. We optimized nursing processes for severe patients to promote their rehabilitation. Since viral clearance patterns after severe acute respiratory syndrome coronavirus 2 infections remained unclear, 2 weeks quarantine for discharged patients was required, and a regular following-up was also needed. These Zhejiang experiences and suggestions have been implemented in our center and achieved good results. However, since COVID-19 was a newly emerging disease, more work is warranted to further improve strategies of prevention, diagnosis, and treatment for COVID-19.

COVID‐19 has been declared a pandemic by the World Health Organization. As of April 1, 2020, Italy was the country with the second highest number of cases in the world. The spread of COVID‐19 has required a rapid reorganization of health service delivery in face of the pandemic. Breast cancer units have reprioritized their workload to guarantee the health of oncologic patients at the highest risk and regular screening activities. However, at the end of the pandemic emergency, many benign and reconstructive cases will return to our attention and their surgical treatment will be necessary as soon as possible.

研究目的 回復期リハビリテーション病棟において患者・家族の意向を尊重し、退院に向けた方向性を確認しながらすすめることができる退院調整プログラムの開発を基盤として、退院支援体制の充実に取り組む。その取り組みを通じて、退院調整プログラムの意義と退院支援の充実について検討する。研究方法 在宅療養に向けた退院調整プログラムを考案し、多職種間で共有した後、取り組みを実施する。実施した退院調整プログラムの取り組みに関する成果の把握とプログラムの修正をする。結果 1．退院調整プログラムについて2 つのパターン（他院からの転院・自施設からの転棟）を考案した。退院調整プログラムには、他院から転院する場合の情報収集方法（病院訪問）、患者・家族を交えた定期的な面談、多職種が参加するケアカンファレンス等を取り入れた。 2．退院調整プログラムを実施した事例（5 事例）では、患者・家族の思いや意向を確認し、その意向に沿った療養生活に繋げることができた。 3．当該取り組みに関して多職種の意見（質問紙調査）では、退院調整プログラムの実施に関して、患者・家族による納得した退院、患者・家族の思いの理解の重要性、多職種との目標の共有等の意見が得られた。考察 退院調整プログラムを基盤として退院調整をすすめることは、患者・家族の意向を尊重し方向性を共有しながら進めることが可能である。また、多職種がケアカンファレンス等で情報共有し、チームとして協働して関わり、患者・家族との面談を繰り返し、思いや希望を受けとめ、目標を確認するとともに、退院後の継続的な関り方を検討することが重要であると考える。 在宅療養に向けた看護のあり方は、患者中心の視点を持ち、多職種との協働と連携を進めながら、在宅療養に向けた退院支援及び調整を行い、退院後の生活を捉え在宅療養の可能性を見出すことである。

BackgroundThe coronavirus disease 2019 pandemic has led to the birth of videoconference multidisciplinary teams, which are now commonplace. This remote way of deciding care demands a new set of rules to ensure the quality of the complex decisions that are made for the patient group needing multidisciplinary care. Videoconference multidisciplinary teams bring with them novel forms of distraction that are under-appreciated and can impair decision-making.MethodA practical checklist was generated as applied to videoconference multidisciplinary teams using the principles of human factors awareness and recognition.ResultsSome of the strategies that should be adopted to minimise errors arising from human factors are: information technology support, a suitable environment to dial in, a global checklist employed prior to the videoconference, visible participants, avoiding distractions from other sources (e.g. e-mail, mobile phone), a videoconference sign-out and rapid dissemination of the outcomes sheet.ConclusionThis article presents a framework that uses human factors principles applied in this setting, which will contribute to enhanced patient safety, team working and a reduction in medical errors.

Einleitung Palliative Care ist das Betreuungskonzept für sterbenskranke Menschen, das mit seiner ganzheitlichen Betreuung das Ziel hat, die Lebensqualität der Betroffenen zu steigern. Aufgrund der teils großen Nachfrage vieler sterbenskranker Menschen, ihren letzten Lebensabschnitt zuhause verbringen zu wollen und auch zuhause zu sterben, gibt es das Angebot der Palliativen Betreuung im Eigenheim durch ein mobiles Palliative Care-Team. Methodik Als Methodik dieser Arbeit wurde die systematische Literaturrecherche eingesetzt. Die drei Phasen, Bestimmung des Untersuchungsgegenstandes, Recherche und Bewertung, Lektüre und Kritik kamen hier zur Anwendung. Insgesamt wurden acht Studien, die sich mit der Thematik befassen, eingeschlossen. Ergebnisse Durch die mobile Palliativbetreuung geht der Wunsch der Betroffenen, die letzte Lebensphase zuhause zu verbringen und zuhause zu sterben, in Erfüllung. Da das multidisziplinäre Team jederzeit erreichbar ist, können in akuten Situationen Symptome gelindert und unnötige Krankenhauseinweisungen verhindert werden. Durch die ganzheitliche Betreuung erfahren die Sterbenskranken Zufriedenheit und eine verbesserte Lebensqualität. Ebenfalls verbessern sich verschiedene Symptome wie zum Beispiel Schmerzen, Fatigue, Angstzustände und Depressionen, was durch richtige Medikation und Betreuung geschieht. Diskussion Die Betreuung durch ein mobiles Palliativteam wirkt sich positiv auf die Lebenszufriedenheit und die Lebensqualität aus. Die Menschen können die letzte Zeit von geliebten Menschen umringt verbringen und auch zuhause sterben. Die Wahl zwischen häuslicher, stationärer oder ambulanter Palliativversorgung sollte jedem selbst obliegen. Hier sollten individuelle Präferenzen bzw. Prioritäten beachtet werden, da letztendlich alle drei Möglichkeiten die Lebensqualität steigern. Introduction Palliative care is the concept of caring for people with life-threatening illnesses, whose holistic approach aims to increase the quality of life of those affected. Due to the high demand of many people to spending their last period of life at home and to dying there, their mobile palliative care teams offer palliative care at home. Methods The method of this work is the systematic literature research. The three stages determination of the object of investigation, research and evaluation, reading and criticism have been used. In total eight studies dealing with the topic are included. Results The desire of the affected to spend the last phase of their lives at home and to die at home is fulfilled by mobile palliative care. Symptoms can be alleviated in acute situations and unnecessary hospitalizations can be prevented because the multidisciplinary team is always available. People with life-threatening illnesses experience satisfaction and an improved quality of life due to the holistic care they receive. With proper medication and care various symptoms such as pain, fatigue, anxiety and depression improved. Discussion The care provided by a mobile palliative team has a positive effect on life satisfaction and quality of life. People can spend their last time surrounded by beloved people and they can die at home. The choice between home, inpatient and outpatient palliative care should be up to each person and their individual preferences or priorities should be considered since all three options increase the quality of life.

The diploma thesis is dedicated to the way of using and way of functioning of the coordinated rehabilitation and the multi-disciplinary team in the organization Focus in Pelhřimov which works with the people with mental disorders. The thesis is divided in the theoretical and practical part. The theoretical part describes the history and function of the coordinated rehabilitation, mental health care history, psychiatric reform and multi-disciplinary cooperation functioning. There is used the strategy of quality analysis in the research part. It was done by the questionnaire and the technique of half-structured interview. The results coming out of the interview were focused on the functioning of multi-disciplinary team in the institution and the cooperating subjects in the first part. The second part was dedicated to the basic parts of the coordinated rehabilitation provided in the organization in view of the fact that there were other participating professionals and non-formal participants during the care of the person with mental disorder. The aim of the research was to map the sectors of the coordinated rehabilitation used by the individuals with mental disorders in the organization Focus in Pelhřimov. The research team was created with the help of the method of the snow ball and basic criteria was employment of an "communication partner" in the particular organization. Their ability to evaluate their job and take part in the lead interview depended on their experience in Focus. In connection with the thesis aim there was also set the main research question: What parts of the coordinated rehabilitation are used in the organization Focus in Pelhřimov? Partial questions were devolved from that which were connected to the particular parts of the coordinated rehabilitation and the function of the multi-disciplinary team. The first contact and the next cooperation is developed by the seriousness, necessity and wishes of the client. The work with the client with mental disorder is based on the philosophy of recuperation, not recovery. In the relationship and the concentration, the work is done in all sectors of the coordinated rehabilitation. The client has the closest relationship to the key worker who provides the care in the multi-disciplinary team and other professionals in the organization. There is the conclusion from the results that there was an agreement that the coordinated rehabilitation is used in this institution and no other from the basic sectors can be omitted. The results of the diploma thesis can be used as feedback for the organization Focus in the practice where it can be useful for mapping of the sectors of coordinated rehabilitation and making clear the needs of the individuals with mental disorder. Taking into consideration the recommendation to use the feedback of the respondents about information sharing, to prefer common space of the whole team and bigger promotion.

Bronchiectasis is a chronic lung disease associated with structurally abnormal bronchi; clinically manifested by a persistent wet/productive cough, airway infections and recurrent exacerbations. Early identification and treatment of acute exacerbations is an integral part of monitoring and annual review, in both adults and children, to minimise further damage due to infection and inflammation. Common modalities used to monitor disease progression include clinical signs and symptoms, frequency of exacerbations and/or number of hospital admissions, lung function (FEV1 %predicted), imaging (radiological severity of disease) and sputum microbiology (chronic infection with P. aeruginosa). There is good evidence that these monitoring tools can be used to accurately assess severity of disease and predict prognosis in terms of mortality and future hospitalisation. Other tools that are currently used in research settings such as health-related quality of life questionnaires, magnetic resonance imaging and lung clearance index can be burdensome and require additional expertise or resource, which limits their use in clinical practice. Studies have demonstrated that cross-infection, especially with P. aeruginosa between patients with bronchiectasis is possible but infrequent. This should not limit participation of patients in group activities such as pulmonary rehabilitation, and simple infection control measures should be carried out to limit the risk of cross-transmission. A multi-disciplinary approach to care which includes respiratory physicians, chest physiotherapists, nurse specialists and other allied health professionals are vital in providing holistic care. Patient education and personalised self-management plans are also important despite limited evidence it improves quality of life or frequency of exacerbations.

Aims: To examine the experiences of inter-professional collaboration of maternity service providers in the Netherlands and to identify potential enhancing and inhibiting factors for inter-professional collaboration within maternity care in the Netherlands. Background: Good collaboration between health care professionals is a key element of safe, effective care, but creating a collaborative culture can be challenging. Good collaboration requires, among other things, negotiating different professional orientations and the organizational constraints of hierarchies and scheduling. Good collaboration is especially important in maternity care. In the Netherlands, suboptimal collaboration has been cited as a significant factor in maternal deaths and in adverse incidents occurring in hospitals during evenings, nights, and weekends. In spite of its importance for effective maternity care, little is known about the nature and quality of collaboration between maternity care professionals. In order to fill this gap, we examined the inter-professional collaboration within multi-disciplinary teams (MDTs) providing maternity services in the Netherlands. Methods: Online survey of MDTs (consisting of hospital and PCMs, doctors, and carers) involved in the provision of maternity services in the Netherlands. We used a validated measure of collaboration (the Leiden Quality of Work Questionnaire) to analyze the attitudes of those involved in the provision of maternity services about multi-disciplinary collaboration in their work. We used descriptive and inferential statistics to assess differences between the groups. Results: 40% of all respondents were not satisfied with collaboration within their MDT. Overall, mean collaboration scores (MCS) were low. We found significant differences in MCS between professional groups. Midwives - community and hospital based - were pessimistic about collaboration in future models of maternity care. Discussion: In the Netherlands, collaboration in maternity care is less than optimal. Poor collaboration is associated with negative consequences for patient safety and quality of care. Strategies to address suboptimal collaboration exist; however, no one-size-fits-all approach is identified in the literature. Conclusion: Suboptimal collaboration exists within the midwifery model of care in the Netherlands and the relationship between care providers is under pressure. This could affect patient safety and quality of care, according to the literature. Précis: This paper presents an in-depth examination of the nature of, and attitudes about, collaboration between members of the MDT involved in the provision of maternity services in the Netherlands.

Multiple sclerosis (MS) is a chronic progressive disease which is one of the leading causes of handicap in young subjects. The large range of symptoms associated with MS lead to continuing decline in neurologic status and quality of life. The coexistence of physical and cognitive impairments, together with the imprevisible evolution of the disease makes MS rehabilitation very challenging. The main objective of rehabilitation is, therefore, to ease the burden of symptoms by improving self-performance and independence. Inpatient, outpatient and Home rehabilitation with multidisciplinary team has been shown to be beneficial in improving disability. Individualized programs elaborated by a multidisciplinary team of experts are the key to success of rehabilitation. Family plays a big role and Family Based Rehabilitation will be important in long term rehab program in MS.

Highlights • Mesenteric pneumatosis of the small bowel is a very rare pathological sign. • CT is the radiological investigation of choice to identify this sign. • It is associated with significant morbidity such as small bowel obstruction and ischaemia. • CT findings of mesenteric pneumatosis should be interpreted within a clinical context when a decision for surgical intervention is being considered, Introduction Pneumatosis of the small bowel mesentery is rare and the preserve of case reports. This case report describes the importance of a multi-disciplinary team (MDT) approach to rare pathologies. Case report A 78-year-old man presented to our unit with a two-day history of upper abdominal pain associated with nausea and intermittent vomiting. An urgent computed tomography (CT) scan was organised. The scan was grossly abnormal and difficult to interpret; it was reported as widespread intra-mural gas within the small bowel wall most likely secondary to extensive small bowel ischaemia. Although surgical intervention was very high risk (predicted P-possum mortality of over 60%) and there was a strong possibility that the patient would not recover from surgery, the disparity between clinical and radiological findings meant that a diagnostic laparoscopy was indicated. A diagnostic laparoscopy showed that the small bowel itself was normal but there was extensive gas within the mesentery, caused by a band adhesion which had eroded into the peritoneal layer of the small bowel mesentery. Discussion Pneumatosis of the small bowel mesentery is a pathological sign rather than a diagnosis and is characterised by gas within the mesenteric sleeves. It is likely associated with significant morbidity and therefore rarely observed as the majority with this sign would not be deemed suitable for surgical intervention. Conclusion The case highlights an unusual pathology, rare imaging findings, the importance of a multi-disciplinary approach and the value of clear communication and informed consent when considering major intervention or surgery.

Background: National guidelines recommend that fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is performed in all patients being considered for radical treatment of oesophageal or oesophago-gastric cancer without computerised tomography scan (CTS) evidence of metastasis. Guidance also mandates that all patients with cancer have treatment decisions made within the context of a multi-disciplinary team (MDT) meeting. Little is known, however, about the influence of PET-CT on decision making within MDTs. The aim of this study was to assess the role of PET-CT in oesophago-gastric cancer on MDT decision making. Methods: A retrospective analysis of a prospectively held database of all patients with biopsy-proven oesophageal or oesophago-gastric cancer discussed by a specialist MDT was interrogated. Patients selected for radical treatment without CTS evidence of M1 disease were identified. The influence of PET-CT on MDT decision making was examined by establishing whether the PET-CT confirmed CTS findings of M0 disease (and did not change the patient staging pathway) or whether the PET-CT changed the pathway by showing unsuspected M1 disease, refuting CTS suspicious metastases, or identifying another lesion (needing further investigation). Results: In 102 MDT meetings, 418 patients were discussed, of whom 240 were initially considered for radical treatment and 238 undergoing PET-CT. The PET-CT confirmed CTS findings for 147 (61.8%) and changed MDT recommendations in 91 patients (38.2%) by (i) identifying M1 disease (n=43), (ii) refuting CTS suspicions of M1 disease (n=25), and (iii) identifying new lesions required for investigations (n=23). Conclusion: The addition of PET-CT to standard staging for oesophageal cancer led to changes in MDT recommendations in 93 (38.2%) patients, improving patient selection for radical treatment. The validity of the proposed methods for evaluating PET-CT on MDT decision making requires more work in other centres and teams.

Effective therapeutic use of music for very young children with multi-system developmental disabilities involves engaging them and their parents/caregivers in musical play activities that can regulate the children’s (and parents’) physiological systems, strengthen parent-child relationships, and open children’s minds to physical, social emotional and intellectual learning and development; both in the context of music therapy and in response to goals set by a multi-disciplinary team. This article, based on a presentation given at the ISME conference in Greece in 2012, describes the therapy programmes at the Champion Centre in Christchurch, New Zealand and presents four case studies designed to illustrate the type and range of activities that have been shown to be effective over twenty years of experience. They show how when music practitioners follow the child’s lead, and draw the parents into the interaction as full partners, the well-being of children is enhanced and their parents are encouraged to engage in similar activities at home, thereby extending music’s therapeutic reach and effectiveness.

Background: Continuity of Care (COC) is considered one of the most relevant indicators representing both output and input of the care continuum during organizational integration. Previous studies usually center on the personal continuity of care-giving, and the theoretical and practical evidence on Continuity of Treatment (COT) for chronic patients between primary- and professional-level are insufficient. In this study, we firstly defined the COT as the continuity of inter-professional collaborative behavior on sequential treatment between community and hospital, and then evaluated the COT and explored into the influential factors through an intervention trial designed using different integration strategies.Methods: A case control study was designed and implemented in a rural pilot place in China from July 2012 to Dec 2014; all doctors in 6 towns randomly sampled and assigned into 3 groups who were intervened either with single intervention of Multi-disciplinary Team (MDT) or double intervention of MDT and integrated prospective payment system, providing them both behavior instructions and motivations. Together 279 medical records mainly concerning hypertension and concurrent diseases were sampled at the baseline and endpoint under certain inclusion/exclusion criteria, and COT was measured and compared using Triple Differences Regression Model. Three control variables included were “pre and post intervention”, “single/double treatment group and control group”, “continuous or discontinuous referral”, and the influential factors were “quality of first-stage treatment” and “continuous information delivery”.Results: 85 records were collected from the control group (38 pre/47 post); 103 from the single treatment group (51 pre/52 post); 91 from double treatment group (39 pre/52 post). After intervention, the total COT was 10.4% higher than before (P

Countering violent extremism (CVE) programs are moving into the realm of intervention, diversion, and deflection. These programs require mental health professionals to conduct assessments, construct treatment plans, and provide the treatment. How can practitioners treat or divert individuals from the path to radicalization but also communicate when an individual remains a threat? An understanding of the laws that facilitate or restrict disclosure of confidential health info, combined with a structure to oversee the process, is critical. Research for this thesis has focused on federal and Maryland state laws pertaining to medical record confidentiality and the duty to warn. This legal analysis has determined that exceptions exist within medical confidentiality laws, enabling mental health practitioners to disclose when a threat exists, and that Maryland's duty-to-warn laws mandate that mental health practitioners have a duty to protect third parties from the actions of patients. Due to the varied disciplines involved in CVE, collaborative group models are suggested to structure the process. http://archive.org/details/theimpactofdutyt1094551635 Lieutenant, Montgomery County Police, Patrol Services Approved for public release; distribution is unlimited.

Background Gastric cancer is a frequent malignant tumor worldwide and its early detection is crucial for curing the disease and enhancing patients’ survival rate. This study aimed to assess whether the multi-disciplinary team (MDT) can improve the detection rate of early gastric cancer (EGC). Methods The detection rate of EGC at the Digestive Endoscopy Center, Affiliated Hospital, Zunyi Medical College, China between September 2013 and September 2015 was analyzed. MDT for the diagnosis of EGC in the hospital was established in September 2014. The study was divided into 2 time periods: September 1, 2013 to August 31, 2014 (period 1) and September 1, 2014 to September 1, 2015 (period 2). Results A total of 60,800 patients’ gastroscopies were performed during the two years. 61 of these patients (0.1%) were diagnosed as EGC, accounting for 16.44% (61/371) of total patients with gastric cancer. The EGC detection rate before MDT (period 1) was 0.05% (16/29403), accounting for 9.09% (16/176) of total patients with gastric cancer during this period. In comparison, the EGC detection rate during MDT (period 2) was 0.15% (45/31397), accounting for 23% (45/195) of total patients with gastric cancer during this period (P

Pain is one of the most misunderstood, under diagnosed, and under treated/untreated medical problems, particularly in children. One of the most challenging roles of medical providers serving children is to appropriately assess and treat their pain. New JCAHO regulations regard pain as “the fifth vital sign” and require caregivers to regularly assess and address pain. Pain being a personal experience, many different terms are used to describe different sensations. Assessment of pain in children is linked to their level of development. Children of the same age vary widely in their perception and tolerance of pain.

Recent research indicates a definite positive impact on treatment outcomes when an integrative approach that focuses on symptom control and quality of life is provided along with the standard therapeutic regimens. However implementation or practice of this approach is not seen widely due to the culture of medical training and practice. This article presents the initial development of a program for incorporating integrative care principles into an ongoing comprehensive cancer care program at a tertiary centre. The key purpose of the program being to develop, facilitate, and establish comprehensive and holistic processes including palliative care principles, that would positively enhance the quantity and quality of life of the person with disease, as well as create an environment that reflects and sustains this approach. The vision, objectives, goals, strategies, activities and results within the 7 months of implementation are documented. The new learnings gained during the process have also been noted in the hope that the model described may be used to conceptualize similar care giving facilities in other centres.

The bachelor thesis deals with problems of rehabilitation nursing in practice. The main aim of the work was to establish the awareness of general nurses on rehabilitation nursing and whether they co-operated within the scope of a multi-disciplinary team. My Partial Aims were to find out what did general nurses consider to be rehabilitation nursing, whether they rehabilitated with patients and whether the multi-disciplinary team was used in practice. The theoretical part of the thesis aims at summary of information as related to rehabilitation nursing. There is also stated the way of education of general nurses nowadays and statutory stipulations on their work contents. The empiric part used quantitative investigations with the data obtained through an Internet questionnaire. The respondents were the general nurses from the Czech Republic. The results reached clearly indicate that general nurses have sufficient knowledge in the field of rehabilitation nursing and they sufficiently co-operate with other members of the multi- disciplinary team. The knowledge obtained will be published in social networks and there will also be created a plan for better orientation in positioning of patients. Keywords: rehabilitation nursing, rehabilitation, nursing, multi-disciplinary team, inter- disciplinary co-operation

The goal of my thesis I have chosen is to identify the way hospice care is perceived in the Telč region by family members of terminally ill patients. I based my thesis on available specialised literature, current legislation and internet sources dealing with home hospice care. In the first theoretical part, I deal with the definition of hospice care trying to explain the term of general and specialised care that have a common objective, namely dignified and tranquil dying. The second section deals with family in the context of palliative care that plays the key role in the patient care. If the family decides to care for the incurable patient at home, it is vital to support it. Moreover, in this section I define needs of family members summarised in three core topics. Including the care for the patient family that I included to the hospice care as not only the patient suffers from the illness but all his/her family does. That means that each family member needs palliative care. The end of this section deals with mourning of the survivors. The core point is not leaving them alone in their mourning, to have them accompanied by someone in their grief. The third chapter focuses on the role and position of the patient. It changes when a seriously ill human becomes dependent on third party´s help losing his/her capacity to fulfil his/her professional and family role. This enormously affects his/her physical and emotional condition. Moreover, I describe needs on terminally ill people that change when the patient approaches his/her death depending on his/her family and social situation. It changes also during his/her adaptation to adverse diagnoses and forecast and emergence of difficulties and complications. I describe four groups of needs: biological, psychological, social and spiritual. The fourth chapter characterises home hospice care that is described as specialised palliative care provided in the home environment amidst patient´s family and friends. I describe the history of Czech hospice care stating that before the WWII it was quite normal to care for terminally ill patients at home till the end. This trend emerges again in the 90s. I define objectives of the home hospice care and related activities. The fourth chapter includes the description of a multi-disciplinary team and funding of home hospice care. In the fifth chapter, I characterise the home care organisation that try to expand the range of services by including the home palliative care and also deal with the home care history, objectives, delimitation of the scope of activities, agency human resources management and home funding methods. In the sixth chapter, I represent the organisation Sdílení, o.p.s. Telč, services provided by it and basic duties according to the Act No.108/2006 Coll. as well as the mission and objectives of this organisation concentrating on help and support of seriously ill people and their family members/friends in such difficult life situation. The key objective of Sdílení is to preserve maximum possible self-sufficiency and dignity of seriously ill people and support of families that are able to find the courage and force to accompany a terminally ill family member to the end of his/her life. In the practical part of my thesis, I analyse data collected by means of qualitative research based on an inquiry in the form of semi-standardised and open-code processing. Who was included to the basic file were family members of terminally ill patients who were divided to two parts. The first group consists of 3 respondents who were entrusted to the care of the home hospice Sdílení. The second group are 3 respondents entrusted to the Home Care hospice. In the practical part, I describe the process of collection of data, record results of the interview process by the open-code method.

Background Rates of contralateral risk-reducing mastectomy (CRRM) are rising, despite a decreasing global incidence of contralateral breast cancer. Reasons for requesting this procedure are complex, and we have previously shown a variable practice amongst breast and plastic surgeons in England. We propose a protocol, based on a published systematic review, a national UK survey and the Manchester experience of CRRM. Methods We reviewed the literature for risk factors for contralateral breast cancer and have devised a 5-step process that includes history taking, calculating contralateral breast cancer risk, cooling off period/counselling, multi-disciplinary assessment and consent. Members of the multi-disciplinary team included the breast surgeon, plastic surgeon and geneticist, who formulated guidelines. Results A simple formula to calculate the life-time risk of contralateral breast cancer has been devised. This allows stratification of breast cancer patients into different risk-groups: low, above average, moderate and high risk. Recommendations vary according to different risk groups. Conclusion These guidelines are a useful tool for clinicians counselling women requesting CRRM. Risk assessment is mandatory in this group of patients, and our formula allows evidence-based recommendations to be made.

Together with surgery and radiotherapy, systemic treatment with cytotoxic chemotherapy and molecular targeted agents is one of the main therapeutic pillars in the treatment of soft-tissue sarcomas and is the mainstay of treatment in patients with advanced or metastatic disease. Unlike other more common malignancies such as breast and colorectal cancer, the role of chemotherapy when used in the adjuvant setting in soft-tissue sarcomas is less well defined. Results from prior studies have been conflicting, in part due to the heterogeneity and rarity of the disease, and large-scale meta-analysis has been performed to address this issue. Neoadjuvant chemotherapy, defined as the use of chemotherapy before definitive treatment with surgery or radiotherapy, has distinct theoretical and practical advantages, which can potentially be beneficial to the patient. However, the currently available evidence to support its use is even more scarce. In this review article, we describe the current established data behind the use of adjuvant chemotherapy in selected patients with localised soft-tissue sarcomas and, through extrapolation of available data, discuss the potential role of it when used in the upfront setting.

The purpose of this chapter is to define the scope and role of the occupational therapist (occupational therapy) within a rehabilitation team. This chapter defines the different types of teams that exist, and presents information across all types. Frequently cited advantages and barriers to teamwork are also discussed. To provide context for the reader, the concepts that are discussed within this chapter are applied to teams working with clients who have experienced a stroke. The principles that are used by occupational therapists working on stroke teams are also applicable to many other clinical populations. Finally, the evidence base for teamwork is discussed, with respect to published studies.

Background Cancer care is commonly managed by multidisciplinary teams (MDTs) who meet to discuss and agree treatment for individual patients. Patients do not attend MDT meetings but recommendations for treatments made in the meetings directly influence the decision-making process between patients and their responsible clinician. No research to-date has considered patient perspectives (or understanding) regarding MDTs or MDT meetings, though research has shown that failure to consider patient-based information can lead to recommendations that are inappropriate or unacceptable, and can consequently delay treatment. Methods Semi-structured interviews were conducted with current cancer patients from one cancer centre who had either upper gastrointestinal or gynaecological cancer (n = 9) and with MDT members (n = 12) from the teams managing their care. Interview transcripts were analysed thematically using Framework approach. Key themes were identified and commonalities and discrepancies within and between individual transcripts and within and between patient and team member samples were identified and examined using the constant comparative method. Results Patients had limited opportunities to input to or influence the decision-making process in MDT meetings. Key explanatory factors included that patients were given limited and inconsistent information about MDTs and MDT meetings, and that MDT members had variable definitions of patient-centredness in the context of MDTs and MDT meetings. Patients that had knowledge of medicine (through current/previous employment themselves or that of a close family member) appeared to have greater understanding and access to the MDT. Reassurance emerged as a ‘benefit’ of informing patients about MDTs and MDT meetings. Conclusions There is a need to ensure MDT processes are both efficient and patient-centred. The operationalization of “No decision about me without me” in the context of MDT models of care – where patients are not present when recommendations for treatment are discussed - requires further consideration. Methods for ensuring that patients are actively integrated into the MDT processes are required to ensure patients have an informed choice regarding engagement, and to ensure recommendations are based on the best available patient-based and clinical evidence. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0488-2) contains supplementary material, which is available to authorized users.

Background The study was conducted to determine the clinical and cost effectiveness of enhanced multi-disciplinary teams (EMDTs) vs. ‘usual care’ for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, Canada Methods We conducted a multi-method study: a pragmatic cluster randomized stepped-wedge trial, ethnographic observation and in-depth interviews, and an economic evaluation. Long term care facilities (clusters) were randomly allocated to start dates of the intervention. An advance practice nurse (APN) with expertise in skin and wound care visited intervention facilities to educate staff on pressure ulcer prevention and treatment, supported by an off-site hospital based expert multi-disciplinary wound care team via email, telephone, or video link as needed. The primary outcome was rate of reduction in pressure ulcer surface area (cm2/day) measured on before and after standard photographs by an assessor blinded to facility allocation. Secondary outcomes were time to healing, probability of healing, pressure ulcer incidence, pressure ulcer prevalence, wound pain, hospitalization, emergency department visits, utility, and cost. Results 12 of 15 eligible LTC facilities were randomly selected to participate and randomized to start date of the intervention following the stepped wedge design. 137 residents with a total of 259 pressure ulcers (stage 2 or greater) were recruited over the 17 month study period. No statistically significant differences were found between control and intervention periods on any of the primary or secondary outcomes. The economic evaluation demonstrated a mean reduction in direct care costs of $650 per resident compared to ‘usual care’. The qualitative study suggested that onsite support by APN wound specialists was welcomed, and is responsible for reduced costs through discontinuation of expensive non evidence based treatments. Insufficient allocation of nursing home staff time to wound care may explain the lack of impact on healing. Conclusion Enhanced multi-disciplinary wound care teams were cost effective, with most benefit through cost reduction initiated by APNs, but did not improve the treatment of pressure ulcers in nursing homes. Policy makers should consider the potential yield of strengthening evidence based primary care within LTC facilities, through outreach by APNs. Trial registration ClinicalTrials.gov identifier NCT01232764

Background: Goal setting is considered ‘best practice’ in stroke rehabilitation; however, there is no consensus regarding the key components of goal setting interventions or how they should be optimally delivered in practice. We developed a theory-based goal setting and action planning framework (G-AP) to guide goal setting practice. G-AP has 4 stages: goal negotiation, goal setting, action planning and coping planning and appraisal and feedback. All stages are recorded in a patient-held record. In this study we examined the implementation, acceptability and perceived benefits of G-AP in one community rehabilitation team with people recovering from stroke.\ud \ud Methods: G-AP was implemented for 6 months with 23 stroke patients. In-depth interviews with 8 patients and 8 health professionals were analysed thematically to investigate views of its implementation, acceptability and perceived benefits. Case notes of interviewed patients were analysed descriptively to assess the fidelity of G-AP implementation.\ud \ud Results: G-AP was mostly implemented according to protocol with deviations noted at the planning and appraisal and feedback stages. Each stage was felt to make a useful contribution to the overall process; however, in practice, goal negotiation and goal setting merged into one stage and the appraisal and feedback stage included an explicit decision making component. Only two issues were raised regarding G-APs acceptability: (i) health professionals were concerned about the impact of goal non-attainment on patient’s well-being (patients did not share their concerns), and (ii) some patients and health professionals found the patient-held record unhelpful. G-AP was felt to have a positive impact on patient goal attainment and professional goal setting practice. Collaborative partnerships between health professionals and patients were apparent throughout the process.\ud \ud Conclusions: G-AP has been perceived as both beneficial and broadly acceptable in one community rehabilitation team; however, implementation of novel aspects of the framework was inconsistent. The regulatory function of goal non-attainment and the importance of creating flexible partnerships with patients have been highlighted. Further development of the G-AP framework, training package and patient held record is required to address the specific issues highlighted by this process evaluation. Further evaluation of G-AP is required across diverse community rehabilitation settings.

The bachelor thesis deals with the cooperation of nurses and nutrition therapists within one multidisciplinary team. The theoretical part focuses on the multidisciplinary team, its tasks and also on what members of medical staff belong to the team and their role in the team. The next part describes the relations between medical staff members and their problems. The following parts describe the education, competences and responsibilities of the nurses and nutrition therapists. The closing part of the theoretical work concentrates on nutritional care and nutritional screening options. The practical part contains the results of the qualitative research. First, an objective was set, which focused on finding out about the cooperation between the nurses and the nutrition therapist within one multidisciplinary team. The objective was established six research questions. The semi-structured type of interview was used for the research. 20 respondents took part in the research, 10 nurses from the departments of dermatovenerology, gastroenterology, surgery, neurology, carcinology and 10 nutrition therapists from the Všeobecná fakultní nemocnice v Praze (General TeachingHospital in Prague). During cooperation, the nurses should focus on the hospital diet system, on the diet types, how to order meals through the hospital information system. They should also learn about the options and news in nutrition therapy at workshops and courses. The nutrition therapists should give the nurses more information about the news in nutrition care and subsequently consult it with them. Both parties should communicate more with each other and make an effort to improve mutual relations in general.

Objectives To provide international consensus on the competencies required by healthcare professionals in order to provide specialist care for teenagers and young adults (TYA) with cancer. Design Modified e-Delphi survey. Setting International, multicentre study. Participants Experts were defined as professionals having worked in TYA cancer care for more than 12 months. They were identified through publications and professional organisations. Methods Round 1, developed from a previous qualitative study, included 87 closed-ended questions with responses on a nine-point Likert scale and further open-ended responses to identify other skills, knowledge and attitudes. Round 2 contained only items with no consensus in round 1 and suggestions of additional items of competency. Consensus was defined as a median score ranging from 7 to 9 and strength of agreement using mean absolute deviation of the median. Results A total of 179 registered to be members of the expert panel; valid responses were available from 158 (88%) in round 1 and 136/158 (86%) in round 2. The majority of participants were nurses (35%) or doctors (39%) from Europe (55%) or North America (35%). All 87 items in round 1 reached consensus with an additional 15 items identified for round 2, which also reached consensus. The strength of agreement was mostly high for statements. The areas of competence rated most important were agreed to be: ‘Identify the impact of disease on young people's life’ (skill), ‘Know about side effects of treatment and how this might be different to those experienced by children or older adults’ (knowledge), ‘Honesty’ (attitude) and ‘Listen to young people's concerns’ (aspect of communication). Conclusions Given the high degree of consensus, this list of competencies should influence education curriculum, professional development and inform workforce planning. Variation in strength of agreement for some competencies between professional groups should be explored further in pursuit of effective multidisciplinary team working.

Background There is a continuing need for research capacity building initiatives for primary health care professionals. Historically strategies have focused on interventions aimed at individuals but more recently theoretical frameworks have proposed team-based approaches. Few studies have evaluated these new approaches. This study aims to evaluate a team-based approach to research capacity building (RCB) in primary health using a validated quantitative measure of research capacity in individual, team and organisation domains. Methods A non-randomised matched-pairs trial design was used to evaluate the impact of a multi-strategy research capacity building intervention. Four intervention teams recruited from one health service district were compared with four control teams from outside the district, matched on service role and approximate size. All were multi-disciplinary allied health teams with a primary health care role. Random-effects mixed models, adjusting for the potential clustering effect of teams, were used to determine the significance of changes in mean scores from pre- to post-intervention. Comparisons of intervention versus control groups were made for each of the three domains: individual, team and organisation. The Individual Domain measures the research skills of the individual, whereas Team and Organisation Domains measure the team/organisation's capacity to support and foster research, including research culture. Results In all three domains (individual, team and organisation) there were no occasions where improvements were significantly greater for the control group (comprising the four control teams, n = 32) compared to the intervention group (comprising the four intervention teams, n = 37) either in total domain score or domain item scores. However, the intervention group had a significantly greater improvement in adjusted scores for the Individual Domain total score and for six of the fifteen Individual Domain items, and to a lesser extent with Team and Organisation Domains (two items in the Team and one in the Organisation domains). Conclusions A team-based approach to RCB resulted in considerable improvements in research skills held by individuals for the intervention group compared to controls; and some improvements in the team and organisation's capacity to support research. More strategies targeted at team and organisation research-related policies and procedures may have resulted in increased improvements in these domains.

Objective There is a body of published research on the effectiveness of home visiting for the prevention of child maltreatment, but little in the peer reviewed literature on cost-effectiveness or value to society. The authors sought to determine the cost-effectiveness of alternative home visiting programmes to inform policy. Conclusions There is great variation in the costeffectiveness of home visiting programmes for the prevention of maltreatment. The most cost-effective programmes use professional home visitors in a multidisciplinary team, target high risk populations and include more than just home visiting. Home visiting programmes must be carefully selected and well targeted if net social benefi ts are to be realised. Results 33 home visiting programmes were evaluated and cost-effectiveness estimates derived for the 25 programmes not dominated. The incremental cost of home visiting compared to usual care ranged from A$1800 to A$30 000 (US$1800-US$30 000) per family. Cost-effectiveness estimates ranged from A$22 000 per case of maltreatment prevented to several million. Seven of the 22 programmes (32%) of at least adequate quality were cost saving when including lifetime cost offsets. Study design All trials reporting child maltreatment outcomes were identifi ed through systematic review. Information on programme effectiveness and components were taken from identifi ed studies, to which 2010 Australian unit costs were applied. Lifetime cost offsets associated with maltreatment were derived from a recent Australian study. Cost-effectiveness results were estimated as programme cost per case of maltreatment prevented and net benefi t estimated by incorporating downstream cost savings. Sensitivity analyses were conducted. Refereed/Peer-reviewed

Applying the principles of user-centered development (UCD) in software development practice is not straightforward. In technology-push type software product development it is not clear how to match the new product innovation to the future needs of potential future users. Intensive collaboration between different organizational functions becomes essential. UCD provides valuable tools and practices as learning mechanisms both for users and for the company. The purpose of cross-functional interaction is to iteratively define the best possible market for the emerging new product. This study investigates cross-functional interaction during the early phases of a new software product. The roots of UCD are in traditional software engineering (SE). However, in a software product company it is necessary to take a broader new product development (NPD) perspective. The results indicate that the early phases of software NPD are actually a collaborative learning process in which representations of the new product are built iteratively, increasing multidisciplinary knowledge related to the evolving shared object of development. The cross-functionally shared object is more than the new software product. It is an emerging new vision for the whole new business area. Both the product and its users-customers-market develop iteratively. Traditionally this is considered to happen through communication within a cross-functional NPD team. Rather than one cross-functional team effort, software NPD seems to be a network of cross-functional activities. Furthermore, in software NPD practice the development of the new business unit may actually overlay the more established business organization. This has not been visible enough, and part of the problems with cross-functional interaction may be due to confusion between these two activity systems during every-day practices. Different mediating representations of the multidimensional object knowledge become crucial. The study starts with a summary of a three-year process improvement effort in one case company, providing the basis for theoretical reflections and analytical generalizations. SE and NPD literature is reviewed to situate the case within current theoretical understanding. The findings are synthesized using concepts from cultural-historical activity theory. This study will hopefully provoke the rethinking of some of the current taken-for-granted issues related to the management of new emerging software product businesses.

This study analyses the figure of the Information Manager specialized in health organizations and the complete justification for his/her presence in the light of the change taking place in decision making regarding both therapy and health management. This new vision, called clinical practice based on scientific evidence, makes it possible to adopt a knowledge-based criterion of action which should be a key point in the provision of health care services in order to attain maximum quality. Se analiza la figura del Gestor de Información, especializado en organizaciones sanitarias y su total justificación a la luz del cambio que se está produciendo en la toma de decisiones en cuanto a terapéutica, como en la gestión sanitaria; esta nueva visión a la que se denomina práctica clínica basada en la evidencia científica permite adoptar un criterio de actuación basado en el conocimiento, el cual debe ser central en la provisión de cuidados para lograr la máxima calidad de los mismos.

We CanSupport provide holistic care to the patients and family. This means, physical, emotional, psychosocial and spiritual care. The objective of this article is to implement a plan for improved high quality care, within a dynamic and complex health care system for palliative care. Twelve years of working experience with palliative care in CanSupport 'India' and 10 years of working palliative care aboard (USA). High level satisfaction of the patient of the patient and families due to the psycho, socio, spiritual model and help for income generation and vocational training. We suggest and encourage, to we this model for all palliative care centre and institutions.

Failure to thrive (FTT) is a term generally used to describe an infant or child whose current weight or rate of weight gains is significantly below that expected of similar children of the same age, sex and ethnicity. It usually describes infants in whom linear growth and head circumference are either not affected, or are affected to a lesser degree than weight. FTT is a common problem, usually recognized within the first 1-2 years of life, but may present at any time in childhood. Most cases of failure to thrive involve inadequate caloric intake caused by behavioral or psychosocial issues. The most important part of the outpatient evaluation is obtaining an accurate account of a child's eating habits and caloric intake. Routine laboratory testing rarely identifies a cause and is not generally recommended. FTT, its evaluation, and its therapeutic interventions are best approached by a multi-disciplinary team includes a nutritionist, a physical therapist, a psychologist and a gastroenterologist. Long term sequelae involving all areas of growth, behavior and development may be seen in children suffering from FTT. Early detection and early intervention by a multi-disciplinary team will minimize its long term disadvantage. Appropriate nutritional counseling and anticipatory guidance at each well child visit may help prevent some cause of FTT.

The reason that probably prompted Dame Cicely Saunders to launch the palliative care movement was the need to move away from the impersonal, technocratic approach to death that had become the norm in hospitals after the Second World War. Palliative care focuses on relieving the suffering of patients and families. Not limited to just management of pain, it includes comprehensive management of any symptom, which affects the quality of life. Care is optimized through early initiation and comprehensive implementation throughout the disease trajectory. Effective palliative care at the outset can help accelerate a positive clinical outcome. At the end of life, it can enhance the opportunity for the patient and family to achieve a sense of growth, resolve differences, and find a comfortable closure. It helps to reduce the suffering and fear associated with dying and prepares the family for bereavement.