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Funder: National Institute for Health Research (NIHR), Funder: Wellcome Trust, BACKGROUND: Multidisciplinary teams (MDTs) are widely used in cancer care. Recent research points to logistical challenges impeding MDT decision-making and dissatisfaction among members. This study sought to identify different types of logistical issues and how they impacted team processes. METHODS: This was a secondary analysis of a cross-sectional observational study. Three cancer MDTs (breast, colorectal, and gynaecological) were recruited from UK hospitals. Validated observational instruments were used to measure decision-making (Metrics of Observational Decision-making, MDT-MODe), communication (Bales' Interaction Process Analysis, Bales' IPA), and case complexity (Measure of Case Discussion Complexity, MeDiC), including logistical challenges (Measure of Case Discussion Complexity, MeDiC), across 822 case discussions from 30 videoed meetings. Descriptive analysis and paired samples t tests were used to identify and compare frequency of different types of logistical challenges, along with partial correlations, controlling for clinical complexity of cases, to understand how such issues related to the MDT decision-making and communication. RESULTS: A significantly higher frequency of administrative and process issues (affecting 30 per cent of cases) was seen compared with the frequency of equipment issues (affecting 5 per cent of cases; P < 0.001) and the frequency of the attendance issues (affecting 16 per cent of cases; P < 0.001). The frequency of the attendance issues was significantly higher than the frequency of equipment issues (P < 0.001). Partial correlation analysis revealed that administrative and process issues, including attendance, were negatively correlated with quality of information (r = -0.15, P < 0.001; r = -0.11, P < 0.001), and equipment issues with the quality of contribution to meeting discussion (r = -0.14, P < 0.001). More questioning and answering by MDT members was evident with the administrative and process issues (r = 0.21, P < 0.001; r = 0.19, P < 0.001). Some differences were observed in teams' socioemotional reactions to the administrative and process issues with the gynaecological MDT showing positive correlation with positive socioemotional reactions (r = 0.20, P < 0.001), and the breast cancer MDT with negative socioemotional reactions (r = 0.17, P < 0.001). CONCLUSION: Administrative and process issues were the most frequent logistical challenges for the studied teams. Where diagnostic results were unavailable, and inadequate patient details provided, the quality of decision-making was reduced.

Background Multidisciplinary teams (MDT) formulate expert informed treatment recommendations for people with cancer. We set out to examine how the factors proposed by the functional perspective of group decision making (DM), that is, interaction process, internal factors (factors emanating from within the group such as group size), external circumstances (factors coming from the outside of the team), and case‐complexity affect the quality of MDT decision making. Methods This was a cross‐sectional observational study. Three cancer MDTs were recruited with 44 members overall and 30 of their weekly meetings filmed. Validated observational instruments were used to measure quality of DM, interactions, and complexity of 822 case discussions. Results The full regression model with the variables proposed by the functional perspective was significant, R 2 = 0.52, F(20, 801) = 43.47, P, To the best of our knowledge, this is the first study to attempt to assess the factors proposed by the functional perspective in the context of cancer MDT meetings. Validated observational instruments were used to measure quality of decision making, interactions, and complexity of 822 case discussions across 3 cancer teams and 30 of their weekly meetings. One novel finding is unraveling the sociocognitive predictors of team DM quality, while another is the cognitive‐catch 22 effect

Background and Objective There is increasing emphasis in cancer care globally for care to be reviewed and managed by multidisciplinary teams (ie, in tumor boards). Evidence and recommendations suggest that the complexity of each patient case needs to be considered as care is planned; however, no tool currently exists for cancer teams to do so. We report the development and early validation of such a tool. Methods We used a mixed‐methods approach involving psychometric evaluation and expert review to develop the Measure of case‐Discussion Complexity (MeDiC) between May 2014 and November 2016. The study ran in six phases and included ethnographic interviews, observations, surveys, feasibility and reliability testing, expert consensus, and multiple expert‐team reviews. Results Phase‐1: case complexity factors identified through literature review and expert interviews; Phase‐2: 51 factors subjected to iterative review and content validation by nine cancer teams across four England Trusts with nine further items identified; Phase 3: 60 items subjected to expert review distilled to the most relevant; Phase 4: item weighing and further content validation through a national UK survey; Phases 5 and 6: excellent interassessor reliability between clinical and nonclinical observers, and adequate validity on 903 video case discussions achieved. A final set of 27 factors, measuring clinical and logistical complexities were integrated into MeDiC. Conclusions MeDiC is an evidence‐based and expert‐driven tool that gauges the complexity of cancer cases. MeDiC may be used as a clinical quality assurance and screening tool for tumor board consideration through case selection and prioritization., There is increasing emphasis in cancer care globally for care to be reviewed and managed by multidisciplinary teams (ie, in tumor boards). Evidence and recommendations suggest that the complexity of each patient case needs to be considered as care is planned, however no tool currently exists for cancer teams to do so. We report the development and early validation of such a tool. We used a mixed‐methods approach involving psychometric evaluation and expert review to develop the Measure of case‐Discussion Complexity (MeDiC).

Assess whether fully-immersive simulation training with structured debriefing of a standardized emergency thoracic endovascular aortic repair (TEVAR) scenario improves team-work performance of the lead surgeon. Secondary aims: assess whether technical skills (TS) and radiation safety behaviors (RSB) improved concurrently.Pre-post study.UK-based training days.General and vascular surgical trainees (n = 16).Fully-immersive simulation training with structured debriefing of a standardized emergency TEVAR scenario. Following standardized emergency TEVAR technical training, trainees led 2 standardized fully-immersive endovascular surgery simulations, with scripted support from a passive surgical team. A non-TS (NTS) structured debrief was delivered following simulations. NTS were assessed using the validated observational teamwork assessment for surgery tool post hoc using video recordings of simulations. TS were assessed through time taken to complete each step of the procedure, as defined during technical training. RSB were assessed through checking for presence of pre-defined actions and the length of time fluoroscopy was used during each simulation.Total observational teamwork assessment for surgery scores improved following structured debrief (p = 0.005, median 52.55/90 vs 73.0/90), alongside all constituent domains - communication (p0.001, median 11.7/20 vs 16.6/20), coordination (p0.001, median 8.6/15 vs 13.4/15), cooperation (p0.001, median 13.15/20 vs 16.35/20), leadership (p0.001, median 8.70/15 vs 11.30/15) and monitoring (p0.001, median 9.85/20 vs 14.85/20). TS improved; time to complete 12 of 13 procedural steps improved (p0.027). Fluoroscopy time (seconds) decreased (p = 0.339, 543.6 vs 495.5), frequency lead surgeons checked the team were wearing leads increased (p = 0.125, 3 vs 7) and asked the team to step back before screening increased (p = 0.003, frequency team asked to step back/total angiography runs before = 2/36 vs after = 14/44).fully-immersive endovascular simulation with structured debrief is a robust tool to improve NTS and TS. Incorporation into surgical training may reduce operating theatres errors, increase efficiency, and improve RSB. However effective translation into the clinical workplace must be demonstrated to see these benefits.

This case highlights the importance of timely diagnosis and management of acute mesenteric ischaemia and illustrates the compensatory mechanisms of the mesenteric vasculature.A 53-year-old female presented with fever, abdominal pain, and vomiting. The patient had no risk factors for atherosclerosis and was a non-smoker in sinus rhythm with no history of coagulopathy. She was initially treated for viral gastroenteritis. Due to lack of clinical improvement and a rising C-Reactive Protein (416), a CT scan was performed. This demonstrated small bowel ischaemia, chronic occlusion of the coeliac axis, and a long acute-on-chronic occlusion of the superior mesenteric artery (SMA). The length and morphology of the SMA occlusion precluded endovascular treatment. Emergency laparotomy demonstrated 1 m of necrotic small bowel and a pulseless mesentery. An aorto-SMA bypass, using good-quality long saphenous vein was performed, with segmental small bowel resection. Postoperative nutritional support was required with discharge on the 23rd post-operative day. Interval surveillance confirmed graft patency. One year post-discharge, she presented to routine clinic with paroxysmal right iliac fossa pain and decreased appetite. CT angiography showed a long tight 75% stenosis of the graft and she was admitted for mesenteric angioplasty. Angiography confirmed a significantly hypertrophied inferior mesenteric artery, which was now the dominant mesenteric supply.This case demonstrates the importance of emergency mesenteric revascularisation and how it acts as a bridge to anatomical compensation, allowing the collateral circulation to develop and the IMA to hypertrophy, becoming the dominant mesenteric supply.

Intermittent claudication has a major impact on the quality of life and functional ability of the patient. However, when treating these patients, management is largely influenced by vascular surgeons' perceptions of risk. There is little information available regarding the level of risk that patients perceive to be acceptable, when considering complications of treatment. This study investigates patients' acceptance of risk associated with current management options for intermittent claudication and explores factors associated with greater risk acceptance.Patients with confirmed intermittent claudication presenting to vascular clinic and supervised exercise classes were surveyed in a single-center prospective study. A standard gamble-type method was used to measure patients' acceptance of risk associated with medical treatment, angioplasty, and surgical bypass. Level of risk acceptance was correlated to patient factors.Fifty patients were surveyed; 74% were male, median age was 68 years (interquartile range [IQR] 59-74), maximal walking distance was 100 m (IQR 70-200), and ankle-brachial pressure index was 0.65 (IQR 0.60-0.78). Median risk acceptance for treatment failure was 70% for medical treatment, 50% for angioplasty, and 40% for surgical bypass. Median risk acceptance for major amputation and death was 0% for all 3 management options. Claudicants with maximal walking distance100 m accepted higher risk of treatment failure (P = 0.0005 for medical treatment, P = 0.0038 for angioplasty), and death with medical treatment (P = 0.0009). There was no significance between claudication distance and risk acceptance of major amputation with any treatment modality or death with angioplasty or surgical bypass. There was no significant correlation among level of risk acceptance and age, gender, or diabetic status.Claudicants are prepared to accept significant risk of treatment failure, in order to gain benefit, but regardless of claudication distance, patients have low acceptance of the risk of amputation or death. Patient acceptance of risk should be considered when planning management.

Integral to maintaining good outcomes post-endovascular aneurysm repair (EVAR) is a robust surveillance protocol. A significant proportion of patients fail to comply with surveillance, exposing themselves to complications. We examine EVAR surveillance in Wessex (UK), exploring factors that may predict poor compliance. Retrospective analysis of 179 consecutive elective EVAR cases [2008–2013] was performed. 167 patients were male, with the age range of 50–95. Surveillance was conducted centrally (tertiary referral trauma centre) and at four spoke units. Surveillance compliance and predictors of non-compliance including age, gender, co-morbid status, residential location and socioeconomic status were analysed for univariate significance. Fifty patients (27.9 %) were non-compliant with surveillance; 14 (8.1 %) had no imaging post-EVAR. At 1 year, 56.1 % (of 123 patients) were compliant. At years 2 and 3, 41.5 and 41.2 % (of 65 and 34 patients, respectively) were compliant. Four years post-EVAR, only one of eight attended surveillance (12.5 %). There were no statistically significant differences in age (p = 0.77), co-morbid status or gender (p = 0.64). Distance to central unit (p = 0.67) and surveillance site (p = 0.56) was non-significant. While there was a trend towards compliance in upper-middle-class socioeconomic groups (ABC1 vs. C1C2D), correlating with >50 % of non-compliant patients living within

BACKGROUND It is believed that bilateral developmental dysplasia of the hip (DDH) has poorer outcomes with higher rates of avascular necrosis (AVN) and reintervention, compared with unilateral DDH. However, there is limited evidence in the literature, with few studies looking specifically at bilateral cases. METHODS A retrospective review of 36 patients (72 hips) with >4 years of follow-up. Patient population included surgically treated DDH including late presentations and failures of conservative treatment. The dislocated hips underwent either simultaneous closed or 1 open and 1 closed, or sequential open reduction. AVN and secondary procedures were used as endpoints for analysis as well as clinical and radiologic outcomes. RESULTS At the last follow-up, 33% of hips had radiologic signs of AVN. Those hips that had no ossific nucleus (ON) at the time of surgery had an odds ratio of developing AVN of 3.05 and a statistically significant association between the 2 variables, whereas open/closed or simultaneous/sequential reduction did not increase the risk for AVN. In addition, 45.8% of those hips required further surgery. The estimated odds ratio of needing additional surgery after simultaneous reduction was 4.04. Clinically, 79.2% of the hips were graded as McKay I, whereas radiologically only 38.8% were Severin I. CONCLUSIONS The AVN rate in bilateral DDH treated surgically is greater than the rate noted in unilateral cases from the same institution undergoing identical protocols. There was no difference in AVN rates between simultaneous and sequential or between the first and second hip to be sequentially reduced. Presence of ON decreases the risk for AVN, suggesting that in bilateral cases, awaiting the appearance of the ON is an important tool to reduce the incidence of AVN. LEVEL OF EVIDENCE IV.

PURPOSE: To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting. MATERIALS AND METHODS: Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained. Field notes were recorded during 55 VIR procedures by a single observer. Two blinded assessors identified failures from field notes and categorized them into one or more errors by using a 22-part classification system. The potential to cause harm, disruption to procedural flow, and preventability of each failure was determined. A preprocedural team rehearsal (PPTR) was then designed and implemented to target frequent preventable potential failures. Thirty-three procedures were observed subsequently to determine the efficacy of the PPTR. Nonparametric statistical analysis was used to determine the effect of intervention on potential failure rates, potential to cause harm and procedural flow disruption scores (Mann-Whitney U test), and number of preventable failures (Fisher exact test). RESULTS: Before intervention, 1197 potential failures were recorded, of which 54.6% were preventable. A total of 2040 errors were deemed to have occurred to produce these failures. Planning error (19.7%), staff absence (16.2%), equipment unavailability (12.2%), communication error (11.2%), and lack of safety consciousness (6.1%) were the most frequent errors, accounting for 65.4% of the total. After intervention, 352 potential failures were recorded. Classification resulted in 477 errors. Preventable failures decreased from 54.6% to 27.3% (P < .001) with implementation of PPTR. Potential failure rates per hour decreased from 18.8 to 9.2 (P < .001), with no increase in potential to cause harm or procedural flow disruption per failure. CONCLUSION: Failures during VIR procedures are largely because of ineffective planning, communication error, and equipment difficulties, rather than a result of technical or patient-related issues. Many of these potential failures are preventable. A PPTR is an effective means of targeting frequent preventable failures, reducing procedural delays and improving patient safety.

The aim of this paper is to review the potential role of endovascular interventions for young patients with lower-limb ischaemia.A literature search was performed of PubMed and Medline databases using appropriate search terms and limits. Case reports, retrospective studies, and prospective studies evaluating treatment of lower-limb ischemia in patients aged50 years were scrutinized. Articles published between 1966 and 2010 were included in this review.Premature atherosclerosis is likely to represent the commonest cause of lower-limb ischemia in patients aged50 years, although the incidence of nonatherosclerotic causes such as popliteal entrapment syndrome, cystic adventitial disease, and arteritis in these patients is greater than in older patients. As with older patients, endovascular interventions may be beneficial for patients with symptoms secondary to atherosclerosis. At present, the perceived durability of open surgery may be more preferable to patients aged50 years, but the development of new endovascular technology is challenging this view. Endovascular interventions such as catheter-directed thrombolysis have specific roles in the treatment of lower-limb ischemia due to nonatherosclerotic causes.The use of angioplasty and stenting procedures to treat young patients with lower-limb ischemia is increasing and has specific roles. However, many developmental causes and nonatherosclerotic conditions still require primary surgical correction.

To clarify the role of epilepsy and genetic background in determining the cognitive outcome of patients with Dravet syndrome.In this retrospective study, we reviewed the clinical history and cognitive development of 26 patients who had been followed with standardized evaluations since seizure onset. The cognitive outcome was quantified as differential general quotient (dGQ) between ages 12 and 60 months. Statistical analysis correlated the dGQ with genotype and epilepsy course.Epilepsy started at the mean age of 5.6 months. All patients experienced prolonged convulsive seizures, whereas absences and myoclonus were reported in 17. Cognitive outcome was poor in almost all patients; the mean dGQ was 33 points, varying from 6-77 points. The analysis of individual cognitive profiles identified seven patients in whom the dGQ was20 points; the main clinical characteristic in this subset of patients was lack of early absences and myoclonus. The statistical analysis of the whole series failed to reveal significant differences in cognitive outcome with regard to the presence of SCN1A mutations and their type. In particular, mutation-carrier patients with the best cognitive outcome harbored either missense or truncating mutations.Dravet syndrome encompasses different epileptic and cognitive phenotypes that probably result from both genetic and epigenetic factors. In this series, early appearance of myoclonus and absences was associated with the worst cognitive outcome.

Aims of our study were to describe the early clinical features of Dravet syndrome (SMEI) and the neurological, cognitive and behavioral outcome. The clinical history of 37 patients with clinical diagnosis of SMEI, associated with a point mutation of SCN1A gene in 84% of cases, were reviewed with particular attention to the symptoms of onset. All the patients received at least one formal cognitive and behavior evaluation. Epilepsy started at a mean age of 5.7 months; the onset was marked by isolated seizure in 25 infants, and by status epilepticus in 12; the first seizure had been triggered by fever, mostly of low degree in 22 infants; the first EEG was normal in all cases. During the second year of life difficult-to-treat seizures recurred, mostly triggered by fever, hot bath, and intermittent lights and delay in psychomotor development became evident. At the last evaluation, performed at a mean age of 16+/-6.9 years, mental retardation was present in 33 patients, associated with behavior disorders in 21. Our data indicate that the most striking features of SMEI are: the early onset of seizures in a previously healthy child, the long duration of the first seizure, the presence of focal ictal symptoms, and sensitivity to low-grade fever. Diagnosis of SMEI may be proposed by the end of the first year of life, and a definite diagnosis can be established during the second year based on the peculiar seizure-favoring factors, EEG photosensitivity and psychomotor slowing. The temporal correlation between high seizure frequency and cognitive impairment support the role of epilepsy in the clinical outcome, even if a role of channelopathy cannot be ruled out.