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PubMed2003

Classification of sudden infant death (SID) cases in a multidisciplinary setting. Ten years experience in Styria (Austria).

OBJECTIVE: Sudden infant death syndrome (SIDS) remains a challenge for health professionals despite decreasing rates in recent years. The figures for different areas and time periods are hardly comparable, because of differences in postmortem investigations and classification criteria. In 1992, the European Society for the Study and Prevention of Infant Deaths (ESPID) proposed a classification for any sudden and unexpected death in infancy. This proposal has been used in our study since 1993 to better classify sudden infant death (SID) cases. METHOD: 56 consecutive SID cases observed between 1993 and 2002 in Styria, the south-eastern province of Austria, were analysed by a multidisciplinary team of health professionals. The study group consisted of pediatricians, forensic pathologists, pathologists, psychologists, nurses, members of the parents' association and health authorities. SID cases were analysed with regard to potential risk factors during pregnancy and early life, the circumstances of death (death scene) and post-mortem findings. From the latter, every SID was classified as either 1) classic SIDS, 2) borderline SIDS, 3) non-autopsied SID or 4) explained death. RESULTS: Of the 56 SID cases, 22 were assigned to category 1, 19 to category 2, four to category 3, and in 11 cases death could be explained by major post-mortem findings. For 17/22 cases in category 1 and 11/19 cases in category 2, the death scene investigation showed the typical risk profile of manner of bedding and/or environmental conditions. In three cases, child abuse or infanticide was considered possible but could not be proven despite careful autopsy. In recent years, SIDS incidence in Styria has decreased to approximately 0.18/1,000 live-born infants, and the few deaths still occurring mainly present with the typical risk profile. CONCLUSION: An extensive analysis of SID events is a prerequisite for reliable and comparable SIDS statistics. Our data show that in several SID cases careful post-mortem examinations led to an explanation of death. In other cases, minor alterations may have contributed to the lethal event. These findings should therefore be considered in the classification of SIDs. The ESPID classification of 1992 appears to be very useful for this purpose and its use may therefore be recommended.

Austria↗

PubMed2002

[Participation--oriented analysis of the anesthesia workplace. A work system for anesthesia in a multidisciplinary operating room].

INTRODUCTION: The aim of this study was the detection and understanding of weak points in the ergonomic design of anaesthesia workplaces in a multidisciplinary operating room facility. METHODS: Analysis of workplaces and of working processes by means of observations, computer-supported task recording and video-photo documentation. During guided interviews the participants were provided with material for naming-by-pointing and drawing. Subsequently, the background of the problems encountered and possible improvements were visualised. RESULTS: Important deficits were devices not positioned within reach and view, difficulties in operating the lines connecting the patient and the devices, and inconsistent workplace layouts. These were caused by erroneous planning of the facility and disregarding ergonomic principles in equipment design. The initial improvements implemented were the development of a new concept for a flexible equipment positioning and the design of a tool for cable handling. DISCUSSION AND CONCLUSION: Although from the very beginning of the study the anaesthesia personnel quoted the handling of the lines connecting patients and devices as the main cause for working difficulties, the external ergonomist could contribute to a broader view of the problems. The method presented here initiated a mutual learning process between ergonomist and users and resulted in a common understanding of the problems and their causes. Compared to the traditional consulting process, more time and efforts were necessary but were offset by the users' acceptance of the improvements and the prevention of design errors.

Anesthesia↗

PubMed2005

[Who needs what? New approaches to multidisciplinary diagnostics and therapy for adipose children and youths in a multiethnic city].

Over the past two decades, obesity in children has been increasing worldwide, leading to serious complications. The treatment for childhood obesity remains largely ineffective; therefore preventive measures are crucial. The prevalence of obesity depends on the BMI-percentiles used. Recent BMI-percentiles may underestimate the problem. Currently, the only representative cross-sectional BMI-data are obtained at the school entry examination. These data reveal certain risk groups (migrants, low socioeconomic status). More representative longitudinal data are needed to study the progression of obesity during childhood. Our obesity clinic provides multidisciplinary therapy programs (group or individual) and is also focused on the diagnosis and treatment of comorbidity, especially of the metabolic syndrome. Almost 60% of our severely obese patients are already affected. The molecular diagnosis of rare monogenetic or syndromal forms of obesity may be helpful in providing additional support for these patients. In general, most obesity programs are successful only in families without severe psychosocial problems and with motivation for lifestyle changes. This can be expected in only 3% of our families. Therefore, a substantial societal effort is needed to facilitate prevention for all children, and effective therapies have to be tailored depending on biological and psychosocial risk factors.

Adolescent↗

PubMed1998

[Operation of multidisciplinary, interventional 0.5 Tesla magnetic resonance tomograph. Technical and logistic problems and initial clinical results].

Multidisciplinary usage of a MRI system with a superconducting 0.5-T magnet (Signa SP, General Electric) with a vertical gap suited for diagnostic and therapeutic interventions raises complex problems. The MR equipment, including a special localizing system and the instruments for diagnostic and therapeutic interventions, is described. Before putting the system into operation tests were necessary to check MR compatibility of various materials and instruments and to build some auxiliary equipment. We report on the coordinating activities of the radiologist in the context of MR use by different medical specialities. Within the course of 12 months, 428 examinations/interventions of different kinds were carried out, among them 75 functional examinations of the spine or of joints, 31 diagnostic biopsies, 23 cerebral biopsies, and 23 operations. The special design of the Signa SP allows the whole scale of functional examinations, up to complete neurosurgical interventions, in the sitting position and under nearly real-time imaging control.

Equipment Design↗

PubMed2002

A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers.

OBJECTIVE: The impact of a multidisciplinary quality management system (MQMS) on the early treatment of severely injured patients was tested. DESIGN AND SETTING: Prospective clinical study in two level 1 trauma centers. METHODS AND MATERIALS: MQMS comprised a protocol for documentation, 20 assessment criteria, and the judgement of data by a quality circle. After implementation in Munich (1st period, n=90; 2nd period, n=77) the validation took place in Essen (1st period, n=175; 2nd period, n=150). RESULTS: Improvements in diagnostics were shown by significant time savings in radiological diagnostics and before computed tomography in severe traumatic brain injury. In patients with hemorrhagic shock there was a reduction in time before transfusion (49 to 14 min in Munich; 31 to 22 min in Essen) and before emergency operation (74 to 43 min in Munich; 69 to 45 min in Essen). The time before craniotomy was reduced from 97 to 67 min in Munich. The incidence of delayed diagnosis of life-threatening lesions was diminished from 6% to 3% in Munich (not found in Essen). The TRISS technique showed a reduction in mortality in both hospitals in the second period (Munich: 15.4% TRISS vs. 9.1% observed mortality; Essen: 17.8% vs. 11.3%). CONCLUSIONS: MQMS improved early clinical treatment in severe injury with respect to therapeutic effectiveness and outcome. The effectiveness of the MQMS was shown at two different hospitals

Germany↗

PubMed2001

Human errors in a multidisciplinary intensive care unit: a 1-year prospective study.

OBJECTIVES: To determine the incidence and identify risk factors of critical incidents in an ICU. DESIGN: Prospective observational study of consecutive patients admitted over 1 year to an ICU. Critical incidents were recorded using predefined criteria. Their causes and consequences were analysed. The causes were classified as technical failure, patient's underlying disease, or human errors (subclassified as planning, execution, or surveillance). The consequences were classified as lethal, leading to sequelae, prolonging the ICU stay, minor, or without consequences. The correlation between critical incidents and specific factors including patient's diagnosis and severity score, use of monitoring and therapeutic modalities was analysed by uni- and multivariate analysis. SETTING: An 11-bed multidisciplinary ICU in a non-university teaching hospital. PATIENTS: 1,024 consecutive patients admitted to the ICU. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The median length of ICU stay by the 1,024 patients was 1.9 days. Of the 777 critical incidents reported 2% were due to technical failure and 67 % to secondary to underlying disease. There were 241 human errors (31%) in 161 patients, evenly distributed among planning (n = 75), execution (n = 88), and surveillance (n = 78). One error was lethal, two led to sequelae, 26 % prolonged ICU stay, and 57 % were minor and 16 % without consequence. Errors with significant consequences were related mainly to planning. Human errors prolonged ICU stay by 425 patient-days, amounting to 15 % of ICU time. Readmitted patients had more frequent and more severe critical incidents than primarily admitted patients. CONCLUSIONS: Critical incidents add morbidity, workload, and financial burden. A substantial proportion of them are related to human factors with dire consequences. Efforts must focus on timely, appropriate care to avoid planning and execution mishaps at the beginning of the ICU stay; surveillance intensity must be maintained, specially after the fourth day.

Adolescent↗

PubMed2006

A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture.

INTRODUCTION: This study evaluates whether a postoperative multidisciplinary, intervention program, including systematic assessment and treatment of fall risk factors, active prevention, detection, and treatment of postoperative complications, could reduce inpatient falls and fall-related injuries after a femoral neck fracture. METHODS: A randomized, controlled trial at the orthopedic and geriatric departments at Umeå University Hospital, Sweden, included 199 patients with femoral neck fracture, aged >or=70 years. RESULTS: Twelve patients fell 18 times in the intervention group compared with 26 patients suffering 60 falls in the control group. Only one patient with dementia fell in the intervention group compared with 11 in the control group. The crude postoperative fall incidence rate was 6.29/1,000 days in the intervention group vs 16.28/1,000 days in the control group. The incidence rate ratio was 0.38 [95% confidence interval (CI): 0.20 - 0.76, p=0.006] for the total sample and 0.07 (95% CI: 0.01-0.57, p=0.013) among patients with dementia. There were no new fractures in the intervention group but four in the control group. CONCLUSION: A team applying comprehensive geriatric assessment and rehabilitation, including prevention, detection, and treatment of fall risk factors, can successfully prevent inpatient falls and injuries, even in patients with dementia.

Accidental Falls↗

PubMed2002

How many children remain fracture-free during growth? a longitudinal study of children and adolescents participating in the Dunedin Multidisciplinary Health and Development Study.

While much is known regarding the incidence and pattern of fractures during growth, information is sparse as to how many children fracture repeatedly and how many remain fracture-free during growth. The Dunedin Multidisciplinary Health and Development Study, a birth cohort, whose members were questioned regularly throughout growth (at ages 5, 7, 9, 11, 13, 15 and 18 years) concerning injuries including fractures, has provided a unique opportunity to answer these questions. Life-table analysis showed that approximately half the children remained fracture-free throughout growth [girls 60.1%, (95% CI 54.7-65.0) and boys 49.3% (95% CI 44.0-54.4)]. Data on fracture history, for participants seen at every phase, was available for 601 members through to the age of 18 years (61.1% of the cohort seen at age 5 years). Two hundred and ninety-one of these 601 participants reported 498 fractures, with 172 sustaining a single fracture, and 119 more than one fracture (15.8% girls and 23.4% boys). The most common site of fracture was the wrist/forearm (24.1% of all fractures). We conclude that although bone fractures are a common adverse event in childhood, half of all children remain fracture-free throughout growth.

Adolescent↗

PubMed2000

A multidisciplinary approach to assess history, environmental risks, and remediation feasability of soils contaminated by metallurgical activities. Part A: chemical and physical properties of metals and leaching ability.

Three soils contaminated by heavy metals (HMs) and aliphatic hydrocarbons originating from different industrial sources were characterized in a multidisciplinary study combining chemical, physical (Part A), and mineralogical (Part B) approaches to define history, environmental risks, and remediation feasibility. These were an agricultural soil located nearby a Zn/Pb smelter and two soils from a steel metallurgical (siderurgy) waste land. High Pb and Zn contents were reported for all, and high Cr, Cd, and aliphatic hydrocarbons were present in different combinations in two out of three soils. Carbonate matrixes more strongly cemented fine particles in the agricultural soil than in both siderurgical ones, but buffering capacities were stronger in the latter. After the disruption of these cements by ultrasounds, HM were concentrated in the <50-microm fraction of the agricultural and of one siderurgical soil. Sequential extractions indicated for all the soils a preferential association of HM with carbonates, Fe-Mn oxides, organic matter, and sulfides. The stirring of one siderurgical soil with water resulted in an immediate leaching of hexavalent chromium (0.3 mg x L(-1)) involving potential ecotoxicological risks.

Feasibility Studies↗

PubMedDate not supplied

Multidisciplinary and multistage treatment of complex facial trauma: case report.

The improved performance of modern automobiles often results in higher driving speeds, rendering traffic accidents much more devastating. Many of our facially injured patients require multidisciplinary and multistage treatment, which is often both sophisticated and radical. We present a patient with complex facial trauma, discuss his injury characteristics and the multistage treatment performed, and review the literature.

Accidents, Traffic↗

PubMed2004

A multidisciplinary decision support system for forest fire crisis management.

A wildland fire is a serious threat for forest ecosystems in Southern Europe affecting severely and irreversibly regions of significant ecological value as well as human communities. To support decision makers during large-scale forest fire incidents, a multidisciplinary system has been developed that provides rational and quantitative information based on the site-specific circumstances and the possible consequences. The system's architecture consists of several distinct supplementary modules of near real-time satellite monitoring and fire forecast using an integrated framework of satellite Remote Sensing, GIS, and RDBMS technologies equipped with interactive communication capabilities. The system may handle multiple fire ignitions and support decisions regarding dispatching of utilities, equipment, and personnel that would appropriately attack the fire front. The operational system was developed for the region of Penteli Mountain in Attika, Greece, one of the mountain areas in the country most hit by fires. Starting from a real fire incident in August 2000, a scenario is presented to illustrate the effectiveness of the proposed approach.

Communication↗

PubMed2005

Diagnostic investigation and multidisciplinary management in motor neuron disease.

Amyotrophic lateral sclerosis (ALS) is the most common adult-onset motor neuron disease. ALS is a progressive neurodegenerative disorder, involving motor neurons in the cerebral cortex, brainstem and spinal cord, presenting with a combination of upper and lower motor neuron signs. Etiology remains undetermined, although a multifactorial origin is widely accepted including genetic factors, auto-immunity, oxidative stress, glutamate excitotoxicity and abnormal neurofilament aggregation. The absence of specific diagnostic testing, and variable clinical presentations make the diagnosis of ALS challenging, relying upon correlation of clinical, electrophysiological and neuroimaging data. The disease is relentlessly progressive, with dysarthria, dysphagia, tetraparesis, and respiratory insufficiency due to ongoing respiratory muscle paresis. There is no specific treatment for ALS. Riluzole, a glutamate antagonist, is the only FDA approved drug for ALS, but has only a modest effect on survival. The multiplicity and progressiveness of the disabilities in ALS, highlights the need for a coordinated multidisciplinary rehabilitation program managing symptoms, respiratory care, dysphagia and nutrition, dysarthria and communication, physical and occupational therapy. The main goals are to prolong independence, prevent complications and improve quality of life.

Amyotrophic Lateral Sclerosis↗

PubMed1996

[Multidisciplinary treatment program for chronic low back pain, part 2. Somatic aspects].

PROBLEM: There is a great need to expand current knowledge of the various functional capacity measurements used in the rehabilitation of chronic low back pain (CLBP) patients. The literature on these patients reports that mobility, endurance, trunk strength and lifting capacity decrease during the process of chronicity. Chronically disabled patients appear to have lower functional capacity than asymptomatic persons. METHODS: Our study group consisted of 90 disabled CLBP patients (44 female, 46 male; average age 42 years) who underwent a multidisciplinary 8-week daily treatment program of functional restoration with behavioral support (instruction, endurance training, strength exercises, behavioral and treatment to facilitate return to work therapy). Initially these patients where compared with 107 asymptomatic persons (44 female, 63 male, average age 41 years). The patients were investigated before and after treatment, and at intervals of 6 and 12 months. The reliability of the functional measurements was evaluated by interrater comparison. Physical assessment included a medical examination (mainly diagnosis of radicular or nonradicular pain), changes in the lumbar spine revealed by X-ray studies according to Herron and Turner, rating of physical impairment according to Waddell, flexibility, length of hamstrings muscles (SLR), test of power and endurance of trunk movement by standardized exercises according to the Swiss group of Spring and isokinetic measurements (LIDO Back), tests of lifting capacity (LIDO Lift), and (in part) of general endurance on a cycle ergometer (CASE 15 Marquette). RESULTS: Physical findings showed that mobility was reduced substantially in patients suffering from back pain due to reduced SLR (shortened hamstrings) and decreased spinal mobility. Patients also demonstrated significant reductions in their ability to perform lifting tasks in comparison to healthy individuals. The results of trunk flexion showed no significant differences between patients and the control group, whereas the ability to perform trunk extension was much better in the control group. In principle we found the same results with isokinetic measurements as in the exercises without machines. Cardiovascular endurance was also much better in the control group than it was in the back pain patients. At the end of the treatment program all physical deficits were improved significantly. In many cases performance was comparable with that of the control group. With time, however, training effects gradually decreased. The success of treatment (return to work, absence from work, pain reduction, use of medical care) was independent of the functional status of the patients before and after treatment. CONCLUSION: Study results showed that physical capacity in disabled patients with low back pain is substantially reduced in comparison to persons who do not suffer from back pain. The only exception was in trunk flexor strength and endurance, in which measurements did not differ between the patients and the control group. However, even CLBP- patients with long-term pain and severe physical illness can successfully improve their physical condition by participating in an active treatment program. Back extensor muscle training has to be included in physical therapy. Because of loss of condition during the time after treatment, regular monitoring of patients and their home training programs is necessary. Overall, treatment of CLBP has to include physical training and psychosocial treatment to achieve satisfactory results.

English Abstract↗

PubMed2003

From oncology pharmacy to pharmaceutical care: new contributions to multidisciplinary cancer care.

In recent years a paradigm shift towards a patient-focused rather than a disease-focused approach occurred in many health care systems. The pharmacy profession experienced an accordant development. The traditional drug-oriented services expanded towards patient-oriented services. In oncology, pharmacists established central services for compounding of cytotoxic drugs and offered therapeutic drug monitoring for critical substances. Pharmaceutical care concepts are now being introduced to optimize individual drug therapy. Pharmaceutical care aims at improving safety and therapeutic outcomes and consequently, the patient's quality of life. These objectives imply a close relationship to supportive care. To achieve this, a multidisciplinary approach seems to be beneficial.

Antineoplastic Agents↗

PubMed1999

Assessing suspected spinal cord compression: a multidisciplinary outcomes analysis of 342 episodes.

The object of this work was to evaluate the assessment and document the outcomes of cancer patients with suspected spinal cord compression (SCC). In a retrospective cohort study of 342 episodes of suspected SCC in cancer patients evaluated by computed tomography (CT) of the spine, a multidisciplinary team of neurologists, radiologists, and oncologists assessed the impact of varying the anatomical criterion for SCC and including new SCC diagnosed shortly after definitive radiographical imaging. We developed a logistic regression model to identify independent clinical predictors of SCC, including the natural history of the underlying cancer as well as neurological and radiological risk factors. Management of suspected SCC infrequently involved neurology consultation (21% of episodes). The frequency of SCC increased more than four-fold when the definition was expanded to include epidural cancer rather than spinal cord displacement only (36% vs. 8%), and 90-day clinical follow-up identified few new lesions not evident on definitive imaging studies. Clinical information about the course of cancer (documentation and duration of metastatic cancer) added independent predictive information to that yielded by neurological assessment and prior imaging studies in a multiple regression model. The a priori predicted risk of SCC, which ranged from 4% to 87% in this study, may vary enough to affect treatment strategies, although our population may have excluded very-low-risk patients. Consistent anatomical definitions of SCC, clinical follow-up of definitive imaging studies and the addition of information on the natural history of cancer to traditional neurological and radiographical evaluation may all improve clinical assessment of suspected SCC in cancer patients.

Adolescent↗

PubMed2005

Cancer disparities: developing a multidisciplinary research agenda - preface.

In this Special Issue, we present a series of papers concerned with developing a multidisciplinary research agenda to address social disparities in cancer. Motivating this Special Issue are two concerns: (1) despite major advances in knowledge during the 20th century about the extent, determinants, treatment, and prevention of cancer, social disparities in cancer, including within the United States, remain serious, persistent, and require redress; and (2) huge gaps in knowledge exist regarding the causes of and solutions to social disparities in cancer across the full cancer continuum, from prevention to occurrence to diagnosis to treatment and, all too often, to death. Consequently, critical research is critically needed, both to answer the unanswered questions and to ascertain why existing knowledge is not implemented to reduce and eliminate these disparities. To help advance work in this field, we share papers developed for a January 2004 workshop on cancer disparities held at the Dana Farber/Harvard Cancer Center (DF/HCC), in Boston, MA. Topics addressed include: the definition and magnitude of, and programmatic responses to, social disparities in cancer, plus development of a systematic approach to raising research questions to address cancer disparities, using the case examples of breast, cervix, colon, and prostate cancer.

Diagnosis, Differential↗

PubMed2005

Social disparities in cancer: lessons from a multidisciplinary workshop.

The problem of social disparities in cancer continues to challenge health care researchers. This article summarizes the themes and lessons emerging from a 2004 workshop that convened researchers from academic and government venues to review and discuss the extant literature, and to develop new conceptual frameworks for future investigations. Workshop participants explored the factors that contribute to social inequalities in cancer in the U.S. including the relative contributions of race and racism, the independent contributions of socioeconomic position, insurance, and access to care. Noting the heterogeneous patterns of inequality across cancer types, the multiple underlying causes of disparities, and the role of the health care system itself, the authors call for an organized program of multidisciplinary research.

Delivery of Health Care↗

PubMed2007

Multidisciplinary work on barium contamination of the karstic upper Kupa River drainage basin (Croatia and Slovenia); calling for watershed management.

The present work was designed as an extension of a previous study of a barium anomaly observed in stream sediments of the Kupa River. In its upper part the Kupa River drains a region underlain by a trans-boundary aquifer. The river is a significant water resource in a region of tourism, sport, and fishing in both Croatia and Slovenia. The contamination source is situated in Homer (Lokve), Croatia, where barite was mined until 10 years ago. The barium processing waste material (<3-mm fraction) was carelessly deposited in gardens, forests, and into a sinkhole, which has an underground link with the Kupica River, a tributary of the Kupa River. Barium waste and stream sediments were analyzed using comparative techniques: X-ray diffraction (XRD), X-ray fluorescence (XRF), Mössbauer spectroscopy, and grain size analysis. XRD of the waste material identified the major minerals quartz, barite, and dolomite and the Fe-containing minor minerals muscovite and goethite. Barite was identified as a minor or trace mineral in the Kupica River sediments. XRF analysis of the waste material has shown Ba and Fe to be the predominant elements, Ca and K to be minor elements, and Mn, Zn, Sr, Pb, Co, Cu, As, Zr, Rb, Y, and Mo to be trace elements. Mössbauer spectroscopy performed at room temperature (RT) was used to study iron minerals, particularly to obtain information on the valence status of Fe ions. Grain size analysis of the waste material (<63-microm fraction) has shown that it contains 23.5% clay-size material in comparison with 7-8% clay-size material in stream sediments. It is our aim to combine geochemical and medical methods to investigate the possible impact of waste disposal on human health in Lokve. At this stage of the work, concentrations of Ba and other toxic elements in the water compartment of the Kupica River (a source of drinking water) have not been monitored by Croatian Waters (name of the Croatian water authorities). The necessity of such measurements in future studies has been highlighted. A preliminary study of diseases diagnosed in Lokve shows that about 18% of the total inhabitants have serious medical problems. Diseases of the circulatory system, endocrine, nutritional, and metabolic diseases, neoplasms, and respiratory diseases predominate. This paper calls for further multidisciplinary research on the health effects of barium and trace elements, as well as for bioremediation of contaminated gardens and for watershed management of vulnerable karstic aquifers.

Barium↗