When teams disagree: Investigating the incidence and causes of dissent occurring in cancer multidisciplinary team meetings.

AIM: Multidisciplinary teams (MDT) are commonly involved in the care of patients with cancer. How frequently dissent occurs within MDT has not been studied. This study aimed to determine how frequently dissent was documented in cancer MDT meetings at our institution, the reasons for this, and the opinions of MDT members on how dissent should be documented and communicated. METHODS: A retrospective review of records from cancer MDT meetings at our institution from 2016 to 2020 was performed to identify cases where dissent was documented and the reasons for this. MDT members were invited to complete an online survey assessing their perceptions of how frequently dissent occurred, how comfortable they felt voicing dissenting opinions, and their opinions on how dissent should be documented and communicated. RESULTS: Dissent was recorded in 30 of 7737 MDT case discussions (0.39%). The incidence of dissent varied from 0 to 1.2% between cancer streams. The most common reason for dissent involved the role of surgery. 27% of survey respondents felt either very or somewhat uncomfortable voicing dissenting opinions. Only 3% felt that dissent should not be documented, and none that it should not be communicated in some way, although there were wide ranging of views on how this should occur. CONCLUSION: Dissent was rarely documented within cancer MDT meetings at our institution, likely due to underreporting. Measuring the incidence of dissent within an MDT may be a useful performance metric. MDT should develop policies for how dissent should be managed, documented, and communicated.

Sydney 'lockout' liquor licensing law restrictions have been associated with a sustained reduction in emergency department presentations from assaults over 5 years.

OBJECTIVES: The present study assessed the impact of changes to the New South Wales Liquor Act in 2014 on assault-related presentations to the ED of St Vincent's Hospital. This hospital is the primary receiving hospital for the area affected by these laws. METHODS: Patients presenting to the ED with an assault-related diagnosis were identified from the ED and trauma registry databases from 2009 to 2019 and retrospectively reviewed. The number of presentations in the 5 years prior to the introduction of the laws in 2014 was compared to the number occurring in the 5 years following this. Admission to the intensive care unit (ICU) and in-hospital death were used as markers for severe injury. RESULTS: From 2009 to 2019 there were 2983 assault-related presentations to the ED, with 153 requiring ICU admission and 12 deaths. The mean number of presentations annually fell from 342 to 255 after the introduction of the laws (P = 0.01). The reduction in presentations was sustained for the entire 5-year period after the introduction of the laws. Although the mean number of patients requiring ICU admission per year fell from 17 to 14, and the mean number of deaths annually fell from 1.6 to 0.8, neither of these were statistically significant. CONCLUSIONS: There has been a significant reduction in assault-related presentations to St Vincent's Hospital following the changes to the liquor licensing laws that has been sustained for 5 years with no significant decrease in the those with severe assault injuries.

Cognitive impairment associated with carcinoid syndrome.

OBJECTIVES: To evaluate the cognitive performance of patients with carcinoid syndrome (CS) compared with population norms and cancer patients with non-neuroendocrine (non-NET) liver metastases. BACKGROUND: The release of serotonin into the systemic circulation from metastatic small bowel neuroendocrine tumors (SB NET) causes CS. Many patients with CS followed in a multidisciplinary NET clinic seemed to exhibit a unique cognitive impairment. Because serotonin is known to influence a range of cognitive function, the question arouse as to whether cognitive impairment is another manifestation of CS. METHODS: Patients were recruited from the multidisciplinary NET and the hepatobilary cancer clinics at the cancer center. The CS group consisted of patients with proven SB NETs metastatic to liver; the cancer comparison group consisted of patients with liver metastases from non-NET cancer. All completed a self-reported cognitive questionnaire and a battery of 6 standardized neurocognitive tests. Both groups were compared to age/sex/educational-matched norms. RESULTS: Thirty-six patients with CS and 20 with non-NET metastases were enrolled. Patients with CS reported greater cognitive dysfunction in all cognitive domains than both norms and the comparison cancer group. On cognitive testing, patients with CS demonstrated weakness in initiation, processing speed, visual memory, cognitive efficiency, and delayed verbal recall compared with norms. Although the patients with non-NET cancer also demonstrated some cognitive dysfunction compared with norms, the patients with CS did significantly worse on delayed recall (P = 0.03) and marginally slower on speeded mental flexibility (P = 0.097) compared with patients with non-NET cancer. CONCLUSION: This study confirmed our clinical observation that patients with CS suffer from cognitive impairment that is different from the non-NET cancer group and population norms.

Invasive melanoma of the face: Management, outcomes, and the role of sentinel lymph node biopsy in 260 patients at a single institution.

BACKGROUND AND OBJECTIVES: The face is a common site of melanoma occurrence. The purpose of this study was to examine the management and outcomes of patients with invasive melanoma of the face. METHODS: Patients with invasive melanoma of the face managed at our institution from 1997 to 2008 were retrospectively reviewed. Details of sentinel lymph node biopsy (SNB), disease recurrence, and deaths were recorded. RESULTS: Two hundred sixty patients were reviewed (mean age 68, mean tumor thickness 0.87 mm). Of 100 patients eligible for SNB (tumor thickness ≥ 1 mm, Clark level ≥ IV, or ulceration) this was performed in only 29 (29%), and those who underwent SNB were younger than those who did not (mean age 59 vs. 79 years, P < 0.0001). SNB was successful in 28 (97%), and no complications occurred. SNB was positive in 3 (11%). After mean follow-up of 30 months, nodal recurrence occurred in 9 (3.5%) and distant recurrence in 20 (7.7%). There were 60 deaths (overall mortality 23%); attributed to melanoma in only 16 cases (disease specific mortality 6.2%). CONCLUSIONS: Facial melanoma is associated with low rates of regional recurrence despite underutilization of SNB. Older patients are less likely to undergo SNB. Due to the advanced age of patients with facial melanoma, most deaths occurring are from unrelated causes.

Role of imaging in the preoperative staging of small bowel neuroendocrine tumors.

BACKGROUND: Imaging studies are important in the preoperative staging of patients with small bowel neuroendocrine tumors (NET) and when selecting patients for cytoreduction procedures for metastatic disease. The purpose of this study was to assess the accuracy of preoperative imaging compared with operative findings in the staging of small bowel NET. STUDY DESIGN: Sixty-four patients with small bowel NET undergoing laparotomy and who had preoperative imaging with combinations of CT, MR, and radionuclide scintigraphy were reviewed. Results of imaging studies were compared with operative findings to assess the ability of these investigations to detect mesenteric, peritoneal, and hepatic metastases. RESULTS: Mesenteric nodal metastases were seen on imaging in 47 (73%) patients and were present at laparotomy in 56 (88%) patients. Peritoneal metastases were seen on preoperative imaging in 4 (6%) patients and found at laparotomy in 16 (25%) patients. Hepatic metastases were seen on imaging in 42 patients (66%) and found at laparotomy in 49 (77%). Sensitivity and specificity for detection of hepatic metastases were 77% and 100% for CT, 82% and 100% for MR, 63% and 100% for (123)I-meta-iodobenzylguanadine scintigraphy, and 63% and 100% for (111)In-octreotide. Imaging studies failed to detect hepatic metastases in 7 patients and underestimated the extent of hepatic metastatic disease in 17 patients. CONCLUSIONS: Imaging of small bowel NET, even with combinations of CT, MR, and radionuclide studies, underestimates the extent of peritoneal, mesenteric, and hepatic metastatic disease. Accurate staging of small bowel NET might be best performed at the time of laparotomy.

Impairment of cognitive function reported by patients suffering from carcinoid syndrome.

BACKGROUND: Carcinoid syndrome (CS) is characterized by symptoms of diarrhea, flushing, bronchospasm, and valvular heart disease. It has been our impression that patients with CS also exhibit features of cognitive impairment. The purpose of this pilot study was to evaluate if symptoms of cognitive impairment were reported by patients with CS. METHODS: Patients with proven CS completed a 38-question multiple-ability self-report questionnaire (MASQ) to assess symptoms in five cognitive domains: language skills, attention/concentration (A/C), visual-perceptual function, visual memory, and verbal memory. Patients subsequently underwent neurocognitive assessment using a battery of six standardized tests. Results of the MASQ and the cognitive test were compared to published results for healthy individuals. RESULTS: Twenty-one patients with CS were studied. MASQ symptom scores were higher than published norms in all five cognitive domains. Patients reported greatest difficulty with verbal memory (mean +/- SD = 2.74 +/- 0.5), followed by A/C (2.41 +/- 0.65), language (2.31 +/- 0.55), visual memory (2.30 +/- 0.65), and visual-perceptual function (2.17 +/- 0.59). In contrast, neurocognitive tests for verbal memory immediate recall, visual memory, language, and executive function were within the normal range. CS patients, however, scored lower than expected in tests of verbal memory delayed recall and visual-perceptual function. CONCLUSIONS: Patients with CS report high levels of symptoms of impairment in all cognitive domains; however, on formal neurocognitive testing, patients scored lower than expected only in tests of verbal memory delayed recall and visual-perceptual function. These findings appear to confirm our clinical impression that cognitive impairment may be an additional feature of CS. Further studies are needed to confirm and elucidate the cause of this cognitive impairment.

Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system.

BACKGROUND: Documentation of thyroidectomy is performed traditionally by surgeon-dictated operative reports (DORs). A Web-based system that generates a synoptic report (WebSMR) for thyroidectomy was developed. The purpose of this study was to assess the completeness of documentation in WebSMR compared with DOR. METHODS: In all, 271 DORs and 133 WebSMR were reviewed for the documentation of (1) prognostic information for the MACIS score calculation; (2) key anatomic structures such as recurrent laryngeal nerve (RLN) and parathyroid glands; and (3) nonessential information such as middle thyroid vein (MTV) ligation and sutures used for closure. RESULTS: Overall DOR documented presence/absence of invasion in 27%, completeness of resection in only 3%, and tumor size in 29%, whereas these were recorded in 100% of WEBSMR (P < .001). The MACIS scores could not be calculated from any DOR, whereas WebSMRs have a MACIS calculator incorporated in the software. Although subtle differences were found in reporting anatomic structures depending on training, DORs were good at reporting the status of the RLNs (>95%) and parathyroids (>83%) compared with 100% in WebSMRs. DOR routinely included nonessential information; MTV (80%) and sutures used for closure (93% to 98%). CONCLUSION: Use of the WebSMRs was superior to DORs in documenting key prognostic and anatomic findings without nonessential information, and it produced a superior document that can aid in postoperative care.

Large subpectoral hematoma: possible complication of sternotomy post-cardiac surgery.

A 62-year-old female patient developed a significantly enlarged left breast 6 hours after sternotomy for a coronary artery bypass graft operation. This was the result of subpectoral bleeding caused by a sternal wire.

The palliative benefit of aggressive surgical intervention for both hepatic and mesenteric metastases from neuroendocrine tumors.

BACKGROUND: Metastatic neuroendocrine tumors (NETs) can present with complications of gastrointestinal tract obstruction or ischemia and carcinoid syndrome (CS). The purpose of this study was to assess whether aggressive surgical intervention of metastatic NETs provides effective palliation from these symptoms. METHODS: Sixty-six patients with metastatic gastrointestinal tract NETs that presented with either CS and/or obstructive symptoms were retrospectively reviewed. All patients were managed according to a standardized protocol that involved initial surgical resection of regional and/or hepatic disease followed by appropriate medical therapy. RESULTS: Symptoms of obstruction or ischemia were present in 24 patients (36%) and CS in 56 (85%). All patients with obstructive symptoms undergoing operative therapy had complete symptomatic relief. Hepatic cytoreduction was performed in 30 (45%). Overall symptoms of CS improved in 42 patients (75%); 86% of patients that underwent hepatic cytoreduction and 64% of those receiving medical therapy alone (P = .064). Postoperative morbidity was 22% with no mortality. Mean follow-up was 47 months (range, 6-156). Overall 5-year survival rate was 74%. CONCLUSIONS: Surgical resection is highly effective in relieving symptoms of intestinal obstruction and ischemia. Hepatic cytoreduction seems to enhance the ability to control the symptoms of carcinoid syndrome. A surgically aggressive approach in patients with metastatic NETs provides effective palliation in carefully selected patients.

Operation Sumatra Assist: surgery for survivors of the tsunami disaster in Indonesia.

The tsunami of 26 December 2004 was one of the deadliest natural disasters recorded, with the Indonesian province of Aceh being the most devastated region. As part of the Australian Government's response to the disaster, the Australian Defence Force deployed personnel from the Sydney-based 1st Health Support Battalion to Banda Aceh, the capital of the province. This unit joined with medical personnel from the New Zealand Defence Force to form the ANZAC field hospital. The mission of this unit as part of Operation Sumatra Assist was to provide medical and surgical care to the people of Aceh during the critical stages of rebuilding of the tsunami-devastated region. Surgical teams of the ANZAC field hospital were some of the first to provide definitive surgical care to the critically injured survivors of the disaster. During the first 4 weeks of the deployment, 173 surgical procedures were carried out for 71 patients in this facility. Thirty patients underwent 119 procedures (69% of total) for injuries sustained in the tsunami. Most of these patients required debridements, dressing changes and wound management procedures for the management of severe soft tissue infections. Three amputations were carried out. The remaining 41 patients underwent 54 procedures (31%) for emergent surgical conditions unrelated to the disaster.

Australian Defence Force surgical support to peacekeeping operations in East Timor.

BACKGROUND: The Australian Defence Force (ADF) has provided surgical support to peacekeeping operations in East Timor since September 1999. The aim of the present paper is to document the wide range of surgical procedures performed by the ADF in East Timor from September 1999 to December 2002 on peacekeeping force personnel and the civilian population. METHODS: Records of all surgical procedures performed by the ADF in East Timor from their arrival in September 1999 to December 2002 were retrospectively reviewed. Details of the type of procedures performed and anaesthetic administered, the age and sex of the patients and whether they were a member of peacekeeping forces or East Timorese civilian were recorded. RESULTS: There were 702 surgical procedures performed by the ADF in East Timor during this period, of which 401 (57%) were for peacekeeping force personnel and 301 (43%) were for East Timorese or other civilians. The most commonly performed procedures were for the management of non-battle wounds, accounting for 181 cases (26%). Battle-type wounds accounted for only 36 procedures (5%). Obstetric and gynaecology cases accounted for 30 procedures (4%). Fifty-six procedures (8%) were on children 12 years or younger. CONCLUSIONS: The wide range of surgical procedures performed by the ADF during peacekeeping operations in East Timor highlights the requirement for deployed surgeons to possess a broad range of clinical skills and has implications for their preparation and training. Battle-type wounds accounted for only a small proportion of procedures.