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1.
Medicine Today ; 22(10):43-45, 2021.
Article in English | Scopus | ID: covidwho-2011394

ABSTRACT

Despite a recent decrease in drowning deaths, the number of drownings in Australia remains too high. Being reminded of key considerations for a drowning emergency is helpful preparation for health professionals who may take control at the scene © 2021 Medicine Today Pty Ltd. All rights reserved.

2.
Journal of Clinical Oncology ; 40(16), 2022.
Article in English | EMBASE | ID: covidwho-2009533

ABSTRACT

Background: Access to health care including clinical trials (CT) leading to paradigm-changing cancer treatments are critical for high quality cancer care and equity in society. In this report, we highlight methods in accruing to ETCTN wherein underrepresented rural, low-income, and racial minorities comprise >50% of enrollment. Methods: University of Kansas Cancer Center (KUCC) is one of eight National Cancer Institute (NCI) designated cancer centers awarded CATCH-UP.2020 (CATCH-UP), a congressionally mandated P30 supplement to enhance access for minority/underserved populations to ETCTN precision medicine CT. KUCC catchment area is 23% rural by Rural Urban Continuum Codes (RUCC);almost 90 % of counties are designated primary care HPSA's (Health Professional Shortage Areas). KUCC Early Phase and Masonic Cancer Alliance (rural outreach network) partnered to operationalize CATCH-UP. We engaged disease-focused champion investigators in disease working groups and MCA physicians who selected scientifically sound CT that fit catchment area needs. Patient and Investigator Voices Organizing Together, a patient research advocacy group provided practical feedback. MCA navigator coordinated recruitment. Telehealth was used for rural patients that would have a significant distance to travel just to be screened. Results: CATCH-UP was initiated in September 2020. Twenty-eight CT were activated, many in community sites. Average activation time was 81 days. Delays were mainly from CT amendments. KUCC enrolled the first patient in the CATCH-UP program. In 6 months, we met accrual requirements (24/year, 50% minorities). During first year, we enrolled 47 (>50% minorities), an increase of 680% from our average accrual of 6/year (>50% minorities) in ETCTN through Early Drug Development Opportunity Program (2016-2020). To date, we have enrolled 61, 54% from rural, HPSA, race and other minorities. Although the proportion of minorities did not change but remained high, this funding allowed us to substantially increase the number of patients from a catchment area with high proportion of geographically and socioeconomically underserved minorities given access to early phase CT through ETCTN. Conclusions: Amid COVID-19 pandemic, the NCI CATCH-UP program and methods we used allowed access to novel therapies for rural, medically underserved, and other minority groups.

3.
Annals of the Rheumatic Diseases ; 81:535-536, 2022.
Article in English | EMBASE | ID: covidwho-2008983

ABSTRACT

Background: The need to avoid the transmission of COVID19 infection has forced to promote teleconsultations for rheumatic diseases follow-up. However, remote monitoring for rheumatic diseases which require clinical examination, as rheumatoid arthritis (RA), may affect to the evaluation of clinical activity, including the biological therapies follow-up. Due to that, count on tools as Patient Reported Outcomes (PROs) could help the remote monitoring of patients when it is not advisable their physical presence in health centers, being a great help in RA control. Objectives: We aim to assess the association among the tiredness, disability and pain perception with the clinical activity in RA patients. Methods: We performed a prospective observational study of three months of follow-up in RA patients (ACR/EULAR 2010) who are newly on biological or anti-JAK therapy. A basal visit and 1, 3 months follow-up visits were conducted. We analyzed changes during follow-up in the PROs parameters reported by patients through FACIT-fatigue and HAQ questionnaires, as well as pain VAS (0-10). Moreover we measured clinical activity through Das28, Das28-CRP, SDAI and CDAI index. Results: We included 60 patients (83.3% female), with a mean age of 55 (13) and mean disease evolution of 13 (11) years. At the basal visit, 55% of them exhibited increased levels of CRP and the 48.3% of ESR, showing moderate or high clinical activity the 83.3% of the total patients. 39 patients started anti-JAK therapy and 21 with TNF-α inhibitors. The 33.34% of patients were under monotherapy, and the 46.67% previously have been treated with biological therapy. The 77.36% of the total number of patients was on the biological therapy at 6 months of follow-up, while the 22.64% discontinued at 6 months of follow-up (9 due to inefficacy and 3 due to adverse effects). 48 patients continued the treatment in the 6 months after, and 12 patients discontinued due to ineffectiveness or drug intolerance. Clinical activity, fatigue, disability and pain perception are shown in Table 1. Using a mixed linear regression model the association among the fatigue, disability and pain perception with clinical activity was conducted, corrected by age, smoking habits, time of disease evolution, BMI, previous biological/anti-JAK therapy administration and current dose of steroids. We observed a signifcant association among clinical activity and fatigue (P<0.001), disability (P<0.001) and pain perception (P<0.001). The statistical analyses showed a signifcant association where a high fatigue is increased in cases with high pain perception (P>0.001) and high number of swollen joints (P=0.002), but not in high levels of CRP and ESR. Fatigue was higher in those cases whom discontinued treatment (P=0.044) regardless of which therapy was chosen. No effect of age, time of disease evolution, steroid dose, BMI or previous therapy and smoking habits in the PROs values was observed. Conclusion: PROs would be helpful in the disease control in those cases where a remote monitoring is needed, since HAQ or FACIT-FATIGUE index showed a signif-cant association with clinical activity index in RA. Because of its ease for shipping and handling by the health professional, PROs could be a useful tool in the disease control. Its implementation in the remote monitoring of RA patient, as has been the case of Covid19 pandemic, results in an improvement of the clinic evaluation of RA patient, due to required information to clinical management is reported, avoiding presence consultation in those situations when it is required.

4.
Journal of Christian nursing : a quarterly publication of Nurses Christian Fellowship ; 39(4):E80-E84, 2022.
Article in English | MEDLINE | ID: covidwho-2008648

ABSTRACT

: During and after COVID-19, African Americans experienced a disparate amount of social isolation and loneliness and subsequent increases in morbidity and mortality. Faith community nurses are equipped to assist community providers, health practitioners, and local officials in addressing gaps in older African Americans' financial, social, physical, and spiritual needs during social distancing.

5.
Journal of Public Health in Africa ; 13:69-70, 2022.
Article in English | EMBASE | ID: covidwho-2006793

ABSTRACT

Introduction/ Background: Since the COVID-19 pandemic engulfed the world, researchers and scientists have explored different techniques to mitigate the impacts of the SARSCoV- 2 virus. Alongside the rollout of COVID vaccines, researchers are implementing predictive algorithms and visualization tools to equip stakeholders with insights on the pandemic and help them make data-driven decisions. Methods: In this research, we leveraged publicly available COVID-19 datasets collected by Oxford University's “Our World in Data” team to build an interactive web-based dashboard that monitors the pandemic across all African countries. We studied and analyzed more than 10 existing COVID-19 dashboards to gain insights and create visualizations that most accurately tell the story in the data to both technical and non-technical persons. We built a data quality pipeline to clean, impute and transform inconsistent and anomalous data points in the Our World in Data COVID dataset before rendering it to the dashboard for public use. Results: Our work has given individuals and government agencies the capability to monitor the pandemic within a centralized repository. Hitherto, information about COVID-19 in African countries has been in websites whose contextual focus is primarily on advanced countries. With our contribution, stakeholders can view information and interact with the charts related to cases, deaths, tests, vaccinations, and other relevant indicators in a unified web platform that focuses primarily on African countries. Besides the many features supported on the dashboard, the ability to compare the pandemic situation between African countries and regions is particularly informative. Impact: We believe that by creating interactive visualizations that leverage open-source datasets, governments and health practitioners can devise mitigative strategies based on the stories told by the data and the visualizations. It is for this purpose that we embarked on this project - to help stakeholders make data-driven decisions and save lives. Conclusion: Finally, our analyses have outlined a number of limitations that make the case for better cooperation between academia and governments in accessing protected data, thereby allowing academic partners to build prototypes, tools and products that accompany policy makers in their decision making.

6.
Journal of Forensic Medicine and Toxicology ; 39(1):1-4, 2022.
Article in English | EMBASE | ID: covidwho-2006462
7.
Tanzania Journal of Health Research ; 23(2), 2022.
Article in English | EMBASE | ID: covidwho-1997958

ABSTRACT

Background: Coronavirus disease 2019 is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak was first identified in the city of Wuhan, Hubei, China in December 2019, and was recognized as a pandemic by the World Health Organization on 11 March 2020. The virus primarily spreads among people via respiratory droplets from coughing, breathing, or sneezing. To reduce virus transmission, close contact between people is discouraged. In response to advice by health practitioners, individuals are advised to wear face masks, regularly wash their hands, and apply sanitisers. However, the effectiveness of locally manufactured masks against COVID 19 and other microbes has not been investigated. Aims and methods: The current study aimed to experimentally determine and compare the effectiveness of two approved surgical masks and two face masks fabricated at the University of Dodoma (UDOM). Results: The effectiveness of the UDOM-made mask was similar when compared to surgical masks (Mann-Whitney, U = 390.000, p > 0.05;Mean ranks: Japan fabric = 32.5;N95 surgical mask = 28.50). However, the Japan fabric mask made at UDOM was more effective than BBL surgical mask made in China (Mann-Whitney, U = 270.000, p < 0.05;Mean ranks: Japan fabric = 24.50;BBL surgical mask = 36.50). Whereas the handkerchief mask made at UDOM and BBL surgical mask had similar levels of effectiveness (Mann-Whitney, U = 369.500, p > 0.05;Mean Ranks: Handkerchief = 27.82;BBL surgical mask = 33.18). The results obtained suggest that the two UDOM types were as effective as the N95 and BBL masks in reducing virus spread. Conclusion: The study recommends the determination of pore sizes of the materials used to make the mask to explain the effectiveness of the single layer, double layers, and double layers with cotton blends in the prevention of different microbes inhalable.

8.
Journal of General Internal Medicine ; 37:S579, 2022.
Article in English | EMBASE | ID: covidwho-1995804

ABSTRACT

STATEMENT OF PROBLEM/QUESTION: Social risk factors (SRF), such as food insecurity, represent adverse social circumstances associated with poor health outcomes. The COVID-19 pandemic impacted impoverished communities by exacerbating existing SRF. Students and faculty at Boston University Medical Center (BUMC), an academic safety net hospital, and Boston University School of Social Work (BUSSW) partnered to develop an outreach call center (CC) to explore SRF of patients with COVID-19 and connect them with available social need resources. In this , the development and operations of the CC and descriptive data on the volume and type of outreach efforts will be presented. DESCRIPTION OF PROGRAM/INTERVENTION: Call Center (CC) Operation: An ambulatory RN performed SRF screening in patients diagnosed with COVID-19 and sent referrals to the CC. Then, students called patients and screened for SRF using the THRIVE screening tool, and used the THRIVE Directory, an online repository of resources, to provide information about organizations to support their social needs. Two weeks later, students called the patients to assess whether they received help and provided additional support as needed. MEASURES OF SUCCESS: Volume of outreach calls and type of outreach efforts were evaluated. Number of patients reached through the CC were tracked using Epic reports. Types of referrals were tracked using automated reports from the THRIVE Directory database. Finally, students completed surveys to reflect on their experiences and to evaluate the impact on skills to address social needs. FINDINGS TO DATE: Between 10/2020 and 03/2021, the CC served 312 patients and 478 referrals were made, with a mean of 1.53 referrals per patient. Patients were most often referred to the City of Boston Food Delivery (148 referrals). Patients were most often referred to Government programs (188), followed by BMC programs (133) and Local Non-Profits (70). The most common primary support area was Food. Preliminary results from students' surveys showed a positive impact in their skills to collaboratively address social needs. KEY LESSONS FOR DISSEMINATION: It was feasible to develop and implement an interdisciplinary social needs outreach workforce to support patients with COVID-19. Food was the most important driver of social need among BUMC patients. Our partnership with the City of Boston was key to effective assistance with food delivery, showing the importance of collaborative partnerships when developing outreach efforts to support patients with social needs. Finally, interdisciplinary outreach opportunities like the CC can be used to teach health professional students about the different scopes of practice and how to effectively collaborate with other disciplines when addressing patient health related social needs.

9.
Journal of Paediatrics and Child Health ; 58(SUPPL 2):147-148, 2022.
Article in English | EMBASE | ID: covidwho-1916225

ABSTRACT

Background: Vaccination against COVID-19 is a key global public health strategy. Health professionals including midwives and doctors support and influence vaccination uptake by childbearing women. The aim of this study was to explore the perceptions and intentions regarding COVID-19 vaccination from consumers and providers of maternity care in Australia. Methods: A national cross-sectional online study conducted in May 2021 in Australia. Recruitment was undertaken through parenting and health professional social media sites and professional college distribution lists. A total of 853 completed responses were received, from women of childbearing age (n = 326), doctors (n = 58), midwives (n = 391) and midwifery students (n = 78). Results: Early on in the 2021 national COVID-19 vaccination roll-out, personal intention to be vaccinated ranged from 48-89%, with doctors most likely and women least likely. Doctors and midwifery students were significantly more likely to recommend the vaccine to pregnant women in their care than midwives (p < 0.001). More than half of the midwives (53%) had concerns about the COVID-19 vaccine for the women in their care compared with 35% of doctors and 46% of midwifery students. Conclusion: This is the first study to explore the perceptions and intentions regarding COVID-19 vaccination from both the perspective of those who receive and those who provide maternity care in Australia. Findings have utility to support targeted public health messaging for these and other cohorts. Critical discussion will reveal contemporary insights from the evidence to enhance the important public health role of midwives and doctors in national maternity vaccination programs.

10.
Epidemiology ; 70(SUPPL 1):S223, 2022.
Article in English | EMBASE | ID: covidwho-1853986

ABSTRACT

Introduction: Despite current recommendations, hospitalized older adults, particularly those with dementia, continue to spend little time engaged in physical activity when hospitalized. The purpose of this study was to 1) describe activity among hospitalized older adults with dementia and 2) test the association between specific factors (age, gender, race, cognitive status, comorbidities, baseline function, quality of care interactions, admission diagnosis, and hospital setting) and their physical activity. Methods: This was a descriptive study utilizing baseline data on the first 155 participants of a randomized clinical trial testing the impact of Function Focused Care for Acute Care using the Evidence Integration Triangle (FFC-AC-EIT). This study's major outcome variable of physical activity was based on accelerometry data (MotionWatch8) over the first 24 hours of admission. Three regression models were tested using linear regression and the stepwise approach. Results: The 155 participants had a mean age of 83.5 years old, were 67.7% female, and 65.2% white. The participants spent an average of 1.3% of time in vigorous activity, 3.9% of time in moderate activity, 14.7% of time in low activity, and 80.1% of time in sedentary activity during the first 24 hours of hospitalization. Less cognitive impairment was associated with greater moderate activity (b=-93.408, p=.007) and better baseline mobility was associated with greater low activity (b=-949.453, p=.049). Alternatively, we found that higher age (b=189.350, p=.047), worse baseline mobility (b=2371.364, p=0.004), and non-white race (b=6705.916, p=<0.001) were associated with sedentary behavior. The examined factors for the moderate activity, low activity, and sedentary behavior models only explained 15%, 8%, and 22% of the variance respectively. Conclusions: The findings from this study support the limited time spent in activity for older adults with dementia when hospitalized. This research highlights patient profiles that are particularly vulnerable to sedentary behavior in the hospital and should be identified for activity interventions. Future research should consider other factors such as providers' racial bias, COVID-19 related health professional staffing shortages and burn out, and patient motivation.

11.
Clinical Epidemiology and Global Health ; 14, 2022.
Article in English | EMBASE | ID: covidwho-1850785

ABSTRACT

Background: In developing countries like Ethiopia one-third of health care expenditure is for medications. However, due to different reasons, patients may not use all the dispensed medications. Thus, the present study aimed to assess the Causes and cost of unused medications at the inpatient setting of the University of Gondar Compressive Specialized Hospital. Methods: A hospital-based cross-sectional study was conducted over two months at University of Gondar Compressive Specialized Hospital. A survey of the Causes and cost of unused medicines was conducted through an interview-guided structured questionnaire in the inpatient setting. Those patients who had unused/leftover medications in the inpatient setting during the study period were the target population. All opened liquid preparations such as vials, ampoules, and bags were excluded from the study since it is tough to calculate the amount leftover/remaining. The collected data were entered with Epi Data version 3.1 and exported to SPSS version 21 for analysis. Descriptive statistics such as standard deviation, percentage, frequency, mean, and median were used for data presentation. Finally, the results were described using texts, tables, and figures. Results: A total of 13 classes of medication were identified during the study period. Among these, antibiotics 74(35.23%) were the most common leftover class of medications with the financial value of 143.48$(25.10%) of total leftover/unused medication. The most common reasons for medication leftover or unused were because of condition resolved 51(24.28%) followed by treatment changed 50(23.8%). Most 86(40.95%) of leftover/unused medication with a monetary value of 5106.80 Ethiopian birr (127.65 USD) was discarded by the patient. About 66(31.43%) of the patients were taken their leftover medication to home for other programs or feature use, 13.80% of patients gave their leftover medications to other patients. More than half 160(76.19%) of unused medications were eligible for use with the monetary value of 17,992.85 (78.7%) Ethiopian birr. Conclusions: Significant amounts of the hospitals’ budget were wasted because of unused/leftover medications and have a serious cost impact. Antibiotics were most frequently class of medication leftover/unused and the condition resolved and treatment changed were the two main reasons for medication leftover/unused. Most of the leftover medications were discarded by the patient, only a very limited number of patients/caregivers plan to return their leftover medications to the pharmacy.

12.
SA Pharmaceutical Journal ; 89(1):5, 2022.
Article in English | EMBASE | ID: covidwho-1848715
13.
Revista de la Federacion Argentina de Cardiologia ; 51(1):11-15, 2022.
Article in Spanish | EMBASE | ID: covidwho-1812703

ABSTRACT

Objectives: Hypertension (HTN), defined as persistence of blood pressure higher than 140/90 mmHg, is considered an important cause of mortality, disability and high sanitary costs. In this paper we propose to evaluate the impact of Social Preventive and Mandatory Isolation (ASPO by its acronym in Spanish) in the control of HTN patients according to socioeconomic level. Materials and methods: a descriptive cross-sectional study was conducted, based on data from a self-generated survey by Google forms with 25 questions;the inclusion criteria were diagnosed HTN, being older than 18 years, living in Bahía Blanca and agreeing to answer the survey. Results: 143 answers were evaluated, the average age was 58 years, 50.3 % of those surveyed were women. Seventy percent follows a treatment for HTN indicated by a health professional;33.6% should have had controls studies done during the ASPO;11.2% had to assist to cardiologic control and couldn’t do it;10.48% of the sample couldn’t undergo all control tests during the quarantine. Conclusions: According to socioeconomic level, we could see that all the people with high income obtained access to all the tests;while none of the people with low income could do it, this could be telling us about the differences in opportunities to achieve a maximum health status due to inequities in access.

14.
Malta Medical Journal ; 34(1):35-42, 2022.
Article in English | EMBASE | ID: covidwho-1812692

ABSTRACT

BACKGROUND COVID-19 was a global shock, causing challenges to many countries’ healthcare services. This paper provides a summary of Malta’s healthcare system journey during the COVID-19 pandemic with its initial preparedness for COVID-19 pandemic and the impact of COVID-19 on the service during the first 12 months of the pandemic. METHODS A literature search was conducted using Google and reviewing Maltese online newspapers. A comprehensive summary of internal operations conducted at Mater Dei Hospital, the country’s only acute general hospital, was provided by the Chief Operating Officer. RESULTS Several infrastructural changes including the increase in bed capacity and ITU areas were instituted in preparation for the pandemic. The health system showed resilience during the first wave. However, the situation was more precarious during the second wave. The end of December 2020 saw the start of the Covid-19 vaccination rollout, with over 30 health system hubs offering this service across the islands. Simultaneously health professional’s burnout is on the rise as resources and workforce are overstretched. CONCLUSION The collaborative effort between the guidance provided by the Public Health Authorities and the hospital’s multi-disciplinary team have been pinnacle during the pandemic. However, the future of the healthcare system is heavily dependent on the population’s behaviour, timely measures, the vaccination rollout and the type of immunity acquired through vaccination or infection.

15.
Journal of Clinical and Diagnostic Research ; 16(SUPPL 1):14, 2022.
Article in English | EMBASE | ID: covidwho-1798692

ABSTRACT

Background: Teaching online has become a new normal during the pandemic. The increased access to the Internet and availability of digital technology led to revolution in online learning. Online delivery of contents provides an opportunity to provide flexibility in learning and to reach distant learners. This study aimed to evaluate the impact of an online faculty development programme on nurse educators' perceived competency in creating and delivering e-content using Google Classroom and other freely available digital tools. Description: A pre-experimental design was adopted for the study. A six-module online course on effective use of Google classrooms and digital tools was conducted on request for 26 faculty members of a Dental college. Total duration of the course was of eight days. A debriefing session was held on ninth day after the completion of the course. A 10-item rating scale was used to assess the participants' perceptions of their competency in using Google Classroom and other digital tools for remote teaching before and after the online course Outcome: Out of 26-trained participants, 20 completed the post-evaluation rating scale, giving a response rate of 76%. In the post-evaluation phase, a high level of competency was perceived by 90% of participants for using Google Classroom and 70.2% for creating video lectures and using an online grade book. A statistically significant difference (p<0.001) between pre- and post-course evaluations was observed. Conclusion: This study showed that the indigenous online developed and conducted through simple platforms enhanced the remote teaching skills of faculty members.

16.
The Lancet ; 399(10328):901, 2022.
Article in English | EMBASE | ID: covidwho-1768609
17.
Revista de la Asociacion Espanola de Especialistas en Medicina del Trabajo ; 30(4):425-435, 2021.
Article in Spanish | EMBASE | ID: covidwho-1766510

ABSTRACT

Background: Peru has been one of the countries with the highest burden of disease due to COVID-19. The Government of Peru has established basic guidelines for the preparation and registration of plans for the surveillance, prevention, and control of COVID-19 at work (PVPC) of Peruvian institutions. Objective:To characterize the PVPC of health sector institutions in Peru. Materials and Methods: retrospective descriptive secondary database study. The PVPCs of the health sector registered in the SISCOVID-Empresas platform of the Ministry of Health of Peru, mandatory registration for the reactivation of activities during the COVID-19 pandemic, were evaluated. Results: 1263 PVPC records from the health sector registered on the SISCOVID-Empresas platform were analyzed. Of the registered PVPCs, 5.8% of companies do not have a supervisor or committee for occupational safety and health, and 38.6% of companies with more than 20 workers do not have a health professional. Conclusions: A high non-compliance with what is required in the PVPCs in institutions of the Peruvian health sector was identified. It is necessary to reinforce and supervise the adequate fulfillment of the PVPC in these institutions.

18.
Critical Reviews in Physical and Rehabilitation Medicine ; 33(1):v-vii, 2021.
Article in English | EMBASE | ID: covidwho-1745249
19.
Irish Medical Journal ; 115(2), 2022.
Article in English | EMBASE | ID: covidwho-1733076
20.
Developmental Medicine and Child Neurology ; 64(SUPPL 1):76, 2022.
Article in English | EMBASE | ID: covidwho-1723127

ABSTRACT

Objectives and Background: Robbie's Rehab provides specialist neuro-rehabilitation for children diagnosed with brain and spinal tumours under the care of Southampton Children's Hospital. Having a brain tumour and its treatment can have a wide impact on a child and their families' quality of life and return to "normal life" with limited time to explore these within standard clinics. A pilot supplementary clinic to focus on these aspects was initiated by a physiotherapist, psychologist and nurse specialist, primarily reviewing non-medical concerns, supporting return to school and home life. Methods: Review of Prospective data collected for patients attending the Robbie's Rehab Multidisciplinary clinic October 2020- February 2021. Results: 22 patients were offered an appointment, 2 declined to attend. Due to COVID only 1 patient attended face to face, the remainder via Attend Anywhere video consultation. 16 patients had a diagnosis of a low grade tumour and 4 patients had high grade tumours. All patients had completed oncology treatment. 3 common areas of concern were identified by patients and parents;fatigue, educational difficulties and emotional difficulties. Advice and support was provided during clinic where appropriate and referrals to other services were made (play support, endocrine referral). Additional interventions occurred outside the clinic from the Robbie's Rehab Team (physio assessment, psychology support, cognitive assessment). Post clinic parental questionnaire completed by 18/20 families. 11/18 parents rated the clinic as helpful and 7/18 parents rated the clinic as extremely helpful. 100% would definitely recommend attending this clinic to other parents. Conclusion: The addition of a quality of life focused MDT clinic run by members of the extended neurooncology team has been effective in improving the patient and parent experience of life after oncology treatment.

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