Home About us Contact
|
Home About us Contact | ||
|
|
||
Surgical Decision (surgical + decision)
Selected AbstractsThe Multicenter Study of Epilepsy Surgery: Recruitment and Selection for SurgeryEPILEPSIA, Issue 11 2003Anne T. Berg Summary:,Purpose: Multiple studies have examined predictors of seizure outcomes after epilepsy surgery. Most are single-center series with limited sample size. Little information is available about the selection process for surgery and, in particular, the proportion of patients who ultimately have surgery and the characteristics that identify those who do versus those who do not. Such information is necessary for providing the epidemiologic and clinical context in which epilepsy surgery is currently performed in the United States and in other developed countries. Methods: An observational cohort of 565 surgical candidates was prospectively recruited from June 1996 through January 2001 at six Northeastern and one Midwestern surgical centers. Standardized eligibility criteria and protocol for presurgical evaluations were used at all seven sites. Results: Three hundred ninety-six (70%) study subjects had resective surgery. Clinical factors such as a well-localized magnetic resonance imaging (MRI) abnormality and consistently localized EEG findings were most strongly associated with having surgery. Of those who underwent intracranial monitoring (189, 34%), 85% went on to have surgery. Race/ethnicity and marital status were marginally associated with having surgery. Age, education, and employment status were not. Demographic factors had little influence over the surgical decision. More than half of the patients had intractable epilepsy for ,10 years and five or more drugs had failed by the time they initiated their surgical evaluation. During the recruitment period, eight new antiepileptic drugs were approved by the Food and Drug Administration for use in the United States and came into increasing use in this study's surgical candidates. Despite the increased availability of new therapeutic options, the proportion that had surgery each year did not fluctuate significantly from year to year. This suggests that, in this group of patients, the new drugs did not provide a substantial therapeutic benefit. Conclusions: Up to 30% of patients who undergo presurgical evaluations for resective epilepsy surgery ultimately do not have this form of surgery. This is a group whose needs are not currently met by available therapies and procedures. Lack of clear localizing evidence appears to be the main reason for not having surgery. To the extent that these data can address the question, they suggest that repeated attempts to control intractable epilepsy with new drugs will not result in sustained seizure control, and eligible patients will proceed to surgery eventually. This is consistent with recent arguments to consider surgery earlier rather than later in the course of epilepsy. Postsurgical follow-up of this group will permit a detailed analysis of presurgical factors that predict the best and worst seizure outcomes. [source] Decision aids in routine practice: lessons from the breast cancer initiativeHEALTH EXPECTATIONS, Issue 3 2006Kerry A. Silvia BA Abstract Background, Many decision aids have been developed to help patients make treatment and screening decisions; however, little is known about implementing them into routine clinical practice. Objective, To assess the feasibility of implementing a patient decision aid (PtDA) for the early stage breast cancer surgical decision into routine clinical care. Design, Structured individual interviews. Setting and participants, A convenience sample of providers from nine sites, including two community resource centres, a community hospital and six academic centres. Main outcome measures, Usage data, barriers to and resources for implementing the PtDAs. Results, Six of the nine sites were using the PtDAs with patients. Two sites were primarily using a scheduling system and four sites relied on a lending system. For the academic centres, the keys to successful implementation included integrating the PtDA into the flow of patients through the centre and having physicians who recommended it to patients. At the community centres, the keys to successful implementation included an informed staff and the flexibility to get the PtDAs to patients in different ways. Barriers that limited or prevented sites from using the PtDA included a lack of clinical support, a lack of system support, competing priorities and scheduling problems. Conclusions, It is feasible to implement a breast cancer PtDA into routine clinical care at academic centres and community resource centres. Future research should assess the effectiveness of PtDAs in routine clinical care as well as resources and barriers to their implementation in community hospitals. [source] Correlates of patient satisfaction and provider trust after breast-conserving surgeryCANCER, Issue 8 2008Jennifer F. Waljee MD Abstract BACKGROUND Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear. METHODS All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n = 714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics. RESULTS Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21,0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21,0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14,0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P = .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P = .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers. CONCLUSIONS Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes. Cancer 2008. © 2008 American Cancer Society. [source] Seizure Outcome after Temporal Lobectomy: Current Research Practice and FindingsEPILEPSIA, Issue 10 2001A. M. McIntosh Summary: ,Purpose: The literature regarding seizure outcome and prognostic factors for outcome after temporal lobectomy is often contradictory. This is problematic, as these data are the basis on which surgical decisions and counseling are founded. We sought to clarify inconsistencies in the literature by critically examining the methods and findings of recent research. Methods: A systematic review of the 126 articles concerning temporal lobectomy outcome published from 1991 was conducted. Results: Major methodologic issues in the literature were heterogeneous definitions of seizure outcome, a predominance of cross-sectional analyses (83% of studies), and relatively short follow-up in many studies. The range of seizure freedom was wide (33,93%; median, 70%); there was a tendency for better outcome in more recent studies. Of 63 factors analyzed, good outcome appeared to be associated with several factors including preoperative hippocampal sclerosis, anterior temporal localization of interictal epileptiform activity, absence of preoperative generalized seizures, and absence of seizures in the first postoperative week. A number of factors had no association with outcome (e.g., age at onset, preoperative seizure frequency, and extent of lateral resection). Conclusions: Apparently conflicting results in the literature may be explained by the methodologic issues identified here (e.g., sample size, selection criteria and method of analysis). To obtain a better understanding of patterns of long-term outcome, increased emphasis on longitudinal analytic methods is required. The systematic review of possible risk factors for seizure recurrence provides a basis for planning further research. [source] | ||||||||||