Risk communication in a patient decision aid for radiotherapy in breast cancer: How to deal with uncertainty?

Background and aimPatient decision aids for oncological treatment options, provide information on the effect on recurrence rates and/or survival benefit, and on side-effects and/or burden of different treatment options. However, often uncertainty exists around the probability estimates for recurrence/survival and side-effects which is too relevant to be ignored. Evidence is lacking on the best way to communicate these uncertainties. The aim of this study is to develop a method to incorporate uncertainties in a patient decision aid for breast cancer patients to support their decision on radiotherapy.MethodsFirstly, qualitative interviews were held with patients and health care professionals. Secondly, in the development phase, thinking aloud sessions were organized with four patients and 12 health care professionals, individual and group-wise.ResultsConsensus was reached on a pictograph illustrating the whole range of uncertainty for local recurrence risks, in combination with textual explanation that a more exact personalized risk would be given by their own physician. The pictograph consisted of 100 female icons in a 10 x 10 array. Icons with a stepwise gradient color indicated the uncertainty margin. The prevalence and severity of possible side-effects were explained using verbal labels.ConclusionsWe developed a novel way of visualizing uncertainties in recurrence rates in a patient decision aid. The effect of this way of communicating risk uncertainty is currently being tested in the BRASA study (NCT03375801).     

大鼠静脉窦高压致硬膜血管变化的研究

目的探讨大鼠静脉窦高压后硬膜血管变化及其静脉窦高压在硬脑膜动静脉瘘形成中的作用。方法体重200～250g的SD雄性大鼠110只,随机分为静脉窦高压组(85只)和假手术组(25只),将静脉窦高压组85只大鼠闭塞左侧横窦和上矢状窦前1／3,并吻合右侧颈总动脉和颈外静脉,制成静脉窦高压模型。假手术组大鼠单纯解剖相应的颈部血管和硬脑膜窦,但不行吻合或闭塞。术后90d,随机取7只静脉窦高压组大鼠和5只假手术组大鼠,行硬脑膜血管明胶墨汁灌注,观察硬膜血管的状况。结果术后90d静脉窦高压组和假手术组大鼠的硬膜血管数分别为(10.7±1.5)条／mm,(10.3±0.6)条／mm,差异无显著性。在静脉窦高压组中1只大鼠有硬脑膜动静脉瘘,其形态和结构与生理性动静脉短路类似。结论大鼠静脉窦高压一段时间后,颅内硬膜血管无明显增生。颅内硬脑膜动静脉瘘的形成很可能是由动静脉间的短路发展而来。     

Laparoscopic Local Resection Based on Sentinel Node Evaluation for Early Gastric Cancer: A Preliminary Report

We previously reported that lymphatic mapping using isosulfan blue can be used to identify sentinel nodes (SNs). This study was undertaken to evaluate the feasibility of using the SN technique in treating early gastric cancer and to explore its usefulness for minimal invasive surgery. Twenty-three patients with early gastric cancer who underwent SN biopsy were retrospectively evaluated. Based on SN evaluation, individualized surgery was performed in five patients with T1N0M0 gastric cancer. When pathological examination of frozen sections revealed metastasis in SNs, we performed a standard D2 gastrectomy. Laparoscopic local resection was applied when the SN biopsy was negative. Our results showed that the success rate with SN biopsy in early gastric cancer was 100%, as were the accuracy, sensitivity, and specificity. All five patients with early gastric cancer had SNs negative for metastases both by frozen section and by postoperative pathology. Thus, all these patients underwent laparoscopic local resection without extended lymphadenectomy. We conclude that SN biopsy is a useful tool to individualize the operative procedure, and laparoscopic local resection can be safely performed using SN guidance in selected patients with early gastric cancer.     

结节性甲状腺肿合并其他甲状腺疾病临床分析

目的探讨结节性甲状腺肿合并其他甲状腺疾病的临床特点。方法回顾性分析我院手术治疗的4622例结节性甲状腺肿中并存其他甲状腺疾病的临床资料。结果4622例结节性甲状腺肿中700例合并其他甲状腺疾病，1418例存在不同的诊断失误。结论在诊断结节性甲状腺肿的同时应注意其合并的其他甲状腺疾病。     

Local health services: some lessons from their evolution in Bolivia

Summary For a decade, numerous projects in Bolivia have tried to put in practice the concept of local health systems. But, so far, no significant changes have been made and local health services still are the 'poor relation' of the system. The main components of the project—expansion of health facilities, training of health personnel and institutional decentralization—were not designed to respond to the complexity of the problems encountered. Decentralization was implemented at the level of health districts but not accompanied by redefinition of functions at the central level, and challenged by civil servants' attempts to save their jobs. While training activities did introduce new methods and subjects, they were too often reduced to short workshops or seminars. Health facilities were built without regard for their significance beyond health care. A strategic approach is needed to adapt the planning process to the degree of liberty allowed by society.     

Epidural block for obstetrics: Comparison of bolus injection of local anesthetic with gravity flow technique

Study Objective: To test the hypothesis that slow administration of local anesthetic into the epidural space by gravity flow reduces the incidence of signs and symptoms of unintended injection.

Design: Prospective, randomized study.

Setting: Teaching hospital.

Patients: 600 ASA physical status I and II parturients scheduled for labor and delivery or elective cesarean section.

Interventions: After identification of the epidural space with pulsations of an air-fluid column, parturients for vaginal delivery (n = 380) were randomized to receive a test dose of 3 ml 3% 2-chloroprocaine with epinephrine 20 μg, two doses of 7 ml bupivacaine 0.03 % with sufentanil 1 μg/ml and epinephrine 2 μg/ml by either gravity flow (Group 1) given over 30 seconds or by bolus injection (Group 2) given over 5 seconds through the epidural needle; parturients for Cesarean delivery (n = 220) were randomized to receive a test dose and two doses of 6 ml lidocaine 2 % with sufentanil 1 μg/ml and epinephrine 2 μg/ml by either gravity flow or by bolus injection through the epidural needle. Changes in maternal heart rate (HR) and blood pressure, signs of intravascular injection, and adverse effects of epidural bupivacaine-sufentanil were recorded after each dose.

Measurements and Main Results: Gravity flow administration (Group 1) was associated with a smaller increase in mean maternal HR (p < 0.001), less hypotension (p < 0.01), sedation (p < 0.01), nausea (p = 0.01), and segmental spread (p < 0.0001) than were corresponding doses given by traditional bolus injection (Group 1) for vaginal or Cesarean deliveries. The incidence of systemic toxicity was zero of 300 (0%) with gravity flow and 4 of 300 (1.3%) by bolus injection, p = 0.12, Fisher's exact test. No patient in either group had an accidental intrathecal injection.

Conclusion: Gravity flow administration of local anesthetic-opioid solution during epidural block for obstetrics was associated with fewer signs of systemic drug absorption and cardiovascular perturbations than was the traditional bolus injection. This study supports the current opinion that slow administration of local anesthetic during epidural black contributes to fewer adverse events.     

The biomechanics of vibration and low back pain

This work is a review of the mechanical factors related to low back pain production in a vibration environment. The sitting posture is an extreme orientation for the lumbar intervertebral disc that 1) increases its internal pressure, 2) increases its anteroposterior shear flexibility, while: 3) decreasing its resistance to buckling instability and 4) stressing the posterior region of the disc. Vibration is an additional mechanical stressor. Several studies suggest that the following preventive measures be taken to reduce the risk of low back pain due to driving: 1) minimize the vibration reaching the driver, 2) avoid lifting or bending immediately following driving, and 3) walk around for a few minutes following driving. © 1993 Wiley-Liss, Inc.     

Isolated and combined effects of prolonged exposures to noise and whole-body vibration on hearing,vision and strain

Summary This study was carried out in order: (1) to examine the effects of isolated and combined prolonged exposures to noise and whole-body vibration on hearing, vision and subjectively experienced strain, and (2) to check the combined effects with repeated exposures. Six male subjects were exposed twice to noise (N) at 92 dBA, whole-body vibration (V) in the Z-axis at 4 Hz and 1.0 ms^–2 rms, and noise and vibration (NV) for 90 min with each condition. Temporary threshold shifts of hearing (TTS) and their integrals (ITTS) were measured at 4, 6, 10, and 12 kHz. Visual acuity was examined by means of a very sensitive test. Cross-modality matching (CMM) of the handgrip force was used to judge the subjectively experienced strain. NV induced a clear tendency of higher TTS and ITTS than N, with several significant differences most pronounced at 10 kHz. With repeated exposures, the effect of NV decreased, while the reactions to N and V remained unchanged. The individual reactions to NV differed. The influence of the duration of exposures on vision depended on the condition; N caused time-dependent changes, whereas V did not. CMM-data increased with the duration of the exposure during V and NV. N was generally judged to be more straining than V; NV caused higher strain than V during the first 30 min of exposure only. Correlations between different effects suggest certain links between them. Additionally, less motivation — daily obtained by a questionnaire — often correlated with higher ITTS during N and NV. The results also illustrate the combined effects on the individual susceptibility, repetition of exposure, the kind of response, and, possibly, the actual psychic state.Abbreviations CMM cross-modality matching - MVC maximum voluntary contraction force - N exposure condition: noise level 92dBA, no whole-body vibration - NV exposure condition: combined exposure to noise with a level of 92 dBA and wholebody vibration with 4 Hz, 1 ms^–2 rms - V exposure condition: whole-body vibration with 4 Hz, 1 ms^–2 rms - TTS temporary threshold shift - ITTS integral of temporary threshold shift - WBV whole-body vibration in the common sense This work was done in the Temporary International Research Team on Combined Effects of Noise and Vibration of the Council of Mutual Economic Assistance of the Socialist Countries. The authors gratefully acknowledge the help and assistance of L.-M. Brumm, Y. Bening, M. Godau, G. Weber, and R. Vizcaino.