PSA-based prostate cancer screening: the role of active surveillance and informed and shared decision making

Since the first publication describing the identification of prostate-specific antigen (PSA) in the 1960s, much progress has been made. The PSA test changed from being initially a monitoring tool to being also used as a diagnostic tool. Over time, the test has been heavily debated due to its lack of sensitivity and specificity. However, up to now the PSA test is still the only biomarker for the detection and monitoring of prostate cancer. PSA-based screening for prostate cancer is associated with a high proportion of unnecessary testing and overdiagnosis with subsequent overtreatment. In the early years of screening for prostate cancer, high rates of uptake were very important. However, over time the opinion on PSA-based screening has shifted towards the notion of informed choice. Nowadays, it is thought to be unethical to screen men without them being aware of the pros and cons of PSA testing, as well as the fact that an informed choice is related to better patient outcomes. Now, as the results of three major screening studies have been presented and the downsides of screening are becoming better understood, informed choice is becoming more relevant.     

术前决策辅助对关节置换患者决策参与的影响

目的探讨术前决策辅助对关节置换患者决策参与的影响。方法将120例关节置换患者以简单随机化法分组,奇数分配到对照组,偶数分配到观察组,每组各60例,对照组按常规实施护理,观察组在常规护理基础上实施术前决策辅助干预,比较两组患者决策参与意愿和实际决策参与有无差异。结果两组决策参与意愿类型比较,差异无统计学意义(P0.05);观察组实际决策参与程度显著高于对照组(P0.01)。结论术前决策辅助能提高关节置换患者在实际临床活动中的决策参与程度。     

Shared decision making in the management of midshaft clavicular fractures: Nonoperative treatment or plate fixation

IntroductionMost patients with a displaced midshaft clavicular fracture can be treated either operatively or nonoperatively, with similar long-term outcomes. The treatment choice depends on individual preferences, and is therefore suited for a shared decision making (SDM) approach. However, little is known about SDM in fracture treatment. The purpose of this study was to evaluate the current daily practice of shared decisional behaviour in clavicular fracture treatment, in order to assess the need for improvement and set a baseline level for future research.Patients and methodsAll consecutive adult patients treated in two hospitals for a displaced, midshaft clavicular fracture in 2015 filled out a questionnaire shortly after the decision making moment, that consisted of questions concerning their knowledge and preferences regarding the treatment options; the SDM-Q-9-NL to measure the perceived degree of SDM, and the Control Preferences Scale to measure patients’ preferred and actual roles in decision making.ResultsFifty patients were included. Eighteen percent of the patients were unaware of the treatment options before the consultation, 48% had no preference for either treatment option. The mean score for perceived degree of SDM was 74 out of 100 (SD 23, range 12.5–100). In 68% of patients, the preferred role matched the actual role in making the decision. Sixteen patients (32%) would have preferred either a less (n = 8) or a more (n = 8) active role.ConclusionThe patient-reported level of SDM in treatment decisions for clavicular fractures was high, but not all patients had the role in this process that they preferred. To improve patients’ involvement in the treatment decision making process for clavicular fractures, it is important to create general awareness about SDM, and increase knowledge of orthopaedic trauma surgeons about SDM behaviour.     

糖尿病足住院患者决策信息需求问题提示列表的构建及可行性评估

目的 构建糖尿病足住院患者决策信息需求问题提示列表,为促进其参与医疗决策提供实用工具。方法 通过查阅文献、咨询临床一线的专科医护人员、半结构式访谈、德尔菲专家函询并经过临床调适后确定问题提示列表患者版本,便利抽样法选取39例住院患者对问题提示列表在临床使用的可行性进行评估。结果 2轮专家函询的积极系数分别为95.00%和100.00%,专家权威系数为0.951、0.948;第2轮专家函询,指标重要性及相关性的肯德尔协调系数分别为0.214、0.200（均P＜0.05）。最终的问题提示列表包括6个一级指标和43个二级指标。41.03%~69.23%的患者认可问题提示列表的临床使用效果。结论 糖尿病足住院患者决策信息需求问题提示列表具有可行性,能够帮助住院患者提出更多疾病相关问题,改善医患沟通,促进患者参与医疗决策。     

肿瘤晚期患者参与临床决策期望的现况研究

目的探讨肿瘤晚期患者参与临床决策的期望,以期更好地为患者提供医疗护理服务。方法采用患者参与医疗决策期望问卷对200例肿瘤晚期患者进行调查。结果该组人群参与临床决策期望总分为(34.74±3.03)分,信息需求、交流需求和决策需求3个维度的条目均分分别为(2.87±0.32)、(2.88±0.24)和(2.21±0.53)分。相比女性患者,男性患者在信息需求方面期望更高(P0.05);相比66岁及以上的患者,年龄18~50岁和51~65岁患者参与临床决策期望总得分和信息需求维度得分更高(均P0.01)。结论肿瘤晚期患者参与临床决策的信息需求和交流需求较高,而决策需求偏低。不同性别、年龄的患者参与临床决策的期望不同。在实际临床工作中,医务人员有必要关注患者参与临床决策的期望,并根据不同患者参与决策的期望开展医疗护理服务,以满足患者对疾病及治疗等相关知识的需求,促进患者参与决策的积极性,进而提高患者治疗依从性和满意度。     

“Medical decision making” for repeated computed tomography in neurosurgical intensive care patients

Multiple CT investigations in critical ill neurosurgical patients are useful for monitoring the course of the illness and for the early detection of complications. CT's, however, are expensive and require transportation of the patient, which is often inconvenient and, in some cases, dangerous. The decision to perform CT scanning should be based on the quantitative knowledge of potential benefits and harms (as well as costs) of the procedure. In a prospective trial, in which 59 such decisions were considered, we found it to be absolutely necessary to order a CT-investigation whenever neurological deterioration occurs. Even in patients not showing changes of neurological symptoms, about 30% of CT findings gave reason for therapeutic intervention. Thus, in critical ill neurosurgical patients, especially in those under sedative medication and artificial ventilation, neurological findings alone are insufficient as sole criteria for the decision to order a CT scan. To optimize this decision, more sensitive indicators of deterioration are needed.     

A resident survey study of orthopedic fellowship specialty decision making and views on arthroplasty as a career

A dramatic shortage of total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeons has been projected because fewer residents enter arthroplasty fellowships, and the demand for THAs/TKAs is rising. The purposes of this study were to ascertain the future supply of THA/TKA surgeons, to identify the criteria residents use to choose their fellowship specialty, and to assess resident perceptions of an arthroplasty career. Four hundred ninety-eight post-graduate year 3 and above residents completed the online survey. Residents most highly prioritize intellectual factors and role models/mentors in determining their fellowship specialty. In the face of a looming patient access-to-care crisis, the data from this study support a policy of highlighting the intellectual challenges and satisfaction of THA/TKA as a career and encouraging mentorship early in a resident's training.     

基于DEMATEL的非计划性拔管风险因素分析

目的应用决策试验与评价实验室方法(DEMATEL)确定非计划性拔管的关键风险因素,为临床管道管理提供决策依据。方法对49例非计划性拔管不良事件,由管道护理小组现场认证确定19项风险因素;选取35名专家进行2轮函询,以函询结果构建风险因素的直接影响矩阵,运用DEMATEL软件计算综合影响度(Tr)、被影响度(Tc)、中心度(Mi)和原因度(Ri)。结果专家积极性为100%,权威程度0.857,协调系数0.297(P0.05);19项风险因素的Tr为0~2.535,Tc为0~2.321,Mi为0.653~3.891,Ri0的风险因素有10个,Ri0的风险因素有9个。结论基于DEMATEL分析影响非计划性拔管的风险因素,其主要风险因素有操作方法、固定方法、肢体约束、健康教育及高危人群评估,其中操作方法为最关键因素。     

Double jeopardy revisited: Clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

Introduction

In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult. Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.

Methods

All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.

Results

Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18-40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80-90 mm Hg). Median base excess was −6.5 (quartile range −12 to −2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.

Conclusion

Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.     

医患共同决策在慢性肾衰竭治疗中的应用现状

医患共同决策模式在全世界得到了广泛认同和重视.应用共同决策模式能够提高患者对疾病的认知、提高患者的依从性和满意度、改善治疗结局、缓解医患关系并控制医疗花费.本文对共同决策在慢性肾衰竭治疗决策领域的应用现状做一介绍,分析中国在慢性肾衰竭诊疗过程中实施共同决策的挑战并给出建议,以帮助更多肾脏内科医务工作者认识并参与和实践共...     

Somato-sensory evoked potentials in root lesions and stenosis of the spinal canal. (Their diagnostic significance in clinical decision making)

The aim of the present study was to determine the significance of different SEP techniques and parameters in clinical evaluation of cases of lumbar and cervical root lesions and stenosis of the spinal canal. Using a qualitative rating scale, 92 cases were analyzed retrospectively whose primary diagnosis was questioned because of conflicting data from clinical, neuroradiological and neurophysiological testing. In conclusion SEP techniques proved to be a useful tool in exclusing other e.g. demyelinating diseases. Except for the time-consuming method of segmental stimulation, the demonstration of the functional deficit itself by SEP techniques in general was frequently disappointing. The contribution of the different SEP parameters to clinical decision making and the clinical consequences are briefly discussed.     

Predicting severity of pathological scarring due to burn injuries: a clinical decision making tool using Bayesian networks

It is important for clinicians to understand which are the clinical signs, the patient characteristics and the procedures that are related with the occurrence of hypertrophic burn scars in order to carry out a possible prognostic assessment. Providing clinicians with an easy‐to‐ use tool for predicting the risk of pathological scars. A total of 703 patients with 2440 anatomical burn sites who were admitted to the Department of Plastic and Reconstructive Surgery, Burn Center of the Traumatological Hospital in Torino between January 1994 and May 2006 were included in the analysis. A Bayesian network (BN) model was implemented. The probability of developing a hypertrophic scar was evaluated on a number of scenarios. The error rate of the BN model was assessed internally and it was equal to 24·83%. While classical statistical method as logistic models can infer only which variables are related to the final outcome, the BN approach displays a set of relationships between the final outcome (scar type) and the explanatory covariates (patient's age and gender, burn surface area, full‐thickness burn surface area, burn anatomical area and wound‐healing time; burn treatment options such as advanced dressings, type of surgical approach, number of surgical procedures, type of skin graft, excision and coverage timing). A web‐based interface to handle the BN model was developed on the website www.pubchild.org (burns header). Clinicians who registered at the website could submit their data in order to get from the BN model the predicted probability of observing a pathological scar type.     

The development of a decision support system for the pathological diagnosis of human cerebral tumours based on a neural network classifier

Summary This study describes the use of a topological mapping system in the classification of cerebral tumours and the development of a decision support system based upon that classifier. Fourteen pathological parameters from two hundred primary cerebral tumours are presented as vectors to a topological map. The map, consisting of a grid of neurones, learns the features of each tumour by means of a shortest Euclidean distance algorithm, after which self adaptation of the neurones occurs. An LVQ algorithm performs the final classification.Study of the map reveals that it can correctly classify tumours following their malignancy potential and their cytogenesis.The decision support system uses the network at its core and helps not only in reaching a diagnosis but also in finding the optimal way to reach that diagnosis. The usefulness of such a mapping system lies in the field of education, clinical research and medically acceptable cost reduction.