Making decisions in a complex information environment: evidential preference and information we trust

Background

Informed decision making requires that those individuals making health and health-care decisions understand the advantages and disadvantages associated with particular health options. Research and theory suggest factors that contribute to the decision-making process: data on the likelihood of risks and benefits, level of certainty about outcomes, familiarity with the health issue, characteristics of information sources and presentation, and patient values and beliefs. As the health information environment increases in complexity, it becomes important to understand how interactions among information sources, family, and friends may affect the processing of health information and choices and their alignment with available evidence.

Analysis

This paper discusses the potential interactions among social networks, information sources and evidential preferences for health information as they influence health decisions. The role of family and friends who increasingly search for health information for others and the potential for information filtering influenced by second- or third-party attitudes and preferences is explored. Evidential preferences suggestive of the potential value of social math (creatively presented statistics) strategies for presenting data, the information-processing factors that may make personal experiences, anecdotes and testimonials that are often shared within social networks and may exert powerful influences on health decisions are examined in this article.

Conclusions

The paper concludes with recommendations for revised health-communication practices, health professional training to improve patient understanding in the clinical encounter, and directions for future research. Simple, direct, and socially relevant communications that avoid conflicts with the values and beliefs of the individual, as well as those of the family and social network, are recommended.

     

Radiotherapy for SMAD4-negative musculoskeletal lesions from pancreatic cancer

Background

Pancreatic cancer (PC) predominantly metastasizes to liver, lung, and peritoneum. Metastatic disease correlates with SMAD4 status. Musculoskeletal metastases (MSM) are rare in pancreatic cancer. The role of radiation therapy (RT) in patients with musculoskeletal metastases is not clear.

Methods

We present a case of a woman with musculoskeletal metastases of PC evolving 4 years after Whipple’s procedure and adjuvant therapy. She was treated with RT for 7 MSM. Radiation dose was 15–45 Gy, delivered in doses of 2.5–5 Gy per fraction. SMAD4 status was examined by immunohistochemistry. Furthermore we undertook a review of the literature to examine the value of RT in musculoskeletal metastasis of PC.

Results

In the presented patient we treated 7 MSM of SMAD4-mutant PC with RT. RT achieved local control in 4 of the 7 MSM. At the resection margin of one MSM recurrent tumor was observed after RT. The status of one MSM was unknown and one MSM showed local progression. Follow-up revealed progression of pain in 1 of the 7 MSM. Except of hyperpigmentation no side effects occurred. There was no dose–correlation effect on tumor control observed. A review of the literature showed that a musculoskeletotrophic phenotype of metastases is rare in PC. MSM of PC are rapidly increasing soft tissue masses causing pain and loss of anatomical function. RT as a treatment option for musculoskeletal metastasis is described in the current literature in only 2 cases. Radiotherapy aims to achieve local control, pain relief, and to maintain anatomical function.

Conclusion

Radiotherapy is an effective and well-tolerated approach for multiple musculoskeletal metastases of PC.

     

The incidence of radioepidermitis and the dose-response relationship in parotid gland cancer patients treated with 125I seed brachytherapy

Background

We studied the incidence and dose–response relationship of radioepidermitis in parotid gland carcinoma patients treated with [¹²⁵I] seed brachytherapy in the hopes of designing an optimized pre-implant treatment plan that would reduce the incidence and severity of radioepidermitis in patients receiving this therapy.

Patients and methods

Between January 2007 and May 2010, 100 parotid gland cancer patients were treated postoperatively with [¹²⁵I] seed brachytherapy. The matched peripheral dose (MPD) was 80–140 Gy, and [¹²⁵I] seed activity was 0.7–0.8 mCi. The mean dose delivered to the skin was calculated in the post-implant CT on day 0 following implantation. Grades of acute and late dermatitis were evaluated at 2, 6, 12, and 18 months post-implantation.

Results

Most patients experienced grade 0–2 acute and late skin side effects (86 and 97?%, respectively), though a small subset developed severe complications. Most grade 1–3 effects resolved within 6 months of implantation, though some grade 1–3 effects and all grade 4 effects remained unchanged throughout the 18-month follow-up period. Grade 3 and 4 effects were most prominent (75 and 25?%, respectively) with doses of 110–140 Gy; doses higher than 140 Gy produced only grade 4 effects.

Conclusion

[¹²⁵I] seed brachytherapy produced acceptable levels of acute and late radioepidermitis with a good clinical outcome. A mean dose under 100 Gy delivered to the skin was safe, though doses of 110–140 Gy should be given with caution and extra monitoring; doses greater than 140 Gy are dangerous and likely to produce grade 4–5 effects.

     

Association between SNPs in defined functional pathways and risk of early or late toxicity as well as individual radiosensitivity

Background and purpose

The aim of this study was to determine the impact of functional single nucleotide polymorphism (SNP) pathways involved in the ROS pathway, DNA repair, or TGFB1 signaling on acute or late normal toxicity as well as individual radiosensitivity.

Materials and methods

Patients receiving breast-conserving surgery and radiotherapy were examined either for erythema (n?=?83), fibrosis (n?=?123), or individual radiosensitivity (n?=?123). The 17 SNPs analyzed are involved in the ROS pathway (GSTP1, SOD2, NQO1, NOS3, XDH), DNA repair (XRCC1, XRCC3, XRCC6, ERCC2, LIG4, ATM) or TGFB signaling (SKIL, EP300, APC, AXIN1, TGFB1). Associations with biological and clinical endpoints were studied for single SNPs but especially for combinations of SNPs assuming that a SNP is either beneficial or deleterious and needs to be weighted.

Results

With one exception, no significant association was seen between a single SNP and the three endpoints studied. No significant associations were also observed when applying a multi-SNP model assuming that each SNP was deleterious. In contrast, significant associations were obtained when SNPs were suggested to be either beneficial or deleterious. These associations increased, when each SNP was weighted individually. Detailed analysis revealed that both erythema and individual radiosensitivity especially depend on SNPs affecting DNA repair and TGFB1 signaling, while SNPs in ROS pathway were of minor importance.

Conclusion

Functional pathways of SNPs may be used to form a risk score allowing to predict acute and late radiation-induced toxicity but also to unravel the underlying biological mechanisms.

     

Restrictive Transfusion Practice During Extracorporeal Membrane Oxygenation Therapy for Severe Acute Respiratory Distress Syndrome

Recommendations concerning the management of hemoglobin levels and hematocrit in patients on extracorporeal membrane oxygenation (ECMO) still advise maintenance of a normal hematocrit. In contrast, current transfusion guidelines for critically ill patients support restrictive transfusion practice. We report on a series of patients receiving venovenous ECMO (vvECMO) for acute respiratory distress syndrome (ARDS) treated according to the restrictive transfusion regimen recommended for critically ill patients. We retrospectively analyzed 18 patients receiving vvECMO due to severe ARDS. Hemoglobin concentrations were kept between 7 and 9 g/dL with a transfusion trigger at 7 g/dL or when physiological transfusion triggers were apparent. We assessed baseline data, hospital mortality, time on ECMO, hemoglobin levels, hematocrit, quantities of packed red blood cells received, and lactate concentrations and compared survivors and nonsurvivors. The overall mortality of all patients on vvECMO was 38.9%. Mean hemoglobin concentration over all patients and ECMO days was 8.30 ± 0.51 g/dL, and hematocrit was 0.25 ± 0.01, with no difference between survivors and nonsurvivors. Mean numbers of given PRBCs showed a trend towards higher quantities in the group of nonsurvivors, but the difference was not significant (1.97 ± 1.47 vs. 0.96 ± 0.76 units; P = 0.07). Mean lactate clearance from the first to the third day was 45.4 ± 28.3%, with no significant difference between survivors and nonsurvivors (P = 0.19). In our cohort of patients treated with ECMO due to severe ARDS, the application of a restrictive transfusion protocol did not result in an increased mortality. Safety and feasibility of the application of a restrictive transfusion protocol in patients on ECMO must further be evaluated in randomized controlled trials.     

Epidermoid Cyst—A Rare Mediastinal Mass

Gallstone disease is a common gastrointestinal problem in day-to-day practice. The Old concept that a typical gallstone sufferer is fat, fertile, flatulent female of 50. This is partially true as the disease has been found in women soon after their first delivery who are thin and underweight and in males also. Conditions that favor the formation of cholesterol gallstones are super saturation of bile with cholesterol, kinetically favorable nucleation and presence of cholesterol crystals in the gall bladder long enough to agglomerate into a stone. Recent studies have defined the role of trace elements (Fe, Ca, Zn and Cu) and defective pH in the formation of gallstones. The aim of the study was to correlate iron-deficiency anemia with gallstone disease. To estimate the serum ferritin level as a diagnostic tool of iron deficiency anemia in patients with gallstone disease, this prospective study of 100 patients was conducted over a period of 24 months in the Department of General Surgery, Jaipur Golden Hospital, New Delhi, India. Serum cholesterol, iron and ferritin levels were compared in patients having gallstones and healthy individuals. A low serum iron level is a factor in bile super saturation with respect to cholesterol, leading to gallstone formation.