Complex Treatment Decisions Research Articles

The benefits of prophylaxis: views of adolescents with severe haemophilia

It is well known and often reported that patients with long-term health conditions have problems adhering to treatment regimens. This is often reportedly worst in adolescents who struggle with the physical and psychological impact of adolescence as well as with the limitations that treatment regimens impose on their day-to-day activities. This article presents results from a larger study that aimed to discover what living with haemophilia in the 21st century was like for boys with severe haemophilia. The overall study was a multi-method, cross-sectional interview based study of 30 boys with severe haemophilia, treated with prophylaxis at a single site in the UK. Although not specifically asked in the interview schedule, opinions about treatment (prophylaxis) were given by 66% of the boys. These boys recognized that prophylaxis offered them protection from bleeding, the older and more sporty boys understood the need for tailored prophylaxis around 'risk' activities such as sport or events away from home. For some boys this meant low dose daily prophylaxis, and this further enhanced treatment adherence, as it became firmly embedded in their daily ritual of health care. This study shows that adolescent boys are in fact adherent with treatment, possibly at a schedule decided upon by them rather than one directed by the haemophilia centre. They are able to comprehend complex treatment decisions and make treatment plans that offer them maximum protection with minimal interference in their day-to-day activities.

A critical appraisal of treatment decisions in multiple sclerosis—old versus new

Interferon β and glatiramer acetate have been available for the treatment of multiple sclerosis (MS) for over a decade and their efficacy and safety are well established. These agents have detectable effects on the immune system, but have not been associated with a breakdown of immune surveillance. Novel MS therapies have been approved, or are awaiting approval, that differ from established immunotherapies with regard to their mechanisms of action, modes of administration, adverse-effect profiles and, possibly, the clinical and paraclinical benefits that they may provide for patients. Neurologists will soon be required to make complex treatment decisions with their patients on the basis of very limited clinical data and evidence. Under these circumstances, optimal assessment of risks and benefits will be challenging. In this Review, the anticipated benefits of novel therapies, including reduction in disease activity, possible prevention of disability, and improvement in quality of life, are outlined. In addition, the current acceptance of potential risks--including serious or even life-threatening adverse effects, the likelihood of which may rise with increased cumulative exposure to a particular agent--by patients with MS will be reviewed.

1477 ACTIVE SURVEILLANCE – CAN WE REDUCE THE RATE OF FAILURE?

You have accessJournal of UrologyProstate Cancer: Localized1 Apr 20111477 ACTIVE SURVEILLANCE – CAN WE REDUCE THE RATE OF FAILURE? Samarth Chopra, David Tamblyn, Tina Kopsaftis, and Carole Pinnock Samarth ChopraSamarth Chopra Adelaide, Australia More articles by this author , David TamblynDavid Tamblyn Adelaide, Australia More articles by this author , Tina KopsaftisTina Kopsaftis Adelaide, Australia More articles by this author , and Carole PinnockCarole Pinnock Adelaide, Australia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1412AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Active Surveillance (AS) is now a widely recognised management option for newly diagnosed low risk prostate cancer patients meeting specific criteria. We investigated failure to predict poor pathological and recurrence outcomes, and further developed four published AS criteria in a SA patient cohort. METHODS We studied prospectively collected data on 579 patients undergoing radical prostatectomy for localised prostate cancer (CaP) at three public hospitals in South Australia between 1998–2009. Patients meeting the Hardie, Roemeling, Choo and D'Amico criteria (Suardi et al Cancer 2008; 112: 2068) were compared for surgical pathology and biochemical recurrence-free survival. RESULTS Patients had mean age 62 [range 37–80] years, mean PSA at biopsy 8.6 ng/ml. Considered by the 4 criteria sets, 27–37% had extra-capsular extension, 3–6% seminal vesicle invasion, 1–3% Gleason 8+ and 6–9% recurred at three years with 30-62% patients having at least one unfavourable outcome. Addition of tumour size at diagnosis (percent positive biopsies or PPB<=25%) improved performance with only 21-28% patients having an unfavourable pathology outcome and no recurrences at five years for D'Amico criteria (see Figure). CONCLUSIONS D'Amico criteria plus PPB may predict suitability for AS with a low failure rate. Our findings are useful for both patients and clinicians who deal with complex treatment decisions. The level of misclassification for this combination (no recurrences at 5 years) is probably better than most criteria combinations in the literature. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e592 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samarth Chopra Adelaide, Australia More articles by this author David Tamblyn Adelaide, Australia More articles by this author Tina Kopsaftis Adelaide, Australia More articles by this author Carole Pinnock Adelaide, Australia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Numeracy and framing bias in epilepsy

Patients with epilepsy are frequently confronted with complex treatment decisions. Communicating treatment risks is often difficult because patients may have difficulty with basic statistical concepts (i.e., low numeracy) or might misconceive the statistical information based on the way information is presented, a phenomenon known as “framing bias.” We assessed numeracy and framing bias in 95 adults with chronic epilepsy and explored cognitive correlates of framing bias. Compared with normal controls, patients with epilepsy had significantly poorer performance on the Numeracy scale (P=0.02), despite a higher level of education than normal controls (P<0.001). Compared with patients with higher numeracy, patients with lower numeracy were significantly more likely to exhibit framing bias. Abstract problem solving performance correlated with the degree of framing bias (r=0.631, P<0.0001), suggesting a relationship between aspects of executive functioning and framing bias. Poor numeracy and susceptibility framing bias place patients with epilepsy at risk for uninformed decisions.

Informational Coping Style and Depressive Symptoms in Family Decision Makers

Overwhelmed family decision makers of chronically critically ill patients must comprehend vital information to make complex treatment decisions that are consistent with patients' preferences. Exploration of informational coping styles of family decision makers may yield evidence for tailored communication practices supporting the psychological and informational needs of family decision makers. To describe patterns in the demographic characteristics and informational coping styles of family decision makers; to assess differences in informational satisfaction, role stress, and depressive symptoms between family decision makers classified as monitors and as blunters; and to describe the predictive associations between informational coping styles, informational satisfaction, and role stress on depressive symptoms in family decision makers. A secondary data analysis of 210 family decision makers of cognitively impaired patients who required 3 days or more of mechanical ventilation. On enrollment, decision makers completed the abbreviated Miller Behavioral Style Scale to assess informational coping styles, the Critical Care Family Satisfaction Survey's informational subscale to assess informational satisfaction, a single-item measure of role stress, and the Center for Epidemiological Studies Depression scale to assess depressive symptoms. No associations emerged between demographic characteristics and informational coping styles of family decision makers. Monitors had higher depression scores than did blunters. Both information coping style and informational satisfaction influenced depressive symptoms; however, role stress was the most significant predictor. Family decision makers classified as monitors were at higher risk for depression than were those who seem to avoid information. Targeting monitors with additional psychological and informational support may mitigate their psychological impairment.

Modern treatment of cerebral metastases: Integrated Medical LearningSM at CNS 2007

Cerebral metastases are a common problem and pose complex treatment decisions, with reference to local control of treated lesions, prevention of new brain metastases, and toxicity of available treatments. At the 2007 Congress of Neurological Surgeons (CNS) Annual Meeting, a novel active learning process, called Integrated Medical Learning(SM), was used to better understand contemporary practice patterns and to monitor the success of education about these critical treatment decisions. CNS members received an electronically distributed premeeting survey and educational materials about single and multiple cerebral metastasis treatment; practice patterns were elicited. At the Annual Meeting, 496 surgeons were polled using handheld devices before and after surgical and radiation oncology expert presentations. Surgeons who had answered premeeting surveys received a second, postmeeting questionnaire. In the premeeting questionnaire (N = 214), higher current volume of practice, Tumor Section membership, and academic practice predicted more correct answers (P < 0.05 for all). Fifty five percent favored routine whole brain radiotherapy (WBRT) after metastasis resection. Thirty four percent "most often" used radiosurgery to the resection bed; these respondents cited "cognitive changes" in justifying WBRT omission. At the meeting, expert presentations were followed by audience shifts toward adjuvant WBRT after resection (P = 0.01) or radiosurgery (P < 0.001)-topics for which class I evidence was discussed. There was no shift in preference for surgery or radiosurgery (P = 0.24) or multiple metastasis treatment (P = 0.8)-topics for which clear class I evidence was not presented. Postmeeting questionnaires showed retained knowledge among meeting attendees. Using IML, we were able to study baseline knowledge and practice patterns for an important neuro-oncological treatment decision. Evidence suggested expert presentations were effective in changing audience opinion when relevant class I evidence was presented, and that knowledge was retained postmeeting.

Examining Decision Making Styles in Patients with Sickle Cell Disease (SCD) Regarding Allogeneic Stem Cell Tranplantation (ASCT)

Background: ASCT is currently the only curative option of cure for patients (pts) with sickle-cell disease. Assessing the risk and benefits of ASCT in pts with SCD is challenging due to variability in the morbidity and mortality of the disease and ASCT for individual pts. The impact of transplantation on quality of life, patient understanding of ASCT, and physician factors, all influence treatment selection. Individuals' decision-making styles can influence how patients evaluate complex treatment decisions and thus how they view ASCT.Methods: To examine how patients with SCD make treatment decisions we performed a pilot study in which we administered an 80-item questionnaire to assess pts': Desired Role in decision making, Need for Cognition, Need for Structure, Personal Fear of Invalidity, and General Decision Making style. During the visit, the research team and pt discussed the risks and benefits of ASCT and how they view their current treatment. Then, a 38-item post-visit questionnaire was administered to assess patients' strength of preference for ASCT, perceptions of physician and caregiver's preferences, and decision satisfaction. Questions were derived from previously validated questionnaires and used 5-point or 6-point Likert scale.Results: Questionnaires were administered to 25 pts (6 Sickle-Hemoglobin C (SC), 18 sickle cell anemia (SS), and 1 Sickle Beta-Thalassemia) undergoing evaluation of sickle cell disease. Patients were 18–71 years of age with 36% of pts being male. On an average, pts had experienced 4–7 episodes of sickle-cell crisis (min 0–3, max 16+). 20% of pts rated their current health as excellent/very good, 44% good, and 36% fair/poor. All pts completed all pre-visit and post-visit questions. Most pts expressed a desire that doctors make treatment decisions alone (68% agree/strongly agree) or with pt input (64%). An equally high number of pts (64%) believed they should make treatment decisions alone or with a doctor's input. 64% of pts had high scores for rational decision making style, whereas 40% scored high for an intuitive style, 24% scored high for dependent style, and only 4% high for an avoidant style of decision making (Distribution shown in table). 72% of pts felt satisfied with the information they received for decision making and 88% were satisfied with their decision. However, 44% of pts wanted clearer advice.Conclusions: Examining pts decision making styles during the process of care is feasible and can uncover pt characteristics that are relevant for improving treatment discussions. Pts in this sample tended to use rational decision making styles but wanted clearer advice. Additional studies are needed examine these factors in larger populations of pts with sickle cell disease, understand their associations with demographic variables, and design and test decision support systems that help pts and hematologists with treatment selection.General Decision Making Style (GDMS)ValuesRationalIntuitiveDependentAvoidantSpontaneousNeed for StructureNeed for CognitionMedian20191712124452Min81010672818Max25252521195863Possible Range5–255–255–255–255–2511–6618–90

Risks and Benefits of Antipsychotic Drugs in Elderly Patients with Dementia

Memory impairment and other cognitive disturbances characterize dementia, but other noncognitive behavioral and psychiatric symptoms are very common. The most important behavioral and psychiatric symptoms associated with dementia (BPSAD) are agitation, aggression, and psychosis, and they have serious consequences for patients and caregivers. No medication has been approved for the treatment of BPSAD, but antipsychotic drugs are the best studied and most commonly used. However, in addition to these drugs' expected side effects, cerebrovascular adverse events and death are two serious adverse effects associated with their use in dementia patients. This article highlights the studies examining the risks and benefits of antipsychotic drugs for BPSAD. Weighing small but significant risks compared with possible benefits is a complex treatment decision.

Deliberate termination of life of newborns with spina bifida

De Jong is to be complimented on his scholarly and lucid discussion of the many ethical dilemmas accompanying the management of children with spina bifida. He focuses particularly on evolving issues pertaining to the ethical and legal standards of practice in the Netherlands, but many aspects are relevant in all cultures and countries. The complex treatment decisions faced by all health professions dealing with parents and relatives of children with myelodysplasia are acute. However, they are never as acute as for paediatric neurosurgeons who usually, together with the obstetrician and delivering paediatrician, are the first to make these life-affecting decisions. De Jong argues compellingly that the correct ethical choice is to operate on all children whatever the level of the myelomeningocoele, degree of hydrocephalus and neurological dysfunction. He rightfully refutes the ability of any medical professional to judge the present and to prognosticate on the future quality of life. He convincingly rejects the concept of active euthanasia on the basis of the unreliability of estimating pain and suffering in neonates. In a first-world setting, where medical and surgical resources are available to all, I think to deny patients the right to life clearly violates their human rights . Especially since, as de Jong points out, virtually all our clinical methods of predicting outcome are unreliable. Emotional issues of religion and culture, both of professionals and parents, make objective decision-making impossible. Therefore, in countries where resources and access are available, the ethically defendable approach is to close the myelomeningocoele at birth and treat these patients actively in all regards. As has been argued elsewhere, it would be inconceivable not to treat a young teenager who sustained an acute spinal cord injury. Traumatic paraplegics have the same concomitant urological and neurological dysfunction asmyelomeningocoele children, but the same ethical debate surrounding the management of these patients does not arise. De Jong also points out that the medical professional’s attitude toward the quality of life of patients with myelomeningocele may have an undue influence on parents’ decision regarding the termination of pregnancy. Since prenatal imaging and ultrasound have improved, such decisions have become more frequent. The effect of overly pessimistic perceptions by obstetricians, paediatricians and paediatric neurosurgeons on such decisions should therefore be kept in mind. It clearly behoves all who deal with these children to be sufficiently informed about all aspects of myelodysplasia as the literature on the subject is huge. Parents whose child has been prenatally diagnosed with a myelomeningocoele should be objectively, not subjectively, informed. Where appropriate, they should be placed in contact with the many resource centres and support groups available. Only then can consent for termination of pregnancy be considered to be truly “informed”. Differing ethical dilemmas arise in countries where not enough resources are available to patients both in hospital and at home; where it is not possible to have urological follow-up or shunt assessments; where there is no access to wheelchairs or intermittent catheterisation ,which is often the case in rural settings. Children born into poor socioeconomic environments are commonly one of many siblings. Myelomeningocoele children often then ”usurp” all the meagre resources of the household so that the care of Childs Nerv Syst (2008) 24:55–56 DOI 10.1007/s00381-007-0489-0

Complexity of treatment decisions with older patients: who, when and what to treat?

<h3>ABSTRACT</h3> <h3>Background</h3> Dystonia is an under-studied motor feature of Parkinson disease (PD). Although considerable efforts have focused on brain oscillations related to the cardinal symptoms of PD, whether dystonia is associated with specific electrophysiological features is unclear. <h3>Objectives</h3> To investigate subcortical and cortical field potentials at rest and during contralateral hand and foot movements in PD patients with and without dystonia. <h3>Methods</h3> We examined the prevalence and distribution of dystonia in PD patients undergoing deep brain stimulation surgery and recorded intracranial electrophysiology from motor cortex and directional electrodes in subthalamic nucleus (STN) both at rest and during self-paced repetitive contralateral hand and foot movements. Wavelet transforms and mixed models characterized changes in spectral content in patients with and without dystonia. <h3>Results</h3> Dystonia was highly prevalent at enrollment (61%) and occurred most commonly in the foot. Regardless of dystonia status, cortical recordings display beta (13-30 Hz) desynchronization during movements versus rest, while STN signals show increased power in low frequencies (6.0±3.3 and 4.2±2.9 Hz peak frequencies for hand and foot movements respectively). PD patients with dystonia during DBS surgery displayed greater M1 beta power at rest and STN low frequency power during movements versus those without dystonia. <h3>Conclusions</h3> Spectral power in motor cortex and STN field potentials differs markedly during repetitive limb movements, with cortical beta desynchronization and subcortical low frequency synchronization, especially in PD patients with dystonia. Greater knowledge on field potential dynamics in human motor circuits can inform dystonia pathophysiology in PD and guide novel approaches to therapy.

Can Computerized Decision Support Help Patients Make Complex Treatment Decisions? A Randomized Controlled Trial of an Individualized Menopause Decision Aid

To compare the effectiveness of an individualized decision aid (DA) with standard educational materials on decisions about menopausal treatments and to assess the feasibility of integrating this DA into clinical practice, with and without coaching. We conducted a 3-armed randomized controlled trial in 3 clinics, enrolling menopausal women between the ages of 45 and 65 years with primary care appointments. Of the 145 women included, 99 completed a 2-week follow-up. The control group received generic educational materials, 1 intervention group received an individualized computer-generated DA mailed to patients and their clinicians before clinic appointment, and the 2nd intervention group received the same DA along with coached care before clinic appointment (DA + CC). Decisional conflict, satisfaction, and knowledge were measured 2 weeks after clinic appointment. Participants' mean age was 52 years, and 97% were white. Most women (98%) read all or most of the documents. Decisional conflict was significantly lower in both intervention groups but not in the control group. DA reduced decisional conflict from preintervention to postintervention (pre-post change) by 0.70 (SD = 0.56) points (on a 1-5 scale), compared to reductions of 0.51 (SD = 0.51) and 0.09 (SD = 0.44) for the DA + CC group and the control group, respectively. Satisfaction with the decision made was significantly higher at 2 weeks in the DA v. control group. Self-reported knowledge significantly improved in DA + CC compared to controls. Our decision aid lowered decisional conflict and improved patient satisfaction; adding coaching provided little additional benefit.

Using Data Mining to Explore Complex Clinical Decisions

Medical education is moving toward developing guidelines using the evidence-based approach; however, controlled data are missing for answering complex treatment decisions such as those made during suicide attempts. A new set of statistical techniques called data mining (or machine learning) is being used by different industries to explore complex databases and can be used to explore large clinical databases. The study goal was to reanalyze, using data mining techniques, a published study of which variables predicted psychiatrists' decisions to hospitalize in 509 suicide attempters over the age of 18 years who were assessed in the emergency department. Patients were recruited for the study between 1996 and 1998. Traditional multivariate statistics were compared with data mining techniques to determine variables predicting hospitalization. Five analyses done by psychiatric researchers using traditional statistical techniques classified 72% to 88% of patients correctly. The model developed by researchers with no psychiatric knowledge and employing data mining techniques used 5 variables (drug consumption during the attempt, relief that the attempt was not effective, lack of family support, being a housewife, and family history of suicide attempts) and classified 99% of patients correctly (99% sensitivity and 100% specificity). This reanalysis of a published study fundamentally tries to make the point that these new multivariate techniques, called data mining, can be used to study large clinical databases in psychiatry. Data mining techniques may be used to explore important treatment questions and outcomes in large clinical databases and to help develop guidelines for problems where controlled data are difficult to obtain. New opportunities for good clinical research may be developed by using data mining analyses.

Design considerations and proposed template for clinical trials in hospitalized patients with decompensated chronic heart failure

Am Heart J 2003;145:S47-50.

Decision making in palliative surgery.

Palliative surgery for advanced cancer patients involves complex decision making. Surgeons with a cancer-focused practice were surveyed to determine the extent to which palliative surgery was currently practiced, to identify ethical dilemmas and barriers they faced in performing palliative surgery, and to evaluate their treatment choices in four different clinical scenarios. A 110-item survey was devised after extensive review of the palliative care and palliative surgery literature to evaluate current practices and attitudes regarding palliative surgery. Case vignettes were devised to evaluate dinical factors influencing surgeons' selection of treatment for symptomatic patients with advanced malignancy. Survey response rate was 24% (419 of 1,740). Respondents reported 74% of their surgery caseload as cancer related, and 21% of these as palliative. On a scale of 1 (uncommon problem) to 7 (common problem), surgeons reported that the most common ethical dilemmas in palliative surgery were providing patients with honest information without destroying hope (5.6 +/- 1.4) (mean +/- standard deviation), and preserving patient choice (5.0 +/- 1.7). Bound on error of the average frequency estimate for ethical dilemmas, based on response rate, was 0.08. On a scale of 1 (not a barrier) to 7 (a severe barrier), surgeons rated the most severe barriers to optimum use of palliative surgery as limitations of managed care (4.1 +/- 2.0) and referral to surgery by other specialists (3.9 +/- 1.8). Bound on error of the estimate for average severity of barriers, based on response rate, was 0.09. They rated the least severe barriers to palliative surgery as surgeon avoidance of dying patients (3.0 +/- 1.8) and surgery department reluctance to perform palliative surgery (2.6 +/- 1.6). Analysis of surgeons' treatment selection in case vignettes indicated that patient age, aggressiveness of tumor biology, local extent of disease, and severity of patient symptoms were all variables of influence for treatment selection in patients with advanced malignancies. Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. We have identified variables of major influence to surgeons in the palliative treatment selection for patients with advanced, solid malignancies. Validation of these variables as meaningful will require future studies focusing on patient outcomes.

Combination endocrine therapy in the management of breast cancer.

Combination endocrine therapy has long been sought after as a means to better treat breast cancer. Agents that suppress estrogen production are given with agents that suppress estrogenic activity at the cellular level. Historically, these combinations have resulted in initial improvements in response rates, but relapse-free and overall survival were not significantly improved. Also, the increased toxicity seen with these regimens was limiting. New endocrine therapies with more potent activity and less toxicity have led to a resurgence of this idea in the management of breast cancer. Complete estrogen blockade has been compared with single-agent treatments in many different settings. The endocrine effects of this type of therapy are intriguing, but apparently do not readily predict a clinical advantage. The combination of an aromatase inhibitor and an antiestrogen, despite pharmacokinetic interactions, may prove to be beneficial. Results from ongoing trials are eagerly awaited to further address this question in postmenopausal breast cancer patients. For premenopausal breast cancer patients the options are more complex. Clinical outcomes with leutinizing hormone releasing hormone (LHRH) agonists plus aromatase inhibitors are limited to very small phase II studies and are not clearly superior to single-agent therapy. Clinical data in the metastatic setting with premenopausal patients favor the use of an LHRH agonist with tamoxifen over the use of an LHRH agonist alone. However, a similar comparison with tamoxifen alone is lacking with only one trial including this as a treatment arm. Adjuvant therapy with this combined endocrine approach (LHRH agonist plus antiestrogen) has been more extensively studied, but lacks crucial comparisons necessary for making complex treatment decisions. Hopefully, through investigative diligence and ingenuity this issue can be adequately understood. However, many exciting new agents are on the horizon that offer hope to further advance the progress made to date although further confounding the questions already answered.

Establishing a new research agenda for studying psychiatric emergency room treatment decisions.

With the growing complexity of treatment decisions made at presentation to a psychiatric emergency room (PER) and the increasing influence of managed care on the decision-making process, it is increasingly important to establish a new and more sophisticated research agenda for studying PER decision making. The main goal of this paper is to propose a comprehensive conceptual model of the PER decision-making process that will facilitate active pursuit of such a research agenda. The proposed model presents both traditional and emerging elements of the PER decision-making process (i.e., determinants, mediating mechanisms, and outcomes) and explicates the nature of the relationships among them at different levels of analysis. The model's theoretical and empirical implications for future research are discussed and suggestions are made as to the research designs and methods needed to pursue this agenda.

Prognostic parameters for the management of advanced testis tumours.

The need for prognostic parameters in testicular germ cell tumours is sometimes questioned based on an overall cure rate of more than 80% of the patients regardless of tumour stage. However, the trend for an earlier and more accurate diagnosis amenable to curative treatment as well as the high effectiveness of standard Cisplatinum containing chemotherapy has masked the continuing need for intensifying therapy in patients with adverse risk factors. This intense treatment is often associated with worrysome morbidity and the assessment of prognostic factors, stage by stage, is warranted on which patient at risk can be identified and treated accordingly. Traditional prognostic factors, on which most classification systems are based, include large tumour volume, the presence of liver, bone or brain metastasis, grossly elevated tumour markers and an extragonadal primary site, particularly in the mediastinum. Novel prognostic factors are either (1) independent from the patient and his disease, (2) inherent on the patient's characteristics or (3) based on tumour biology. Clearly, the infrastructure and the experience of the treating uro-oncology unit (see 1) is decisive for treatment outcomes, and -at least-'difficult to treat' patients should be referred to properly resourced cancer centres. Patients with higher socio-economic status, willing to travel and well educated enough to be worried about their diseases status apparently gain access to expert centres more easily (see 2), translating into an upgrade on prognosis. Finally, biologic factors (see 3) such as beta-human chorionic gonadotrophin or MAGE epitopes in seminoma or the percentage of embryonal carcinoma components orvascular invasion mayor may not inversely influence the prognosis and need further assessment in prospective trials. However, the search for even better (molecular) biologic factors is speeding up because more complex treatment decisions such as in advanced testicular cancers rely on a more precise determination of prognosis, enabling a more tailored selection of individualized therapeutic options.

Should treatment of Parkinson's disease be started with a dopamine agonist?

Which drugs to use when initiating pharmacotherapy in early Parkinson's disease (PD) is a complex treatment decision that depends on factors such as disease severity, functional disability, and psychosocial handicap, as well as individual aspects of age, employment status, cognitive impairment, and co-morbidity. Without clear proof of a drug's capacity to markedly alter or even stop progression of the disease, there is no pharmacologic strategy that can be currently viewed as universal first-line treatment. Dopamine (DA) replacement strategies offer greatest symptomatic relief and are needed whenever there is significant functional disability. All currently available oral DA agonists have been shown to be less effective and less well tolerated than levodopa. This has also been shown in recent double-blind controlled studies for the novel agonists such as ropinirole or cabergoline, although they appear equally effective in mild disease for the first 6-12 months of therapy. Taking into account the significant difference in cost between levodopa and DA agonists, there is at present no reason to universally start DA replacement therapy with a DA agonist in most patients. Dopamine agonists remain first-line treatment only for those at particular risk for developing levodopa-induced dyskinesias, i.e., young-onset PD patients.

A Patient Care Travelling Record for Palliative Care: A Feasibility Study

The provision of palliative care can be a complex process. Patients are treated in a variety of settings, by multiple persons, thus risking loss of continuity of care. These patients take numerous medications and require many complex treatment decisions in the course of their illness, making the ready availability of current and accurate information a vital component of effective care. The use of a patient care travelling health record, while requiring time and commitment from all parties to be effective, has been shown to be both feasible and helpful to patients, families, and health professionals. Considerable education and commitment is necessary to ensure compliance by all involved parties.

Therapy in Gout

The effective management of patients with gout is outlined. The treatment of the acute attack, the prevention of recurrent episodes, and the dissolution of tophi, when present, are generally straightforward and associated with relatively few complications. Patients with a resistant acute attack, with extensive tophaceous deposition, or with allergy or toxicity to any of the standard drugs, present more complex treatment decisions. All agents must be used in an individualized manner for each patient with appropriate concern for risks as well as for benefit.