Decision For Surgical Intervention Research Articles

Artificial intelligence in plastic surgery: current developments and future perspectives

Driven by the rapid development of big data, the amount of clinical data, including complex information, is expanding. Traditional data analysis methods cannot meet the need for mining data information, and artificial intelligence (AI) solves this problem. AI is increasingly being incorporated into modern medical practice. Algorithms provided by AI support advanced analysis and provide individualized aid to optimize medical decision-making. In plastic surgery, AI has made many breakthroughs in diagnosis, pre-operative surgical design, treatment decisions, and patient management. Plastic surgeons must recognize AI’s potential development and limitations. This review describes the current application of AI in plastic surgery and discusses the challenges and problems that need to be solved. This study aims to foster the application of this new AI technology in clinical practice.

Retka prezentacija pleomorfnog adenoma kao peritonzilarni tumor - prikaz slučaja

Pleomorphic adenoma, which is considered to be the most common benign neoplasm of small salivary glands, occurs mainly in the region of the hard palate with mild predilection for women and the peak incidence between the third and sixth decades of life. We present the case of a fifty-one-year-old patient with a left peritonsillar region tumor that the patient has been familiar with for several years. Clinical and radiological examination (computed tomography) indicated a clearly limited, encapsulated tumor change in the left peritonsillar region, 2.5 x 2.5 cm in diameter. The change was completely surgically removed transorally and pathohistologically verified as a pleomorphic adenoma of the small salivary gland. Computed tomography and correct pathohistological diagnosis are essential for the decision on surgical treatment in order to completely remove the lesion. Although it is a benign tumor, early detection is important for a timely decision for surgical treatment. Complete excision of tumor is necessary to prevent regrowth and possible malignant transformation.

Patient decision-making for surgical treatment of post-prostatectomy stress urinary incontinence: a mixed-methods exploratory pilot study.

Male stress urinary incontinence (SUI) is a known complication following surgical intervention on the prostate, particularly following surgery for prostate cancer. Effective surgical treatments for SUI include artificial urinary sphincter (AUS) and male urethral sling. Prior data suggest that men may forego available treatment despite bothersome symptoms. The objective was to explore how men who underwent surgical correction for post-prostatectomy SUI navigated SUI treatment decisions. Mixed method study was employed. Semi-structured interviews, participant surveys and objective clinical assessment of SUI were performed among a group of men living with incontinence after prostate cancer surgery who underwent surgery for SUI at the University of California in 2017. Eleven men were interviewed after consultation for SUI and all had complete quantitative clinical data. Surgery for SUI included AUS (n=8) and sling (n=3). There was a decrease in pads per day from 3.2 to 0.9 and no major complications. Most patients found that the impact on activities and their treating urologist were of great importance. Sexual and relationships played a variable role with some participants ranking these as "great deal of influence" and others "little or no influence". Participants who underwent AUS were more likely to cite a higher importance on "being very dry" in choosing that surgery while sling patients had more variable ranking of important factors. Participants found a variety of inputs helpful in hearing information about SUI treatment options. Among a group of 11 men who underwent surgical correction for post-prostatectomy SUI, there were identifiable themes on how men make decisions, evaluate quality of life (QoL) changes and approach treatment options. Men value more than being dry with measures of individual success that can include sexual and relationship health. Furthermore the role of the Urologist remains crucial as patients relied heavily on input and discussion with their Urologist to assist in treatment decisions. These findings can be used to inform future studies of the experience of men with SUI.

Level of agreement between three-dimensional transthoracic and transesophageal echocardiography for mitral annulus evaluation: A feasibility and comparison study.

Mitral annulus assessment is of utmost importance for the management of patients with mitral valve (MV) abnormalities, as it helps to determine the decision for surgical or transcatheter treatment. Three-dimensional (3D) transesophageal echocardiography (TOE) has been the only reliable echocardiographic method for the evaluation of the mitral annulus by now. However, newer transthoracic echocardiography (TTE) 3D probes have enabled to provide accurate measurements as well and become a valuable tool when TOE is contraindicated. The aim of this study is to assess the feasibility of 3D TTE analysis of mitral annulus and the level of agreement with 3D TOE measurements. A total of 121 consecutive patients were assessed with 3D TTE and TOE. All mitral annulus parameters were retrospectively analyzed with the dedicated 4D autoMVQ application. Bland-Altman analysis and intraclass correlation coefficient were used for the comparison and agreement between the two methods. Half of our patients had normal mitral valves and served as control group, while the other half had various mitral valve pathologies. AutoMVQ analysis was not feasible in 11 out of 121 TTE examinations (91% feasibility) and in 4 out of 121 TOE examinations (96% feasibility). Mitral annular area and perimeter were slightly larger in TTE than those measured by TOE (12.7±3.6vs. 12.4±3.2 cm2 for area and 12.7±1.7vs. 12.5±1.6cm for perimeter), however still showing strong correlation (r=.942 and r=.922, respectively). The majority of mitral valve measurements (anterior-posterior, medial-lateral and commissural diameter, aorto-mitral angle and anterior leaflet length) were similar among the two methods with strong correlation (r>.80). Inter-trigonal distance, posterior leaflet length and tenting height showed weaker agreement between TTE and TOE (r=.687, r=.687, r=.634, respectively). Mitral annular dimensions (by 3D area) were found to be significantly larger in patients with MV pathology (13.5±3.5vs. 11±2.3 cm2 ), atrial fibrillation (14.4±3vs. 11.4±2.8 cm2 ), left ventricular (13.8±3.1vs. 11.7±3.1cm2 ) and left atrial dilatation (13±3.3vs. 10.6±2.3cm2 ) compared to the individuals in the control group (p<.001 for all comparisons). Assessment of the MV with 3D TTE with dedicated MVQ software is feasible and accurate, showing strong correlation and agreement with TOE measurements.

Modeling Optimal Clinical Thresholds for Elective Abdominal Hernia Repair in Patients With Cirrhosis

Patients with cirrhosis have increased risk of postoperative mortality. Several models have been developed to estimate this risk; however, current risk estimation scores cannot compare surgical risk with the risk of not operating. To identify clinical optimal thresholds to favor operative or nonoperative management for a common cirrhosis surgical scenario, the symptomatic abdominal hernia. This was a Markov cohort decision analytical modeling study evaluating elective surgery vs nonoperative management for a symptomatic abdominal hernia in a patient with cirrhosis. Transition probabilities and utilities were derived from the literature and from data using an established cirrhosis cohort in the Veterans Health Administration. Participants included patients who were referred to a surgery clinic for a symptomatic abdominal hernia. Data were obtained from patients diagnosed with cirrhosis between January 1, 2008 and December 31, 2018. Data were analyzed from January 1 to May 1, 2022. Expected quality-adjusted life-years (QALYs) were estimated for each pathway and iterated over baseline model for end-stage liver disease-sodium (MELD-Na) scores ranging from 6 to 25. Markov models were cycled over a 5-year time horizon. A total 2740 patients with cirrhosis (median [IQR] age, 62 [56-66] years; 2699 [98.5%] men) were referred to a surgery clinic for a symptomatic abdominal hernia; 1752 patients (63.9%) did not receive surgery. The median (IQR) follow-up was 42.1 (25.3-70.0) months. Using this cohort to estimate the mortality risk of operative and nonoperative pathways, an initial MELD-Na threshold of 21.3 points, below which surgery was associated with maximized QALYs was identified. Nonoperative management was associated with increased QALYs above this MELD-Na threshold. Although more patients experienced death with a surgical treatment decision across all initial MELD-Na values, this was counterbalanced by increased time spent in a resolved hernia state associated with increased utility. Model results were sensitive to the probability of hernia recurrence and hernia incarceration and utility decrement in the symptomatic hernia state. This decision analytical model study found that elective surgical treatment for a symptomatic abdominal hernia was favored even in the setting of relatively high MELD-Na scores. Patient symptoms, hernia-specific characteristics, and surgeon and center expertise may potentially impact the optimal strategy, emphasizing the importance of shared decision-making.

Several issues on surgical treatment for adenocarcinoma of esophagogastric junction

There are several controversies and issues in the surgical treatment of esophagogastric junction (AEG) currently. The Siewert classification and TNM staging system are commonly used to assist clinical decision and prognosis prediction. Generally, transthoracic procedure is more suitable for Siewert Ⅰ type and longer esophageal invasion patients, while transhiatal is more suitable for Siewert Ⅲ type patients. The optimal extent of lymph node dissection for AEG should be based on tumor location and esophageal invasion range. The extent of surgical resection and the method of digestive tract reconstruction should be based on the principle of radical resection and surgical safety, and the postoperative life quality of patients should be fully considered. Roux-en-Y anastomosis is the most common and efficient anastomosis after total gastrectomy, while double tract anastomosis is recommended by many experts after proximal gastrectomy. With the continuous advancement of minimally invasive techniques, experienced centers and teams can perform digestive tract reconstruction under total laparoscopy. In the future, more high-quality studies are expected to provide evidence-based medical evidence for AEG's surgical treatment decisions.

FDG-PET Predicts Neoadjuvant Therapy Response and Survival in Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma.

Neoadjuvant therapy (NAT) is used in borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Anatomic imaging (CT/MRI) poorly predicts response, and biochemical (CA 19-9) markers are not useful (nonsecretors/nonelevated) in many patients. Pathologic response highly predicts survival post-NAT, but is only known postoperatively. Because metabolic imaging (FDG-PET) reveals primary tumor viability, this study aimed to evaluate our experience with preoperative FDG-PET in patients with BR/LA PDAC in predicting NAT response and survival. We reviewed all patients with resected BR/LA PDAC who underwent NAT with FDG-PET within 60 days of resection. Pre- and post-NAT metabolic (FDG-PET) and biochemical (CA 19-9) responses were dichotomized in addition to pathologic responses. We compared post-NAT metabolic and biochemical responses as preoperative predictors of pathologic responses and recurrence-free survival (RFS) and overall survival (OS). We identified 202 eligible patients. Post-NAT, 58% of patients had optimization of CA 19-9 levels. Major metabolic and pathologic responses were present in 51% and 38% of patients, respectively. Median RFS and OS times were 21 and 48.7 months, respectively. Metabolic response was superior to biochemical response in predicting pathologic response (area under the curve, 0.86 vs 0.75; P&lt;.001). Metabolic response was the only univariate preoperative predictor of OS (odds ratio, 0.25; 95% CI, 0.13-0.40), and was highly correlated (P=.001) with pathologic response as opposed to biochemical response alone. After multivariate adjustment, metabolic response was the single largest independent preoperative predictor (P&lt;.001) for pathologic response (odds ratio, 43.2; 95% CI, 16.9-153.2), RFS (hazard ratio, 0.37; 95% CI, 0.2-0.6), and OS (hazard ratio, 0.21; 95% CI, 0.1-0.4). Among patients with post-NAT resected BR/LA PDAC, FDG-PET highly predicts pathologic response and survival, superior to biochemical responses alone. Given the poor ability of anatomic imaging or biochemical markers to assess NAT responses in these patients, FDG-PET is a preoperative metric of NAT efficacy, thereby allowing potential therapeutic alterations and surgical treatment decisions. We suggest that FDG-PET should be an adjunct and recommended modality during the NAT phase of care for these patients.

The clinical application of lateral chest flap transfer combined with relay skin flap transfer to repair soft tissue defects of the chest wall after tumor resection.

BackgroundAfter thoracic tumor resection, there is often a large area of soft tissue defect left, even with exposed ribs and sternum, which needs to be repaired by skin flap transplantation. This study aims to introduce lateral thoracic flaps combined with local flaps to repair the soft tissue defect of the chest wall after the repair of malignant tumors, and try to retain the latissimus dorsi myocutaneous flap as a spare repair myocutaneous flap to avoid subsequent tumor recurrence and lack of local flaps for supply body source.MethodsA total of 26 patients with chest wall soft tissue defect with or without exposed rib and sternum after tumor resection at presentation from January 2017 to October 2021 were included in this study. None of the patients required breast reconstruction. Patients ranged in age from 34 to 56 years old. The above patients were treated with lateral thoracic flaps combined with local rotational advancement flaps to repair chest wall soft tissue defects. The postoperative wound healing, scar hyperplasia and recurrence of the patients were followed up.ResultsAmong the patients in this study, 25 incisions healed by primary incision, 1 incision was delayed, and healed after 10 days of dressing change. Postoperatively, the incisions of the patients were all intact, and there were no complications such as skin necrosis and infection. All patients were followed up for 6–18 months, and the incision healed well without complications such as skin necrosis and infection. Of the patients, 2 males developed dermatofibrosarcoma carina recurrence 6 and 10 months after surgery, respectively. After extensive excision, an ipsilateral latissimus dorsi myocutaneous flap was used to repair the defect. The Vancouver scar scale was used to evaluate the hyperplasia of all incisions at 6 months postoperatively. The mean score was 5.92±1.6.ConclusionsThe lateral thoracic flap combined with the local flap to repair the chest wall soft tissue defect after tumor surgery is a strategic decision for surgical treatment, which is beneficial to the sequential surgical treatment of tumor patients.

The risk analysis of perioperative complications of cementless hip arthroplasty in octogenarians

IntroductionHip arthroplasty is exposed to demographic change as patients age. Analysis of risk factors for surgical treatment decisions in the group of ≥ 80-year-old patients is crucial. Healthcare systems in developed countries are being tested medically and financially by the ageing population. Therefore, this study analysed the perioperative complications of cementless primary hip arthroplasty in octogenarians and compared them with patients aged ≤ 60 years.MethodsA retrospective data analysis of the year 2017 was done in a maximum care hospital of General Orthopaedic Surgery. Patients aged ≥ 80 years or ≤ 60 years with primary cementless hip arthroplasty were included. The outcome of interest was surgery-related and systemic complications, the development of haemoglobin and the incidence of blood transfusion after cementless primary hip arthroplasty in octogenarians during the hospitalisation and the follow-up treatment. Chi-square tests and Fischer's exact test were used for nominal variables. The two-factorial variance analysis-mixed model was used for Hb analyses and the Welch test for group comparison for metric parameters.ResultsThere was a significantly increased incidence of systemic complications during hospitalisation in the ≥ 80-year-old patients (phi 0.26; Std. Ri − 0.8 (A), 2.2 (B); p = 0.007), as well as a significantly increased rate of blood transfusions (phi 0.403; Std. Ri − 1.3 (A), 3.2 (B); p = < 0.001). No clustered pre-existing conditions in the ≥ 80-year-old patients pointed out a significant association with the incidence of systemic complications. Surgery-related complications showed no significant difference during hospitalisation and follow-up treatment.ConclusionThe study reveals that primary cementless hip prosthesis implantation is a safe procedure without increased incidence of surgery-related complications. Increased attention should be paid to interdisciplinary preoperative optimisation (adjustment of blood pressure, blood transfusions, if necessary, safe exclusion of urinary tract infections) and postoperative care of octogenarians (tight laboratory examinations, geriatric co-attendance).

Patients’ perspectives on the benefits of feedback on patient-reported outcome measures in a web-based personalized decision report for hip and knee osteoarthritis

BackgroundApplications of patient-reported outcome measures (PROMs) for individual patient management are expanding with the support of digital tools. Providing PROM-based information to patients can potentially improve care experiences and outcomes through informing and activating patients. This study explored patients’ perspectives on the benefits of receiving feedback on PROMs in the context of a web-based personalized decision report to guide care for their hip or knee osteoarthritis.MethodsThis qualitative descriptive interview study was nested in a pragmatic clinical trial of a personalized report, which includes descriptive PROM scores and predicted postoperative PROM scores. Patients completed a semi-structured interview within 6 weeks of an office visit with an orthopaedic surgeon. Only patients who reported receiving the report and reviewing it with the surgeon and/or a health educator were included. Data were iteratively analyzed using a combination of deductive and inductive coding strategies.ResultsTwenty-five patients aged 49–82 years (60% female, 72% surgical treatment decision) participated and described three primary benefits of the PROM feedback within the report: 1. Gaining Information About My Health Status, including data teaching new information, confirming what was known, or providing a frame of reference; 2. Fostering Communication Between Patient and Surgeon, encompassing use of the data to set expectations, ask and answer questions, and facilitate shared understanding; and 3. Increasing My Confidence and Trust, relating to the treatment outcomes, treatment decision, and surgeon.ConclusionsPatients identified actual and hypothetical benefits of receiving feedback on PROM scores in the context of a web-based decision report, including advantages for those who had already made a treatment decision before seeing the surgeon. Findings provide insight into patients’ perspectives on how digital PROM data can promote patient-centered care. Results should be considered in the context of the homogeneous sample and complex trial. While participants perceived value in this personalized report, questions remain regarding best practices in patient-facing data presentation and engagement.Trial registrationClinicalTrials.gov, NCT03102580. Registered on 5 April 2017.

The assessment of lower extremity peripheral artery disease impact on body mass center disorders

BackgroundLower extremity peripheral artery disease is a problem of contemporary medicine and along with the ischemic heart disease it is considered to be a civilization disease. The risk of the disease increases significantly within a group of people reaching the age of 55 years and is closely related to co-occurring hazardous factors, such as diabetes, hyperlipidemia, hypertension or tobacco smoking. The first symptom reported by patients is intermittent claudication. Such symptoms may indicate that lower extremity peripheral artery disease does have an impact on posture disorders and motor skills. MethodsThe study covered four stages. The first stage involved medical interviews to obtain information regarding anthropometry, age, motor organ surgery, concomitant diseases and the lifestyle. In the following stage the value of the ankle brachial index for both lower limbs were calculated. In case of symptomatic patients, additionally, the location of artery stenosis/aortoiliac section, was verified. The third stage involved using a dynamometric platform for determination of the body mass center position for both studied groups. In the fourth stage a treadmill walk test was used to assess the participants for intermittent claudication. FindingsBased on the obtained results, an attempt was taken to observe the relationship between the clinical characteristics of the disease and the body mass center position deviations. Interpretation: The attempt was undertaken to assess whether the measurement of body mass center position might be a diagnostic parameter to evaluate the patient's condition and thus an indication for taking a decision for surgical treatment or rehabilitation.

This issue of ACTA

This issue of ACTA

Comparing the diagnostic accuracy of modified RIPASA and MASS in patients diagnosed with acute appendicitis in Suez Canal University Hospital Emergency Department: a cross-sectional study

IntroductionAcute appendicitis is the most common surgical condition presented in emergency departments globally. It is also the most common cause of abdominal pain treated surgically, with a lifetime risk of 7%. Recent studies show MASS to be easy, simple and cheap diagnostic tool for supporting the diagnosis of acute appendicitis.The modified RIPASA scoring system includes more parameters than MASS and the latter did not contain certain parameters. These parameters are shown to add to the accuracy of modified RIPASA over MASS especially in Asian population.Aim of this studyThe aim of the study was to improve the diagnosis of acute appendicitis in order to lower the negative appendectomy rates.Patients & methodsThis is cross sectional study, the study included 40 patients presented to the emergency department at Suez Canal University hospital with abdominal pain and suspected clinically as acute appendicitis. Then the decision of surgical intervention was made by surgeons, who were blinded for our study, based on their clinical judgment. Then both scores were calculated for all patients and other clinical data were obtained from patients after accepting being included in our study with an informed consent.After operations, the operating theatre records were obtained and cases pathological investigation of the appendices was done. Then the sensitivity, specificity, positive and negative predictive values were calculated and so the diagnostic accuracy for both scoring systems.ResultsClinically, all the patients were suffering acute right iliac fossa tenderness (100%), rebound tenderness (90%), and nausea/ vomiting (70%). Only 45% had elevated White blood count and 55% had negative urine analysis.Histopathological analysis of appendices of the studied patients showed that 40% of the patients had suppurative appendicitis, one quarter of them had catarrhal appendicitis and only 20% had complicated perforated appendicitis. Meanwhile, about 15% had normal (negative) appendix. Modified RIPASA showed a good discriminative ability in our study where the area under the curve for modified RIPASA was 0.902 (95% CI: 0.798 – 1.00) (p = 0.002). Moreover, a value of 8.5 or higher was found to be the best cut-off point to predict acute appendicitis among patient suspected clinically as acute appendicitis with sensitivity = 70.6%, specificity = 100%, positive predictive value of 100%, and negative predictive value of 37.5% and 75% accuracy.The best cut-off score to diagnose acute appendicitis in our sample based on MASS was fixed at 5.5, where the sensitivity of the MASS reached 47.1%, with specificity of 33.3%, positive predictive value of 80%, negative predictive value of 10% and accuracy 45%.ConclusionThe modified RIPASA score is the best diagnostic scoring system for acute appendicitis if compared to the modified Alvarado score, with the former achieving significantly higher sensitivity and diagnostic accuracy. Modified RIPASA was concluded to be a more applicable and useful score. Negative appendicectomy rates can also be avoided by using modified RIPASA score.

Update on non-unions 2022 : Imaging diagnostics, classification and treatment algorithms

Fracture healing is acomplex regenerative process. An unconsolidated fracture that will not heal without further surgical intervention is called non-union. The causes are multifactorial. Diagnostic imaging is acentral pillar and provides insights into the morphology and biology of the fracture as abasis for optimal surgical treatment decisions. Knowledge of fracture healing, targeted radiological and nuclear medical diagnostics, and interdisciplinary standardized classification are of high importance for optimal treatment. In this article, the proven and modern diagnostic procedures are presented, an overview of the currently used scoring and classification models is given and the optimal therapeutic approach based on the extended "diamond concept" is addressed. Apossible diagnostic and therapeutic approach is shown using an algorithm. For successful treatment of pseudarthrosis, targeted radiological and nuclear medical diagnostics with old established but also newest methods, such as dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and hybrid imaging, are necessary. An exact classification of non-unions using additional classification models makes it possible to determine and carry out the optimal surgical treatment at an early stage.

An evaluation of fiber-based damage for assessing the failure of aortic tissue: comparison between healthy and aneurysmal aortas

The decision of surgical intervention for an aortic aneurysm is usually associated with an assessment of risk of its rupture. Global rupture risk assessment parameters like wall diameter and growth of the aneurysm over time often fail at predicting the risk of rupture with accuracy. This paper will investigate the hypothesis that the tissue’s microstructure determines its macroscopic failure. To this aim, two different testing protocols have been implemented. Human ascending thoracic aortic aneurysm (ATAA) tissue samples were subjected to bulge-inflation testing until rupture coupled with multi-photon microscopy (MPM) imaging. Image stacks of the sample were acquired at different pressure levels. Additionally, porcine aorta samples were tested under uniaxial tension until failure and their response was recorded. Prior to mechanical testing, MPM image stacks were acquired at four different zones on the sample. The image stacks acquired at the load free state were used to extract morphological information relating to collagen fibers. Then, an inverse random sampling approach was used to generate pseudomorphological parameters for network reconstruction. A discrete model of the collagen network signifying its stochastic nature was then developed, including both prefailure and post-failure mechanics. The model was able to replicate the mechanical response and failure of the tissue, and demonstrated that fiber-based damage can strongly shape the macroscopic failure response of the tissue. Identified values of collagen fiber failure strain were in the range of 8.8 to 29.3% in the case of aneurysmal samples, and 18.7 to 25.5% in the case of porcine samples. A statistical analysis enabled the characterization of correlation between fiber morphology and tissue failure. The model may serve as a useful tool for predicting macroscale failure of the aortic wall based on the variations in microscale morphology.

Universal tumor screening for lynch syndrome on colorectal cancer biopsies impacts surgical treatment decisions

Universal tumor screening (UTS) for Lynch syndrome (LS) on colorectal cancer (CRC) can be performed on biopsies or resection specimens. The advantage of biopsies is the chance to provide preoperative genetic counseling/testing (GC/T) so patients diagnosed with LS can make informed decisions regarding resection extent. We evaluated utilization of UTS on biopsies, percentage of patients with deficient mismatch repair (dMMR) who underwent GC/T preoperatively, and whether surgical/treatment decisions were impacted. We performed a retrospective review of medical records to assess CRC cases with dMMR immunohistochemical staining from 1/1/2017 to 2/26/2021. 1144 CRC patients had UTS using MMR immunohistochemistry; 559 biopsies (48.9%) and 585 resections (51.1%). The main reason UTS was not performed on biopsy was it occurred outside our health system. 58 (5%) of CRCs were dMMR and did not have MLH1 promoter hypermethylation (if MLH1 and PMS2 absent). 28/58 (48.3%) of dMMR cases were diagnosed on biopsy. Of those 28, 14 (50%) eventually underwent GC/T, and 7 (25%) had GT results prior to surgery. One of the 7 had incomplete documentation of results affecting their treatment plan. Of the remaining 6 with complete documentation, 5 underwent surgery and one was treated with immunotherapy only. Three patients elected a more extensive surgery. 6/28 (21.4%) dMMR patients identified on biopsy made an informed surgical/treatment decision based on their dMMR status/LS diagnosis. When applied, UTS on biopsy followed by genetic counseling and testing informs surgical decision-making. Process and implementation strategies are in place to overcome challenges to more broadly optimize this approach.

Decision quality and regret with treatment decisions in women with breast cancer: Pre-operative breast MRI and breast density.

We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer. We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density. Survey participation rate was 27.9% (957/3430). Study population was primarily > 60years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age (< 50years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reportedpre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome. Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship. NCT03029286.

The Relationship between Pathological Features and 18 F-FDG PET/CT that Changed the Surgeon's Decision as Neoadjuvant Therapy in Breast Cancer.

Objective Patients diagnosed with breast cancer and decided to undergo surgical treatment can undergo neoadjuvant therapy following their 2-deoxy-2-[fluorine-18]fluoro-D-glucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) findings. The present study aims to determine the statistical significance of these patients whose treatment plan was changed and the reasons for the change in the plan. Materials and Methods The demographic features and treatment plans of 151 cases who were diagnosed with any stage of breast cancer were evaluated. These patients consist of those who admitted to Mersin University Hospital Breast Outpatient Clinic between January 2016 and December 2019. All of these patients aged between 41 and 85 years were examined with 18 F-FDG PET/CT after the decision for surgical treatment is made. The analysis included tumor pathology, side, type, subtype, size, and centricity in this study. Results About 18.5% ( n = 28) of patients' treatment plan was changed after 18 F-FDG PET/CT. They received neoadjuvant therapy. About 81.5% ( n = 123) of patients did not receive neoadjuvant therapy. Significant differences were observed between patients changed treatment plan and not changed concerning age, lymph node involvement, tumor size, centricity, and subtypes parameters. Conclusion Conventional imaging examinations are used in patients with breast cancer. These examinations may not be sufficient to determine advanced disease requiring neoadjuvant treatment. With 18 F-FDG PET/CT examination, these advanced stage patients are not overlooked. In our study, approximately one in five patients, treatment plan changed after 18 F-FDG PET/CT examination.

Effect of patient decision aids on decisional conflict and regret associated with breast cancer surgery: a randomized controlled trial

Patients with breast cancer encounter difficulties in making surgical treatment decisions. Shared decision-making (SDM) with patient decision aids (PDAs) can minimize patients' decisional conflicts. However, the effect of PDAs in Asia remains inconclusive. This study investigated the effect of SDM assisted by PDAs on the decisional conflict of patients with breast cancer. In this two-group, outcome assessor-blind, randomized controlled trial, 151 patients diagnosed as having breast cancer were assigned to the PDA (SDM with PDA) group or the standard (SDM without PDA) group. Demographic and clinical variables were analyzed to identify variables affecting the treatment choice. The patients' decision-making difficulties were evaluated using the four-item SURE scale during preoperative hospitalization, and decisional conflicts were examined using the five-item Decision Regret scale and Hospital Anxiety and Depression Scale (HADS) 1month after surgery. The choice of breast conservation therapy and mastectomy did not significantly differ between the PDA and standard groups. The PDA group had a higher level of depression after making decisions (P = 0.029) than did the standard group. No significant difference in the total scores of the SURE scale and Decision Regret scale were noted between the groups. PDAs did not assist the patients with breast cancer in making breast surgery-related decisions. Clinicians should focus on SDM grounded in evidence-based medicine with care and help patients consider their individual preferences. ClinicalTrial.gov, NCT03105076; April 7, 2017 ( http://www. gov ).

Current Trends in Skeletal Borderline Patients: Surgical versus Orthodontic Treatment Decisions—What Is the Evidence?

Background: The aim is to assess the current evidence-based knowledge about treatment decisions for skeletal malocclusion in adult borderline patients. Methods: A literature search was conducted through three databases. Inclusion criteria were restricted to systematic reviews, prospective, retrospective, and control studies. Only articles comparing orthodontic camouflage and orthognathic surgical treatment for Class II and Class III malocclusions in adult patients were selected to be reviewed. Results: Seven articles concerning Class II and nine concerning Class III met the inclusion criteria. Scientific evidence was poor due to low methodological quality. Conclusions: Surgical treatment was found to better improve skeletal and soft-tissue cephalometric values, whereas camouflage treatment mainly involved dentoalveolar movements. Aesthetic changes, as perceived by the patient, were not significantly different in the two groups. Recently improved surgical techniques, differing from those described in the analyzed articles, may provide similar or more stable outcomes compared with orthodontic-only treatment. Although some cephalometric variables can be helpful, the most important parameters for treatment selection are the patient’s presenting complaint and their self-image perception. Further studies with larger sample sizes and similar pretreatment conditions, and considering patient self-evaluation of esthetics and function, should be undertaken.