Surgeon Recommendation Research Articles

Shared Decision Making for Urolithiasis: The Use of a Patient Decision Making Aid

IntroductionPatients desire an active role in health care decisions. We evaluated whether a patient decision making aid is useful when considering surgical treatment for urolithiasis. MethodsPatients with a history of urolithiasis were recruited for study. They were asked to consider a hypothetical case of an asymptomatic 10 mm proximal ureteral stone for which elective surgical intervention was recommended. Shock wave lithotripsy and ureteroscopy were presented as potential options. A patient decision making aid was developed to explain and compare the options. A urologist presented the information to the patients, once using the patient decision making aid and then without the aid. We assessed participant satisfaction with each format, and invited comments about the aid and its content, design and clarity. ResultsMean ± SD age of the 4 male and 10 female participants was 61 ± 9 years. Of the participants 86% found the patient decision making aid helpful but identified areas for improvement. Specifically, patients wanted more information on stent placement, stent discomfort, long-term effects and cost. Of the participants 79% reported that the aid improved their understanding of the treatment options compared to the session without the aid. While 8 of 14 participants preferred hearing surgeon recommendations, most still reported value in the patient decision making aid. ConclusionsPatient decision making aids are increasingly used in the management of several diseases and they require patient input into development. In our study the aid improved patient self-reported understanding of surgical options for ureteral stone removal. Notably, most participants still preferred to make decisions based on the surgeon recommendation. Modification of the patient decision making aid based on patient suggestions will enhance its usefulness and applicability in the clinical setting.

Contralateral prophylactic mastectomy decision-making in the population-based iCanCare study of early-stage breast cancer patients.

177 Background: Contralateral prophylactic mastectomy (CPM) use is increasing in women who are not at increased risk of contralateral cancer development and will experience no survival benefit from the more morbid procedure. Little is known about treatment decision-making or provider interactions. Methods: We surveyed a weighted random sample of newly diagnosed patients with early-stage breast cancer who were treated in 2013-14, identified through the population-based SEER registries of Los Angeles and Georgia about 3 months after surgical treatment, and merged with SEER data (N=2632, RR=70%), to determine receipt of diagnostic tests and factors related to the decision about surgery (including knowledge and perceived physician recommendation). Results: Nearly half of 2,436 respondents with unilateral non-metastatic cancer considered CPM (25% strongly). Only 37% of those who considered CPM knew that it does not improve survival for all women with breast cancer (24% believed it does, 39% didn’t know). Among women receiving CPM, 37% believed it generally improves survival. Ultimately, 1,464 (60%) received BCS and 972 (40%) mastectomy (of whom 438, or 18% overall, received CPM). On multivariable analysis, pts who received CPM were younger, more likely to be white, and more likely to have a family history, private rather than Medicaid insurance, and received MRI. Even among pts without a deleterious genetic mutation or family history in multiple relatives (2,303), 400 (17%) received CPM. CPM was uncommon among pts who reported that their surgeons recommended against it (2.0% [17/832]) but much higher among those who reported no surgeon recommendation regarding CPM (21.3% [229/1,077]), and among those who perceived their surgeons to have recommended it (55.4% [147/265]). Conclusions: Many patients consider CPM, but knowledge is low. Use of CPM is substantial among patients without clinical indications but is low when patients report their surgeon recommended against it. In the context of shared decision-making, surgeon recommendations against CPM might help reduce potential overtreatment.

Suture Cruroplasty Versus Prosthetic Hiatal Herniorrhaphy for Large Hiatal Hernia: A Meta-analysis and Systematic Review of Randomized Controlled Trials.

The aim was to conduct a meta-analysis of randomized controlled trials (RCTs) comparing 2 methods of hiatal closure for large hiatal hernia and to evaluate their strengths and flaws. Prospective RCTs comparing suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1991 and October 2014. The outcome variables analyzed included operating time, complications, recurrence of hiatal hernia or wrap migration, and reoperation. These outcomes were unanimously decided to be important because they influence the practical approach toward patient management. Random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran's Q statistic and I index. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. Four RCTs were analyzed totaling 406 patients (Suture = 186, Prosthesis = 220). For only 1 of the 4 outcomes, ie, reoperation rate (OR 3.73, 95% CI 1.18, 11.82, P = 0.03), the pooled effect size favored prosthetic hiatal herniorrhaphy over suture cruroplasty. For other outcomes, comparable effect sizes were noted for both groups which included recurrence of hiatal hernia or wrap migration (OR 2.01, 95% CI 0.92, 4.39, P = 0.07), operating time (SMD -0.46, 95% CI -1.16, -0.24, P = 0.19) and complication rates (OR 1.06, 95% CI 0.45, 2.50, P = 0.90). On the basis of our meta-analysis and its limitations, we believe that the prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair of large hiatal hernias. In the future, a number of issues need to be addressed to determine the clinical outcomes, safety, and effectiveness of these 2 methods for elective surgical treatment of large hiatal hernias. Presently, the use of prosthetic hiatal herniorrhaphy for large hiatal hernia cannot be endorsed routinely and the decision for the placement of mesh needs to be individualized based on the operative findings and the surgeon's recommendation.

Decision-Making in Prostate Cancer: Active Surveillance Over Other Treatment Options

A qualitative-descriptive study of four patients with prostate cancer used the Cognitive-Social Health Information Processing framework to understand how and why men diagnosed with prostate cancer choose active surveillance over other treatment options. In accordance with the literature, it was found that the surgeon or general practitioner's recommendation was the most influential factor when patients are making a treatment decision.

Intra-hepatic Atherosclerosis Disease: An Incidental Finding in Acute Abdominal Pain Patient

Introduction: A 69 year-old female was incidentally diagnosed to have an intra-hepatic atherosclerosis disease on 3D Reconstruction of Abdominal Computed Tomography Angiography performed at the Emergency Room, while surgeons and urologist were evaluating an acute abdominal pain in a patient with several comorbidities. The radiological findings and differential diagnosed are briefly discussed. For academic, research and publication purposes, the patient signed an informed consent Keywords: Abdominal pain; Atherosclerosis disease; Intrahepatic; Vascular biology. Clinical Scenario/Question: A previously well-known 69 year-old female with a large medical history of Systemic Lupus Erythematous (SLE), Lupus Nephritis (LN), Hypertension (High Blood Pressure), Hypothyroidism, Antiphospholipid Syndrome (APS) Chronic renal disease stage III B, episode of extensive Deep Vein Thrombosis (DVT) in the right lower limb andPulmonary Embolism (PE), an episode of Multiple Organ Failure (MOF), that required Renal Replacement Therapy (RRT), was brought to the emergency room consulting for a suddenly acute abdominal pain focused in the right lumbar region and right flank, intensity 8/10 in the Visual Analog Scale (VAS), associated with nauseas, vomiting. Abdominal CT scan and CT urography were performed by general surgeon recommendation. Abdominal CT scan images showed a hypodense, homogeneous, well- demarcated lesion of 42 × 38 mm, without the presence of enhancement, nearly the bifurcation of the right common iliac artery, which implies adnexal origin. No free abdominal fluid was observed and no intra-abdominal collections were considered (Figure 1). CT urography reported right hydroureteronephrosis, hepatic residual calcifications and pelvic cystic lesion with no relevant anatomical impact in this area. Secondary to the wide range of findings and unclear principal diagnosis, a 3D Reconstruction of Abdominal Computed Tomography Angiography was ordered, incidentally diagnosed to have an intra-hepatic atherosclerosis (Figure 2). What is the possible diagnosis? 1. Intra-hhepatic atherosclerosis 2. Hematogenous metastasis 3. Giant cell arteritis 4. Hemangiomas 5. Polyarteritis nodosa The atherosclerosis disease is a common disorder in general population characterized by the present of endothelial damage, secondary to the deposition in plaques of fatty material on their inner walls, silently and slowly blocking the lumen of the arteries, putting the blood flows at risk. This medical situation may finally develop ischemic and embolic event [1,2]. This pathophysiologic disorder may be affected or exacerbated by other comorbidities in some patients such as exogenous and endogenous factors. The atherosclerosis disease is commonly found in vessels of great or middle caliber, most of them illustrated to have a rich laminar blood flow, which allow the development of atherosclerotic plaques [3,4]. In this medical case, the patient presented an important autoimmune background; including SLE, APS, a prothrombotic predisposition, calcium, lipids and inflammation factors deposits, that may lead a deleterious role in the genesis of atherosclerosis in minor vessels that are not expected to be affected. Finally, the blood flow compromised in these vessels can be reflected in lesions of important organs such as kidneys, brain, heart and splanchnic bed [5,6,7]. In conclusion, Intra-Hepatic Atherosclerosis Disease discovered at the emergency room in the clinical scenario of the acute abdominal pain, has to be considered by clinicians and emergency physicians as differential diagnosis.

Return to work after general surgery: A comparative study

PurposesThere is scarce information on the time to return to work after general surgery. The aim of this study was to analyze time off work after elective cholecystectomy and to compare the results with those in patients undergoing other surgical interventions. MethodsObservational and comparative study. Inclusion criteria were: being of working age and undergoing elective laparoscopic cholecystectomy (group 1) or unilateral inguinal hernia or haemorrhoidectomy (group 2). Results36 patients were included: 18 patients in each group. Overall, return to work occurred at a mean of 35.7 days, with no significant differences (p=0.656) between groups (group 1: 36.6 days vs. group 2: 35.44 days). The reasons for not returning to work earlier were fear of complications (37.5%), pain control (37.5%), surgeon recommendation (12.5%), and general practitioner recommendation (12.5%). ConclusionsTime to recovery after laparoscopic cholecystectomy is prolonged. No statistically significant differences with less complex surgical procedures were detected.

High self-assessment of disability and the surgeon's recommendation against surgical intervention may negatively impact satisfaction scores in patients with spinal disorders.

OBJECT Patient satisfaction scores have become a common metric for health care quality. Because satisfaction scores are right-skewed, even small differences in mean scores can have a large impact. Little information, however, is available on the specific factors that play a role in satisfaction in patients with spinal disorders. The authors investigated whether disability severity and the surgeon's recommendation for or against surgical intervention were associated with patient satisfaction scores. METHODS The authors conducted a retrospective cohort study involving adult patients who were referred to a spine surgeon for an outpatient evaluation of back pain. Patients completed the Oswestry Disability Index (ODI) before their clinic appointment and a Press Ganey patient satisfaction survey after their visit. Patients were grouped by self-assessed disability severity: mild to moderate (ODI < 40%) and severe (≥ 40%). Satisfaction scores were graded from 0 (very poor) to 100 (very good). Nonparametric tests were used to evaluate the association between patient satisfaction and current disability self-assessment. The authors also investigated whether the surgeon's recommendation against surgery negatively affected patient satisfaction. RESULTS One hundred thirty patients completed the ODI questionnaire before and satisfaction surveys after seeing a spine surgeon for a new outpatient back pain consultation. Of these, 68 patients had severe disability, 62 had mild to moderate disability, 67 received a recommendation for surgery, and 63 received a recommendation against surgery. Composite satisfaction scores were lower among patients who had severe disability than among those with mild to moderate disability (median [interquartile range]: 91.7 [83.7-96.4] vs 95.8 [91.0-99.3], respectively; p = 0.0040). Patients who received a recommendation against surgery reported lower satisfaction scores than those who received a recommendation for surgery (91.7 [83.5-95.8] vs 95.8 [88.5-99.8]; p = 0.0059). CONCLUSIONS High self-assessment of disability and a surgeon's recommendation against surgical intervention are associated with lower satisfaction scores in patients with spinal disorders.

Management of regional lymph nodes in the elderly melanoma patient: Patient selection, accuracy and prognostic implications

BackgroundAmong older melanoma patients, lymphatic mapping failure, lower rates of SLN positivity and poor prognosis are reported reasons for omission of sentinel lymph node biopsy (SLNB). We investigated reasons for non-compliance with guidelines, sensitivity and prognostic significance of SLNB and completion lymphadenectomy (CLND) for elderly melanoma patients. MethodsRetrospective review of patients ≥65 years with ≥1 mm thick melanoma treated at a single Institution. Wilcoxon, chi-square and Fisher's exact tests were used for analysis as appropriate. Univariable and multivariable Cox regressions were used to analyze time-to-event variables. Results72 of 358 patients (20%) did not undergo SLNB. Reasons for omission included selective neck dissection in 26 (7%), patient refusal in 11 (3%), physician recommendation in 15 (4%) and significant comorbidities in 8 (2%). Of the 286 patients undergoing SLNB, only 5 (1.7%) had lymphatic mapping failures. 76 patients (26.6%) were SLN-positive. The sensitivity of SLNB was 90.5%, the negative predictive value was 96.3% and the false negative rate was 3.8%. Sixty-seven (88%) SLN-positive patients underwent CLND and 10 (15%) had positive non-SLNs. Reasons for omission of CLND included patient refusal in 3 (4%), surgeon recommendation in 5 (7%) and postoperative complication in 1 (1%). SLN and non-SLN status were independently associated with disease-free survival. SLN status was independently associated with melanoma-specific survival. ConclusionsSLNB was successful in 98.7% of elderly patients with high sensitivity and a low false negative rate. Only 2% of our elderly patients appeared too frail for SLNB. Age alone should not be a contraindication to SLNB and CLND for melanoma.

Failure of Patients with Peripheral Arterial Disease to Accept the Recommended Treatment Results in Worse Outcomes

Strategies available to facilitate decision making for patients with peripheral arterial disease (PAD) include a Markov-based decision analysis (DA) model and the Lower Extremity Grading System (LEGS) score. Both have suggested inferior outcomes when the actual treatment received (ATX) differs from that predicted. This study focuses on patient outcomes when such discordance exists. All patients referred for symptomatic lower extremity PAD over a 3-year period were evaluated using the DA model and the LEGS score. Calculated quality of life (cQOL) values were assigned before treatment based on patient symptom, perfusion, and amputation status and at follow-up (range 1.000 [perfect health] to .000 [death]). The primary outcome of cQOL was compared according to whether the ATX matched that proposed by the surgeon or predicted by the DA model or LEGS score. Secondary outcomes for revascularized patients included major adverse limb event with perioperative death (MALE + POD) and amputation-free survival (AFS). Among 375 procedures in 345 consecutive patients, the greatest improvement in cQOL at last follow-up (median 16 months) was observed with endovascular (0.23 ± 0.16, n = 93) or open (0.21 ± 0.17, n = 137) revascularization compared with primary amputation (0.10 ± 0.07, n = 23) or medical therapy (0.04 ± 0.09, n = 122). Multivariate regression showed discordance with the surgeon's recommendation (P < 0.05) and/or the DA model (P < 0.05) to be independent predictors of improvement failure. ATX did not always agree with that proposed by the surgeon (89% agree, κ = 0.84), the DA model (68% agree, κ = 0.53), or the LEGS score (53% agree, κ = 0.32). Improvement in cQOL was greatest when ATX was concordant with treatment proposed by the surgeon (0.18 vs. 0.08, P < 0.01), the DA model (0.19 vs. 0.13, P < 0.01), or the LEGS score (0.23 vs. 0.10, P < 0.01). Patient refusal to follow the surgeon's recommendations and continued smoking were associated with minimal improvement (cQOL ranges 0.05-0.07 and 0.00-0.02, respectively), while pursuing a less morbid procedure was associated with greater improvement (cQOL range 0.28-0.38). Among revascularized patients, MALE + POD was lower at 36 months after endovascular than open surgery (21% ± 5% vs. 36% ± 4%, P < 0.05), while AFS was not significantly different. Only discordance with the surgeon's recommendation was an independent predictor of MALE + POD, possibly because of limitations in sample subset size. Mean cQOL improved most with direct revascularization, especially when the treatment received matched that predicted by the models or proposed by the surgeon. Type of treatment received was an independent predictor of agreement of treatment with recommendations. Patient refusal to follow the recommended treatment as well as the strategy not to revascularize claudicants who persist in smoking were associated with much less patient benefit from treatment.

Management of Breast Cancer in Older Women: Factors which Influence Patients` Decision§

Background: Most studies on cancer patient preferences and information needs have not focused specifically on elderly breast cancer patients. Objective: To determine factors which are taken into account by elderly breast cancer patients (>70 years of age) when deciding between primary endocrine therapy or surgery and between mastectomy or wide local excision. Methods: Cross-sectional study of 34 female breast cancer patients who were at least 70 years of age at the time of diagnosis. Structured interviews were conducted either after a follow-up clinic appointment or at home via a telephone interview. Results: Seventy-six per cent of patients were given a choice of treatment and the patients who felt that they were not given a choice did not prefer to choose. Forty-two per cent of patients chose primary endocrine therapy based on the surgeon's recommendation. The same proportion reported that they were afraid of surgery. A quarter wanted to try tablets first and were prepared to undergo surgery if unresponsive. All patients who chose a modified radical mastectomy +/- axillary node clearance or sampling felt that it was safer and wanted to avoid the possibility of further surgery. All patients were satisfied with the amount of information provided and emphasized that the service provided by breast care nurses was invaluable. Conclusion: Not all patients based their decision on the surgeon's recommendation. Some patients were not given any recommendation. Individual preferences of patients should be determined and the management plan should be tailored accordingly.

Determinants of choice of surgery in Asian patients with early breast cancer in a middle income country.

Breast-conserving surgery (BCS) plus radiotherapy is equivalent to modified radical mastectomy (MRM) in terms of outcome. However there is wide variation in mastectomy rates dependent both on tumour and patient characteristics. This study aimed to assess the determinants of surgery choice in Asian patients with early breast cancer in a middle-income country. 184 patients with early breast cancer treated between Jan 2008 and Dec 2010 were recruited to complete a questionnaire. Chi-square test was used to analyze the association between surgery choice and demographic and tumour factors, surgeon recommendation, family member and partner opinions, fear of recurrence, avoidance of second surgery, fear of disfigurement, interference with sex life, fear of radiation and loss of femininity. 85 (46%) had BCS while 99 (54%) had mastectomy. Age >60, Chinese ethnicity, lower education level, and larger tumour size were significantly associated with mastectomy. Surgeon recommendation was important in surgery choice. Although both groups did not place much importance on interference with sex life, 14.1% of the BCS group felt it was very important compared to 5.1% in the mastectomy group and this was statistically significant. There was no statistical difference between the two groups in terms of the other factors. When analyzed by ethnicity, significantly more Malay and Indian women considered partner and family member opinions very important and were more concerned about loss of femininity compared to Chinese women. There were no statistical differences between the three ethnic groups in terms of the other factors. When counseling on surgical options, the surgeon has to take into account the ethnicity, social background and education level, age and reliance on partner and family members. Decision-making is usually a collective effort rather than just between the patient and surgeon, and involving the whole family into the process early is important.

Older women's experience with breast cancer treatment decisions.

The purpose of this study was to better understand older women's experience with breast cancer treatment decisions. We conducted a longitudinal study of non-demented, English-speaking women ≥ 65 years recruited from three Boston-based breast imaging centers. We interviewed women at the time of breast biopsy (before they knew their results) and 6 months later. At baseline, we assessed intention to accept different breast cancer treatments, sociodemographic, and health characteristics. At follow-up, we asked women about their involvement in treatment decisions, to describe how they chose a treatment, and influencing factors. We assessed tumor characteristics through chart abstraction. We used quantitative and qualitative analyses. Seventy women (43 ≥ 75 years) completed both interviews and were diagnosed with breast cancer; 91 % were non-Hispanic white. At baseline, women 75+ were less likely than women 65-74 to report that they would accept surgery and/or take a medication for ≥ 5 years if recommended for breast disease. Women 75+ were ultimately less likely to receive hormonal therapy for estrogen receptor positive tumors than women 65-74. Women 75+ asked their surgeons fewer questions about their treatment options and were less likely to seek information from other sources. A surgeon's recommendation was the most influential factor affecting older women's treatment decisions. In open-ended comments, 17 women reported having no perceived choice about treatment and 42 stated they simply followed their physician's recommendation for at least one treatment choice. In conclusion, to improve care of older women with breast cancer, interventions are needed to increase their engagement in treatment decision-making.

PD37-12 PATIENTS PREFER THE USE OF A PATIENT DECISION-MAKING AID WHEN DISCUSSING SURGICAL OPTIONS FOR NEPHROLITHIASIS

You have accessJournal of UrologyStone Disease: New Technology II1 Apr 2014PD37-12 PATIENTS PREFER THE USE OF A PATIENT DECISION-MAKING AID WHEN DISCUSSING SURGICAL OPTIONS FOR NEPHROLITHIASIS Necole M. Streeper, Brian C. Sninsky, Kristina L. Penniston, Sara L. Best, and Stephen Y. Nakada Necole M. StreeperNecole M. Streeper More articles by this author , Brian C. SninskyBrian C. Sninsky More articles by this author , Kristina L. PennistonKristina L. Penniston More articles by this author , Sara L. BestSara L. Best More articles by this author , and Stephen Y. NakadaStephen Y. Nakada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2030AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients desire to have an active role in making their own healthcare decisions. The purpose of this study was to evaluate whether a patient decision-making aid (PDMA) would be useful for patients considering surgical treatment for nephrolithiasis. METHODS Patients with a history of nephrolithiasis were recruited from our stone clinics and were given a hypothetical case of an asymptomatic 10 mm proximal ureteral stone for which the urologist recommends elective surgical intervention. Shock wave lithotripsy (SWL) and ureteroscopy (URS) were presented as acceptable options in this scenario. A PDMA was developed to educate the patients about the two surgical options, comparing equivalent procedural variables and providing pictures of relevant urinary tract anatomy. Patients were presented with information about both surgical therapies by a urologist in a lecture format, both utilizing the PDMA and without the aid. We assessed patients’ satisfaction with each format and invited comments about the PDMA and its content, design, and clarity. RESULTS Participants (n=14; 4 male, 10 female) were 61.3±8.8 years of age. The majority of the participants found the PDMA helpful (85.7%), but identified areas for improvement. Specifically, patients wanted more information about the possibility of stent placement, details about stent discomfort, information about long-term effects for each surgical modality and financial comparison. There was a preference for utilization of a PDMA (78.6%) because it was felt to help them understand the treatment options more clearly with the visual aid compared to the session without the aid. Interestingly, 8 of 14 participants prefer to decide based on the surgeon’s recommendations but still reported a utility for the PDMA in this process. CONCLUSIONS PDMAs are increasingly used in medical and surgical management of several diseases and require patient input in their development. In our study, the use of a PDMA was preferred by patients and assists in making an informed decision with regard to surgical options for the management of stone disease. Of note, most of our patients still preferred to make decisions based on the surgeon's recommendation. Patients suggested the addition of specific information to the PDMA that may enhance its utility and applicability in the clinical setting. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e950 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Necole M. Streeper More articles by this author Brian C. Sninsky More articles by this author Kristina L. Penniston More articles by this author Sara L. Best More articles by this author Stephen Y. Nakada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Acute Complications Associated With Removal of Flexible Intramedullary Femoral Rods Placed for Pediatric Femoral Shaft Fractures

The American Academy of Orthopaedic Surgeons position statement on the treatment of pediatric femoral shaft fractures could not comment on the safety of flexible intramedullary (IM) rod removal because of a lack of published evidence. This study reviews the acute complications of flexible IM rod removal from pediatric patients treated for femoral shaft fractures. A retrospective clinical and radiographic analysis at a single institution over a 5-year period. Demographic and radiographic parameters were analyzed to determine their influence on intraoperative and immediate postoperative complications. One hundred sixty-three subjects (133 males, 30 females), mean age of 9.3±2.8 years (range, 2.7 to 14.8 y) and mean weight of 34.4±15.3 kg (range, 14.0 to 139.0 kg), underwent femoral flexible IM rod removal a mean 12.4±10.8 months (range, 2.4 to 63.8 mo) after placement with mean operative time of 51.1±22.3 minutes (range, 10 to 131 min). One hundred fifty-one subjects (92.6%) had stainless-steel Ender rods and the remaining nails were titanium. There were no significant demographic, intraoperative, or radiographic differences comparing subjects with Ender versus titanium rods. Indications for rod removal were pain at insertion site, family request, or surgeon's recommendation. There were 4 (2.5%) minor intraoperative difficulties, including the inability to remove 1 of 2 rods secondary to IM migration (n=1) and complete bone overgrowth at insertion site resulting in prolonged extraction time (n=3). Three of the 4 subjects had the rods placed >60 months before removal. Immediately postoperative (n=134), there were 4 (3.0%) complications, including superficial wound infection (n=3, 2.2%) and knee contracture (n=1, 0.8%). Subjects were released to full activities at a mean 4.7±1.8 weeks postoperatively with no known postoperative fractures. The rate of intraoperative and immediate postoperative complications is low. Neither patient demographics, fracture characteristics, nor operative technique influenced the complication rate. Intraoperative difficulties may be minimized with removal of rods before signs of overgrowth. Level IV, intervention case series.

Participation in decision making regarding type of surgery and treatment-related satisfaction in North Indian women with early breast cancer

Breast conserving surgery followed by radiotherapy is an established modality of treatment in early breast cancer patients since three decades, but yet it has not been adopted worldwide. The aim of this study is to investigate the factors affecting decision making regarding type of surgery and satisfaction with type of surgery in North Indian women with early breast cancer. A questionnaire was prepared to assess the factors responsible for decision making regarding type of surgery (breast conserving surgery (BCS) versus modified radical mastectomy (MRM) and to evaluate involvement of patient in decision making regarding the type of surgery. 47 women with early breast cancer on radiotherapy or on follow-up were interviewed by the resident doctors. Out of 47 patients, 28 underwent BCS and 19 MRM. Women undergoing BCS were younger, more literate than in those undergoing MRM. In the two arms (BCS versus MRM), decision for surgery was made by surgeon alone in 53% versus 73%, along with patient in 42% versus 6%, and only 10% women participated in decision making in each arm. Only 50% versus 30% patients had a clear understanding of the risks and benefits of both procedures in the two arms. North Indian women do not independently take decision regarding any type of surgery. The reason for opting for either kind of surgery was based on surgeon's recommendation or concern about recurrence. Body image was not an issue amongst majority.

Patients' attitudes and factors in their selection of grafts for anterior cruciate ligament reconstruction

Surgeon recommendation is the primary influence for patients choosing a graft for their ACL reconstruction. However, it is unknown if demographic factors also play a role. We hypothesize that education, age, and living in an urban setting may influence a patient's graft choice. Patients who had an ACL reconstruction from 2005 to 2009 were identified retrospectively, and received a written survey on their demographics and the factors affecting graft choice. They also rated their perception of those factors based on a Likert scale. Out of 471 surveys distributed, 151 responses were received. The mean follow-up time was 19 months (range, 1 to 63 months). Autograft was used in 57%. Surgeon recommendation was the primary factor in graft choice (63%). 87.4% of patients felt they made the right choice; only 4.6% would have picked a different graft if they could choose over again. More than half (51.7%) of patients did significant personal research, and used mostly medical websites (41.1%). 67.6% of patients were not adverse to allograft. The primary factor for patients in graft choice was surgeon recommendation. Still, the use of medical websites was widespread, and patients in an urban environment were less likely to rely solely on their surgeon's recommendation. Older patients were more concerned with autograft donor site morbidity, and patients with a higher level of education were less averse to allograft.

Surgeon Recommendations and Receipt of Mastectomy for Treatment of Breast Cancer

A number of studies have suggested that many women undergo mastectomy because of personal preference despite support of breast-conserving surgery (BCS) by their surgeon, or contraindication to BCS or adjuvant radiation. Other studies, however, have not confirmed these findings. The primary aim of this observational study was to determine the rate of mastectomy as the initial treatment in women with breast cancer and investigate reasons for choosing this intervention (physician recommendation, patient preference, or medical contraindication). The rate of mastectomy after attempted BCS was also determined. A patient survey was performed between 2005 and 2007 in 2 large urban areas in the United States. The participants were women aged 20 to 79 years with a diagnosis of ductal carcinoma in situ or invasive breast cancer (stages I and II). Eligibility of patients for the survey was determined from the National Cancer Institute's Surveillance, Epidemiology, and End Results program registries. The response rate was 73.1% (2290/3133). The final sample (n = 1984) was comprised of 502 Latinas, 529 blacks, and 953 non-Hispanic whites or others. Of the 1984 patients, 66.6% underwent BCS only and 14.5% received initial mastectomy following recommendation by their surgeon largely based on a contraindication to BCS or radiation; 8.8% preferred and had initial mastectomy when their first surgeon made no recommendation; and 8.8% underwent mastectomy after unsuccessful attempts at BCS. A total of 378 women (19.1%) sought a second opinion before treatment; this was more common among women advised to undergo mastectomy (33.4%) than among those advised to have BCS (15.6%) or those who received no recommendation (21.2%) (P < 0.001). A discordant recommendation was given to only 12.1% (n = 43) of the patients who consulted a second surgeon. There was no difference in treatment recommendations across race/ethnicity, education, and geographic site. Additional surgery was required for 525 patients (37.9%) who initially underwent BCS. Following the failure of BCS as the initial treatment, the likelihood for mastectomy differed by cancer stage; patients with stage II disease had the highest risk (P < 0.001). These findings demonstrate the choice between BCS and mastectomy as initial treatment for breast cancer is a multifactorial decision with patient preference, surgical recommendation, and failure of BCS all playing an important role.

Surgeon Recommendations and Receipt of Mastectomy for Treatment of Breast Cancer

There is concern that mastectomy is overused in the United States. To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS). A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other). The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS. Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001). Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

Willingness to undergo colorectal cancer screening in first-degree relatives of hospitalized patients with colorectal cancer

To evaluate whether willingness to undergo colonoscopy screening is influenced by being a first-degree relative of hospitalized patients with or without colorectal cancer after briefing and surgeon recommendation. We performed a cross-sectional study of 327 first-degree relatives of hospitalized patients aged higher than 40 years, divided into Group A (151 relatives of colorectal cancer patients) and Group B (176 relatives of non-cancer patients) at the University Hospital of the Canary Islands, Spain. All were personally briefed by a surgeon, aided by a colorectal cancer pamphlet, and encouraged to accept screening colonoscopy with sedation. Willingness to undergo colonoscopy screening was greater in Group A (66.9%) than in Group B (29.0%); (odds ratio: 11.1; 95% confidence interval = 4.27 to 29.14; P < 0.001). Pre-briefing awareness of screening colonoscopy was also significantly higher in Group A (76.8% vs. 33.5%; P < 0.001), the main source of information being a close relative with colorectal cancer. Being a close relative of a colorectal cancer patient is positively related with willingness to undergo colonoscopy screening in this study. This cross-sectional study outlines a strategy for increasing the level of willingness to undergo colorectal cancer screening in a group of people at risk.

Artificial Urinary Sphincter Versus Male Sling for Post-Prostatectomy Incontinence—What Do Patients Choose?

Early outcomes of the male sling to correct post-prostatectomy incontinence have been promising in select patients. Long-term data are lacking to determine whether the male sling is as effective as the artificial urinary sphincter, which is the current gold standard. Because the male sling offers the significant advantage of avoiding a mechanical device but without established success, we determined the patient preference for the male sling vs the artificial urinary sphincter. We reviewed the charts of 133 men with post-prostatectomy incontinence who underwent the first procedure to correct incontinence. After urodynamics the surgeon recommended an artificial urinary sphincter or a male sling and patients were told the artificial urinary sphincter satisfaction rate and shorter term data on the male sling. Patients with high grade post-prostatectomy incontinence (pad weight greater than 400 gm/24 hours) were recommended to receive an artificial urinary sphincter, those with moderate post-prostatectomy incontinence (pad weight 100 to 400 gm/24 hours) were recommended to receive an artificial urinary sphincter or a male sling and those with mild post-prostatectomy incontinence (pad weight less than 100 gm/24 hours) were recommended to receive a male sling. A total of 84 male sling (63%) and 49 artificial urinary sphincter (37%) procedures were performed. The surgeon recommendation was an artificial urinary sphincter in 63 men (47%) and a male sling in 46 (35%). A total of 24 men (18%) were given the option of either procedure. All patients recommended to receive a male sling chose it. When an artificial urinary sphincter was recommended, 75% of patients chose it, while 25% chose a male sling. When given a choice, 92% of patients chose a male sling and 8% chose an artificial urinary sphincter. Most patients adhere to the surgeon recommendation. When men with post-prostatectomy incontinence are offered the choice of an artificial urinary sphincter vs a male sling, the opportunity to avoid using a mechanical device is preferable to undergoing a well established procedure. Men who strongly wish to avoid a mechanical device are willing to go against the surgeon recommendation for an artificial urinary sphincter.