Outcomes of Revision Surgery for Pseudarthrosis After Anterior Cervical Fusion: Case Series and Systematic Review

Study Design: Case series/systematic review. Objectives: To report on patients undergoing posterior cervical fusion for symptomatic pseudarthrosis following anterior cervical discectomy and fusion (ACDF), and to assess outcomes reporting in the literature. Methods: Patients undergoing posterior instrumented fusion for pseudarthrosis after primary ACDF from 2013 to 2018 by a single surgeon were reviewed consecutively. Neck Disability Index (NDI) and visual analogue scale (VAS) arm/neck were recorded at preoperative, 6-month, and 1-year time points. A systematic review of the literature was performed, and outcomes reporting was recorded. Results: NDI scores were 54.4 (SD 19.1), 36.6 (SD 18.1), and 41.2 (SD 19.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months ( P = .004). VAS neck scores were 8.1 (SD 1.3), 5.0 (SD 2.9), and 5.8 (SD 2.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months ( P = .038). VAS arm scores were 5.1 (SD 4.1), 3.5 (SD 3.2), and 3.6 (SD 2.7) at preoperative, 6-month, and 1-year time points, respectively, with improvement although these did not reach statistical significance ( P = .145). The most common subjective outcomes reported in the literature were general symptoms assessments (43%), ordinal scales (43%), and VAS neck (19%) scales, with the majority of studies (67%) documenting one measure. Conclusions: Patient-reported outcomes demonstrate clinically meaningful improvement within the first 6 months after posterior fusion for pseudarthrosis. Studies demonstrate substantial variability and no standardization in outcomes reporting, limiting the ability to compare results across interventions and pathologies. Standardized reporting will enable comparisons to inform patients and physicians on the optimal approach to treat this difficult problem.

Download Full-text

The Patient-Reported Outcomes Measurement Information System in spine surgery: a systematic review

Journal of Neurosurgery Spine ◽

10.3171/2018.8.spine18608 ◽

2019 ◽

Vol 30 (3) ◽

pp. 405-413 ◽

Cited By ~ 11

Author(s):

Brittany E. Haws ◽

Benjamin Khechen ◽

Mundeep S. Bawa ◽

Dil V. Patel ◽

Harmeet S. Bawa ◽

...

Keyword(s):

Systematic Review ◽

Information System ◽

Patient Reported Outcomes ◽

Neck Disability Index ◽

Measurement Information ◽

Strong Correlations ◽

Comprehensive Overview ◽

Outcomes Measurement ◽

Patient Reported ◽

Measurement Information System

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide a standardized measure of clinical outcomes that is valid and reliable across a variety of patient populations. PROMIS has exhibited strong correlations with many legacy patient-reported outcome (PRO) measures. However, it is unclear to what extent PROMIS has been used within the spine literature. In this context, the purpose of this systematic review was to provide a comprehensive overview of the PROMIS literature for spine-specific populations that can be used to inform clinicians and guide future work. Specifically, the authors aimed to 1) evaluate publication trends of PROMIS in the spine literature, 2) assess how studies have used PROMIS, and 3) determine the correlations of PROMIS domains with legacy PROs as reported for spine populations.METHODSStudies reporting PROMIS scores among spine populations were identified from PubMed/MEDLINE and a review of reference lists from obtained studies. Articles were excluded if they did not report original results, or if the study population was not evaluated or treated for spine-related complaints. Characteristics of each study and journal in which it was published were recorded. Correlation of PROMIS to legacy PROs was reported with 0.1 ≤ |r| < 0.3, 0.3 ≤ |r| < 0.5, and |r| ≥ 0.5 indicating weak, moderate, and strong correlations, respectively.RESULTSTwenty-one articles were included in this analysis. Twelve studies assessed the validity of PROMIS whereas 9 used PROMIS as an outcome measure. The first study discussing PROMIS in patients with spine disorders was published in 2012, whereas the majority were published in 2017. The most common PROMIS domain used was Pain Interference. Assessments of PROMIS validity were most frequently performed with the Neck Disability Index. PROMIS domains demonstrated moderate to strong correlations with the legacy PROs that were evaluated. Studies assessing the validity of PROMIS exhibited substantial variability in PROMIS domains and legacy PROs used for comparisons.CONCLUSIONSThere has been a recent increase in the use of PROMIS within the spine literature. However, only a minority of studies have incorporated PROMIS for its intended use as an outcomes measure. Overall, PROMIS has exhibited moderate to strong correlations with a majority of legacy PROs used in the spine literature. These results suggest that PROMIS can be effective in the assessment and tracking of PROs among spine populations.

Download Full-text

Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid Combination Therapy: A Systematic Review

The American Journal of Sports Medicine ◽

10.1177/0363546521998010 ◽

2021 ◽

pp. 036354652199801

Author(s):

Michael R. Baria ◽

W. Kelton Vasileff ◽

James Borchers ◽

Alex DiBartola ◽

David C. Flanigan ◽

...

Keyword(s):

Systematic Review ◽

Hyaluronic Acid ◽

Combination Therapy ◽

Knee Osteoarthritis ◽

Platelet Rich Plasma ◽

Case Series ◽

Final Analysis ◽

Preparation Technique ◽

Randomized Studies ◽

Patient Reported

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect. Purpose: To systematically review the clinical literature examining the combined use of PRP + HA. Design: Systematic review. Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs). Results: A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone. Conclusion: Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.

Download Full-text

Two Year Follow-Up of Patient Reported Outcomes Following Third Generation Minimally Invasive Chevron Akin Osteotomies (MICA) in Hallux Valgus Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00052 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0005

Author(s):

Thomas L. Lewis ◽

Robbie Ray ◽

David Gordon

Keyword(s):

Minimally Invasive ◽

Hallux Valgus ◽

Patient Reported Outcomes ◽

Statistical Significance ◽

Case Series ◽

Published Data ◽

Third Generation ◽

Specific Patient ◽

Patient Reported

Category: Bunion Introduction/Purpose: The aim of this study was to explore the 2 year results of third generation (using screw fixation) Minimally Invasive Chevron and Akin osteotomies (MICA) for hallux valgus correction. There is a paucity of published data regarding the outcomes of this relatively new technique. We present the largest series in the literature, using three separate validated patient-reported outcome measures (EQ-5DL, VAS Pain and Manchester Oxford Foot Questionnaire (MOXFQ), for this time point. Methods: A single surgeon case series of patients with hallux valgus underwent primary third generation minimally invasive chevron and akin osteotomies for hallux valgus correction. Between August 2015 and January 2018, 290 MICAs were performed in 203 patients that were eligible for 2 year follow up. Baseline and 2 year post-operative patient reported outcomes were collected for 164 feet in 130 patients (124 females; 6 males). Paired t-tests were used to determine the statistical significance of the difference between pre- and post-operative scores. Results: The mean age was 56.6 (range 29.5-81.0, standard deviation (s.d.) 10.9). At two year follow up, mean MOXFQ scores improved for each domain: Pain; baseline 40.6 (range 0-100, s.d. 22.8), reduced to 11.3 (range 0-75, s.d. 16.0, p<0.001); Walking; 36.0 (range 0-100, s.d. 25.9) reduced to 8.2 (range 0-75.0, s.d. 16.0, p<0.001); Social interaction; 46.7 (range 0-100, s.d. 24.3), reduced to 7.7 (range 0-75.0, s.d. 13.9, p<0.001). Mean VAS Pain score improved from 30.4 (range 0.0-90.0, s.d. 23.6) to 9.4 (range 0.00-70.0, s.d. 15.6, p<0.001). Mean EQ-5D index score improved from 0.750 (range 0.066-1.000, s.d. 0.148) to 0.892 (range 0.410-1.000, s.d. 0.135, p<0.001). Mean EQ-5D VAS score did not significantly improve from 81.9 (range 0-100, s.d. 17.1) to 83.0 (range 0-100, s.d. 18.0, p=0.559). Conclusion: This is the largest prospective case series of short-term patient reported outcomes using a validated assessment method for hallux valgus, following third generation MICA to date. These data show that this technique is effective at improving foot and ankle specific patient reported outcomes at 2 years. This cohort is being followed over the longer term.

Download Full-text

Integrated care pathways in neurosurgery: A systematic review

PLoS ONE ◽

10.1371/journal.pone.0255628 ◽

2021 ◽

Vol 16 (8) ◽

pp. e0255628

Author(s):

Keng Siang Lee ◽

Stefan Yordanov ◽

Daniel Stubbs ◽

Ellie Edlmann ◽

Alexis Joannides ◽

...

Keyword(s):

Systematic Review ◽

Integrated Care ◽

Performance Metrics ◽

Positive Impact ◽

Case Series ◽

The United States ◽

Control Group ◽

Care Pathways ◽

Patient Reported ◽

Integrated Care Pathways

Introduction Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success. Methods Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded. Results Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods Conclusions ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient’s perspective.

Download Full-text

Bilateral versus unilateral hip arthroscopy for femoroacetabular impingement: a systematic review

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnaa013 ◽

2020 ◽

Vol 7 (2) ◽

pp. 225-232

Author(s):

Claire E Fernandez ◽

Allison M Morgan ◽

Ujash Sheth ◽

Vehniah K Tjong ◽

Michael A Terry

Keyword(s):

Systematic Review ◽

Femoroacetabular Impingement ◽

Hip Arthroscopy ◽

Case Reports ◽

Case Series ◽

Return To Sport ◽

Harris Hip Score ◽

Study Patient ◽

Significant Difference ◽

Patient Reported

Abstract One in four patients presenting with femoroacetabular impingement (FAI) has bilateral symptoms, and despite excellent outcomes reported after arthroscopic treatment of FAI, there remains a paucity of data on the outcomes following bilateral hip arthroscopy. This systematic review aims to examine the outcomes following bilateral (either ‘simultaneous’ or ‘staged’) versus unilateral hip arthroscopy for FAI. A systematic review of multiple electronic databases was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. All studies comparing simultaneous, staged and/or unilateral hip arthroscopy for FAI were eligible for inclusion. Case series, case reports and reviews were excluded. All study, patient and hip-specific data were extracted and analyzed. The Newcastle–Ottawa Scale was used to assess study quality. A meta-analysis was not performed due to heterogeneity among outcome measures. A total of six studies, including 722 patients (42.8% male) and 933 hips were eligible for inclusion. The mean age across patients was 35.5. The average time between staged procedures was 7.7 months. Four of the six studies were retrospective cohort studies, while the remaining two were prospective in nature. The overall quality of the eligible studies was found to be good. No significant difference was noted among patient-reported outcomes (modified Harris hip score, hip outcome score and non-arthritic hip score), visual analog scale, return to sport, traction time and complications between those undergoing bilateral (simultaneous or staged) versus unilateral hip arthroscopy. Based on the current available evidence, bilateral hip arthroscopy (whether simultaneous or staged) exhibits similar efficacy and safety when compared with unilateral hip arthroscopy. However, further prospective study is required to confirm this finding.

Download Full-text

Tissue-Sparing Posterior Cervical Fusion With Interfacet Cages: A Systematic Review of the Literature

Global Spine Journal ◽

10.1177/2192568219837145 ◽

2019 ◽

Vol 10 (2) ◽

pp. 230-236

Author(s):

Joseph L. Laratta ◽

Karishma Gupta ◽

William D. Smith

Keyword(s):

Systematic Review ◽

Patient Reported Outcomes ◽

Extensive Literature ◽

Cervical Fusion ◽

Cervical Spine Surgery ◽

Radiographic Outcomes ◽

Patient Reported ◽

Posterior Cervical Fusion ◽

Extensive Literature Search ◽

Tissue Sparing

Study Design: Literature review. Objectives: Posterior cervical interfacet cages are an alternative to lateral mass fixation in patients undergoing cervical spine surgery. Recently, a percutaneous, tissue-sparing system for interfacet cage placement has been developed, however, there is limited clinical evidence supporting its widespread use. The aim was to review studies published on this system for patient reported outcomes, radiographic outcomes, intraoperative outcomes, and complications. Methods: Four electronic databases (PubMed, EMBASE, Scopus, and MEDLINE) were queried for original published studies that evaluated the percutaneous, tissue-sparing technique for posterior cervical fusion with interfacet cage placement. All studies reporting on open techniques and purely biomechanical studies were excluded. Results: The extensive literature search returned 7852 studies. After systematic review, a total of 7 studies met inclusion criteria. Studies were independently classified as retrospective or prospective cohort studies and each assessed by the GRADE criteria. Patient reported outcomes, radiographic outcomes, intraoperative outcomes, and complications were extracted from each study and presented. Conclusions: Tissue-sparing, posterior cervical fusion with interfacet cages may be considered a safe and effective surgical intervention in patients failing conservative management for cervical spondylotic disease. However, the quality of evidence in the literature is lacking, and controlled, comparative studies are needed for definitive assessment.

Download Full-text

Is There a Preoperative Morphine Equianalgesic Dose that Predicts Ability to Achieve a Clinically Meaningful Improvement Following Spine Surgery?

Neurosurgery ◽

10.1093/neuros/nyx382 ◽

2017 ◽

Vol 83 (2) ◽

pp. 245-251 ◽

Cited By ~ 5

Author(s):

Joseph B Wick ◽

Ahilan Sivaganesan ◽

Silky Chotai ◽

Kristin R Archer ◽

Samuel L Posey ◽

...

Keyword(s):

Logistic Regression ◽

Spine Surgery ◽

Elective Surgery ◽

Neck Disability Index ◽

Credible Interval ◽

Minimum Clinically Important Difference ◽

Opioid Use ◽

Meaningful Improvement ◽

Opioid Dose ◽

Patient Reported

Abstract BACKGROUND Preoperative opioid use is widespread and associated with worse patient-reported outcomes following spine surgery. OBJECTIVE To calculate a threshold preoperative morphine equianalgesic (MEA) dose beyond which patients are less likely to achieve the minimum clinically important difference (MCID) following elective surgery for degenerative spine disease. METHODS The study included 543 cervical and 1293 lumbar patients. Neck Disability Index and Oswestry Disability Index scores were collected at baseline and 12 mo postoperatively. Preoperative MEA doses were calculated retrospectively. Multivariate logistic regression was then performed to determine the relationship between MEA dose and the odds of achieving MCID. As a part of this regression, Bayesian inference and Markov Chain Monte Carlo methods were used to estimate the values of inflection points (or “thresholds”) in MEA. RESULTS Overall, 1020 (55.5%) patients used preoperative opioids. A total of 50.3% of cervical and 61.9% of lumbar patients achieved MCID. The final logistic regression model demonstrated that MCID achievement decreased significantly when mean preoperative MEA dose exceeded 47.8 mg/d, with a 95% credible interval of 29.0 to 60.0 mg/d. CONCLUSION Minimum and maximum MEA doses exist, between which increasing opioid dose is associated with decreased ability to achieve clinically meaningful improvement following spine surgery. Patients with preoperative MEA dose exceeding 29 mg/d, the lower limit of the 95% credible interval for the mean MEA dose above which patients exhibit significantly decreased achievement of MCID, may be considered for preoperative opioid weaning.

Download Full-text

Manual Therapy and Exercise to Improve Outcomes in Patients With Muscle Tension Dysphonia: A Case Series

Physical Therapy ◽

10.2522/ptj.20130547 ◽

2015 ◽

Vol 95 (1) ◽

pp. 117-128 ◽

Cited By ~ 21

Author(s):

Carey A. Tomlinson ◽

Kristin R. Archer

Keyword(s):

Physical Therapy ◽

Manual Therapy ◽

Rating Scale ◽

Muscle Tension ◽

Case Series ◽

Vocal Folds ◽

Patient Specific ◽

Meaningful Improvement ◽

Muscle Tension Dysphonia ◽

Patient Reported

Background and Purpose Muscle tension dysphonia (MTD), a common voice disorder that is not commonly referred for physical therapy intervention, is characterized by excessive muscle recruitment, resulting in incorrect vibratory patterns of vocal folds and an alteration in voice production. This case series was conducted to determine whether physical therapy including manual therapy, exercise, and stress management education would be beneficial to this population by reducing excess muscle tension. Case Description Nine patients with MTD completed a minimum of 9 sessions of the intervention. Patient-reported outcomes of pain, function, and quality of life were assessed at baseline and the conclusion of treatment. The outcome measures were the numeric rating scale (NRS), Patient-Specific Functional Scale (PSFS), and Voice Handicap Index (VHI). Cervical and jaw range of motion also were assessed at baseline and postintervention using standard goniometric measurements. Outcomes Eight of the patients had no pain after treatment. All 9 of the patients demonstrated an improvement in PSFS score, with 7 patients exceeding a clinically meaningful improvement at the conclusion of the intervention. Three of the patients also had a clinically meaningful change in VHI scores. All 9 of the patients demonstrated improvement in cervical flexion and lateral flexion and jaw opening, whereas 8 patients improved in cervical extension and rotation postintervention. Discussion The findings suggest that physical therapists can feasibly implement an intervention to improve outcomes in patients with MTD. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the intervention. A clinical implication is the expansion of physical therapy to include referrals from voice centers for the treatment of MTD.

Download Full-text

Systematic Review of Outcome Measures Used in Observational Studies of Adults with Eosinophilic Esophagitis

International Archives of Allergy and Immunology ◽

10.1159/000516898 ◽

2021 ◽

pp. 1-25

Author(s):

Alain M. Schoepfer ◽

Camilla Schürmann ◽

Sven Trelle ◽

Marcel Zwahlen ◽

Christopher Ma ◽

...

Keyword(s):

Systematic Review ◽

Outcome Measures ◽

Eosinophilic Esophagitis ◽

Observational Studies ◽

Patient Reported Outcomes ◽

Case Series ◽

Open Label ◽

Topical Corticosteroids ◽

Therapeutic Trials ◽

Patient Reported

Background: Over the last 20 years, diverse outcome measures have been used to evaluate the effectiveness of therapies for eosinophilic esophagitis (EoE). This systematic review aims to identify the readouts used in observational studies of topical corticosteroids, diet, and dilation in adult EoE patients. Methods: We searched MEDLINE and Embase for prospective and retrospective studies (cohorts/case series, randomized open-label, and case-control) evaluating the use of diets, dilation, and topical corticosteroids in adults with EoE. Two authors independently assessed the articles and extracted information about histologic, endoscopic, and patient-reported outcomes and tools used to assess treatment effects. Results: We included 69 studies that met inclusion criteria. EoE-associated endoscopic findings (assessed either as absence/presence or using Endoscopic Reference Score) were evaluated in 24/35, 11/17, and 9/17 studies of topical corticosteroids, diet, and dilation, respectively. Esophageal eosinophil density was recorded in 32/35, 17/17, and 11/17 studies of topical corticosteroids, diet, and dilation, respectively. Patient-reported outcomes were not uniformly used (only in 14, 8, and 3 studies of topical corticosteroids, diet, and dilation, respectively), and most tools were not validated for use in adults with EoE. Conclusions: Despite the lack of an agreed set of core outcomes that should be recorded and reported in studies in adult EoE patients, endoscopic EoE-associated findings and esophageal eosinophil density are commonly used to assess disease activity in observational studies. Standardization of outcomes and data supporting the use of outcomes are needed to facilitate interpretation of evidence, its synthesis, and comparisons of interventions in meta-analyses of therapeutic trials in adults with EoE.

Download Full-text

Surgery and Conservative Management of Camptodactyly in Pediatric Patients: A Systematic Review

Hand ◽

10.1177/1558944719834654 ◽

2019 ◽

Vol 15 (6) ◽

pp. 761-770

Author(s):

Annie M. Q. Wang ◽

Min Kim ◽

Emily S. Ho ◽

Kristen M. Davidge

Keyword(s):

Systematic Review ◽

Patient Care ◽

Conservative Management ◽

Case Series ◽

Flexion Contracture ◽

Current Evidence ◽

Future Research ◽

Global Rating ◽

Patient Reported ◽

Definition Of

Camptodactyly is a pediatric hand condition, the treatment of which remains controversial. The authors’ aim was to improve patient care through clarifying the definition of camptodactyly and indications for surgical and/or conservative management, summarizing outcomes, and defining risks. A systematic review was conducted of articles in all languages on outcomes following surgical and/or conservative management of idiopathic camptodactyly in children using MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, EMBASE (Excerpta Medica database), AMED (Allied and Complementary Medicine), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) (until January 2017). The primary outcome was posttreatment flexion contracture, and the secondary outcomes were indications for surgery, complications, and patient satisfaction. Database searching generated 16 final articles, with 7 case series and 9 retrospective cohort studies. There was a lack of consistency on the definition of camptodactyly and in outcome reporting. All 16 studies received a “Weak” global rating and demonstrated low-quality evidence, suggesting that treatment of camptodactyly with operative or nonoperative measures reduces the degree of flexion contracture in most patients (from pretreatment averages of 20°-85° to posttreatment averages of 5°-37°). There was general agreement that surgery should be reserved for contracture >30° or failure to respond to conservative management. Surgery generally led to more complications compared with conservative management. Only one study reported on functional limitations, and another reported on patient-reported outcomes. Current evidence of the effectiveness of camptodactyly treatment in addressing both joint-specific deformity and patient-perceived function and appearance is insufficient to guide patient care. Future research may consider the development of decision aids to guide patients and families through selecting management strategies and to promote shared decision making.

Download Full-text