Real-world experience of treatment decision-making in carotid stenosis in a neurovascular board

Neurology ◽  
2017 ◽  
Vol 89 (4) ◽  
pp. 399-407 ◽  
Author(s):  
David Leander Rimmele ◽  
Axel Larena-Avellaneda ◽  
Anna C. Alegiani ◽  
Michael Rosenkranz ◽  
Nils Ole Schmidt ◽  
...  
Keyword(s):  
Decision Making ◽  
Carotid Artery ◽  
Medical Management ◽  
Treatment Strategies ◽  
Treatment Decision ◽  
Treatment Recommendations ◽  
Adherence To Treatment ◽  
Treatment Decision Making ◽  
Time Period ◽  
Ica Stenosis

Objective:To describe our experience with consensus-based decision-making for treatment of internal carotid artery (ICA) stenosis by neurologists, interventional neuroradiologists, vascular surgeons, and neurosurgeons in a multidisciplinary neurovascular board and to study adherence to treatment recommendations in the context of uncertainty with respect to the best treatment option.Methods:We established a multidisciplinary neurovascular board meeting twice a week with structured documentation of consensus decisions. Over a time period of 53 months, 614 cases with ICA stenosis were discussed, with 285 (46%) symptomatic and 279 (45%) asymptomatic cases.Results:Recommendation for symptomatic ICA stenosis was revascularization in 76%, medical management alone in 8%, and further diagnostics in 16%. For asymptomatic ICA stenosis, recommendation was randomization in a clinical trial in 29%, revascularization in 27%, medical management alone in 23%, and further diagnostics in 22%. Treatment recommendations were followed in 94% of symptomatic ICA stenosis and 69% of asymptomatic ICA stenosis. Patients in whom carotid artery stenting was recommended for revascularization were younger and showed a higher rate of severe (≥70%) ICA stenosis.Conclusions:Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence.

Abstract P214: Patient and Physician Factors Influence Decision-Making in Hypercholesterolemia

Circulation ◽  
2015 ◽  
Vol 131 (suppl_1) ◽  
Author(s):  
Michel Krempf ◽  
Ross J Simpson ◽  
Dena R Ramey ◽  
Philippe Brudi ◽  
Hilde Giezek ◽  
...  
Keyword(s):  
Decision Making ◽  
Goal Attainment ◽  
Clinical Decision Making ◽  
Treatment Strategies ◽  
Treatment Decision ◽  
Clinical Decision ◽  
Treatment Recommendations ◽  
Treatment Choice ◽  
Treatment Recommendation ◽  
Double Blind

Objectives: Little is known about how patient factors influence physicians’ treatment decision-making in hypercholesterolemia. We surveyed physicians’ treatment recommendations in high-risk patients with LDL-C not controlled on statin monotherapy. Methods: Physicians completed a questionnaire pre-randomization for each patient in a double-blind trial (NCT01154036) assessing LDL-C goal attainment rates with different treatment strategies. Patients had LDL-C ≥100 mg/dL after 5 weeks’ atorvastatin 10 mg/day and before randomization. Physicians were asked about treatment recommendations for three scenarios: (1) LDL-C near goal (100-105 mg/dL), (2) LDL-C far from goal (120 mg/dL), then (3) known baseline LDL-C of enrolled patients on atorvastatin 10 mg/day. Factors considered in their choice were specified. Physicians had been informed of projected LDL-C reductions for each treatment strategy in the trial. Regression analysis identified prognostic factors associated with each scenario, and projected LDL-C values for physicians’ treatment choices were compared to actual LDL-C values achieved in the trial. Results: Physicians at 296 sites completed questionnaires for 1535 patients. The most common treatment strategies for all three scenarios were: 1) not to change therapy, 2) double atorvastatin dose, 3) add ezetimibe, 4) double atorvastatin dose and add ezetimibe. Doubling atorvastatin dose was the most common treatment recommendation in all scenarios (43-52% of patients). ‘No change in therapy’ was recommended in 6.5% of patients when LDL-C was assumed far from goal. Treatment recommendations were more aggressive if actual LDL-C was known or considered far from goal. When compared with the ‘no change in therapy’ recommendation, CV risk factors and desire to achieve a more aggressive LDL-C goal were generally considered in decision-making for each treatment choice, regardless of LDL-C scenario. Patients randomized to a more aggressive regimen than recommended by physicians had larger reductions in LDL-C: the actual reduction in LDL-C in patients randomized to ‘add ezetimibe’ was -20.8% versus a projected reduction of -10.0% when physicians recommended ‘doubling atorvastatin dose’. Conclusions: This study provides insight into physicians’ perspectives on clinical management of hypercholesterolemia and highlights a gap in knowledge translation from guidelines to clinical practice. Targeting lower LDL-C and CV risk were key drivers in clinical decision-making but, generally, physicians were more conservative in their treatment choice than guidelines recommend, which may result in poorer LDL-C reduction. When compared with actual outcomes, projected LDL-C control was better if physicians used more comprehensive strategies rather than simply doubling the statin dose.

More Versus Less Therapy for Older Adults With Acute Myeloid Leukemia: New Perspectives on an Old Debate

2019 ◽  
pp. 421-432 ◽  
Author(s):  
Heidi D. Klepin ◽  
Elihu Estey ◽  
Tapan Kadia
Keyword(s):  
Older Adults ◽  
Decision Making ◽  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Treatment Options ◽  
Treatment Strategies ◽  
Treatment Decision ◽  
Important Conclusion ◽  
Treatment Decision Making ◽  
Acute Myeloid

Most patients with newly diagnosed acute myeloid leukemia (AML) are at least age 65 and continue to have short survival, with many patients receiving no specific anti-AML therapy, particularly if they are older than age 75. Although consensus regarding optimal treatment of this growing population is lacking, treatment options are expanding even for the oldest patients. A fundamental question when seeing an older patient with AML is whether to recommend “more intensive” or “less intensive” induction therapy. Existing data can support more intensive treatment strategies for selected older adults, although there is growing evidence to support less intensive therapies as well. Randomized trials to provide clear comparisons between treatment strategies among well-characterized older adult populations are lacking. Reliance on age alone to determine treatment choice is problematic, as “fitness” or “unfitness” varies dramatically among patients of the same chronologic age and remains poorly characterized in existing studies. This article will provide differing perspectives on the “more” versus “less” question, with particular attention to recent drug approvals. Issues relevant to both treatment decision-making in practice and alternative trial design to inform gaps in knowledge will be discussed. Given the heterogeneity, an important conclusion will be that there is unlikely to be a single best approach and that appropriate decision-making requires considerations of many factors specific to individual patients.

Free-Floating Thrombus in the Distal Internal Carotid Artery Causing a Stroke

2020 ◽  
Author(s):  
Spyros Papadoulas ◽  
Konstantinos Moulakakis ◽  
Natasa Kouri ◽  
Petros Zampakis ◽  
Stavros K. Kakkos
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Medical Management ◽  
Internal Carotid ◽  
Treatment Strategies ◽  
Rare Condition ◽  
Residual Stenosis ◽  
Floating Thrombus ◽  
Distal Internal Carotid Artery ◽  
Carotid Bulb

AbstractWe present a patient suffering from a stroke with a free-floating thrombus extending up to the distal internal carotid artery. The thrombus was totally resolved after a 2-week anticoagulation regimen without leaving behind any severe residual stenosis in the carotid bulb. The optimal treatment of this rare condition remains uncertain. We report some important treatment strategies that have been used in the literature, emphasizing the anticoagulation as the mainstay of therapy. Immediate surgical and interventional manipulations carry the risk of thrombus dislodgement and embolization and should be considered if there are recurrent symptoms despite medical management.

Patients’ practices for taking the initiative in decision-making in outpatient psychiatric consultations

2017 ◽  
Vol 13 (2) ◽  
pp. 169-184 ◽  
Author(s):  
Shuya Kushida ◽  
Takeshi Hiramoto ◽  
Yuriko Yamakawa
Keyword(s):  
Decision Making ◽  
Conversation Analysis ◽  
Treatment Decision ◽  
Close Inspection ◽  
Important Resource ◽  
Treatment Decision Making ◽  
The Way

In spite of increasing advocacy for patients’ participation in psychiatric decision-making, there has been little research on how patients actually participate in decision-making in psychiatric consultations. This study explores how patients take the initiative in decision-making over treatment in outpatient psychiatric consultations in Japan. Using the methodology of conversation analysis, we analyze 85 video-recorded ongoing consultations and find that patients select between two practices for taking the initiative in decision-making: making explicit requests for a treatment and displaying interest in a treatment without explicitly requesting it. A close inspection of transcribed interaction reveals that patients make explicit requests under the circumstances where they believe the candidate treatment is appropriate for their condition, whereas they merely display interest in a treatment when they are not certain about its appropriateness. By fitting practices to take the initiative in decision-making with the way they describe their current condition, patients are optimally managing their desire for particular treatments and the validity of their initiative actions. In conclusion, we argue that the orderly use of the two practices is one important resource for patients’ participation in treatment decision-making.

Enhancing Involvement in Treatment Decision Making by Women with Breast Cancer

2007 ◽  
Author(s):  
Mary A. O'Brien ◽  
Timothy Whelan ◽  
Amiram Gafni ◽  
Cathy Charles ◽  
Peter Ellis
Keyword(s):  
Breast Cancer ◽  
Decision Making ◽  
Treatment Decision ◽  
Treatment Decision Making
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