scholarly journals Therapeutic Decision-Making and Outcomes in Elderly Patients With Severe Symptomatic Aortic Stenosis: Prognostic Implications of Elderly Patients' Initial Decisions

2021 ◽  
Vol 8 ◽  
Author(s):  
Qinghao Zhao ◽  
Haiyan Xu ◽  
Qingrong Liu ◽  
Yunqing Ye ◽  
Bin Zhang ◽  
...  
Keyword(s):  
Decision Making ◽  
Logistic Regression ◽  
Cohort Study ◽  
Elderly Patients ◽  
Logistic Regression Model ◽  
Therapeutic Decision ◽  
Therapeutic Decisions ◽  
Therapeutic Decision Making ◽  
Penalized Logistic Regression ◽  
Subsequent Intervention

Background: Despite clear indications for intervention, therapeutic decision-making for elderly patients with severe symptomatic aortic stenosis (AS) remains a complex issue due to the wide variation in individual risk profiles and the involvement of patients' subjective preferences. We aimed to investigate the reasons leading to the decisions against intervention and the consequences thereof on survival.Methods: Data were derived from the China Elderly Valve Disease (China-DVD) Cohort Study on patients aged ≥60-year-old with severe symptomatic AS consecutively enrolled between September to December 2016. Patients were analyzed according to the initial therapeutic decisions made by consensus between patients and physicians at the time of the index evaluation: intervention group (patients who were evaluated as suitable for intervention and accepted the treatment proposal); patient-refusal group (patients who were evaluated as suitable for intervention but refused due to subjective preferences); physician-deny group (patients who were denied intervention by physicians after evaluation). The least absolute shrinkage and selection operator (LASSO)-penalized logistic regression model was used to identify the factors associated with physicians' decisions against intervention. Twelve-month survival was analyzed using Cox proportional hazards models, with multivariate adjustment using inverse probability weighting (IPW).Results: Among the enrolled 456 elderly patients with severe symptomatic AS, 52 (11.4%) patients refused intervention and 49 (10.7%) patients were denied intervention by their physicians. LASSO-penalized logistic regression model identified that reduced left ventricular ejection fraction and increased EuroSCORE-II were strongly associated with physicians' decisions against intervention. At 12-month follow-up, only 8 (15.4%) patients who initially refused the intervention proposal underwent the subsequent intervention, with an average delay of 195 days. Patients' initial decisions against intervention were significantly associated with 12-month mortality, even after IPW adjustment (Hazard ratio: 2.61; 95% confidence interval: 1.09–6.20; P = 0.031).Conclusions: The decision against intervention was taken in about one-fifth of elderly patients with symptomatic severe AS, half of which were due to patients' subjective preferences. Surgical risk remains the primary concern for physicians when making therapeutic decisions. Elderly patients' initial decisions against intervention have a profound impact on subsequent intervention rates and prognosis, and therefore should be treated as a “risk factor” at the subjective level.Clinical Trial Registration:clinicaltrials.gov/ct2/show/NCT02865798, China elDerly Valve Disease (China-DVD) cohort study (NCT02865798).

Bone marrow examination (BMex) in staging of SCLC after implementation of PET/CT scan.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e20014-e20014
Author(s):  
Karin Holmskov Hansen ◽  
Mette Boes Eriksen ◽  
Tine Schytte ◽  
Olfred Hansen
Keyword(s):  
Decision Making ◽  
Ct Scan ◽  
Bone Metastases ◽  
Bone Lesions ◽  
Therapeutic Decision ◽  
Therapeutic Decisions ◽  
Pet Ct ◽  
Therapeutic Decision Making ◽  
The Impact ◽  
Pet Ct Scan

e20014 Background: Correct staging of small cell lung cancer (SCLC) in limited disease (LD) or extensive disease (ED) is crucial as it has an impact on the therapeutic decision-making. The staging procedures in SCLC in the late 1990s included chest X-ray, blood samples, abdominal ultrasonography (UL), and iliac crest BMex. The aim of this study was to evaluate the continued eligibility of performing BMex in patients (ptt) with SCLC as a routine staging procedure, and to see how often therapeutic decisions were influenced by a positive BM before and after the PET/CT scan era. Methods: All diagnostic and staging procedures were registered in ptt with SCLC referred to our department from 1995 to 1999 in cohort 1 (C1). Cohort 2 (C2) included SCLC patients referred from 2009 to 2013. In C2 results of PET/CT in terms of bone metastases were related to results of BMex. Results: In C1 194 ptt was referred with 136 (70%) having ED. BMex was omitted in 32 (17%) fragile ptt having known ED while all LD ptt underwent BMex. BM involvement was seen in 37 (23%) of all 162 BMex and 36% of the 104 ED ptt examined. When BM was negative the staging of ED was due to other imaging. The BM had an impact on therapeutic decision-making in 5 (4%) of 136 having ED and 5 (3%) of 162 BMex. In C2 211 ptt of 292 (72%) had ED and 203 (70%) of all ptt underwent BMex. BM biopsy was done in 137 (65 %) ED and in 66 (69 %) LD. Of 137 ED ptt BM involvement was found in 31 (23 %) cases. A PET/CT scan was performed in 13 (42 %) of these ptt of which bone metastases was found in 12 (92 %). One patient (8%) had a PET/CT without bone lesions. Bone metastases were seen at PET/CT scan in 61 ptt in C2, of these 22 (36%) had negative BM, whereas 12 (20%) had BM involvement and in 3 ptt (5%) BMex were inconclusive. No BMex was performed in 24 ptt (39%). BMex had an impact on therapeutic decision-making in 3 (1.4%) of 211 having ED and 5 (2.5%) of 203 BMex. Conclusions: Due to staging by PET/CT and CT scan in SCLC ptt the impact of BMex in the therapeutic decision-making has decreased and fewer ptt are undergoing BMex. Though a negative PET/CT cannot exclude BM involvement BMex may be considered omitted.

scholarly journals Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases

2016 ◽  
Vol 57 (4) ◽  
pp. 434-440 ◽  
Author(s):  
Kui Hu ◽  
Yun Wan ◽  
Tao Hong ◽  
Shu yang Lu ◽  
Chang fa Guo ◽  
...  
Keyword(s):  
Decision Making ◽  
Elderly Patients ◽  
Heart Diseases ◽  
Therapeutic Decision ◽  
Valvular Heart Diseases ◽  
Therapeutic Decision Making

scholarly journals Health emergencies and interoceptive sensibility modulate the perception of non-evidence-based drug use: Findings from the COVID-19 outbreak

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0256806
Author(s):  
Gerardo Salvato ◽  
Daniela Ovadia ◽  
Alessandro Messina ◽  
Gabriella Bottini
Keyword(s):  
Decision Making ◽  
Individual Characteristics ◽  
Decision Making Process ◽  
Evidence Based ◽  
Care Providers ◽  
Therapeutic Decision ◽  
Therapeutic Approaches ◽  
Experimental Drugs ◽  
Therapeutic Decisions ◽  
Therapeutic Decision Making

Scientific evidence plays an important role in the therapeutic decision-making process. What happens when physicians are forced to make therapeutic decisions under uncertainty? The absence of scientific guidelines at the beginning of a pandemic due to an unknown virus, such as COVID-19, could influence the perceived legitimacy of the application of non-evidence-based therapeutic approaches. This paper reports on a test of this hypothesis, in which we administered an ad hoc questionnaire to a sample of 64 Italian physicians during the first wave of the COVID-19 pandemic in Italy (April 2020). The questionnaire statements regarding the legitimacy of off-label or experimental drugs were framed according to three different scenarios (Normality, Emergency and COVID-19). Furthermore, as the perception of internal bodily sensations (i.e., interoception) modulates the decision-making process, we tested participants’ interoceptive sensibility using the Multidimensional Assessment of Interoceptive Awareness (MAIA). The results showed that participants were more inclined to legitimate non-evidence-based therapeutic approaches in the COVID-19 and Emergency scenarios than the Normality scenario. We also found that scores on the MAIA Trusting subscale positively predicted this difference. Our findings demonstrate that uncertain medical scenarios, involving a dramatic increase in patient volume and acuity, can increase risk-taking in therapeutic decision-making. Furthermore, individual characteristics of health care providers, such as interoceptive ability, should be taken into account when constructing models to prevent the breakdown of healthcare systems in cases of severe emergency.

scholarly journals High-Frequency Ultrasound to Assess Activity in Connective Tissue Panniculitis

2021 ◽  
Vol 10 (19) ◽  
pp. 4516
Author(s):  
Priscila Giavedoni ◽  
Sebastian Podlipnik ◽  
Irene Fuertes de Vega ◽  
Pilar Iranzo ◽  
José Manuel Mascaró
Keyword(s):  
Decision Making ◽  
Connective Tissue ◽  
Disease Activity ◽  
High Frequency ◽  
Therapeutic Decision ◽  
High Frequency Ultrasound ◽  
Therapeutic Decisions ◽  
Therapeutic Decision Making ◽  
Frequency Ultrasound

Determining disease activity from clinical signs in patients with connective tissue panniculitis (CTP) is often challenging but is essential for therapeutic decision making, which largely relies on immunosuppressant treatment. High-frequency ultrasound (HFUS) may be useful in supporting such decisions by accurately determining CTP activity. This study aimed to investigate the accuracy of HFUS in identifying signs of CTP activity or inactivity and assess its usefulness in therapeutic decision making. A prospective cohort study of consecutive patients with biopsy-proven CTP receiving HFUS was conducted in a tertiary university hospital (2016–2020). HFUS was performed at inclusion and at each 3- or 6-month follow-up visit, depending on disease activity. Twenty-three patients with CTP were included, and 134 HFUSs were performed. In 59.7% (80) of the evaluations, the clinical presentation did not show whether CTP was active or not. In these cases, HFUS showed activity in 38.7% (31) and inactivity in 61.3% (49). In 71.25% (57) of the visits, HFUS was the determinant for therapeutic decisions. Further follow-up showed consistent clinical and HFUS responses in all unclear cases after treatment modification. HFUS appears to be a useful adjunct to the clinical examination for CTP to assess activity and make therapeutic decisions.

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