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Fields MW, Kaushal NK, Patel NM, McCormick SK, Eberson CP, Schmitz ML, Swarup I, Blanco JS, Crawford LM, Edobor-Osula OF. Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons. J Pediatr Orthop B 2022; 31:e141-e146. [PMID: 34561383 DOI: 10.1097/bpb.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to determine the variability in clinical management of tibial tubercle fractures among a group of pediatric orthopedic surgeons. Nine fellowship-trained academic pediatric orthopedic surgeons reviewed 51 anteroposterior and lateral knee radiographs with associated case age. Respondents were asked to describe each fracture using the Ogden classification (type 1-5 with A/B modifiers), desired radiographic workup, operative vs. nonoperative treatment strategy and plans for post-treatment follow-up. Fair agreement was reached when classifying the fracture type using the Ogden classification (k = 0.39; P < 0.001). Overall, surgeons had a moderate agreement on whether to treat the fractures operatively vs. nonoperatively (k = 0.51; P < 0.001). Nonoperative management was selected for 80.4% (45/56) of type 1A fractures. Respondents selected operative treatment for 75% (30/40) of type 1B, 58.3% (14/24) of type 2A, 97.4% (74/76) of type 2B, 90.7% (39/43) of type 3A, 96.3% (79/82) of type 3B, 71.9% (87/121) of type 4 and 94.1% (16/17) of type 5 fractures. Regarding operative treatment, fair/slight agreement was reached when selecting the specifics of operative treatment including surgical fixation technique (k = 0.25; P < 0.001), screw type (k = 0.26; P < 0.001), screw size (k = 0.08; P < 0.001), use of washers (k = 0.21; P < 0.001) and performing a prophylactic anterior compartment fasciotomy (k = 0.20; P < 0.001). Furthermore, surgeons had fair/moderate agreement regarding the specifics of nonoperative treatment including degree of knee extension during immobilization (k = 0.46; P < 0.001), length of immobilization (k = 0.34; P < 0.001), post-treatment weight bearing status (k = 0.30; P < 0.001) and post-treatment rehabilitation (k = 0.34; P < 0.001). Significant variability exists between surgeons when evaluating and treating pediatric tibial tubercle fractures.
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Affiliation(s)
- Michael W Fields
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Neil K Kaushal
- Department of Pediatric Orthopedic Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Craig P Eberson
- Warren Alpert Medical School of Brown University, Providence Rhode Island
| | | | - Ishaan Swarup
- University of California San Francisco, San Francisco, California
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Mansouri A, Brar K, Cusimano MD. Considerations for a surgical RCT for diffuse low-grade glioma: a survey. Neurooncol Pract 2020; 7:338-343. [PMID: 32537182 DOI: 10.1093/nop/npz058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Diffuse low-grade gliomas (DLGGs) are heterogeneous tumors that inevitably differentiate into malignant entities, leading to disability and death. Recently, a shift toward up-front maximal safe resection of DLGGs has been favored. However, this transition is not supported by randomized controlled trial (RCT) data. Here, we sought to survey the neuro-oncology community on considerations for a surgical RCT for DLGGs. Methods A 21-question survey focusing on a surgical RCT for DLGGs was developed and validated by 2 neurosurgeons. A sample case of a patient for whom management might be debatable was presented to gather additional insight. The survey was disseminated to members of the Society for Neuro-Oncology (SNO) and responses were collected from March 16 to July 10, 2018. Results A total of 131 responses were collected. Sixty-three of 117 (54%) respondents thought an RCT would not be ethical, 39 of 117 (33%) would consider participating, and 56 of 117 (48%) believed an RCT would be valuable for determining the differing roles of biopsy, surgery, and observation. This was exemplified by an evenly distributed selection of the latter management options for our sample case. Eighty-three of 120 (69.2%) respondents did not believe in equipoise for DLGG patients. Quality of life and overall survival were deemed equally important end points for a putative RCT. Conclusions Based on our survey, it is evident that management of certain DLGG patients is not well defined and an RCT may be justified. As with any surgical RCT, logistic challenges are anticipated. Robust patient-relevant end points and standardization of perioperative adjuncts are necessary if a surgical RCT is undertaken.
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Affiliation(s)
- Alireza Mansouri
- Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
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Fowler GE, Siddiqui J, Zahid A, Young CJ. Treatment of hemorrhoids: A survey of surgical practice in Australia and New Zealand. World J Clin Cases 2019; 7:3742-3750. [PMID: 31799299 PMCID: PMC6887603 DOI: 10.12998/wjcc.v7.i22.3742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/21/2019] [Accepted: 10/29/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention.
AIM To determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand.
METHODS An online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios.
RESULTS There were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain.
CONCLUSION Although there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.
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Affiliation(s)
- George E Fowler
- Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, United Kingdom
| | - Javariah Siddiqui
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Newtown 2042, NSW, Australia
| | - Assad Zahid
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Newtown 2042, NSW, Australia
| | - Christopher John Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Newtown 2042, NSW, Australia
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Siddiqui J, Fowler GE, Zahid A, Brown K, Young CJ. Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand. Colorectal Dis 2019; 21:226-233. [PMID: 30411476 DOI: 10.1111/codi.14466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/19/2018] [Indexed: 12/19/2022]
Abstract
AIM The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. METHODS A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. RESULTS The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. CONCLUSION While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.
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Affiliation(s)
- J Siddiqui
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - G E Fowler
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A Zahid
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - K Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - C J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Robinson AHN, Johnson-Lynn SE, Humphrey JA, Haddad FS. The challenges of translating the results of randomized controlled trials in orthopaedic surgery into clinical practice. Bone Joint J 2019; 101-B:121-123. [DOI: 10.1302/0301-620x.101b2.bjj-2018-1352.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - J. A. Humphrey
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - F. S. Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Unit at UCLH, London, UK
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Siddiqui J, Zahid A, Hong J, Young CJ. Colorectal surgeon consensus with diverticulitis clinical practice guidelines. World J Gastrointest Surg 2017; 9:224-232. [PMID: 29225733 PMCID: PMC5714804 DOI: 10.4240/wjgs.v9.i11.224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand.
METHODS A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios.
RESULTS The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher’s exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001).
CONCLUSION While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.
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Affiliation(s)
- Javariah Siddiqui
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
| | - Assad Zahid
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Jonathan Hong
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Christopher John Young
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
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Savulescu J, Wartolowska K, Carr A. Randomised placebo-controlled trials of surgery: ethical analysis and guidelines. JOURNAL OF MEDICAL ETHICS 2016; 42:776-783. [PMID: 27777269 PMCID: PMC5256399 DOI: 10.1136/medethics-2015-103333] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 09/06/2016] [Accepted: 09/27/2016] [Indexed: 05/03/2023]
Abstract
Use of a placebo control in surgical trials is a divisive issue. We argue that, in principle, placebo controls for surgery are necessary in the same way as for medicine. However, there are important differences between these types of trial, which both increase justification and limit application of surgical studies. We propose that surgical randomised placebo-controlled trials are ethical if certain conditions are fulfilled: (1) the presence of equipoise, defined as a lack of unbiased evidence for efficacy of an intervention; (2) clinically important research question; (3) the risk to patients is minimised and reasonable; (4) there is uncertainty about treatment allocation rather than deception; (5) there is preliminary evidence for efficacy, which justifies a placebo-controlled design; and (6) ideally, the placebo procedure should have some direct benefit to the patient, for example, as a diagnostic tool. Placebo-controlled trials in surgery will most often be justified when surgery is performed to improve function or relieve symptoms and when objective outcomes are not available, while the risk of mortality or significant morbidity is low. In line with medical placebo-controlled trials, the surgical trial (1) should be sufficiently powered and (2) standardised so that its results are valid, (3) consent should be valid, (4) the standard treatment or rescue medication should be provided if possible, and (5) after the trial, the patients should be told which treatment they received and there should be provision for post-trial care if the study may result in long-term negative effects. We comment and contrast our guidelines with those of the American Medical Association.
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Affiliation(s)
- Julian Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, Oxford, UK
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Andy Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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8
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Increased Patient Enrollment to a Randomized Surgical Trial Through Equipoise Polling of an Expert Surgeon Panel. Ann Surg 2016; 264:81-6. [DOI: 10.1097/sla.0000000000001483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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9
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Brown B, Egger S, Young J, Kneebone AB, Brooks AJ, Dominello A, Haines M. Changing attitudes towards management of men with locally advanced prostate cancer following radical prostatectomy: A follow-up survey of Australia-based urologists. J Med Imaging Radiat Oncol 2016; 60:744-755. [DOI: 10.1111/1754-9485.12483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/14/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Bernadette Brown
- Sax Institute; Sydney New South Wales Australia
- School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - Sam Egger
- Cancer Council NSW; Sydney New South Wales Australia
| | - Jane Young
- School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - Andrew B Kneebone
- Northern Sydney Cancer Centre; Sydney New South Wales Australia
- Northern Clinical School; University of Sydney; Sydney New South Wales Australia
| | - Andrew J Brooks
- NSW Agency for Clinical Innovation; Sydney New South Wales Australia
- Westmead Private Hospital; Sydney New South Wales Australia
- Westmead Clinical School; University of Sydney; Sydney New South Wales Australia
| | | | - Mary Haines
- Sax Institute; Sydney New South Wales Australia
- School of Public Health; University of Sydney; Sydney New South Wales Australia
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10
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Brown B, Young J, Kneebone AB, Brooks AJ, Dominello A, Haines M. Knowledge, attitudes and beliefs towards management of men with locally advanced prostate cancer following radical prostatectomy: an Australian survey of urologists. BJU Int 2016; 117 Suppl 4:35-44. [DOI: 10.1111/bju.13037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bernadette Brown
- Sax Institute; Haymarket New South Wales Australia
- School of Public Health; University of Sydney; Camperdown New South Wales Australia
| | - Jane Young
- School of Public Health; University of Sydney; Camperdown New South Wales Australia
| | - Andrew B Kneebone
- Northern Sydney Cancer Centre; Sydney New South Wales Australia
- Northern Clinical School; University of Sydney; Camperdown New South Wales Australia
| | - Andrew J Brooks
- Westmead Private Hospital; Westmead New South Wales Australia
- Westmead Clinical School; University of Sydney; Camperdown New South Wales Australia
- NSW Agency for Clinical Innovation; Sydney New South Wales Australia
| | | | - Mary Haines
- Sax Institute; Haymarket New South Wales Australia
- School of Public Health; University of Sydney; Camperdown New South Wales Australia
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Suen MKL, Zahid A, Young JM, Rodwell L, Solomon MJ, Young CJ. How to decide to undertake a randomized, controlled trial of stent or surgery in colorectal obstruction. Surgery 2015; 157:1137-41. [PMID: 25796417 DOI: 10.1016/j.surg.2015.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 12/12/2014] [Accepted: 01/07/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Colorectal stents have been available as a management option in obstruction for 23 years, yet there is little randomized evidence of their effectiveness. This study investigated current surgeon-related barriers to conducting a randomized, controlled trial (RCT) of colorectal stent insertion for obstruction in patients with colorectal cancer. METHODS A binational survey of current members of the Colorectal Surgical Society of Australia and New Zealand was conducted by a mailed questionnaire assessing perceived barriers to adoption of colonic stents and willingness to participate in future multicentre randomized controlled trials, and surgeons' treatment preferences in 16 hypothetical clinical scenarios. RESULTS Of 148 eligible surgeons, 96 (65%) responded. Colonic stenting was available to 98% of respondents. In the clinical setting of colorectal obstruction, only 29% (95% CI, 20-39%) of surgeons expressed a willingness to participate in a RCT involving colonic stents in the curative setting. More than 70% of surgeons preferred the use of stents in unfit patients for palliation, and preferred surgery in fit patients with curable disease. In the curative setting, most respondents considered colonic stents not cost effective (90%; 95% CI, 82-94%) and believed that their patients would not prefer stents over surgery (80%; 95% CI, 71-87%). CONCLUSION This study highlights the limitation to conducting a future randomized controlled trial to assess the efficacy of colonic stenting, especially in the curative setting, based on surgeon preference, despite the lack of level I evidence.
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Affiliation(s)
- Michael K L Suen
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, NSW, Australia; University of Sydney, Sydney, Australia
| | - Assad Zahid
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, NSW, Australia
| | - Jane M Young
- Surgical Outcomes Research Centre (SOuRCe), University of Sydney, Sydney, Australia
| | - Laura Rodwell
- Surgical Outcomes Research Centre (SOuRCe), University of Sydney, Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, NSW, Australia; Surgical Outcomes Research Centre (SOuRCe), University of Sydney, Sydney, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, NSW, Australia; University of Sydney, Sydney, Australia.
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12
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Corona J, Miller DJ, Downs J, Akbarnia BA, Betz RR, Blakemore LC, Campbell RM, Flynn JM, Johnston CE, McCarthy RE, Roye DP, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, Sturm PF, Thompson GH, Yazici M, Vitale MG. Evaluating the extent of clinical uncertainty among treatment options for patients with early-onset scoliosis. J Bone Joint Surg Am 2013; 95:e67. [PMID: 23677368 DOI: 10.2106/jbjs.k.00805] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Literature guiding the management of early-onset scoliosis consists primarily of studies with a low level of evidence. Evaluation of clinical equipoise (i.e., when there is no known superiority among treatment modalities) allows for prioritization of research efforts. The objective of this study was to evaluate areas of clinical uncertainty among pediatric spine surgeons regarding the treatment of early-onset scoliosis. METHODS Fourteen experienced pediatric spine surgeons participated in semistructured interviews to identify clinical variables that influence decision making in the treatment of early-onset scoliosis. A series of case scenarios of 315 patients with idiopathic and neuromuscular early-onset scoliosis was then developed to be representative of those encountered in clinical practice. Using an online survey, eleven surgeons selected their choice of eight treatment options for each case scenario. Associations between case characteristics and treatment choices were assessed with chi-square and logistic regression analysis. Participants then reviewed the areas of treatment uncertainty identified in the survey, nominated additional research questions of interest, and ranked their interest to further explore the identified research questions. RESULTS Collective equipoise was identified in numerous scenarios in the survey spanning a range of ages and magnitudes of scoliosis, and additional questions were identified during the nominal group technique. Areas that had the greatest clinical uncertainty included the management of patients who have finished treatment with a growing-rod, timing of rod-lengthening intervals, and indications for spine-based and rib-based proximal instrumentation anchors. The use of rib anchors compared with spine-based anchors was ranked highly for consideration in future clinical trials. CONCLUSIONS Variability in decision making with regard to the optimum treatment of certain subsets of patients with early-onset scoliosis reflects gaps in the available evidence. Structured consensus methods identified priorities for higher levels of research in this area of scoliosis. Higher-level studies, including randomized trials, should focus on answering the questions highlighted in this report.
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Affiliation(s)
- Jacqueline Corona
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, 701 North First Street, Room D220, Springfield, IL 62702, USA
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Parsons NR, Kulikov Y, Girling A, Griffin D. A statistical framework for quantifying clinical equipoise for individual cases during randomized controlled surgical trials. Trials 2011; 12:258. [PMID: 22166100 PMCID: PMC3261829 DOI: 10.1186/1745-6215-12-258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 12/13/2011] [Indexed: 12/28/2022] Open
Abstract
Background Randomised controlled trials are being increasingly used to evaluate new surgical interventions. There are a number of problematic methodological issues specific to surgical trials, the most important being identifying whether patients are eligible for recruitment into the trial. This is in part due to the diversity in practice patterns across institutions and the enormous range of available interventions that often leads to a low level of agreement between clinicians about both the value and the appropriate choice of intervention. We argue that a clinician should offer patients the option of recruitment into a trial, even if the clinician is not individually in a position of equipoise, if there is collective (clinical) equipoise amongst the wider clinical community about the effectiveness of a proposed intervention (the clinical equipoise principle). We show how this process can work using data collected from an ongoing trial of a surgical intervention. Results We describe a statistical framework for the assessment of uncertainty prior to patient recruitment to a clinical trial using a panel of expert clinical assessors and techniques for eliciting, pooling and modelling of expert opinions. The methodology is illustrated using example data from the UK Heel Fracture Trial. The statistical modelling provided results that were clear and simple to present to clinicians and showed how decisions regarding recruitment were influenced by both the collective opinion of the expert panel and the type of decision rule selected. Conclusions The statistical framework presented has potential to identify eligible patients and assist in the simplification of eligibility criteria which might encourage greater participation in clinical trials evaluating surgical interventions.
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Field CJ, Robinson S, Mackay S, Harrison JD, Marshall NS. Clinical Equipoise in Sleep Surgery. Otolaryngol Head Neck Surg 2011; 145:347-53. [DOI: 10.1177/0194599811406053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. Surgical approaches for alleviating snoring and/or obstructive sleep apnea (OSA) have been questioned because of a lack of evidence from high-quality randomized controlled trials (RCTs). An ethical requirement for RCTs is that they must test questions where community equipoise (ie, uncertainty) exists as to the correct treatment. We aimed to measure perceived importance, community equipoise, and willingness to enroll patients in 5 potential trial targets among members of the Australian Society for Otolaryngology Head and Neck Surgery (ASOHNS). Study Design, Setting, and Subjects. All ASOHNS members were surveyed using a multistage mail, email, Internet, and phone-based questionnaire. Methods. Equipoise was measured for each of the scenarios using a bidirectional linear scale comparing 2 treatments. Responses were categorized into 1 of 3 groups: (A) preferred treatment 1, (B) completely undecided, and (C) preferred treatment 2. The resulting proportions are called equipoise ratios: A:B:C. Using tick boxes, the authors queried the general clinical importance and willingness to enroll patients for all scenarios. Results. A total of 167 of 313 surgeons responded (53.4%). Three of the 5 trial scenarios exhibited evidence of community equipoise, but 2 scenarios, radiofrequency ablation plus uvulopalatopharyngoplasty (UPPP) versus UPPP alone and upper-airway reconstruction versus mandibular advancement splint (MAS), did not have strong support for enrolling patients. Informal feedback indicates one of these may be feasible in a smaller number of specifically trained surgeons. Conclusion. We suggest 2 potential RCT targets: septoplasty and turbinate reduction versus conservative measures for snoring and airway reconstruction versus MAS for OSA, where importance, clinical equipoise, and willingness all exist.
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Affiliation(s)
- Clarice J. Field
- Australasian Sleep Trials Network and National Health and Medical Research Council Centre for Integrated Research and Understanding of Sleep, Sydney Medical School, University of Sydney, Sydney, Australia
| | | | - Stuart Mackay
- University of Wollongong and the South-Eastern Sydney and Illawarra Area Health Service, Wollongong, Australia
| | - James D. Harrison
- Surgical Outcomes Research Centre, Sydney South West Area Health Service & School of Public Health, University of Sydney, Sydney, Australia
| | - Nathaniel S. Marshall
- Australasian Sleep Trials Network and National Health and Medical Research Council Centre for Integrated Research and Understanding of Sleep, Sydney Medical School, University of Sydney, Sydney, Australia
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Harrison JD, Masya L, Butow P, Solomon M, Young J, Salkeld G, Whelan T. Implementing patient decision support tools: moving beyond academia? PATIENT EDUCATION AND COUNSELING 2009; 76:120-125. [PMID: 19157763 DOI: 10.1016/j.pec.2008.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 10/02/2008] [Accepted: 12/12/2008] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To ascertain the feasibility of implementing three decision support tools (DSTs) for people with rectal cancer within the surgical consultation. METHODS Twenty colorectal surgeons participated in a focus group or individual interviews. Colorectal surgeons were also asked to complete a self-administered questionnaire. RESULTS All surgeons responded encouragingly to the concept of DSTs. However, for every positive statement an accompanying caveat was made and these were either a criticism of each tool or a barrier to their implementation. Surgeons stated DSTs should be used by patients and surgeons together (80%). The majority (70-75%) thought each tool was 'useful' or 'extremely useful'. However, there were strong views that in their current form the DSTs would not feasible to be used within the surgical consultation. Time restraints, personal and clinical characteristics of the patient, the content of each tool, the potential negative impact on the doctor-patient relationship were noted as real barriers to their implementation. CONCLUSION Surgeons have identified a number of barriers that may limit implementation of DSTs into routine clinical practice. PRACTICE IMPLICATIONS Feasibility and implementation studies have the potential to provide important information to help guide development, evaluation and implementation of DSTs.
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Affiliation(s)
- James D Harrison
- Surgical Outcomes Research Centre, Sydney South West Area Health Service & School of Public Health, University of Sydney, Sydney, NSW, Australia.
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Turner CE, Young JM, Solomon MJ, Ludlow J, Benness C, Phipps H. Willingness of pregnant women and clinicians to participate in a hypothetical randomised controlled trial comparing vaginal delivery and elective caesarean section. Aust N Z J Obstet Gynaecol 2009; 48:542-6. [PMID: 19133040 DOI: 10.1111/j.1479-828x.2008.00923.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible. AIMS To ascertain the proportion of primiparas and clinicians who would participate in a hypothetical randomised controlled trial comparing vaginal delivery with elective caesarean section. METHODS Pregnant women (mean 22 weeks gestation) recruited from public and private antenatal clinics at a major tertiary referral centre were interviewed to ascertain their willingness to participate in a hypothetical randomised controlled trial. A self-administered questionnaire was mailed to midwives, obstetricians, urogynaecologists and colorectal surgeons, and results between groups were compared. RESULTS One hundred pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 87 colorectal surgeons participated. Only 14% (95% confidence interval (CI), 8-22) of pregnant women and 31% (95% CI, 26-36) of clinicians indicated that they would participate in a randomised controlled trial. CONCLUSIONS A randomised controlled trial comparing vaginal delivery and elective caesarean section may not be feasible due to low levels of willingness to participate, particularly among pregnant women.
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Affiliation(s)
- Catherine E Turner
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
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Wong S, Solomon M, Crowe P, Ooi K. CURE, CONTINENCE AND QUALITY OF LIFE AFTER TREATMENT FOR FISTULA-IN-ANO. ANZ J Surg 2008; 78:675-82. [DOI: 10.1111/j.1445-2197.2008.04616.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Young JM, Solomon MJ, Harrison JD, Salkeld G, Butow P. Measuring patient preference and surgeon choice. Surgery 2008; 143:582-8. [PMID: 18436005 DOI: 10.1016/j.surg.2008.01.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 01/15/2008] [Indexed: 11/30/2022]
Abstract
One of the major barriers to randomized trials in the field of surgery is the presence of strong preferences for one of the treatment options. Patients and surgeons who favor strongly a particular treatment approach are usually reluctant to participate in trials where operative intervention is determined on the basis of randomization. This then affects both the feasibility of the trial in terms of achieving the required sample size as well as the generalizability of the study's findings. Therefore, measurement of patient and surgeon preference is a crucial component of the feasibility assessment for surgery trials. In this article, we introduce the Prospective Measure of Preference, which is a novel method to measure preferences that has been designed to accommodate the complexity of surgical decision-making. We also present a simple method to measure individual and community equipoise among expert clinicians to assess the feasibility of future randomized trials in surgery.
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Affiliation(s)
- Jane M Young
- Surgical Outcomes Research Centre, University of Sydney and Royal Prince Albert Hospital, Sydney, Australia.
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Raymond J, Nguyen T, Chagnon M, Gevry G. Unruptured Intracranial Aneurysms. Opinions of Experts in Endovascular Treatment Are Coherent,Weighted in Favour of Treatment, and Incompatible with ISUIA. Interv Neuroradiol 2007; 13:225-37. [PMID: 20566114 PMCID: PMC3345486 DOI: 10.1177/159101990701300302] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2007] [Accepted: 08/14/2007] [Indexed: 12/30/2022] Open
Abstract
SUMMARY In the absence of level one evidence, the treatment of unruptured intracranial aneurysms is grounded on opinions. Results of the largest registry available, ISUIA (the International Study on Unruptured Intraacranial Aneurysms) suggest that surgical or endovascular treatments are rarely justified. Yet the unruptured aneurysm is the most frequent indication for treatment in many endovascular centres. In preparation for the initiation of a randomized trial, we aimed at a better knowledge of endovascular expert opinions on unruptured aneurysms. We administered a standard questionnaire to 175 endovascular experts gathered at the WFITN meeting in Val d'Isère in 2007. Four paradigm unruptured aneurysms were used to poll opinions on risks of treatment or observation, as well as on their willingness to treat, observe or propose to the patient participation in a randomized trial, using six questions for each aneurysm. Opinions varied widely among lesions and among participants. Most participants (92.5%) were consistent, as they would offer treatment only if their estimate of the ten-year risk of spontaneous hemorrhage would exceed risks of treatment. Estimates of the natural history were consistently higher than that reported by ISUIA. Conversely, treatment risks were underestimated compared to those reported in ISUIA, but within the range reported in a recent French registry (ATENA). Participants were more confident in their evaluation of treatment risks and in their skills at treating aneurysms than in their estimates of risks of rupture entailed by the presence of the lesion, the latter being anchored at or close to 1%/year. The gulf between expert opinions, clinical practices and available data from registries persist. Expert opinions are compatible with the primary hypothesis of a recently initiated randomized trial on unruptured aneurysms (TEAM), which is a benefit of endovascular treatment of 4% compared to observation over ten years.Only data from a randomized trial could provide convincing objective evidence in favour or against preventive treatment of unruptured intracranial aneurysms.
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Affiliation(s)
- J Raymond
- Interventional Neuroradiology Research Unit, Department of Radiology, Centre hospitalier de l'Université de Montréal (CHUM) - Notre-Dame Hospital, Montreal, Canada -
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Scales CD, Preminger GM, Keitz SA, Dahm P. Evidence Based Clinical Practice: A Primer for Urologists. J Urol 2007; 178:775-82. [PMID: 17631350 DOI: 10.1016/j.juro.2007.05.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Indexed: 12/11/2022]
Abstract
PURPOSE Evidence based clinical practice has been defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. It refers to a broad set of principles and methods intended to ensure that medical decisions, guidelines and health policy are based on well designed studies of therapeutic effectiveness and benefit. MATERIALS AND METHODS We review the principles and practice of evidence based clinical practice using examples from the urology literature. We further provide a guide to currently available web based evidence based clinical practice resources and guidelines for urologists. RESULTS Evidence based clinical practice integrates a hierarchy of evidence and patient values with practitioner judgment to guide decision making for the individual patient. Important steps in the evidence based clinical practice process include the formulation of an answerable question and a systematic search of the literature. In the absence of pre-appraised evidence or disease specific guidelines, the practice of evidence based clinical practice relies heavily on the evaluation of the primary literature by the individual urologist. Depending on the question domain (therapy/prevention, etiology/cause/harm, diagnosis or prognosis) and study design, a given study is critically appraised for validity, impact and applicability. Evidence is then integrated with clinical judgment, and patient circumstances and preferences. Finally, the practice of evidence based clinical practice includes a self-assessment of provider performance. CONCLUSIONS Knowledge, practice and documentation of evidence based clinical practice are of increasing importance to every urologist. Urologists should embrace evidence based clinical practice principles by acquiring the necessary skills to critically appraise the literature for the best evidence applicable to patient care.
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Affiliation(s)
- Charles D Scales
- Department of Surgery, Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Harrison JD, Solomon MJ, Young JM, Meagher A, Hruby G, Salkeld G, Clarke S. Surgical and oncology trials for rectal cancer: Who will participate? Surgery 2007; 142:94-101. [PMID: 17630005 DOI: 10.1016/j.surg.2007.01.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Revised: 12/22/2006] [Accepted: 01/02/2007] [Indexed: 12/14/2022]
Abstract
BACKGROUND The assessment of patients' and clinicians' willingness to participate in clinical trials is advisable as part of a feasibility exercise prior to the commencement of randomized controlled trials (RCTs) to ensure adequate support in terms of likely accrual to achieve the required sample size in a timely fashion. Furthermore, understanding why patients are unwilling to enter RCTs is imperative before the current trend of low participation can be reversed. METHODS Patients, colorectal surgeons, and medical and radiation oncologists, were presented with 5 different, detailed treatments for locally advanced rectal cancer. They were asked whether they would be willing to enter an RCT comparing each treatment choice. Patients who would not participate were asked to indicate their reason for refusal. RESULTS Patients' willingness to participate in each trial was consistently low (19% to 32%). Similar low levels of participation were indicated by each clinical subspecialty (15% to 38%). Of the scenarios, patients and clinicians were most willing to enter a trial investigating surgery plus preoperative radiotherapy. A dislike of randomization, a desire to be involved in decision-making, and quality of life considerations were the most commonly stated reasons for refusal. CONCLUSIONS This study highlights the difficulties in performing RCTs in surgery and oncology. However, results suggest that improvements in communication regarding randomization and clinical trial processes and the actual, rather than perceived, side effects of treatments are strategies that may enhance patient participation.
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Affiliation(s)
- James D Harrison
- Surgical Outcomes Research Centre, Sydney South West Area Health Service & University of Sydney, Sydney, Australia.
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Dolan LA, Donnelly MJ, Spratt KF, Weinstein SL. Professional opinion concerning the effectiveness of bracing relative to observation in adolescent idiopathic scoliosis. J Pediatr Orthop 2007; 27:270-6. [PMID: 17414008 PMCID: PMC4668936 DOI: 10.1097/01.bpb.0000248579.11864.47] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine if community equipoise exists concerning the effectiveness of bracing in adolescent idiopathic scoliosis. BACKGROUND DATA Bracing is the standard of care for adolescent idiopathic scoliosis despite the lack of strong reasearch evidence concerning its effectiveness. Thus, some researchers support the idea of a randomized trial, whereas others think that randomization in the face of a standard of care would be unethical. METHODS A random of Scoliosis Research Society and Pediatric Orthopaedic Society of North America members were asked to consider 12 clinical profiles and to give their opinion concerning the radiographic outcomes after observation and bracing. RESULTS An expert panel was created from the respondents. They expressed a wide array of opinions concerning the percentage of patients within each scenario who would benefit from bracing. Agreement was noted concerning the risk due to bracing for post-menarchal patients only. CONCLUSIONS : This study found a high degree of variability in opinion among clinicians concerning the effectiveness of bracing, suggesting that a randomized trial of bracing would be ethical.
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Affiliation(s)
- Lori A Dolan
- Department of Orthopaedics and Rehabilitation, University of Iowa Health Care, Iowa City, IA 52242, USA.
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Harrison JD, Carter J, Young JM, Solomon MJ. Difficult clinical decisions in gynecological oncology: identifying priorities for future clinical research. Int J Gynecol Cancer 2006; 16:1-7. [PMID: 16445602 DOI: 10.1111/j.1525-1438.2006.00424.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This study investigates the acceptability and feasibility of conducting randomized controlled trials (RCTs) in gynecological oncology by ascertaining the views of the Australian Society of Gynaecologic Oncologists (ASGO) about important clinical questions in this field, current treatment preferences, and willingness to participate in trials to address these questions. Members of ASGO received a mailed survey. Thirty-one gyneoncologists participated in this study (79% response fraction). There was considerable support for an RCT (81%; 95% confidence interval [CI], 63-93%) to compare sentinel node biopsy with total groin dissection for women with vulval cancer. This clinical question was also rated as "extremely" or "very" important by 91% (95% CI, 74-98%) of respondents, who also indicated high levels of individual equipoise. Another priority for research involved the use of second-line chemotherapy for women who have rising CA125 titers. This clinical question was rated as extremely or very important by 71% (95% CI, 52-86%), exhibited high levels of individual equipoise, with 74% (95% CI, 55-88%) of respondents willing to participate in an RCT to address this issue. The conduct of surveys of representative groups of clinicians provides useful empirical data to focus clinical research efforts where they are most likely to be successful based on equipoise, feasibility, and clinical interest.
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Affiliation(s)
- J D Harrison
- Surgical Outcomes Research Centre, Sydney South West Area Health Service and the University of Sydney, Missenden Road, NSW 2050, Sydney, Australia.
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Toniato A, Bernante P, Rossi GP, Pelizzo MR. The Role of Adrenal Venous Sampling in the Surgical Management of Primary Aldosteronism. World J Surg 2006; 30:624-7. [PMID: 16568223 DOI: 10.1007/s00268-005-0482-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Primary aldosteronism is the most common endocrine form of secondary hypertension, but no single test or imaging method always identifies it. Identification of a unilateral overproduction of aldosterone due to Conn's adenoma or unilateral hyperplasia is of utmost importance to the surgeon. MATERIALS AND METHODS We reviewed our experience with primary aldosteronism in 46 consecutive patients who had undergone adrenalectomy at the Surgical Pathology Institute, University of Padua since 1993. All the patients underwent a CT scan. Adrenal venous sampling was performed in those patients with negative or equivocal findings on imaging studies. RESULTS Computed tomography was non-contributory in 12 patients and frankly misleading in 2 patients, demonstrating a probable mass lesion in the contralateral but not in the ipsilateral adrenal. Eighteen patients had selective venous sampling that was successful in altering the management of 14 cases. Eleven patients who biochemically had an adrenal adenoma, had normal/equivocal CT, while the remaining 3 had bilateral or contralateral adrenal masses. Venous sampling localized aldosterone secretion and an adenoma, less than 1 cm in diameter, was removed, curing their hypertension. Eleven patients were treated by open adrenalectomy and 35 by the lateral transperitoneal laparoscopic approach. Histological examination revealed 45 Conn's adenomas, of which 13 had a diameter of less than 1 cm (range 0.3-0.8), and 1 case of nodular hyperplasia. CONCLUSIONS Patients who have equivocal or unexpected CT findings should proceed to hormonal localization. Adrenal venous sampling is essential in patients with equivocal CT scans to avoid unnecessary and inappropriate adrenalectomy.
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Affiliation(s)
- Antonio Toniato
- Department of Medical Surgical Sciences, School of Medicine, University of Padua, Padua 35128, Italy.
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Young JM, O'brien C, Harrison JD, Solomon MJ. Clinical trials in head and neck oncology: An evaluation of clinicians' willingness to participate. Head Neck 2006; 28:235-43. [PMID: 16265653 DOI: 10.1002/hed.20315] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study investigated the individual and collective ("community") equipoise of surgeons and oncologists and their willingness to take part in each of six hypothetical randomized controlled trials in head and neck oncology. METHODS A survey was mailed to Australasian head and neck specialists. RESULTS Among 109 respondents (74% response), the scenario with the highest level of individual equipoise pertained to the use of adjuvant interferon for patients with high-risk malignant melanoma, with 45% indicating complete uncertainty between treatment approaches. Significant differences in levels of community equipoise were demonstrated between surgeons and oncologists for three of the scenarios. Willingness to participate in randomized controlled trials ranged from 39% to 72%. Increasing strength of treatment preference was associated with unwillingness to participate in randomized controlled trials for two of six scenarios. CONCLUSION High levels of equipoise and willingness to participate in clinical research augur well for future randomized controlled trials in head and neck oncology.
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Affiliation(s)
- Jane M Young
- Surgical Outcomes Research Centre, Sydney South West Area Health Service and the University of Sydney, PO Box M157, Missenden Rd NSW 2050, Sydney, Australia.
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Guller U. Surgical Outcomes Research Based on Administrative Data: Inferior or Complementary to Prospective Randomized Clinical Trials? World J Surg 2006; 30:255-66. [PMID: 16485067 DOI: 10.1007/s00268-005-0156-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The importance of surgical research has gained new prominence over the past decades as the relevance of well designed and well conducted studies has become increasingly evident. There are two basic but diametrically different methods of conducting research: the prospective randomized clinical trial and the retrospective surgical outcomes study based on administrative data. Administrative databases contain data that were initially collected for purposes other than scientific research. Whereas the prospective randomized clinical trial is familiar to most surgeons, surgical outcomes research based on administrative data constitutes a genre of investigation that is often unfamiliar to and even disparaged by the surgical community. In the present article, the strengths and weaknesses of both prospective randomized clinical trials and retrospective surgical outcomes research are discussed. Specifically, the advantages and limitations of investigations based on large administrative databases are outlined. Because both study designs play an important role in surgical research, carefully designed and implemented surgical outcomes research based on administrative data should be viewed as being complementary and not inferior to prospective randomized clinical trials.
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Affiliation(s)
- Ulrich Guller
- Department of Surgery, Division of General Surgery, University Hospital Basel, Basel, CH-4031, Switzerland.
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