Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Pseudomixoma peritonei associated with appendiceal cistoadenoma rupture: case report

Appendiceal mucocele represents specimen finding in 0.2-0.3% out of appendectomies. The rupture or perforation in peritoneal cavity might cause pseudomixoma peritonei (PMP), with multiple mucinous deposits in the abdominal cavity. We report a case of PMP caused by a perforated appendiceal cistoadeonoma.

Sequential Treatment with Interferon and Chemotherapy of Metastatic Malignant Melanoma. Total Remission of Cutaneous and Visceral Metastasis, but not of Cerebral Metastasis

A woman 35 years of age suffering from cutaneous and visceral metastatic melanoma was treated with recombinant Interferon α 2b (rIFNα2b) subcutaneously 3 × 106 U/m2 3 times a week for 3 months with no apparent effect on the course of the illness. Two months after IFN therapy the patient developed cerebral metastasis. A cycle of carmustine, 100 mg/day for 3 days, was given, and complete disappearance of the cutaneous and visceral, but not of the cerebral manifestations was observed. Two consolidation cycles based on vincristine, dacarbazine and lomustine were then administered. The patient died 26 months after beginning treatment with IFN and 18 months after chemotherapy for the cerebral metastasis. No trace of tumor at the cutaneous or visceral level was found at autopsy.

Adenosine kinase gene expression in human colorectal cancer

Real-time reverse transcription polymerase chain reaction (qRT-PCR) was used to evaluate gene expression of adenosine kinase, a key enzyme in adenosine metabolism, in human intestinal biopsy specimens of 10 colorectal cancer patients. Quantitative mRNA expression levels were normalized against the reference gene beta-actin. The results showed that adenosine kinase gene expression was significantly higher in cancer than in normal-appearing tissue, in line with our previous measurements of adenosine kinase enzyme activities in colorectal tumor samples.

[Comparison between virtual and conventional colonoscopy in the screening of colorectal polyps]

Aim of this study was to compare virtual and conventional colonoscopy for the detection of colon-rectal polyps. The authors studied 20 patients with these two methods and it was found that virtual colonoscopy is dependent on the size of lesions regarding sensitivity and specificity, is expensive and the learning process with reading images is very long.

[Gastrointestinal stromal tumors: a series of 23 surgically treated cases]

AIM OF THE STUDY

The recently introduced new nosological category, Gastro Intestinal Stromal Tumors, brought the Authors to a revision of their series and to a critical analysis of surgical behaviour for the treatment of that pathology.

MATERIAL AND METHOD

A series of 23 cases of GIST, observed between 1977 and 1999 has been taken into account. In the earlier cases, histopathological classification has been reviewed according to the most used criterions in international scientific literature.

RESULTS

17 of 23 observed tumors were located on the stomach, 4 on the duodenum and 2 on the jejunum. 20 of these cases derived from muscular tissue and 3 cases derived both from muscular and neural tissues. In 7 cases (30%) tumors were accidentally discovered during surgical intervention or diagnostic procedures for other causes. Surgical treatment was performed in all cases and consisted in 6 gastric resections, 14 gastric free-margin excisions, 2 duodenal resections and 1 jejunal resection. The follow-up (performed on 18 patients, with a minimum of 1 year, a maximum of 17 years and a median of 6 years) showed 2 deaths (11%) due to oncological causes, while 2 of the patients (11%) died for other causes.

CONCLUSIONS

The only treatment for that group of tumors is, at the moment, surgery. Although that kind of neoplasms has mainly non-aggressive biological behaviour, a radical resection must be performed, due to the absence of macroscopic criterions to help distinguishing, during surgical intervention, aggressive tumors from non-aggressive ones.

Adenomas with severe dysplasia and early carcinoma of the colon-rectum: our experience of 27 patients

Authors report their experience in the treatment of adenomas with severe dysplasia and early cancer of the colon-rectum confirming that the endoscopic resection of these lesions is safe and curative when completely removed and no submucosal invasion is found. Between 1995 and 1999, 219 patients underwent colonoscopy and 287 polyps were removed. Histologic examination showed 217 adenomatous polyps (75.6%), 58 non adenomatous (20.2%) and 12 early carcinomas (4.2%). Severe dysplasia was found in 15 adenomas. There were no complications. The Authors focused on 12 patient with early carcinoma and 15 with severe dysplasia. The mean follow-up was 34 months. No recurrences were observed, supporting that this procedure is the treatment of choice in selected cases.

Administration of antigen by intralymphatic route in the rat. II. Results in tumor active immunotherapy (delta). Preliminary report

Tumor growth and survival time were followed in rats transplanted with Morris hepatoma 5123 and previously injected with a crude homogenate of the same tumor by the intradermic or intralymphatic route. Female rats treated by the intralymphatic route showed a longer survival time and impaired tumor growth. Male rats did not show any difference.

Administration of antigen by intralymphatic route in the rat I. Humoral response to soluble antigens. (delta). Preliminary report

Male rats were immunized against bovine albumin injected by either intradermic or intralymphatic routes. A significantly higher number of animals treated by the latter route did respond, probably because antigens introduced by this route directly reach lymph nodes, by passing blood and tissue lytic enzymes.

Technique of lymphography in the rat

Most the lymphatic system in the rat was directly observed in our experiment by radiological means. The lymphatics of the limbs were firstly revealed by subcutaneous injection of Patent Blue V. Lipiodol was used as radio-opaque compound injected by a micro-technique fully described by the authors.