Shared decision-making in palliative cancer care:a life span perspective

Background: Due to complex treatment decisions, shared decision-making is advocated for in elderly cancer patients and in palliative cancer care. However, the process of (shared) decision-making is not comprehensively understood in these groups. Studies suggest age-based differences in patients’ level of preferences and actual involvement. Methods: Patients with metastatic cancers (n = 77) were included in three age groups: ‘middle aged’ (40-64 years), ‘young elderly-’ (65-74 years) and ‘old elderly’ (≥ 75 years). A cross-sectional questionnaire assessed patients’ preferences (CPS), perceived involvement (PICS), level of information (decisional conflict scale) and self-efficacy in patient-physician interaction (PEPPI), health-related quality of life (EORTC QLQ-C30), loneliness and temporal perspective (TFS) as potential correlates. Findings: Χ2 testing revealed that preferences, perceived participation and degrees of concordance do not differ between age groups. A majority of patients preferred and perceived to be involved in decision-making. Nearly 20% of patients was less involved than preferred. Age related factors were not related to perceived and preferred decision-making, although ‘old elderly’ patients were less encouraged by their oncologist to talk about worries. Shared decision-making was more often perceived by women than men and was associated with higher levels of self-efficacy in communication with oncologists. Discussion: Age-related differences with regard to decision making preferences and perceived participation seemed to be cancelled out in palliative cancer care, probably due to near-to-death perception. If clinical practice aims to achieve higher concordance levels, patients’ preferences for involvement should be explicitly discussed. Increased attention to (older) patients’ psycho-social needs is suggested

Genioplasty

Genioplasty can enhance the esthetic features of the face. The operative procedure concerns mainly osteotomy of the lower border of the anterior region of the mandible. The commonly used types of osteotomies are discussed and subdivided in all planes of reference.</p

Genioplasty

Genioplasty can enhance the esthetic features of the face. The operative procedure concerns mainly osteotomy of the lower border of the anterior region of the mandible. The commonly used types of osteotomies are discussed and subdivided in all planes of reference.</p

Genioplasty

Genioplasty can enhance the esthetic features of the face. The operative procedure concerns mainly osteotomy of the lower border of the anterior region of the mandible. The commonly used types of osteotomies are discussed and subdivided in all planes of reference.</p

Genioplasty

Genioplasty can enhance the esthetic features of the face. The operative procedure concerns mainly osteotomy of the lower border of the anterior region of the mandible. The commonly used types of osteotomies are discussed and subdivided in all planes of reference.</p

Genioplasty

Genioplasty can enhance the esthetic features of the face. The operative procedure concerns mainly osteotomy of the lower border of the anterior region of the mandible. The commonly used types of osteotomies are discussed and subdivided in all planes of reference.</p

Genioplasty

Genioplasty can enhance the esthetic features of the face. The operative procedure concerns mainly osteotomy of the lower border of the anterior region of the mandible. The commonly used types of osteotomies are discussed and subdivided in all planes of reference.</p

Evaluation of laxity tests with a musculoskeletal model of total knee arthroplasty

Introduction Musculoskeletal models are emerging as potential tools for the use in many clinical applications. One important example is aid to the clinical decision in the orthopaedic field. Recently, a patient-specific model of Cruciate-Retaining Total Knee Arthroplasty (CR-TKA) was presented and validated with respect to knee joint forces and kinematics [1]. However, the ligament restraints were not calibrated and inaccuracies in knee kinematic predictions were present. The objective of this study was to evaluate the effect of ligament calibration on the performance of simulated laxity tests. Methods A musculoskeletal model of CR-TKA was previously described [1]. The model comprised the musculoskeletal architecture of a TKA patient and a force-dependent model of the prosthetic knee and patellofemoral joint. Ligament restraints were modelled using non-linear springs and contact was solved using a rigid formulation. To calibrate the ligament parameters we simulated anterior/posterior, valgus/varus and endo-/exorotation laxity tests. Each test was performed at four different knee flexion angles (0, 30, 60, 90 deg). The anterior (respectively posterior) laxity load consisted of a 35 N force applied on the tibia at a distance of approximately 15 cm from the surface of the tibial component, pointing anteriorly (respectively posteriorly). Valgus (respectively varus) test was simulated by applying a force on the tibia at a distance of approximately 15 cm from the ankle joint, pointing laterally (respectively medially) so that the resulting moment was equal to 10 Nm. For the endo- (respectively exo-) rotation a 1.5 Nm torque was applied to the longitudinal axis of the tibia. Laxity envelopes for each test were calculated as the difference between the values obtained in the two opposite directions of the test. Manual changes to ligament insertion site, stiffness, and reference strain were made iteratively in order to obtain laxity envelopes close to those reported in the literature for cadaveric tests on a CR-TKA [2]. All the laxity tests were eventually simulated with the same ligament configuration. Results The results for all simulated laxity tests and the reference values from the literature are summarized in Table 1. 0° 30° 60° 90° AP (M) 3.5mm 4.2mm 1.0mm 1.0mm AP (L) 1.5mm 5mm 4mm 4.5mm VV (M) 0.9° 4.3° 2.6° 1.5° VV (L) 3.0° 6.0° 7.0° 7.0° EE (M) 7.0° 16.5° 4.0° 5.5° EE (L) 6.5° 22.0° 21.0° 23.0° Table 1: AP: Anterior/Posterior, VV: Valgus/Varus, EE: Endo-/Exorotation, M: Model prediction, L: Literature value Discussion The laxity envelopes predicted by the model were in partial agreement with those reported in the literature. The largest differences were noted for 60-90 degrees of knee flexion for all laxity tests, where the model showed considerably less laxity. These deviations may be attributable to actual differences between the implant design and subject geometry currently simulated and those used in the cadaveric tests. In future studies we aim to simulate surgical variations such as implant size and positioning, joint line elevation and ligament restraint. This musculoskeletal model of TKA has potential as a pre-operative planning tool for orthopaedic interventions. References Marra et al, J Biomech Eng, 137, 2015 Saeki et al, Clin Orthop Relat Res, 392:184-189, 200

Computed Tomography-Based Body Composition Is Not Consistently Associated with Outcome in Older Patients with Colorectal Cancer

Background: Current literature is inconsistent in the associations between computed tomography (CT)-based body composition measures and adverse outcomes in older patients with colorectal cancer (CRC). Moreover, the associations with consecutive treatment modalities have not been studied. This study compared the associations of CT-based body composition measures with surgery- and chemotherapy-related complications and survival in older patients with CRC. Materials and Methods: A retrospective single-center cohort study was conducted in patients with CRC aged ≥65 years who underwent elective surgery between 2010 and 2014. Gender-specific standardized scores of preoperative CT-based skeletal muscle (SM), muscle density, intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), subcutaneous adipose tissue, IMAT percentage, SM/VAT, and body mass index (BMI) were tested for their associations with severe postoperative complications, prolonged length of stay (LOS), readmission, and dose-limiting toxicity using logistic regression and 1-year and long-term survival (range 3.7–6.6 years) using Cox regression. Bonferroni correction was applied to account for multiple testing. Results: The study population consisted of 378 patients with CRC with a median age of 73.4 (interquartile range 69.5–78.4) years. Severe postoperative complications occurred in 13.0%, and 39.4% of patients died during follow-up. Dose-limiting toxicity occurred in 77.4% of patients receiving chemotherapy (n = 53). SM, muscle density, VAT, SM/VAT, and BMI were associated with surgery-related complications, and muscle density, IMAT, IMAT percentage, and SM/VAT were associated with long-term survival. After Bonferroni correction, no CT-based body composition measure was significantly associated with adverse outcomes. Higher BMI was associated with prolonged LOS. Conclusion: The associations between CT-based body composition measures and adverse outcomes of consecutive treatment modalities in older patients with CRC were not consistent or statistically significant. Implications for Practice: Computed tomography (CT)-based body composition, including muscle mass, muscle density, and intermuscular, visceral, and subcutaneous adipose tissue, showed inconsistent and nonsignificant associations with surgery-related complications, dose-limiting toxicity, and overall survival in older adults with colorectal cancer. This study underscores the need to verify whether CT-based body composition measures are worth implementing in clinical practice