Thyroid cancer patients' involvement in adjuvant radioactive iodine treatment decision-making and decision regret: an exploratory study.

PURPOSE: We explored regret in thyroid cancer patients, relating to the decision to accept or reject adjuvant radioactive iodine treatment. METHODS: We studied patients with a recent diagnosis of early stage papillary thyroid carcinoma, in whom treatment decisions on adjuvant radioactive iodine had been finalized. Participants completed a Decision Regret Scale questionnaire. We asked the participants to identify who made the final decision about radioactive iodine treatment. We explored the relationship between decision regret and a) degree of patient involvement in decision-making and b) receipt of radioactive iodine treatment. RESULTS: We included 44 individuals, more than half of whom received adjuvant radioactive iodine treatment (26/44). Decision regret was generally low (mean 22.1, standard deviation [SD] 13.0). Participants reported that the final treatment decision was made by the following: patient and doctor (52.3%, 23/44), completely the patient (27.3%, 12/44), or completely the physician (20.5%, 9/44). Decision regret significantly differed according to who made the final decision: the patient (mean 19.0, SD 11.3), patient and doctor (mean 19.5, SD 7.4), and the doctor (mean 32.9, SD 20.37) (F = 4.569; degrees of freedom = 2, 41; p = 0.016). There was no significant difference in decision regret between patients who received radioactive iodine and those who did not (mean difference -2.5; 95% confidence interval -10.6, 5.6; p = 0.540). CONCLUSION: Thyroid cancer patients who reported being involved in the final treatment decision on adjuvant radioactive iodine had less regret than those who did not.

How can we meet the information needs of patients with early stage papillary thyroid cancer considering radioactive iodine remnant ablation?

In patients with early stage papillary thyroid carcinoma (PTC) who have had a thyroidectomy, the decision must be made to accept or reject radioactive iodine remnant ablation (RRA). Counselling patients about this decision can be challenging, given the medical evidence uncertainties and the complexity of related information. Although physicians are the primary source of medical information for patients considering RRA, some patients have a desire for supplemental information from sources such as the internet. Yet, thyroid cancer resources on the internet are of variable quality, and some may not be applicable to the individual case. We have developed a computerized educational tool [called a decision aid (DA)], directed to patients with early stage papillary thyroid cancer, and intended as an adjunct to physician counselling, to relay evidence-based medical information on disease prognosis and the choice to accept or reject RRA. DAs are tools used to inform patients about available treatment options and have been utilized in oncologic decision-making. We tested our web-based DA in fifty patients with early stage PTC and found that it improved medical knowledge. Furthermore, participants found the technical usability of the tool acceptable. We are currently conducting a randomized controlled trial comparing the use of the DA plus usual care to usual care alone to confirm the educational benefit of the website and examine its impact on the decision-making process. In the future, DAs may play an expanded role as an adjunct to physician counselling in the care of patients with thyroid cancer.

Development of software for pulse oximeter and investigation of its realtime response in clinical environment.

We developed a pulse oximeter software at Thorax Centre, Erasmus University as a joint project with an industry and evaluated it in the clinical environment of thorax anaesthesia using a computerized protocol for realtime data collection during routine clinical procedures. This paper gives an account of the results we obtained from the development project and the clinical study. The paper consists of two parts. First part describes different components of the software module and their influence on different aspects of the clinical behaviour of the oximeter. The second part describes the results of realtime response investigation. The investigation was carried out using a personal computer to collect the data continuously during anaesthesia, surgery and post-operative periods. Two other industry standard oximeters, Nellcor and Ohmeda were also included in our study. We collected data on more than fifty patients on an average of eight hours per patient over a period of four months with major emphasis on low-saturation occurrences. The interpretation of the data was focused more on the realtime response anomalies on random cases than on ensemble statistical data evaluation. We found, that there are few factors in clinical environment which often influences the measurement of a pulse oximeter very strongly. Most often the anomalies were found during low saturation measurement. The main objective of this paper is to make the results available to practising clinicians so that it may be useful to identify these occurrences during routine clinical usage.

Real-time respiratory monitoring workstation--software and hardware engineering aspects.

We have applied advanced real-time techniques in software, that are intensively used in critical areas like space research and defence applications, to realise an Integrated Real-Time Respiratory Monitoring System at the Thorax Anesthesiology, Academic Hospital Rotterdam. The system is called the 'SERVO WINDOW'--a window to the servo ventilator. The heart of the system is a real-time kernel that uses preemptive scheduling to achieve multitasking on a IBM PC compatible hardware platform. To the clinician this means that he gets all relevant information from one source i.e. the Respiratory Workstation. The waveforms of the airway pressure, airway flow and the expired CO2 curve are displayed continuously on the screen. The Vector Loops like Pressure Volume, Flow Pressure and Flow Volume loops are also available in addition to the lung mechanics parameters like Expiratory and Inspiratory Resistances, Compliances, Peak Pressure, PEEP, etc. The Single Breath Diagram i.e. expired CO2 concentration versus volume and dead space ventilation is also calculated. The blood gas analysis data is plotted in convenient diagrams like the O2-CO2 diagram, Oxygen Chart, etc. The trend of all these parameters are available with a granularity of one minute. An industry standard laser printer is used for report generation to produce reports of the real-time waveforms, parameter values and the trends. User interface is through easy menus with the traditional keyboard, touchscreen including keyboard on screen for data entry and the mouse.

A new approach: reusable real-time database for medical instrumentation applications.

Medical instrumentation (MI) software development work differs from other software development works mainly in the testing and validation phase. For MI software, this phase has always been most difficult, time-consuming and yet the most doubted phase. The primary reason being the input to these programs (ie) the physiological signals like ECG, pulse, etc. To be more specific, the problem is because 1. These physiological signal patterns vary so widely from person to person and hence these programs have to be validated statistically on all categories of persons including those on the extreme ends. 2. There are also artifacts riding on these signals (inherent, intentional or due to inevitable physical movements) 3. These signals are real-time ones to the order of a second. Above all, 4. They are not reproducible patterns, if you need them for study and analysis at a later date. Though it is tough to find alternatives for the present technique of statistical validation, there can be ways to make use of this time-consuming validation process to its fullest potential. One such way is to make a kind of 'CAPTURE-RETAIN AND REUSE' databases that can reduce the future efforts in the validation phase substantially. The main areas where these databases can make vital contributions are: 1. Medical Instrumentation software testing and validation 2. Medical Instruments' results and performance comparison 3. Expert system building, testing and enhancement of its capabilities.

Proteinmorphosis: a mechanical model for protein conformational changes.

Proteinmorphosis is a physically-based interactive modeling system for simulating large or small conformational changes of proteins and protein complexes. It takes advantage of the cross-linked one-dimensional nature of protein chains. The user can, based on her chemical knowledge, pull pairs of points (lying either on a single protein or on different molecules) together by specifying geometric distance constraints. The resulting conformation(s) of the molecule(s) of interest is computed by an efficient finite element formalism taking into account elasticity of the protein backbone, van der Waals repulsions, hydrogen bonds, salt bridges and the imposed distance constraints. The conformational change is computed incrementally and the result can be visualized as an animation; complete interactivity is provided to position and view the proteins as desired by the user. Physical properties of regions on the protein can also be chosen interactively. The conformational change of calmodulin upon peptide binding is examined as a first experiment. It is found that the result is satisfactory in reproducing the conformational change that follows on peptide binding. We use Proteinmorphosis to study the cooperative hemoglobin oxygen binding mechanism in a second, more sophisticated, experiment. Different modeling strategies are designed to understand the allosteric (cooperative) binding process in this system and the results are found to be consistent with existing hypotheses.