Showing papers by "Stephen G. Pauker published in 1984"

The cold thyroid nodule: an analysis of diagnostic and therapeutic options.

Abstract: We applied decision analysis to the controversy over the management of the solitary nonfunctioning thyroid nodule. Three standard management plans were considered: immediate subtotal thyroidectomy; a six month trial of thyroid suppression with L-thyroxine, with non-suppressible lesions being removed surgically; and aspiration cytology followed by surgery or thyroid suppression based on the cytologic examination. The literature formed the basis for quantitative assumptions of the analysis, including the consequences of thyroidectomy, the probability of malignancy, the types and prognoses of cancers found at operation, the likelihood of successful suppression adn relapse, and the possible results of aspiration cytology. We used Bayes' rule to revise the probability of cancer on the basis of cytological results. The relative worths of the 59 possible diagnostic and therapeutic outcomes were expressed as quality-adjusted life expectancies. The expected utility of each management plan was determined by "folding back" the decision tree. Although we found that each possible approach yielded a quality-adjusted life expectancy very close to that of the healthy population, aspiration biopsy with cytologic examination appeared slightly superior. Extensive sensitivity analyses demonstrated that either aspiration biopsy or immediate thyroid suppression was the treatment of choice over a wide range of assumptions, although in no case did the benefit exceed 1 year of life. We conclude that all therapies for cold thyroid nodule are essentially equal, viewed in terms of mortality and morbidity. The decision to operate, suppress or aspirate is thus a " tossup ", dependent in the individual case upon such subjective factors as psychological disutility , relative cost, and attitudes toward operative risk and long-term medical therapy. The controversy concerning the "best" management of the cold thyroid nodule is an illusion: quantitative analysis shows the futility of pursuing the debate any further.

Decision Analysis for Public Health: Principles and Illustrations

Abstract: SUMMARY Over the past decade decision analysis has been applied increasingly to choices in the domain of public health. The technique allows policy makers to examine alternative health strategies in an explicit and logical manner. Each problem yields a model in standardized form so that disparate opinions and goals can be incorporated into the policy. The most common notation uses a decision tree to represent the model. Events are separated into those requiring a choice and those occurring by chance. The relative worth or utility of each potential outcome is specified separately from the probability of its occurrence. All possible outcomes are valued on a single coherent scale, although that scale may include many different attributes. The resource costs and the public health effectiveness (in terms of quality adjusted years of life saved) are two of the potential attributes commonly used in such analyses. The use of sensitivity analyses allows one to examine how changes in soft data can influence policy decisions. In this chapter, we present some of the basic principles that underlie this technology and illustrate its application to several recent controversies.

Kidney failure or cancer. Should immunosuppression be continued in a transplant patient with malignant melanoma

Abstract: HB, a healthy 42-year-old white male contractor, developed poststreptococcal, rapidly progressive glomerulonephritis two years ago. He became uremic and required chronic hemodialysis. Six months later he underwent cadaveric renal transplantation, receiving azathioprine and prednisone to prevent allograft rejection. One early mild rejection episode was treated successfully with &dquo;pulse&dquo; steroid therapy and irradiation of the allograft. The functional status of the transplanted kidney remained excellent; serum

Decision analysis as a basis for medical decision making: the tree of hippocrates.

Abstract: Physicians have developed a number of implicit and explicit approaches to complex medical decisions. Decision analysis is an explicit, quantitative method of clinical decision making that involves the separation of the probabilities of events from their relative values, or utilities. Its use can help physicians make difficult choices in a manner that promotes true patient participation. Decision analysis also provides a framework for the incorporation of data from multiple sources and for the assessment of the impact of uncertain data on the final decision. Although this approach is imperfect, it represents a significant advance in clinical decision making.

Repeated syncope with negative diagnostic evaluation. To pace or not to pace

Abstract: was witnessed. She had no previous history of syncope or seizures and denied any history of head trauma. She had taken hydrochlorothiazide daily for many years for mild hypertension. On admission the physical examination, including careful neurologic and cardiac exams, was unremarkable except for a scalp laceration and atrial fibrillation at a rate of 70. The blood pressure was 160/90 mmHg, without postural changes. Routine laboratory examinations were unrevealing. A chest x ray was normal, without evidence of cardiomegaly or congestive heart failure. Her

A ten-year-old boy with cerebral palsy and femoral anteversion. How much does it hurt to break a leg?

Abstract: DW, an active, well-adjusted 10-year-old boy of normal intelligence with spastic left hemiplegic cerebral palsy, had developed severe internal rotation of his left leg from femoral anteversion. His spasticity had thus far been managed conservatively, with braces and exercises. The orthopedic surgeon who had provided care for the past two years felt that continued conservative measures could not reverse or arrest the rotational deformity and that a left femoral derotational osteotomy with appropriate muscle and tendon releases was indicated. Surgery would place the leg in a more straightforward or neutral position, providing an immediate cosmetic benefit. More importantly, the surgeon believed that without corrective therapy DW would begin to exhibit a declining functional efficiency of the leg, manifested by increased energy expenditure for daily activities and increased fatigue. Furthermore, the derotational osteotomy would improve the mechanical function of the leg and delay the onset of degenerative changes of the hip and knee, which would otherwise begin to develop over the next 20 to 30 years. In addition to causing perioperative pain, surgery would require three to six weeks of hospitalization and an additional three to five months of rehabilitation before the child could return to his current level of function. If the operation was deferred for more than a year, the surgeon