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Injury is a major cause of morbidity and mortality in developing countries. Utilizing a partnership between Kamuzu Central Hospital (KCH) and the University of North Carolina Departments of Surgery, we describe an approach to injury surveillance, examine the utility of trauma scoring systems, and outline steps necessary before such scoring systems can be reliably instituted in a resource-constrained setting.

Discussions about breast reconstruction should include factual information and consideration of the patient's personal concerns. Providers are familiar with the relevant facts but may not know which personal concerns are important to patients. Experience with breast cancer patients has found that providers frequently do not know their patients' treatment preferences. To help reconstructive surgeons discuss personal preferences with their patients, we sought to identify women's key concerns related to breast reconstruction. We employed a qualitative design and convened a sample of 65 women in 7 focus groups and 15 semi-structured interviews. Women with a recent history of early-stage breast cancer who had a mastectomy with or without reconstruction were included. A variety of backgrounds, including underserved populations, low education levels, and various ages were represented. Qualitative content analysis was performed, and key themes were identified. Five key themes emerged. (1) Magnitude of surgery and recovery. Many women reported that concerns over the number of operations, duration of recovery, and risk of complications strongly affected their decision-making. (2) Using one's own tissue. Several women felt comforted by the notion of using their own tissue for reconstruction. (3) Looking natural in clothing. Many women pointed out the difference between how they look in clothing versus how they look naked. (4) Avoiding an external prosthesis. Several women stressed practical concerns and framed the reconstruction decision in terms of not having to use prosthesis. (5) Considering others' opinions. A few women reported that their partners' opinion strongly influenced their decision. Many women stated that they ultimately followed their doctor's recommendation. Women considering reconstruction have some unmet emotional and physical needs as well as important goals and concerns that can affect their decisions about and experience with reconstruction. In particular, some breast cancer patients are unprepared for the full effect of surgery on their lives and for the recovery process. Discussions about reconstruction would benefit from inclusion of these key concerns.

Objective To provide health-care providers, patients, and the general public with a responsible assessment of currently available data on the diagnosis and management of ductal carcinoma in situ (DCIS). Participants A non-Department of Health and Human Services, nonadvocate, 14-member panel representing the fields of oncology, radiology, surgery (general and reconstructive), pathology, radiation oncology, internal medicine, epidemiology, biostatistics, nursing, obstetrics and gynecology, preventative medicine and population health, and social work. In addition, 22 experts from pertinent fields presented data to the panel and conference audience. Evidence Presentations by experts and a systematic review of the literature prepared by the Minnesota Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience. Conference process The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the Federal Government. Conclusions Clearly, the diagnosis and management of DCIS is highly complex with many unanswered questions, including the fundamental natural history of untreated disease. Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term "carcinoma" from the description of DCIS. The outcomes in women treated with available therapies are excellent. Thus, the primary question for future research must focus on the accurate identification of patient subsets diagnosed with DCIS, including those persons who may be managed with less therapeutic intervention without sacrificing the excellent outcomes presently achieved. Essential in this quest will be the development and validation of accurate risk stratification methods based on a comprehensive understanding of the clinical, pathological, and biological factors associated with DCIS.

To provide health care providers, patients, and the general public with a responsible assessment of currently available data on the diagnosis and management of ductal carcinoma in situ (DCIS).An non-DHHS, nonadvocate 14-member panel representing the fields of fields of oncology, radiology, surgery (general and reconstructive), pathology, radiation oncology, internal medicine, epidemiology, biostatistics, nursing, obstetrics and gynecology, preventative medicine and population health, and social work. In addition, 22 experts from pertinent fields presented data to the panel and conference audience.Presentations by experts and a systematic review of the literature prepared by the Minnesota Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.The diagnosis and management of DCIS is highly complex with many unanswered questions, including the fundamental natural history of untreated disease. Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to remove the anxiety-producing term "carcinoma" from the description of DCIS. The outcomes in women treated with available therapies are excellent. Thus, the primary question for future research must focus on the accurate identification of patient subsets diagnosed with DCIS, including those persons who may be managed with less therapeutic intervention without sacrificing the excellent outcomes presently achieved. Essential in this quest will be the development and validation of accurate risk stratification methods based on a comprehensive understanding of the clinical, radiological, pathological, and biological factors associated with DCIS.

Injury surveillance is an ongoing process required for primary, secondary, and tertiary injury prevention. In Malawi, hospital-based injury data are not available.From February to June 2008 we collected data on injured patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi. The sample (n = 1,474) was predominantly male (75.7%), and age distribution was bimodal (peak age groups5 years and 26-30 years). Road-traffic injury (RTI) was the most common reason for treatment (43.4%), followed by assault (24.0%), which was more common than expected. The most common injuries were lacerations, contusions, and abrasions. We observed both gender- and age-specific patterns in injury mechanism: Injured females were more likely than injured males to have suffered an injury as a passenger in a car or on a bicycle, or to have suffered from falls, foreign bodies, and burns; injured males were more likely than injured females to have suffered an injury as an automobile driver or bicyclist, or from an assault. Falls, burns, and foreign bodies affected younger victims, whereas bicyclists, automobile drivers, and motorcycle operators were generally older persons.The hospital admission rate was 26.8%. Most patients arrived by private vehicle (43.8%), which was also the fastest means of transportation. There were 25 mass casualties leading to 102 admissions; all but one were due to RTIs, and seven were associated with at least one fatality.This study elucidated injury epidemiology in Malawi and identified questions for future research. Other developing countries should conduct such prospective data collection to identify region-specific injury patterns and to promote injury prevention.

9534 Background: Risk perceptions (RP) play an important role in decision making in localized BC. Little is known about RP in the context of adjuvant (adj) therapy decisions. We examined the accuracy of estimate of absolute benefit of adj therapy among patients (pts) with localized BC and sought to identify determinants of accurate RP. Methods: A cross-sectional survey was conducted in localized (Stage I-III) BC pts within 3 months after surgery at 4 U.S. cancer centers. Pts completed the Decision Quality Instrument, which includes items on BC knowledge, numerical estimates of benefit of adj therapy, and communication with providers. We analyzed pts with Stage I/II and calculated objective estimates of benefit of adj therapy using Adjuvant! Online. Based on published data, an estimate that was +/- 5% of the calculated risk was considered correct. We used multivariable (MV) regression to identify determinants of accuracy including tumor stage, age, adj treatment, education, total knowledge score, and decision involvement. Results: 192/249 (77.1%) pts completed the survey; analyses were limited to 166 pts stage I/II with complete risk estimate data. Mean age was 56.4 years (SD 12.1), 83% of respondents were white, and 58.5% were college graduates. 56.3% had stage I and 43.7% had stage II disease. Most (95.6%) had some type of adj therapy, either endocrine therapy only (43.2%), chemotherapy only (15.3%), or both (32%). On average, pts estimated the absolute benefit of adj therapy to be 31.8% (SD24.9), and this varied by stage (28.4 and 35.9 for stage I and II, p=0.06). The overall estimate for this sample from Adjuvant! Online was 11.8% (SD 7.67) and this varied by stage (8.6/16.0 for stage I/II respectively, p

Background:Most breast cancer patients who have a mastectomy do not have breast reconstruction, and rates of reconstruction vary by race, education, and geographic location, suggesting problems with decision making. We sought to assess the quality of decisions about breast reconstruction by measuring patient involvement in decision making, patient knowledge, and the degree to which decisions reflected patients' goals.Methods: Breast cancer survivors from four sites who were treated with mastectomy in the past 3 years completed a mailed survey, as part of a larger study to validate decision quality instruments. The survey contained questions about the decision making process, factual questions, and questions about personal goals and concerns. Characteristics associated with knowledge were identified with linear regression. Goals/concerns associated with reconstruction were identified using logistic regression. The percent match between treatment preference and treatment received was calculated.Results: The larger study recruited 456 patients (overall response rate 59%). 91 patients completed the reconstruction module. Average age was 56.9 years, 82.6% were white, 63.7% had a college degree, and 64% had Stage I disease. 45.8% had reconstruction.Decision making: 78% of patients reported that their doctor mentioned reconstruction. Most reported a discussion of the pros of reconstruction (63.8%), whereas the minority reported a discussion of the cons (20.9%). 76% reported being asked for their preference about reconstruction. 3% said the doctor mainly made the decision, 74% said they made the decision, and 15% said both made the decision. Most (81%) felt their level of involvement was about right.Knowledge:The mean knowledge score was 32.9% (SD=19). 41% knew that reconstruction has little effect on cancer surveillance. 54% knew that recovery after implant surgery is easier than after flap surgery. 3.3% knew that about 1/3 of patients have a major complication. On bivariate analysis, reconstruction (43.3 vs. 32.6, p=0.053), higher income (43.4 vs. 26.3, p=0.008), a college degree (43.4 vs. 26.2, p Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3103.

Background: Decisions about adjuvant chemotherapy are highly challenging for many women with early stage breast cancer. We sought to assess the quality of breast cancer patients' decisions about chemotherapy by measuring their knowledge and the degree to which their treatment decisions reflect their goals and preferences.Methods: We mailed a survey to early stage (I, II) breast cancer survivors who were treated at one of four sites, as part of a larger study to validate decision quality instruments. A subset of women completed the chemotherapy module, which included questions about the patient-provider interaction, about facts, about treatment goals, and about the patient's preferred treatment. Characteristics associated with knowledge were identified with linear regression. Characteristics associated with chemotherapy were identified with logistic regression.The percentage of patients who received their preferred treatment was calculated.Results: 358 patients completed the survey (response rate 59%). 64% of patients had Stage I disease, and 57% had chemotherapy. Average age was 56.9 years, 82.6% were white, and 63.7% had a college degree.Decision making: 70% of patients reported that their provider mentioned chemotherapy as an option. 43% reported that their provider asked for their preference about chemotherapy. 23% said the doctor mainly made the decision, 29% said they mainly made the decision, and 46% said both made the decision.Most women (92%) felt their level of involvement was about right.Knowledge: The mean knowledge score was 39.6% (SD 20.3). 29.9% knew that less than half of women with early stage breast cancer eventually die from breast cancer without chemotherapy or hormone therapy.21.8% knew that more than half are free from recurrence in 10 years without chemotherapy or hormone therapy. Chemotherapy treatment and the doctor having discussed chemotherapy were significantly associated (p Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2083.

To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them.The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies.Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions.Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results.The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume-outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume-outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data.High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

Two types of reflux episodes have been identified: upright or daytime and supine or nocturnal. The population-based prevalence of symptoms of nocturnal gastroesophageal reflux disease (GERD) and the impact of those symptoms on health-related quality of life (HRQL) have not been established.A national random-sample telephone survey was conducted to estimate the prevalence of frequent GERD and nocturnal GERD-like symptoms and to assess the relationship between HRQL, GERD, and nocturnal GERD symptoms. Respondents were classified as controls, subjects with symptomatic nonnocturnal GERD, and subjects with symptomatic nocturnal GERD. The HRQL was assessed using the Medical Outcomes Study Short-Form 36 Health Survey (SF-36).The prevalence of frequent GERD was 14%, with an overall prevalence of nocturnal GERD of 10%. Seventy-four percent of those with frequent GERD symptoms reported nocturnal GERD symptoms. Subjects with nonnocturnal GERD had significant decrements on the SF-36 physical and mental component summary scores compared with the US general population. Subjects reporting nocturnal GERD symptoms were significantly more impaired than subjects reporting nonnocturnal GERD symptoms on both the physical component summary (38.94 vs 41. 52; P.001) and mental component summary (46.78 vs 49.51; P.001) and all 8 subscales of the SF-36 (P.001). Subjects with nocturnal GERD demonstrated considerable impairment compared with the US general population and chronic disease populations. Subjects with nocturnal GERD had significantly more pain than those with hypertension and diabetes (P.001) and similar pain compared with those with angina and congestive heart failure.Nocturnal symptoms are commonly experienced by individuals who report frequent GERD symptoms. In addition, HRQL is significantly impaired in those persons who report frequent GERD symptoms, and HRQL impairment is exacerbated in those who report nocturnal GERD symptoms.

Background What do patients want when looking for an aesthetic surgeon? When faced with attributes like reputation, years in practice, testimonials, photos, and pricing, which is more valuable? Moreover, are attributes procedure-specific? Currently, inadequate evidence exists on which attributes are most important to patients, and to our knowledge, none on procedure-specific preferences. Objectives First, to determine the most important attributes to breast augmentation, combined breast/abdominal surgery, and facelift patients using conjoint analysis. Second, to test the conjoint using an internet crowdsourcing service (Amazon Mechanical Turk [MTurk]). Methods Anonymous university members were asked, via mass electronic survey, to pick a surgeon for facelift surgery based on five attributes. Attribute importance and preference was calculated. Once pre-tested, the facelift, breast augmentation and combined breast/abdominal surgery surveys were administered worldwide to MTurk. Results The university facelift cohort valued testimonials (33.9%) as the most important, followed by photos (31.6%), reputation (18.2%), pricing (14.4%), and practice years (1.9%). MTurk breast augmentation participants valued photos (35.3%), then testimonials (33.9%), reputation (15.7%), pricing (12.2%), and practice years (3%). MTurk combined breast/abdominal surgery and facelift participants valued testimonials (38.3% and 38.1%, respectively), then photos (27.9%, 29.4%), reputation (17.5%, 15.8%), pricing (13.9%, 13.9%), practice years (2.4%, 2.8%). Conclusions Breast augmentation patients placed higher importance on photos; combined breast/abdominal surgery and facelift patients valued testimonials. Conjoint analysis has had limited application in plastic surgery. To our knowledge, internet crowdsourcing is a novel participant recruitment method in plastic surgery. Its unique benefits include broad, diverse and anonymous participant pools, low-cost, rapid data collection, and high completion rate.