ABSTRACT
PURPOSE OF REVIEW: Minimally invasive interventional procedures are increasingly popular options for patients who are high-risk candidates for open surgical procedures. It is unclear how to proceed in the rare circumstance of a complication during an interventional procedure, where addressing the complication would require exposing the patient to the full risk that was being avoided with the minimally invasive technique. This review provides recommendations on how to approach this paradoxical scenario. RECENT FINDINGS: Risk stratification, communication frameworks, and advanced care planning can facilitate shared decision-making between physicians and patients. Risk stratification may include mortality predictive models, disability and frailty scores, and patient-centered outcome studies. In the event of procedural complication or failure, aggressive surgical treatment or limited repair should be guided by patient preferences to best ensure value concordant care. SUMMARY: Interventional procedures, and emergent open surgery, should be offered as long as patients are fully informed about the benefits and risks, including the implications of potential life-sustaining treatments, and whether their respective goals of treatment are consistent with the intervention. Implementing this framework will require a cultural shift in physician attitudes to recognize that in some cases, nonintervention or less aggressive treatment may be a reasonable alternative to surgical intervention.
Subject(s)
Critical Illness/therapy , Decision Making/ethics , Minimally Invasive Surgical Procedures/ethics , Physician-Patient Relations , Physicians/psychology , Attitude of Health Personnel , Critical Illness/psychology , Humans , Minimally Invasive Surgical Procedures/adverse effects , Minimally Invasive Surgical Procedures/methods , Palliative Care/ethics , Palliative Care/methods , Palliative Care/psychology , Patient Preference , Physicians/ethics , Preoperative Period , Risk Assessment/methods , Terminal Care/ethics , Terminal Care/methods , Terminal Care/psychology , Treatment OutcomeABSTRACT
BACKGROUND: Mutations in the α-synuclein gene (SNCA) cause autosomal dominant forms of Parkinson's disease, but the substantial risk conferred by this locus to the common sporadic disease has only recently emerged from genome-wide association studies. METHODS: We genotyped a prioritized noncoding variant in SNCA intron 4 in 344 patients with Parkinson's disease and 275 controls from the longitudinal Harvard NeuroDiscovery Center Biomarker Study. RESULTS: The common minor allele of rs2736990 was associated with elevated disease susceptibility (odds ratio, 1.40; P = .0032). CONCLUSIONS: This result increases confidence in the notion that in many clinically well-characterized patients, genetic variation in SNCA contributes to "sporadic" disease.
