User login
What is the prognosis for acute low back pain?
The proportion of patients who are pain free or completely recovered after an acute episode of low back pain within 2 weeks to 6 months ranges from 21% to 90%, depending on the population studied and the method of measuring outcomes. The reported recurrence rates are also variable, from a low of 35% to a high of 75%, again depending on the length of follow-up and the study design. Grade of recommendation: C (on the basis of case-series, poor quality cohort studies, and case-control studies).
Evidence summary
It has been widely stated that 80% to 90% of attacks of acute low back pain resolve within approximately 6 weeks,1 though there is little evidence to support this claim. Although there are many studies and guidelines regarding treatment methods for low back pain, few studies evaluate the natural history of low back pain. One prospective series in a primary care setting found that 90% of patients were without pain 2 weeks after initial evaluation by their physician.2 This study had a 3-month follow-up period for 103 patients presenting with pain of less than 72 hours’ duration.
Another prospective study found that 94% of patients evaluated for a new episode of low back pain were no longer visiting their physician for treatment after 3 months. However, this was not an adequate measure of resolution of pain. Only 21% (39/188) were pain free at 3 months and only 25% (42/170) were pain free at 12 months.3 A larger study involved 1555 patients during a 6-month follow up after an episode of acute low back pain. The article reports a mean of 16 days to functional recovery, although only 69% of the patients considered themselves “completely recovered” at 6 months.4
Recurrences of low back pain are common. In one prospective cohort study of 443 patients with low back pain, 75% had a recurrence with a mean of 2 relapses in 1 year of follow-up, but only 228 patients completed the study.5 Another prospective study of 208 patients found that 35% to 44% of patients had recurrence of pain within 6 months of their first episode, and 50% to 59% had a recurrence in 22 months of follow-up.6 No studies identified findings or risk factors associated with higher recurrence rates.
Recommendations from others
The Agency for Healthcare Research and Quality (www.ahcpr.gov) section on health outcomes (see http://www.ahcpr.gov/research/jan99/ra6.htm) states, “recent studies suggest that once experienced, low back pain becomes a part of life for almost half of those affected, and for many, it is intermittently disabling. Repeated visits and procedures do not appear to improve patients’ long-term well-being, but they clearly account for substantial health care costs. Finally, back pain prognosis does not differ based on the type of provider initially seen or the level of practitioner confidence.” This site offers several nice summaries of studies on low back pain.
Read the clinical commentary by Anne Fitzsimmons, MD, at www.fpin.org.
1. Dixon AJ. Rheumatol Rehabil 1973;12:165-75.
2. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. BMJ 1994;308:577-80.
3. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. BMJ 1998;316:1356-9.
4. Carey TS, Garrett JM, Jackman A, et al. N Engl J Med 1995;333:913.-
5. van den Hoogen HJ, Koes BW, van Eijk JT, Bouter LM, Deville W. Ann Rheum Dis 1998;57:13-9.
6. Carey TS, Garrett JM, Jackman A, Hadler N. Med Care 1999;37:157-64.
The proportion of patients who are pain free or completely recovered after an acute episode of low back pain within 2 weeks to 6 months ranges from 21% to 90%, depending on the population studied and the method of measuring outcomes. The reported recurrence rates are also variable, from a low of 35% to a high of 75%, again depending on the length of follow-up and the study design. Grade of recommendation: C (on the basis of case-series, poor quality cohort studies, and case-control studies).
Evidence summary
It has been widely stated that 80% to 90% of attacks of acute low back pain resolve within approximately 6 weeks,1 though there is little evidence to support this claim. Although there are many studies and guidelines regarding treatment methods for low back pain, few studies evaluate the natural history of low back pain. One prospective series in a primary care setting found that 90% of patients were without pain 2 weeks after initial evaluation by their physician.2 This study had a 3-month follow-up period for 103 patients presenting with pain of less than 72 hours’ duration.
Another prospective study found that 94% of patients evaluated for a new episode of low back pain were no longer visiting their physician for treatment after 3 months. However, this was not an adequate measure of resolution of pain. Only 21% (39/188) were pain free at 3 months and only 25% (42/170) were pain free at 12 months.3 A larger study involved 1555 patients during a 6-month follow up after an episode of acute low back pain. The article reports a mean of 16 days to functional recovery, although only 69% of the patients considered themselves “completely recovered” at 6 months.4
Recurrences of low back pain are common. In one prospective cohort study of 443 patients with low back pain, 75% had a recurrence with a mean of 2 relapses in 1 year of follow-up, but only 228 patients completed the study.5 Another prospective study of 208 patients found that 35% to 44% of patients had recurrence of pain within 6 months of their first episode, and 50% to 59% had a recurrence in 22 months of follow-up.6 No studies identified findings or risk factors associated with higher recurrence rates.
Recommendations from others
The Agency for Healthcare Research and Quality (www.ahcpr.gov) section on health outcomes (see http://www.ahcpr.gov/research/jan99/ra6.htm) states, “recent studies suggest that once experienced, low back pain becomes a part of life for almost half of those affected, and for many, it is intermittently disabling. Repeated visits and procedures do not appear to improve patients’ long-term well-being, but they clearly account for substantial health care costs. Finally, back pain prognosis does not differ based on the type of provider initially seen or the level of practitioner confidence.” This site offers several nice summaries of studies on low back pain.
Read the clinical commentary by Anne Fitzsimmons, MD, at www.fpin.org.
The proportion of patients who are pain free or completely recovered after an acute episode of low back pain within 2 weeks to 6 months ranges from 21% to 90%, depending on the population studied and the method of measuring outcomes. The reported recurrence rates are also variable, from a low of 35% to a high of 75%, again depending on the length of follow-up and the study design. Grade of recommendation: C (on the basis of case-series, poor quality cohort studies, and case-control studies).
Evidence summary
It has been widely stated that 80% to 90% of attacks of acute low back pain resolve within approximately 6 weeks,1 though there is little evidence to support this claim. Although there are many studies and guidelines regarding treatment methods for low back pain, few studies evaluate the natural history of low back pain. One prospective series in a primary care setting found that 90% of patients were without pain 2 weeks after initial evaluation by their physician.2 This study had a 3-month follow-up period for 103 patients presenting with pain of less than 72 hours’ duration.
Another prospective study found that 94% of patients evaluated for a new episode of low back pain were no longer visiting their physician for treatment after 3 months. However, this was not an adequate measure of resolution of pain. Only 21% (39/188) were pain free at 3 months and only 25% (42/170) were pain free at 12 months.3 A larger study involved 1555 patients during a 6-month follow up after an episode of acute low back pain. The article reports a mean of 16 days to functional recovery, although only 69% of the patients considered themselves “completely recovered” at 6 months.4
Recurrences of low back pain are common. In one prospective cohort study of 443 patients with low back pain, 75% had a recurrence with a mean of 2 relapses in 1 year of follow-up, but only 228 patients completed the study.5 Another prospective study of 208 patients found that 35% to 44% of patients had recurrence of pain within 6 months of their first episode, and 50% to 59% had a recurrence in 22 months of follow-up.6 No studies identified findings or risk factors associated with higher recurrence rates.
Recommendations from others
The Agency for Healthcare Research and Quality (www.ahcpr.gov) section on health outcomes (see http://www.ahcpr.gov/research/jan99/ra6.htm) states, “recent studies suggest that once experienced, low back pain becomes a part of life for almost half of those affected, and for many, it is intermittently disabling. Repeated visits and procedures do not appear to improve patients’ long-term well-being, but they clearly account for substantial health care costs. Finally, back pain prognosis does not differ based on the type of provider initially seen or the level of practitioner confidence.” This site offers several nice summaries of studies on low back pain.
Read the clinical commentary by Anne Fitzsimmons, MD, at www.fpin.org.
1. Dixon AJ. Rheumatol Rehabil 1973;12:165-75.
2. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. BMJ 1994;308:577-80.
3. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. BMJ 1998;316:1356-9.
4. Carey TS, Garrett JM, Jackman A, et al. N Engl J Med 1995;333:913.-
5. van den Hoogen HJ, Koes BW, van Eijk JT, Bouter LM, Deville W. Ann Rheum Dis 1998;57:13-9.
6. Carey TS, Garrett JM, Jackman A, Hadler N. Med Care 1999;37:157-64.
1. Dixon AJ. Rheumatol Rehabil 1973;12:165-75.
2. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. BMJ 1994;308:577-80.
3. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. BMJ 1998;316:1356-9.
4. Carey TS, Garrett JM, Jackman A, et al. N Engl J Med 1995;333:913.-
5. van den Hoogen HJ, Koes BW, van Eijk JT, Bouter LM, Deville W. Ann Rheum Dis 1998;57:13-9.
6. Carey TS, Garrett JM, Jackman A, Hadler N. Med Care 1999;37:157-64.
Evidence-based answers from the Family Physicians Inquiries Network
Does adding estrogen to the hormone-free days of an oral contraceptive (OC) cycle reduce menopausal symptoms in perimenopausal OC users?
BACKGROUND: Women older than 40 years using OCs for birth control often experience perimenopausal symptoms, such as hot flashes, vaginal dryness, or emotional disturbances, especially during the hormone-free days of an OC cycle. The authors of this study conducted a randomized controlled trial to assess whether the addition of estrogen to the hormone-free days during OC use can reduce perimenopausal symptomatology.
POPULATION STUDIED: The study population included 60 healthy Chilean women aged 40 to 49 years presenting to various outpatient clinics with mood disorders or hot flashes who were already taking OCs. Women taking concurrent psychiatric medications were excluded.
STUDY DESIGN AND VALIDITY: This was a randomized controlled double-blind study during 3 cycles of OC use. A total of 26 women received an OC containing 20 μg of ethinyl estradiol and 150 μg desogestrel for 21 days followed by 7 placebo tablets; the other group of 34 women received the same OC combination, followed by 2 placebo tablets and then 5 identical-appearing ethinyl estradiol tablets (10 μg). Three women from the placebo group and 1 woman from the estrogen group did not complete the study. The patients were evaluated at baseline and the end of 3 cycles using the Greene scale. This scale, a questionnaire tool used to analyze 21 perimenopausal symptoms in the categories of vasomotor, somatic, psychologic, and sexual function, is intended to standardize climacteric complaints for comparative purposes.
OUTCOMES MEASURED: The outcomes measured were changes in vasomotor symptoms, symptoms of depression, somatic symptoms (headaches, musculoskeletal pain, and dizziness) and sexual dysfunction between the 2 study groups.
RESULTS: There were no significant differences at baseline between the treatment groups regarding age, height, weight, or parity. Symptom scores at the end of the study (3 months later) were improved in both the estrogen and placebo groups; however, there was statistically significant greater improvement in the estrogen group. Depression scores fell 61% in the estrogen group versus 24% in the placebo group (P <.004). Likewise, somatic scores fell 59% versus 32% (P <.04); vasomotor scores fell 76% versus 48% (P <.03); and sexual dysfunction scores fell 75% versus 33% (P <.002) in the estrogen and placebo groups. Anxiety scores did not differ between the groups. Interestingly, headache scores were reduced with estrogen but not with placebo.
Perimenopausal women taking OCs who complain of depressive symptoms, hot flashes, or other somatic symptoms during the rest week of the 4-week cycle will likely experience a reduction in these symptoms by taking ethinyl estradiol (10 μg) for 5 of the 7 rest days. Keep in mind that side effects and long-term safety have not been formally assessed.
BACKGROUND: Women older than 40 years using OCs for birth control often experience perimenopausal symptoms, such as hot flashes, vaginal dryness, or emotional disturbances, especially during the hormone-free days of an OC cycle. The authors of this study conducted a randomized controlled trial to assess whether the addition of estrogen to the hormone-free days during OC use can reduce perimenopausal symptomatology.
POPULATION STUDIED: The study population included 60 healthy Chilean women aged 40 to 49 years presenting to various outpatient clinics with mood disorders or hot flashes who were already taking OCs. Women taking concurrent psychiatric medications were excluded.
STUDY DESIGN AND VALIDITY: This was a randomized controlled double-blind study during 3 cycles of OC use. A total of 26 women received an OC containing 20 μg of ethinyl estradiol and 150 μg desogestrel for 21 days followed by 7 placebo tablets; the other group of 34 women received the same OC combination, followed by 2 placebo tablets and then 5 identical-appearing ethinyl estradiol tablets (10 μg). Three women from the placebo group and 1 woman from the estrogen group did not complete the study. The patients were evaluated at baseline and the end of 3 cycles using the Greene scale. This scale, a questionnaire tool used to analyze 21 perimenopausal symptoms in the categories of vasomotor, somatic, psychologic, and sexual function, is intended to standardize climacteric complaints for comparative purposes.
OUTCOMES MEASURED: The outcomes measured were changes in vasomotor symptoms, symptoms of depression, somatic symptoms (headaches, musculoskeletal pain, and dizziness) and sexual dysfunction between the 2 study groups.
RESULTS: There were no significant differences at baseline between the treatment groups regarding age, height, weight, or parity. Symptom scores at the end of the study (3 months later) were improved in both the estrogen and placebo groups; however, there was statistically significant greater improvement in the estrogen group. Depression scores fell 61% in the estrogen group versus 24% in the placebo group (P <.004). Likewise, somatic scores fell 59% versus 32% (P <.04); vasomotor scores fell 76% versus 48% (P <.03); and sexual dysfunction scores fell 75% versus 33% (P <.002) in the estrogen and placebo groups. Anxiety scores did not differ between the groups. Interestingly, headache scores were reduced with estrogen but not with placebo.
Perimenopausal women taking OCs who complain of depressive symptoms, hot flashes, or other somatic symptoms during the rest week of the 4-week cycle will likely experience a reduction in these symptoms by taking ethinyl estradiol (10 μg) for 5 of the 7 rest days. Keep in mind that side effects and long-term safety have not been formally assessed.
BACKGROUND: Women older than 40 years using OCs for birth control often experience perimenopausal symptoms, such as hot flashes, vaginal dryness, or emotional disturbances, especially during the hormone-free days of an OC cycle. The authors of this study conducted a randomized controlled trial to assess whether the addition of estrogen to the hormone-free days during OC use can reduce perimenopausal symptomatology.
POPULATION STUDIED: The study population included 60 healthy Chilean women aged 40 to 49 years presenting to various outpatient clinics with mood disorders or hot flashes who were already taking OCs. Women taking concurrent psychiatric medications were excluded.
STUDY DESIGN AND VALIDITY: This was a randomized controlled double-blind study during 3 cycles of OC use. A total of 26 women received an OC containing 20 μg of ethinyl estradiol and 150 μg desogestrel for 21 days followed by 7 placebo tablets; the other group of 34 women received the same OC combination, followed by 2 placebo tablets and then 5 identical-appearing ethinyl estradiol tablets (10 μg). Three women from the placebo group and 1 woman from the estrogen group did not complete the study. The patients were evaluated at baseline and the end of 3 cycles using the Greene scale. This scale, a questionnaire tool used to analyze 21 perimenopausal symptoms in the categories of vasomotor, somatic, psychologic, and sexual function, is intended to standardize climacteric complaints for comparative purposes.
OUTCOMES MEASURED: The outcomes measured were changes in vasomotor symptoms, symptoms of depression, somatic symptoms (headaches, musculoskeletal pain, and dizziness) and sexual dysfunction between the 2 study groups.
RESULTS: There were no significant differences at baseline between the treatment groups regarding age, height, weight, or parity. Symptom scores at the end of the study (3 months later) were improved in both the estrogen and placebo groups; however, there was statistically significant greater improvement in the estrogen group. Depression scores fell 61% in the estrogen group versus 24% in the placebo group (P <.004). Likewise, somatic scores fell 59% versus 32% (P <.04); vasomotor scores fell 76% versus 48% (P <.03); and sexual dysfunction scores fell 75% versus 33% (P <.002) in the estrogen and placebo groups. Anxiety scores did not differ between the groups. Interestingly, headache scores were reduced with estrogen but not with placebo.
Perimenopausal women taking OCs who complain of depressive symptoms, hot flashes, or other somatic symptoms during the rest week of the 4-week cycle will likely experience a reduction in these symptoms by taking ethinyl estradiol (10 μg) for 5 of the 7 rest days. Keep in mind that side effects and long-term safety have not been formally assessed.
Does prophylactic mastectomy in women at high risk for breast cancer provide a psychological benefit?
BACKGROUND: Bilateral prophylactic mastectomy can significantly reduce the risk of breast cancer in women at increased risk, but little is known about the psychological impact of this surgery. The authors of this study designed a prospective analysis of the psychosocial implications of prophylactic surgery for breast cancer.
POPULATION STUDIED: Women at increased risk for developing breast cancer who had been offered bilateral prophylactic mastectomy were referred to the researchers from 20 centers throughout the United Kingdom. A total of 168 women were referred after meeting the eligibility criteria consisting of family history of breast cancer or high risk of developing breast cancer. The researchers did not know the risk level used by the referring clinicians to select patients. More than 73% of both groups were employed, and more than 75% had children. Ethnicity and education level were not reported.
STUDY DESIGN AND VALIDITY: The authors conducted a prospective nonrandomized controlled trial using 6 validated questionnaires to assess the psychological morbidity, anxiety state, sexual activity, coping strategies, risk perception, and body image of the study participants. Women accepting surgery were interviewed at the time of referral and at 6 and 18 months postoperatively. Those declining surgery were interviewed at referral and 18 months later. Of the 168 women, 11 were lost to contact before completing the assessment. Of the 154 remaining participants, 79 (51%) chose surgery; 64 (42%) declined; and 11 (7%) chose to defer their decision making and were not included in the analysis.
OUTCOMES MEASURED: This study involved a comparison of the psychological and sexual morbidity in women having prophylactic mastectomy with those who were offered the surgery but declined.
RESULTS: Psychological morbidity decreased significantly (P <.001) over time in the group accepting surgery, as measured by the “General health questionnaire 30,” a tool used to determine psychiatric morbidity in outpatients. Those who declined showed no change in psychiatric morbidity over the 18 months. Anxiety scores declined significantly over this time period for those who accepted (P=.001) but remained unchanged for those who declined. A significantly higher proportion of those who declined had high baseline anxiety (P=.006), and their anxiety levels remained high at the 18-month follow-up. Those who accepted tended to use a problem-focused approach to coping, while those who declined tended to use a detached style of coping. Sexual activity and sexual discomfort did not change significantly over time in either group, and it did not differ between the groups. Body image was not different in either group (most women who had surgery had immediate breast reconstruction). A risk perception questionnaire revealed that those who accepted had a significantly higher (32% vs 10%, P=.001) belief that it was inevitable that they would develop breast cancer. More than half of those who accepted felt they had at least a 50-50 chance of developing cancer (their actual likelihood was much lower).
Psychological morbidity and anxiety are significantly reduced in women at high risk for developing breast cancer who undergo bilateral prophylactic mastectomy. The women having surgery had less anxiety without an impact on their body image or sexual functioning. Women at high risk for developing breast cancer who are contemplating this radical surgical intervention should be made aware of the results of this study to assist them in their decision-making process.
BACKGROUND: Bilateral prophylactic mastectomy can significantly reduce the risk of breast cancer in women at increased risk, but little is known about the psychological impact of this surgery. The authors of this study designed a prospective analysis of the psychosocial implications of prophylactic surgery for breast cancer.
POPULATION STUDIED: Women at increased risk for developing breast cancer who had been offered bilateral prophylactic mastectomy were referred to the researchers from 20 centers throughout the United Kingdom. A total of 168 women were referred after meeting the eligibility criteria consisting of family history of breast cancer or high risk of developing breast cancer. The researchers did not know the risk level used by the referring clinicians to select patients. More than 73% of both groups were employed, and more than 75% had children. Ethnicity and education level were not reported.
STUDY DESIGN AND VALIDITY: The authors conducted a prospective nonrandomized controlled trial using 6 validated questionnaires to assess the psychological morbidity, anxiety state, sexual activity, coping strategies, risk perception, and body image of the study participants. Women accepting surgery were interviewed at the time of referral and at 6 and 18 months postoperatively. Those declining surgery were interviewed at referral and 18 months later. Of the 168 women, 11 were lost to contact before completing the assessment. Of the 154 remaining participants, 79 (51%) chose surgery; 64 (42%) declined; and 11 (7%) chose to defer their decision making and were not included in the analysis.
OUTCOMES MEASURED: This study involved a comparison of the psychological and sexual morbidity in women having prophylactic mastectomy with those who were offered the surgery but declined.
RESULTS: Psychological morbidity decreased significantly (P <.001) over time in the group accepting surgery, as measured by the “General health questionnaire 30,” a tool used to determine psychiatric morbidity in outpatients. Those who declined showed no change in psychiatric morbidity over the 18 months. Anxiety scores declined significantly over this time period for those who accepted (P=.001) but remained unchanged for those who declined. A significantly higher proportion of those who declined had high baseline anxiety (P=.006), and their anxiety levels remained high at the 18-month follow-up. Those who accepted tended to use a problem-focused approach to coping, while those who declined tended to use a detached style of coping. Sexual activity and sexual discomfort did not change significantly over time in either group, and it did not differ between the groups. Body image was not different in either group (most women who had surgery had immediate breast reconstruction). A risk perception questionnaire revealed that those who accepted had a significantly higher (32% vs 10%, P=.001) belief that it was inevitable that they would develop breast cancer. More than half of those who accepted felt they had at least a 50-50 chance of developing cancer (their actual likelihood was much lower).
Psychological morbidity and anxiety are significantly reduced in women at high risk for developing breast cancer who undergo bilateral prophylactic mastectomy. The women having surgery had less anxiety without an impact on their body image or sexual functioning. Women at high risk for developing breast cancer who are contemplating this radical surgical intervention should be made aware of the results of this study to assist them in their decision-making process.
BACKGROUND: Bilateral prophylactic mastectomy can significantly reduce the risk of breast cancer in women at increased risk, but little is known about the psychological impact of this surgery. The authors of this study designed a prospective analysis of the psychosocial implications of prophylactic surgery for breast cancer.
POPULATION STUDIED: Women at increased risk for developing breast cancer who had been offered bilateral prophylactic mastectomy were referred to the researchers from 20 centers throughout the United Kingdom. A total of 168 women were referred after meeting the eligibility criteria consisting of family history of breast cancer or high risk of developing breast cancer. The researchers did not know the risk level used by the referring clinicians to select patients. More than 73% of both groups were employed, and more than 75% had children. Ethnicity and education level were not reported.
STUDY DESIGN AND VALIDITY: The authors conducted a prospective nonrandomized controlled trial using 6 validated questionnaires to assess the psychological morbidity, anxiety state, sexual activity, coping strategies, risk perception, and body image of the study participants. Women accepting surgery were interviewed at the time of referral and at 6 and 18 months postoperatively. Those declining surgery were interviewed at referral and 18 months later. Of the 168 women, 11 were lost to contact before completing the assessment. Of the 154 remaining participants, 79 (51%) chose surgery; 64 (42%) declined; and 11 (7%) chose to defer their decision making and were not included in the analysis.
OUTCOMES MEASURED: This study involved a comparison of the psychological and sexual morbidity in women having prophylactic mastectomy with those who were offered the surgery but declined.
RESULTS: Psychological morbidity decreased significantly (P <.001) over time in the group accepting surgery, as measured by the “General health questionnaire 30,” a tool used to determine psychiatric morbidity in outpatients. Those who declined showed no change in psychiatric morbidity over the 18 months. Anxiety scores declined significantly over this time period for those who accepted (P=.001) but remained unchanged for those who declined. A significantly higher proportion of those who declined had high baseline anxiety (P=.006), and their anxiety levels remained high at the 18-month follow-up. Those who accepted tended to use a problem-focused approach to coping, while those who declined tended to use a detached style of coping. Sexual activity and sexual discomfort did not change significantly over time in either group, and it did not differ between the groups. Body image was not different in either group (most women who had surgery had immediate breast reconstruction). A risk perception questionnaire revealed that those who accepted had a significantly higher (32% vs 10%, P=.001) belief that it was inevitable that they would develop breast cancer. More than half of those who accepted felt they had at least a 50-50 chance of developing cancer (their actual likelihood was much lower).
Psychological morbidity and anxiety are significantly reduced in women at high risk for developing breast cancer who undergo bilateral prophylactic mastectomy. The women having surgery had less anxiety without an impact on their body image or sexual functioning. Women at high risk for developing breast cancer who are contemplating this radical surgical intervention should be made aware of the results of this study to assist them in their decision-making process.