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The literature on communication, compliance, and patient satisfaction is selectively reviewed. As in earlier reviews, it is concluded that dissatisfaction with communication remains widespread, as does lack of compliance with medical advice. Related factors include poor transmission of information from patient to doctor, low understandability of communications addressed to the patient, and low levels of recall of information by patients. There does not appear to be any evidence that provision of additional information leads to adverse reactions by patients. Theoretical approaches to communication and compliance are described, and it is concluded that these should be used to direct future research.

The frequency with which patients fail to recall advice presented by their doctors is discribed. The amount forgotten is shown to be a linear function of the amount presented, to be correlated with the patient's medical knowledge, anxiety level and possibly age, but not with intelligence. It is probable that instructions and advice are more often forgotten than other information, and that this is the result of their low perceived importance, and their being presented late in the series of statements presented-there being (a) a primacy effect in recall of medical information, and (b) a tendency for statements perceived as more important to be better recalled. Experiments to control the content and amount of forgetting are described. Control of content can be obtained by use of the primacy and importance effects, while control of amount forgotten can be achieved by use of (a) simpler language, (b) explicit categorization, (c) repetition, and (d) concrete-specific rather than general-abstract advice statements.

ObjectiveTo determine the optimal radioactive colloid injection technique for sentinel lymph node (SLN) biopsy for breast cancer. Summary Background DataThe optimal radioactive colloid injection technique for breast cancer SLN biopsy has not yet been defined. Peritumoral injection of radioactive colloid has been used in most studies. Although dermal injection of radioactive colloid has been proposed, no published data exist to establish the false-negative rate associated with this technique. MethodsThe University of Louisville Breast Cancer Sentinel Lymph Node Study is a multiinstitutional study involving 229 surgeons. Patients with clinical stage T1-2, N0 breast cancer were eligible for the study. All patients underwent SLN biopsy, followed by level I/II axillary dissection. Peritumoral, subdermal, or dermal injection of radioactive colloid was performed at the discretion of the operating surgeon. Peritumoral injection of isosulfan blue dye was performed concomitantly in most patients. The SLN identification rates and false-negative rates were compared. The ratios of the transcutaneous and ex vivo radioactive SLN count to the final background count were calculated as a measure of the relative degree of radioactivity of the nodes. One-way analysis of variance and chisquare tests were used for statistical analysis. ResultsA total of 2,206 patients were enrolled. Peritumoral, subdermal, or dermal injection of radioactive colloid was performed in 1,074, 297, and 511 patients, respectively. Most of the patients (94%) who underwent radioactive colloid injection also received peritumoral blue dye injection. The SLN identification rate was improved by the use of dermal injection compared with subdermal or peritumoral injection of radioactive colloid. The false-negative rates were 9.5%, 7.8%, and 6.5% (not significant) for peritumoral, subdermal, and dermal injection techniques, respectively. The relative degree of radioactivity of the SLN was five-to sevenfold higher with the dermal injection technique compared with peritumoral injection. ConclusionsDermal injection of radioactive colloid significantly improves the SLN identification rate compared with peritumoral or subdermal injection. The false-negative rate is also minimized by the use of dermal injection. Dermal injection also is associated with SLNs that are five-to sevenfold more radioactive than with peritumoral injection, which simplifies SLN localization and may shorten the learning curve.

ObjectiveTo determine the optimal experience required to minimize the false-negative rate of sentinel lymph node (SLN) biopsy for breast cancer. Summary Background DataBefore abandoning routine axillary dissection in favor of SLN biopsy for breast cancer, each surgeon and institution must document acceptable SLN identification and false-negative rates. Although some studies have examined the impact of individual surgeon experience on the SLN identification rate, minimal data exist to determine the optimal experience required to minimize the more crucial false-negative rate. MethodsAnalysis was performed of a large prospective multiinstitutional study involving 226 surgeons. SLN biopsy was performed using blue dye, radioactive colloid, or both. SLN biopsy was performed with completion axillary LN dissection in all patients. The impact of surgeon experience on the SLN identification and false-negative rates was examined. Logistic regression analysis was performed to evaluate independent factors in addition to surgeon experience associated with these outcomes. ResultsA total of 2,148 patients were enrolled in the study. Improvement in the SLN identification and false-negative rates was found after 20 cases had been performed. Multivariate analysis revealed that patient age, nonpalpable tumors, and injection of blue dye alone for SLN biopsy were independently associated with decreased SLN identification rates, whereas upper outer quadrant tumor location was the only factor associated with an increased false-negative rate. ConclusionsSurgeons should perform at least 20 SLN cases with acceptable results before abandoning routine axillary dissection. This study provides a model for surgeon training and experience that may be applicable to the implementation of other new surgical technologies.Sentinel lymph node (SLN) biopsy has become increasingly accepted as a minimally invasive alternative to level I/II axillary dissection for the staging of breast cancer. Because approximately 70% of patients with clinical stage T1 to 2, N0 breast cancer have pathologically negative axillary nodes, SLN biopsy has the potential to eliminate the complications of axillary dissection in most patients. Patients with axillary metastasis are then selected for completion axillary dissection.There are two key parameters of successful SLN biopsy: the SLN identification rate and the false-negative rate. The

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SYNOPSIS Eighty anxious and eighty depressed patients were assigned randomly to receiving one of three versions of an information leaflet about their medication, or to receiving no leaflet at all.Mean medication errors were reduced from 15 to 4 % by provision of suitably constructed leaflets.The results show the practical importance of informing patients about their medication and of paying attention to the difficulty level of any leaflets issued.