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Uncertainty in clinical decision making

Miriam S Menezes, Maria das Graças Mota da Cruz de Assis Figueiredo
BACKGROUND AND OBJECTIVE: Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the issue regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas...
May 15, 2018: Revista Brasileira de Anestesiologia
L Solman, M Glover, P E Beattie, H Buckley, S Clark, J E Gach, A Giardini, I Helbling, R J Hewitt, B Laguda, S M Langan, A E Martinez, R Murphy, L Proudfoot, J Ravenscroft, H Shahidullah, L Shaw, S B Syed, L Wells, C Flohr
BACKGROUND: Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified UK guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pre-treatment investigations, its use in PHACES syndrome, and cessation of treatment. METHODS: This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting...
May 17, 2018: British Journal of Dermatology
Yibing Wang, Steven F Petit, Eliana Vasquez Osorio, Vikas Gupta, Alejandra Méndez Romero, Ben J M Heijmen
In the abdomen, it is challenging to assess the accuracy of deformable image registration (DIR) for individual patients, due to the lack of clear anatomical landmarks, which can hamper clinical applications that require high accuracy DIR, such as adaptive radiotherapy. In this study, we propose and evaluate a methodology for estimating the impact of uncertainties in DIR on calculated accumulated dose in the upper abdomen, in order to aid decision making in adaptive treatment approaches. 
 Sixteen liver metastasis patients treated with SBRT were evaluated...
May 17, 2018: Physics in Medicine and Biology
Katharine A Edey, Stuart Rundle, Martha Hickey
BACKGROUND: Endometrial cancer is the sixth most common cancer in women worldwide and most commonly occurs after the menopause (75%) ( About 319,000 new cases were diagnosed worldwide in 2012. Endometrial cancer is commonly considered as a potentially 'curable cancer,' as approximately 75% of cases are diagnosed before disease has spread outside the uterus (FIGO (International Federation of Gynecology and Obstetrics) stage I). The overall five-year survival for all stages is about 86%, and, if the cancer is confined to the uterus, the five-year survival rate may increase to 97%...
May 15, 2018: Cochrane Database of Systematic Reviews
Jae Kwon Kim, Mun Joo Choi, Jong Sik Lee, Jun Hyuk Hong, Choung-Soo Kim, Seong Il Seo, Chang Wook Jeong, Seok-Soo Byun, Kyo Chul Koo, Byung Ha Chung, Yong Hyun Park, Ji Youl Lee, In Young Choi
Object: Pathologic prediction of prostate cancer can be made by predicting the patient's prostate metastasis prior to surgery based on biopsy information. Because biopsy variables associated with pathology have uncertainty regarding individual patient differences, a method for classification according to these variables is needed. Method: We propose a deep belief network and Dempster-Shafer- (DBN-DS-) based multiclassifier for the pathologic prediction of prostate cancer...
2018: Journal of Healthcare Engineering
Jessica A Schults, Marie Cooke, Debbie Long, Marion L Mitchell
BACKGROUND: The complex nature of the Paediatric Intensive Care Unit (PICU) patient requires the bedside nurse to make rapid, complex decisions regarding endotracheal suction (ETS) interventions. It is not understood what influences nurses' decision making in the context of ETS, however, the actions of the clinician have a direct impact on the efficacy of the ETS event and patient outcomes. OBJECTIVES: To explore and describe the use of normal saline instillation and lung recruitment with paediatric ETS in a cohort of Australian nurses, and to identify factors that influence normal saline use with ETS...
May 8, 2018: Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses
Johannes A Landsheer
BACKGROUND: although the existence of inconclusive medical test results or bio-markers is widely recognized, there are indications that this inherent diagnostic uncertainty is sometimes ignored. This paper discusses three methods for defining and determining inconclusive medical test results, which use different definitions and differ in clinical relevance. METHODS: the TG-ROC (two graphs receiver operating characteristics) method is the easiest to use, while the grey zone method and the uncertain interval method require more extensive calculations...
May 9, 2018: Diagnostics
Selena S Au, Amanda L Roze des Ordons, Jeanna Parsons Leigh, Andrea Soo, Simon Guienguere, Sean M Bagshaw, Henry T Stelfox
OBJECTIVES: Guidelines recommend offering family members of critically ill patients the option to attend interdisciplinary team rounds as a way to improve communication and satisfaction. Uncertainty remains around the benefits and risks. DESIGN: We conducted an observational study to describe family participation in ICU rounds and its association with rounding processes. SETTING: Rounds conducted under the leadership of 33 attending physicians in seven hospitals across three Canadian cities...
May 7, 2018: Critical Care Medicine
Pavel Tesner, Marketa Vlckova, Jana Drabova, Jan Vseticka, Anna Klimova, Jana Lastuvkova, Jana Zidovska, Radka Kremlikova Pourova, Miroslava Hancarova, Zdenek Sedlacek, Eduard Kocarek
The prenatal finding of a small supernumerary marker chromosome (sSMC) is a challenge for genetic counseling. Our analytic algorithm is based on sSMC frequencies and multicolor FISH to accelerate the procedure. The chromosomal origin, size, and degree of mosaicism of the sSMC then determine the prognosis. We illustrate the effectiveness on 4 prenatally identified de novo mosaic sSMCs derived from chromosomes 13/21, X, 3, and 17. Three sSMC carriers had a good prognosis and apparently healthy children were born, showing no abnormality till the last examination at the age of 4 years...
May 9, 2018: Cytogenetic and Genome Research
Eliza Courtney, Shao-Tzu Li, Tarryn Shaw, Yanni Chen, John Carson Allen, Joanne Ngeow
The introduction of next-generation sequencing panels has transformed the approach for genetic testing in cancer patients, however, established guidelines for their use are lacking. A shared decision-making approach has been adopted by our service, where patients play an active role in panel selection and we sought to identify factors associated with panel selection and report testing outcomes. Demographic and clinical data were gathered for female breast and/or ovarian cancer patients aged 21 and over who underwent panel testing...
2018: NPJ Genomic Medicine
D G M Coppens, S de Wilde, H J Guchelaar, M L De Bruin, H G M Leufkens, P Meij, J Hoekman
There is a widely held expectation of clinical advance with the development of gene and cell-based therapies (GCTs). Yet, establishing benefits and risks is highly uncertain. We examine differences in decision-making for GCT approval between jurisdictions by comparing regulatory assessment procedures in the United States (US), European Union (EU) and Japan. A cohort of 18 assessment procedures was analyzed by comparing product characteristics, evidentiary and non-evidentiary factors considered for approval and post-marketing risk management...
May 2, 2018: Cytotherapy
Paul Corben, Julie Leask
BACKGROUND: Recent reports of childhood vaccination coverage in Australia have shown steadily improving vaccination coverage and narrowing differences between highest and lowest coverage regions, yet the NSW North Coast consistently has the lowest coverage rates nationally. Better understanding of parents' vaccination attitudes and actions within this region may guide strategies to improve uptake. The antenatal period is when many parents explore and consolidate vaccination attitudes and so is pivotal for study...
May 2, 2018: BMC Public Health
Aaron T Seaman, Kimberly Dukes, Richard M Hoffman, Alan J Christensen, Nicholas Kendell, Andrew L Sussman, Miriam Veléz-Bermúdez, Robert J Volk, Nitin A Pagedar
OBJECTIVE: Shared decision making (SDM) is recommended when offering lung cancer screening (LCS)-which presents challenges with tobacco-related cancer survivors because they were excluded from clinical trials. Our objective was to characterize head and neck cancer (HNC) survivors' knowledge, attitudes, and beliefs toward LCS and SDM. METHODS: Between November 2017 and June 2018, we conducted semi-structured qualitative interviews with 19 HNC survivors, focusing on patients' cancer and smoking history, receptivity to and perceptions of LCS, and decision-making preferences RESULTS: Participants were receptive to LCS, referencing their successful HNC outcomes...
April 22, 2018: Patient Education and Counseling
Chris Hollis, Charlotte L Hall, Boliang Guo, Marilyn James, Janet Boadu, Madeleine J Groom, Nikki Brown, Catherine Kaylor-Hughes, Maria Moldavsky, Althea Z Valentine, Gemma M Walker, David Daley, Kapil Sayal, Richard Morriss
BACKGROUND: Diagnosis of attention deficit hyperactivity disorder (ADHD) relies on subjective methods which can lead to diagnostic uncertainty and delay. This trial evaluated the impact of providing a computerised test of attention and activity (QbTest) report on the speed and accuracy of diagnostic decision-making in children with suspected ADHD. METHODS: Randomised, parallel, single-blind controlled trial in mental health and community paediatric clinics in England...
April 26, 2018: Journal of Child Psychology and Psychiatry, and Allied Disciplines
Mojtaba Sepandi, Maryam Taghdir, Abbas Rezaianzadeh, Salar Rahimikazerooni
Objectives: Radiologists face uncertainty in making decisions based on their judgment of breast cancer risk. Artificial intelligence and machine learning techniques have been widely applied in detection/recognition of cancer. This study aimed to establish a model to aid radiologists in breast cancer risk estimation. This incorporated imaging methods and fine needle aspiration biopsy (FNAB) for cyto-pathological diagnosis. Methods: An artificial neural network (ANN) technique was used on a retrospectively collected dataset including mammographic results, risk factors, and clinical findings to accurately predict the probability of breast cancer in individual patients...
April 25, 2018: Asian Pacific Journal of Cancer Prevention: APJCP
Jorge S López, Maria Soria-Oliver, Begoña Aramayona, Rubén García-Sánchez, José M Martínez, María J Martín
Organ transplantation remains currently limited because the demand for organs far exceeds the supply. Though organ procurement is a complex process involving social, organizational, and clinical factors, one of the most relevant limitations of organ availability is family refusal to donate organs of a deceased relative. In the past decades, a remarkable corpus of evidence about the factors conditioning relatives' consent has been generated. However, research in the field has been carried out mainly by means of merely empirical approaches, and only partial attempts have been made to integrate the existing empirical evidence within conceptual and theoretically based frameworks...
2018: Frontiers in Psychology
Irene Teo, Ratna Singh, Chetna Malhotra, Semra Ozdemir, Rebecca A Dent, Nesaretnam Barr Kumarakulasinghe, Wee Lee Yeo, Yin Bun Cheung, Rahul Malhotra, Ravindran Kanesvaran, Alethea Chung Pheng Yee, Noreen Chan, Huei Yaw Wu, Soh Mun Chin, Hum Yin Mei Allyn, Grace Meijuan Yang, Patricia Soek Hui Neo, Nivedita V Nadkarni, Richard Harding, Eric A Finkelstein
BACKGROUND: Advanced cancer significantly impacts quality of life of patients and families as they cope with symptom burden, treatment decision-making, uncertainty and costs of treatment. In Singapore, information about the experiences of advanced cancer patients and families and the financial cost they incur for end-of-life care is lacking. Understanding of this information is needed to inform practice and policy to ensure continuity and affordability of care at the end of life. The primary objectives of the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore (COMPASS) cohort study are to describe changes in quality of life and to quantify healthcare utilization and costs of patients with advanced cancer at the end of life...
April 23, 2018: BMC Cancer
John R Corboy, Brian G Weinshenker, Dean M Wingerchuk
The American Academy of Neurology has published a comprehensive review and guidelines for the use of disease-modifying therapies (DMTs) in multiple sclerosis (MS) for the first time since 2002. These guidelines represent the work of MS experts, patients, and guideline experts and are based on their review of randomized controlled trials and observational evidence that addresses a set of prespecified questions related to starting, switching, and potentially discontinuing DMTs. Many of the recommendations address decision-making regarding the use of DMTs and incorporate the perspective of patients...
April 23, 2018: Neurology
Victoria Saigle, Eric Racine
For each one of the approximately 800,000 people who die from suicide every year, an additional twenty people attempt suicide. Many of these attempts result in hospitalization or in contact with other healthcare services. However, many personal, educational, and institutional barriers make it difficult for healthcare professionals to care for suicidal individuals. We reviewed literature that discusses suicidal patients in healthcare settings in order to highlight common ethical issues and to identify knowledge gaps...
April 17, 2018: Monash Bioethics Review
Marcello Migliore, Mariaconcetta Fornito, Manuela Palazzolo, Alessandra Criscione, Mariapia Gangemi, Francesco Borrata, Paolo Vigneri, Marco Nardini, Joel Dunning
Pulmonary ground glass opacity (GGO) is becoming an important clinical dilemma in oncology as its diagnosis in clinical practice is increasing due to the introduction of low dose computed tomography (CT) scan and screening. The incidence of cancer in GGO has been reported as high as 63%. The purpose of this manuscript is to review best available evidence papers on management of GGO in lung cancer to address the following questions: (I) how to correlate CT findings with malignancy; (II) when and who operate? (III) how to perform intraoperative detection of intrapulmonary GGO? (IV) wedge, segmentectomy or lobectomy? Taking a cue from a clinical scenario, a review on PubMed was conducted...
March 2018: Annals of Translational Medicine
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