Qualifying Statements Research Articles

ENGAGE: COMMUNITY – A STUDENT LED, TELEHEALTH EXERCISE PHYSIOLOGY SERVICE DELIVERY MODEL TO COMBAT SOCIAL ISOLATION IN OLDER ADULTS

BACKGROUND AND AIMS EngAGE: Community is a student-led Exercise Physiology service delivery model that provides accessible, enjoyable and socially engaged exercise programs for older adults to combat loneliness. We aimed to assess the impact of EngAGE: Community on social, psychological, and quality of life outcomes in community-dwelling older adults, and student development. METHODS EngAGE: Community was a 15-week telehealth group-exercise program that recruited community-dwelling older adults and student Exercise Physiology practitioners. Classes were supervised by an Accredited Exercise Physiologist. Each EngAGE session consisted of exercise, educational and community-developing activities. Participant survey outcomes for social and psychological health, and quality of life were collected online before and following the program. Student development outcomes were also collected online before and following the program. RESULTS Across four programs, 73 community participants and 15 student participants were recruited, providing 1042 community engagement hours and 900 student development hours. Of these, 45 community participants completed sufficient attendance for data inclusion, and 14 student datasets were included. Community participants reported significant improvements in social [UCLA Loneliness Scale (p=0.001), Social Anxiety and Phobias Scale (p=0.007)] and psychological health [Kessler-10 (p=0.03)], as well as quality of life [SF-12 (p=0.02) and Satisfaction with Life Scale (p=0.05)]. A subset of the population demonstrated significant improvements in lower (p<0.001) and upper body strength (p=0.003). Student practitioners reported significant improvements in Work Self-Efficacy (p=0.002), Confidence in Skills (p=0.02) and Work Readiness (p=0.03). Community participants (n=48) provided an 81-98% agree/strongly agree response to qualifying statements suggesting the program was enjoyable, educational, social, and beneficial for their wellbeing. The cost per practitioner contact minute for all EngAGE: Community rotations was calculated as $1.92 compared to $4.21 for usual care (45% saving). CONCLUSION EngAGE: Community is a viable and cost-effective telehealth strategy to improve older Australians social and psychological health while developing Exercise Physiology student practitioners.

Embryonic Exposure to Benzotriazole Ultraviolet Stabilizer 327 Alters Behavior of Rainbow Trout Alevin.

Benzotriazole ultraviolet (UV) stabilizers (BUVSs) are used in great quantities during industrial production of a variety of consumer and industrial goods. As a result of leaching and spill, BUVSs are detectable ubiquitously in the environment. As of May 2023, citing concerns related to bioaccumulation, biomagnification, and environmental persistence, (B)UV(S)-328 was recommended to be listed under Annex A of the Stockholm Convention on Persistent Organic Pollutants. However, a phaseout of UV-328 could result in a regrettable substitution because the replacement chemical(s) could cause similar or unpredicted toxicity in vivo, relative to UV-328. Therefore, the influence of UV-327, a potential replacement of UV-328, was investigated with respect to early life development of newly fertilized rainbow trout embryos (Oncorhynchus mykiss), microinjected with environmentally relevant concentrations of UV-327. Developmental parameters (standard length), energy consumption (yolk area), heart function, blue sac disease, mortality, and behavior were investigated. Alevins at 14 days posthatching, exposed to 107 ng UV-327 g-1 egg, presented significant signs of hyperactivity; they moved on average 1.8-fold the distance and at 1.5-fold the velocity of controls. Although a substantial reduction in body burden of UV-327 was observed at hatching, it is postulated that UV-327, due to its lipophilic properties, interfered with neurological development and signaling from the onset of neurogenesis. If these results hold true across multiple taxa and species, a potential contributor to neurodevelopmental disorders might have been identified. These findings suggest that UV-327 poses an unknown hazard to rainbow trout embryos and alevins, rendering UV-327 a potential regrettable substitution to UV-328. However, a qualified statement on a regrettable substitution requires a comparative investigation on the teratogenic effects between the two BUVSs. Environ Toxicol Chem 2024;43:762-771. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Early Identification of Autism Spectrum Disorder Among Children Aged 4 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2020

Autism spectrum disorder (ASD). 2020. The Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates prevalence and characteristics of ASD and monitors timing of ASD identification among children aged 4 and 8 years. In 2020, a total of 11 sites (located in Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin) conducted surveillance of ASD among children aged 4 and 8 years and suspected ASD among children aged 4 years. Surveillance included children who lived in the surveillance area at any time during 2020. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement in an evaluation, 2) a special education classification of autism (eligibility), or 3) an ASD International Classification of Diseases (ICD) code (revisions 9 or 10). Children aged 4 years were classified as having suspected ASD if they did not meet the case definition for ASD but had a documented qualified professional's statement indicating a suspicion of ASD. This report focuses on children aged 4 years in 2020 compared with children aged 8 years in 2020. For 2020, ASD prevalence among children aged 4 years varied across sites, from 12.7 per 1,000 children in Utah to 46.4 in California. The overall prevalence was 21.5 and was higher among boys than girls at every site. Compared with non-Hispanic White children, ASD prevalence was 1.8 times as high among Hispanic, 1.6 times as high among non-Hispanic Black, 1.4 times as high among Asian or Pacific Islander, and 1.2 times as high among multiracial children. Among the 58.3% of children aged 4 years with ASD and information on intellectual ability, 48.5% had an IQ score of ≤70 on their most recent IQ test or an examiner's statement of intellectual disability. Among children with a documented developmental evaluation, 78.0% were evaluated by age 36 months. Children aged 4 years had a higher cumulative incidence of ASD diagnosis or eligibility by age 48 months compared with children aged 8 years at all sites; risk ratios ranged from 1.3 in New Jersey and Utah to 2.0 in Tennessee. In the 6 months before the March 2020 COVID-19 pandemic declaration by the World Health Organization, there were 1,593 more evaluations and 1.89 more ASD identifications per 1,000 children aged 4 years than children aged 8 years received 4 years earlier. After the COVID-19 pandemic declaration, this pattern reversed: in the 6 months after pandemic onset, there were 217 fewer evaluations and 0.26 fewer identifications per 1,000 children aged 4 years than children aged 8 years received 4 years earlier. Patterns of evaluation and identification varied among sites, but there was not recovery to pre-COVID-19 pandemic levels by the end of 2020 at most sites or overall. For 2020, prevalence of suspected ASD ranged from 0.5 (California) to 10.4 (Arkansas) per 1,000 children aged 4 years, with an increase from 2018 at five sites (Arizona, Arkansas, Maryland, New Jersey, and Utah). Demographic and cognitive characteristics of children aged 4 years with suspected ASD were similar to children aged 4 years with ASD. A wide range of prevalence of ASD by age 4 years was observed, suggesting differences in early ASD identification practices among communities. At all sites, cumulative incidence of ASD by age 48 months among children aged 4 years was higher compared with children aged 8 years in 2020, indicating improvements in early identification of ASD. Higher numbers of evaluations and rates of identification were evident among children aged 4 years until the COVID-19 pandemic onset in 2020. Sustained lower levels of ASD evaluations and identification seen at a majority of sites after the pandemic onset could indicate disruptions in typical practices in evaluations and identification for health service providers and schools through the end of 2020. Sites with more recovery could indicate successful strategies to mitigate service interruption, such as pivoting to telehealth approaches for evaluation. From 2016 through February of 2020, ASD evaluation and identification among the cohort of children aged 4 years was outpacing ASD evaluation and identification 4 years earlier (from 2012 until March 2016) among the cohort of children aged 8 years in 2020 . From 2016 to March 2020, ASD evaluation and identification among the cohort of children aged 4 years was outpacing that among children aged 8 years in 2020 from 2012 until March 2016. The disruptions in evaluation that coincided with the start of the COVID-19 pandemic and the increase in prevalence of suspected ASD in 2020 could have led to delays in ASD identification and interventions. Communities could evaluate the impact of these disruptions as children in affected cohorts age and consider strategies to mitigate service disruptions caused by future public health emergencies.

Early Identification of Autism Spectrum Disorder Among Children Aged 4 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2018.

Problem/ConditionAutism spectrum disorder (ASD).Period Covered2018.Description of SystemThe Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates ASD prevalence and monitors timing of ASD identification among children aged 4 and 8 years. This report focuses on children aged 4 years in 2018, who were born in 2014 and had a parent or guardian who lived in the surveillance area in one of 11 sites (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin) at any time during 2018. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement (diagnosis) in an evaluation, 2) a special education classification of ASD (eligibility), or 3) an ASD International Classification of Diseases (ICD) code. Suspected ASD also was tracked among children aged 4 years. Children who did not meet the case definition for ASD were classified as having suspected ASD if their records contained a qualified professional’s statement indicating a suspicion of ASD.ResultsFor 2018, the overall ASD prevalence was 17.0 per 1,000 (one in 59) children aged 4 years. Prevalence varied from 9.1 per 1,000 in Utah to 41.6 per 1,000 in California. At every site, prevalence was higher among boys than girls, with an overall male-to-female prevalence ratio of 3.4. Prevalence of ASD among children aged 4 years was lower among non-Hispanic White (White) children (12.9 per 1,000) than among non-Hispanic Black (Black) children (16.6 per 1,000), Hispanic children (21.1 per 1,000), and Asian/Pacific Islander (A/PI) children (22.7 per 1,000). Among children aged 4 years with ASD and information on intellectual ability, 52% met the surveillance case definition of co-occurring intellectual disability (intelligence quotient ≤70 or an examiner’s statement of intellectual disability documented in an evaluation). Of children aged 4 years with ASD, 72% had a first evaluation at age ≤36 months. Stratified by census-tract–level median household income (MHI) tertile, a lower percentage of children with ASD and intellectual disability was evaluated by age 36 months in the low MHI tertile (72%) than in the high MHI tertile (84%). Cumulative incidence of ASD diagnosis or eligibility received by age 48 months was 1.5 times as high among children aged 4 years (13.6 per 1,000 children born in 2014) as among those aged 8 years (8.9 per 1,000 children born in 2010). Across MHI tertiles, higher cumulative incidence of ASD diagnosis or eligibility received by age 48 months was associated with lower MHI. Suspected ASD prevalence was 2.6 per 1,000 children aged 4 years, meaning for every six children with ASD, one child had suspected ASD. The combined prevalence of ASD and suspected ASD (19.7 per 1,000 children aged 4 years) was lower than ASD prevalence among children aged 8 years (23.0 per 1,000 children aged 8 years).InterpretationGroups with historically lower prevalence of ASD (non-White and lower MHI) had higher prevalence and cumulative incidence of ASD among children aged 4 years in 2018, suggesting progress in identification among these groups. However, a lower percentage of children with ASD and intellectual disability in the low MHI tertile were evaluated by age 36 months than in the high MHI group, indicating disparity in timely evaluation. Children aged 4 years had a higher cumulative incidence of diagnosis or eligibility by age 48 months compared with children aged 8 years, indicating improvement in early identification of ASD. The overall prevalence for children aged 4 years was less than children aged 8 years, even when prevalence of children suspected of having ASD by age 4 years is included. This finding suggests that many children identified after age 4 years do not have suspected ASD documented by age 48 months.Public Health ActionChildren born in 2014 were more likely to be identified with ASD by age 48 months than children born in 2010, indicating increased early identification. However, ASD identification among children aged 4 years varied by site, suggesting opportunities to examine developmental screening and diagnostic practices that promote earlier identification. Children aged 4 years also were more likely to have co-occurring intellectual disability than children aged 8 years, suggesting that improvement in the early identification and evaluation of developmental concerns outside of cognitive impairments is still needed. Improving early identification of ASD could lead to earlier receipt of evidence-based interventions and potentially improve developmental outcomes.

Afterword: Conversing with the Good Left about PRC History

Afterword: Conversing with the Good Left about PRC History

Optimizing the Introduction of Wearable Sensors Into the German Armed Forces for Military Medical Applications.

A wide variety of different types of wearable sensors are being developed around the world and introduced into the armed forces for military purposes. Competing states must rapidly develop ready-to-use systems that are robust, functional, valid, and practical. There appears to be potential for optimizing the successful and effective introduction of wearable sensors into the German armed forces (Bundeswehr) for military medical applications. The purpose of this study was to identify specific options for improving and optimizing the introduction of modern technologies such as wearable sensors into the structures of the German armed forces. Nine stakeholders were identified who could provide a qualified statement on the introduction of wearable sensors, of which six agreed to participate in an expert interview. The six qualitative expert interviews, which were conducted for a master's thesis at the Bundeswehr University in Hamburg, were selected on the basis of their thematic involvement and readiness for an interview and provided the basis for exploring processes that can possibly optimize the introduction of wearable sensors into modern armed forces such as the Bundeswehr. These interviews were carried out and analyzed using the Lamnek's method. Six expert interviews were analyzed and the most relevant statements were summarized and presented. Thirteen options for optimization were identified and included, for example, interdisciplinary networking, optimization of information flow, and strategic weighting. Several potential options have been identified that can optimize the introduction of wearable sensors into the German armed forces to a greater or lesser extent. Bundeswehr experts agree that above all structurally relevant improvements such as "development of data analysis standards," "legal requirements," "interdisciplinarity," "acceleration of development," and "centralization and structured cooperation" should play an important role in the implementation of wearable sensors.

Corona Virus Disease 2019 and Paediatric Inflammatory Bowel Diseases: Global Experience and Provisional Guidance (March 2020) from the Paediatric IBD Porto Group of European Society of Paediatric Gastroenterology, Hepatology, and Nutrition.

ABSTRACTIntroduction:With the current coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised about the risk to children with inflammatory bowel diseases (IBD). We aimed to collate global experience and provide provisional guidance for managing paediatric IBD (PIBD) in the era of COVID-19.Methods:An electronic reporting system of children with IBD infected with SARS-CoV-2 has been circulated among 102 PIBD centres affiliated with the Porto and Interest-group of ESPGHAN. A survey has been completed by major PIBD centres in China and South-Korea to explore management during the pandemic. A third survey collected current practice of PIBD treatment. Finally, guidance points for practice have been formulated and voted upon by 37 PIBD authors and Porto group members.Results:Eight PIBD children had COVID-19 globally, all with mild infection without needing hospitalization despite treatment with immunomodulators and/or biologics. No cases have been reported in China and South Korea but biologic treatment has been delayed in 79 children, of whom 17 (22%) had exacerbation of their IBD. Among the Porto group members, face-to-face appointments were often replaced by remote consultations but almost all did not change current IBD treatment. Ten guidance points for clinicians caring for PIBD patients in epidemic areas have been endorsed with consensus rate of 92% to 100%.Conclusions:Preliminary data for PIBD patients during COVID-19 outbreak are reassuring. Standard IBD treatments including biologics should continue at present through the pandemic, especially in children who generally have more severe IBD course on one hand, and milder SARS-CoV-2 infection on the other.Supplemental digital content:An infographic accompanying this article can be found at.

Limitations of transoesophageal echocardiogram in acute ischaemic stroke

ObjectiveThe role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the...

Do choosing wisely recommendations about low-value care target income-generating treatments provided by members? A content analysis of 1293 recommendations

BackgroundIt is unknown to what extent Choosing Wisely recommendations about income-generating treatments apply to members of the society generating the recommendations.The primary aim of this study is to determine the proportion of Choosing Wisely recommendations targeting income-generating treatments, and whether recommendations from professional societies on income-generating treatments are more likely to target members or non-members. The secondary aim is to determine the prevalence of qualified statements, and whether qualified statements are more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members.MethodsWe performed a content analysis of all Choosing Wisely recommendations, with data extracted from Choosing Wisely websites. Two researchers coded recommendations as test or treatment-based, for or against a procedure, containing qualified statements, income-generating and applying to members. Disagreements were resolved by discussion or consultation with a third researcher. A Chi-squared test evaluated whether society recommendations on income-generating treatments were more likely to target members or non-members; and whether qualified statements were more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members.ResultsWe found 1293 Choosing Wisely recommendations (48.3% tests and 48.6% treatments). Ninety-eight treatment recommendations targeted income-generating treatments (17.8%), and recommendations on income-generating treatments were less likely to target members compared to non-members (15.6% vs. 40.4%, p < 0.001). Nearly half of all recommendations were qualified (41.9%), with a similar proportion of recommendations targeting income-generating and non-income-generating treatments that apply to members containing qualified statements (49.4% vs. 42.0%, p = 0.23).ConclusionsMany societies provide Choosing Wisely recommendations that minimise impact on their own members. Only 20% of treatment recommendations target income-generating treatments, and of these recommendations mostly target non-members. Many recommendations are also qualified. Increasing the number of recommendations from societies that are unqualified and target member clinicians responsible for de-implementation of low-value and costly treatments should be a priority.

Adjuvant Therapy for Resected Biliary Tract Cancer: ASCO Clinical Practice Guideline.

To develop an evidence-based clinical practice guideline to assist in clinical decision making for patients with resected biliary tract cancer. ASCO convened an Expert Panel to conduct a systematic review of the literature on adjuvant therapy for resected biliary tract cancer and provide recommended care options for this patient population. Three phase III randomized controlled trials, one phase II trial, and 16 retrospective studies met the inclusion criteria. Based on evidence from a phase III randomized controlled trial, patients with resected biliary tract cancer should be offered adjuvant capecitabine chemotherapy for a duration of 6 months. The dosing used in this trial is described in the qualifying statements, while it should be noted that the dose of capecitabine may also be determined by institutional and regional practices. Patients with extrahepatic cholangiocarcinoma or gallbladder cancer and a microscopically positive surgical resection margin (R1 resection) may be offered chemoradiation therapy. A shared decision-making approach is recommended, considering the risk of harm and potential for benefit associated with radiation therapy for patients with extrahepatic cholangiocarcinoma or gallbladder cancer. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines .

The Gospel according to the Hebrews and the Gospel of the Ebionites ed. by Andrew Gregory

Reviewed by: The Gospel according to the Hebrews and the Gospel of the Ebionites ed. by Andrew Gregory Matthew Goldstone andrew gregory (ed.), The Gospel according to the Hebrews and the Gospel of the Ebionites (Oxford Early Christian Gospel Texts; New York: Oxford University Press, 2017). Pp. xvi + 344. $170. As part of a series devoted to noncanonical Gospel texts, this work provides a thorough, cautious, and well-balanced assessment of the evidence for two no longer extant works: the Gospel according to the Hebrews and the Gospel of the Ebionites (the latter title reflecting modern nomenclature). Grounded in previous scholarship and presented in a well-organized fashion, this work offers the reader an accessible and comprehensive overview of the relevant data for understanding each of these lost Gospels. Gregory is wary of the numerous pitfalls that plague such a project and masterfully reminds the reader that the available evidence is ambiguous and open to alternative interpretation. G. truly succeeds in the series' goals of providing a clear presentation of the available textual evidence and an up-to-date survey of the pertinent scholarship. The first part of the book is devoted to fleshing out the many issues involved in approaching the difficult project of analyzing brief excerpts from these lost Gospels recorded in the works of the early Church Fathers. G. draws a clear line between literary issues, the primary focus of the project, and theological and historical issues. Previous scholarship often jumped to hasty conclusions about the communities these texts reflect, and G. admirably relegates such discussions to brief and tentative sections at the conclusion [End Page 730] of his discussion of each Gospel and in an appendix. Overall, G.'s introduction sets up a critical and qualified statement about what we can and cannot say about these two Gospels. The two central parts of the work engage in an in-depth textual analysis of the available evidence for the Gospel according to the Hebrews and the Gospel of the Ebionites, respectively. In each part, G. opens with a presentation of the available witnesses and the literary issues involved in approaching the texts before turning to the texts themselves. These sections summarize many of the crucial points and prime the reader for the evidence that follows. For the Gospel according to the Hebrews, G. creates two distinct sections in order to distinguish between probable and doubtful testimony. He also includes an appendix for those sources he considers to be spurious patristic witnesses. G.'s decision regarding the reliability of each piece of evidence is regularly clarified and supported within his discussion of the text. For each passage, G. provides the original Greek or Latin (although not Syriac), an English translation, a discussion of the context, and his commentary. Some texts also include observations regarding the attribution, that is to say, the way the patristic author refers to the Gospel. Some pericopae are accompanied by mention of parallels either in the Synoptic Gospels, for which a synopsis is typically provided, or in later works. The volume concludes with several appendixes that contain tangentially related materials as well as a discussion of the broader historical question of the groups or sects whose names are associated with these Jewish-Christian Gospels. The work is replete with qualifications of G.'s interpretations and conclusions. Although some may perhaps find this redundant, the constant reminder of the tentative nature of the assumptions upon which particular readings lie, and the regular presentation of multiple ways of understanding the evidence, force the reader to confront the implications of our paucity of evidence. While this work is firmly grounded in strong philological and linguistic analysis of Greek and Latin texts, some readers may find the engagement with Hebrew elements somewhat lacking. For example, G. (p. 142) reproduces the typographical error of tav (as opposed to ṭav), for "good ones," which originally appeared in the work of A. F. J. Klijn (Jewish-Christian Gospel Tradition [VCSup 17; Leiden: Brill, 1992] 64). In discussing Jerome's translation of the term barrama, G. notes, "Both the Latin and Greek are in the plural, whereas the word that Jerome quotes appears to be a singular form, and it is difficult...

Human Papillomavirus Testing in Head and Neck Carcinomas: ASCO Clinical Practice Guideline Endorsement of the College of American Pathologists Guideline.

The College of American Pathologists produced an evidence-based guideline on testing, application, interpretation, and reporting of human papillomavirus (HPV) and surrogate marker tests in head and neck carcinomas that was determined to be relevant to the American Society of Clinical Oncology (ASCO) membership. The College of American Pathologists HPV Testing in Head and Neck Carcinomas guideline was reviewed by ASCO content experts for clinical accuracy and by methodologists for developmental rigor. On favorable review, an ASCO Expert Panel was convened to review the guideline contents and recommendations. The ASCO Expert Panel determined that the recommendations from the HPV Testing in Head and Neck Carcinomas guideline, published in 2018, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the guideline and added minor qualifying statements. It is recommended that HPV tumor status should be determined for newly diagnosed oropharyngeal squamous cell carcinomas. HPV tumor status testing may be performed by surrogate marker p16 immunohistochemistry either on the primary tumor or from cervical nodal metastases only if an oropharyngeal primary tumor is present. The threshold for positivity is at least 70% nuclear and cytoplasmic expression with at least moderate to strong intensity. Additional confirmatory testing may be done at the discretion of the pathologist and/or treating clinician. Pathologists should not routinely determine HPV tumor status in nonsquamous carcinomas of the oropharynx or non-oropharyngeal squamous cell carcinomas of the head and neck. When there is uncertainty of histologic type or whether a poorly differentiated oropharyngeal tumor is nonsquamous, HPV tumor status testing may be warranted and at the discretion of the pathologist and/or treating clinician. Additional information is available at: www.asco.org/head-neck-cancer-guidelines .

La realización de lo cristiano en una sociedad pluralista

In view of the laws that liberized abortion and divorce in the German Federal Republic, the author poses the question of how the Church can implement its teaching in a pluralist society. To this end he analyses the address given by the Chancellor of the German Federal Republic to the Catholic Academy of Hamburg. The central idea in the quotes adduced by the author from this address is the difference between fundamental values and fundamental rights. According to Chancellor H. Schmidt, the State should concern itself with fundamental rights which are a reflection of society and which possibly are not in accord with what up to now have been taken as fundamental values. The Church should concern itself with these values and see to it that society maintains them, but, if it fails to achieve this, the State should not impose them. It is the Church's fault if society looses some fundamental values. The State limits itself to noting social change and reflecting it in its laws, thus concerning itself with rights. In a later qualifying statement on these words, the Commission on Fundamental Values of the SPD, the Socialist party in power, recognises that the State should concern itself not only with rights but also with fundamental values which should be based on a broad consensus within the whole of society. This is an attitude which could give rise to complete arbitrariness in the content of these values. What is the role of the Church with respect to unjust laws? It is evident, says the Author, that the democratic state of freedom tends to become identified with intermediate groups between the individual and the State. This is as much an error as is strict dualism. It also means that the Church in the context of the democratic state of freedom is simply one grouping among others. The State is considered as ideologically and religiously neutral. All of which, the author concludes, implies a complete turn-around of the traditional teaching of the Church on the essence and function of the state as was held to until Leo XIII. The function of the State at present is solely the tranquillitas ordinis civilis, as St. Thomas Aquinas puts it. The author upholds that the Church has to act prudently in the specification of its ideas. The State at times deviates considerably from the theological-moral norms of the Church as the price to be paid for bringing about the tranquillitas ordinis civilis. And it is here that the problem lies. However, in the social sphere, the Church as an institution is necessarily in the back ground while it is here that the citizens have their true field of action. The Church's influence in the public sphere is produced through christian citizens and not through its ministers. Another problem posed by the author is the question of the specific challenges and difficulties which this situation gives rise to regarding the Church’s preaching and the commitment of christians and christian groupings. Here it should be considered not only the influence of the Church on catholics but also the reverse: that of the Church on society and on catholics and of these latter on the Church and between themselves. All of this because exists a dialectic relationship between religion and society and between Church and society. The Church, says the author quoting Vatican II, should not specify the action of the christian in each particular case. That would be a sterile approach. Rather it should give guidelines of a very general nature and be very wary of specifying. The Church, for example should foster in the faithful the virtue of justice but not say in each case what is the most just action.

Analisis Akuntansi Pendapatan Perpajakan dalam Rangka Penerapan Akuntansi Berbasis Akrual (Studi Kasus KPP Pratama Baubau)

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Assessing appropriateness of drug therapy in older persons: Development and application of a medication assessment tool for long-term management of atrial fibrillation.

Background:Atrial fibrillation (AF) is highly prevalent in older persons and is associated with considerable morbidity and mortality. Assessing appropriateness of drug therapy in AF may be facilitated by application of medication assessment tools (MATs).Objective:To develop, psychometrically evaluate and apply an innovative MAT for the long-term management of AF with particular relevance to older persons.Methods:Key recommendations from clinical practice guidelines for the long-term management of AF were selected and review criteria defining appropriate drug therapy were constructed as a ‘qualifying statement’ followed by a ‘standard’. The developed MAT was given the designation MAT-AF. An application guide was compiled where justifications for non-adherence were specified. Content validity was tested by an expert group using a three-round Delphi process. Inter- and intra-observer reliability testing was conducted with agreement expressed by Cohen’s kappa and application time measured to assess feasibility. MAT-AF was applied to 150 patients with a diagnosis of AF admitted to a rehabilitation hospital.Results:MAT-AF consists of 15 criteria sectioned into antithrombotic, rate control and rhythm control therapy. Content validity was demonstrated for all criteria. Reliability was confirmed with kappa values of 0.84 and 0.91 for inter- and intra-observer agreements. Mean application time for the two observers was 3.9 and 2.4 minutes, which decreased significantly in the second application conducted after a four-week interval (p<0.001). Overall adherence to applicable criteria was 59.8%. Non-adherence was evident for prescription of anticoagulation in patients with a CHA2DS2VASc score ≥1 (29.5%). Monitoring of laboratory parameters for digoxin was suboptimal. Ophthalmic and pulmonary monitoring and patient counselling regarding amiodarone therapy could not be assessed since relevant records were not readily available.Conclusion:MAT-AF application highlighted key aspects which need to be addressed to improve patient care.

ANALISIS PENGARUH SISTEM PENGENDALIAN INTERN DAN IMPLEMENTASI SISTEM AKUNTANSI KEUANGAN DAERAH (SAKD) TERHADAP KUALITAS LAPORAN KEUANGAN PEMERINTAH DAERAH (STUDI EMPIRIS PADA SKPD KOTA MANADO)

Local government financial statement made to provide information about financial position and all transactions conducted by local government. A qualified local government financial statement must have relevant, reliable, comparable and understandable characteristics. There are several factors that may affect the quality of local government financial statements, that is, internal control system and financial accounting system of local government. This research was aimed to determine the effect of internal control system and financial accounting system of local government to the quality of financial statements at the local government of Manado City. Respondents of this research were 40 financial management personnel from 10 Manado City SKPD from 168 population of financial management personnel of Manado City SKPD. This research used a quantitative approach, using primary data through questionnaires. The variables in this research is the internal control system and financial accounting system of local government as the independent variables and the quality of local government financial statement as the dependent variable. The data collected were processed using SPSS version 23.0. The statistical methods used to test the hypotheses is multiple linear regression analysis. The results of hypothesis shown that the internal control system has a significant positive effect on the quality of Manado City local government financial statement while the implementation of financial accounting system of local government has no significant positive effect on the quality of Manado City local government financial statements and internal control system and financial accounting system of local government has a significant positive effect on the quality of Manado City local government financial statement.Keywords : Internal control system, financial accounting system of local government, financial accounting system of local government

Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update

To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma. An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma. Nine new observational studies, two systematic reviews and an updated randomized controlled trial (RCT) of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included. Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (non-ulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or <0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of >1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors, and details of the reference patient populations are included within the guideline.

Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update.

Purpose To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma. Methods An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma. Results Nine new observational studies, two systematic reviews, and an updated randomized controlled trial of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included. Recommendations Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (nonulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or < 0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of > 1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher-risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors and details of the reference patient populations are included within the guideline. Additional information is available at www.asco.org/melanoma-guidelines and www.asco.org/guidelineswiki .

Radiation Therapy for Oropharyngeal Squamous Cell Carcinoma: American Society of Clinical Oncology Endorsement of the American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline.

Purpose The American Society for Radiation Oncology (ASTRO) produced an evidence-based guideline on radiation therapy in oropharyngeal squamous cell carcinoma (OPSCC) that was determined to be relevant to the American Society of Clinical Oncology (ASCO) membership. After applying standard critical appraisal policy and endorsement procedures, ASCO chose to endorse the ASTRO guideline. Methods The ASTRO guideline was reviewed by ASCO content experts for clinical accuracy and by ASCO methodologists for developmental rigor. On favorable review, an ASCO Expert Panel was convened to review the guideline contents and recommendations. The ASCO guideline approval body, the Clinical Practice Guidelines Committee, approved the final endorsement. Results The ASCO Expert Panel determined that the ASTRO guideline recommendations, published in July 2017, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the ASTRO guideline and added minor qualifying statements. Recommendations Recommendations for the addition of systemic therapy to definitive radiotherapy in the treatment of OPSCC, postoperative radiotherapy with and without systemic therapy following primary surgery of OPSCC, induction chemotherapy in the treatment of OPSCC, and the appropriate dose, fractionation, and volume regimens with and without systemic therapy in the treatment of OPSCC are outlined for a variety of disease stages and clinical scenarios. ASCO Endorsement Panel qualifying statements and minor modifications were made to the ASTRO recommendations. The staging system that is referenced in these guidelines is the American Joint Committee on Cancer Staging Manual, 7th edition. Additional information is available at: www.asco.org/head-neck-cancer-guidelines and www.asco.org/guidelineswiki .

Head and Neck Cancer Survivorship Care Guideline: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the American Cancer Society Guideline

Purpose This guideline provides recommendations on the management of adults after head and neck cancer (HNC) treatment, focusing on surveillance and screening for recurrence or second primary cancers, assessment and management of long-term and late effects, health promotion, care coordination, and practice implications. Methods ASCO has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations. The American Cancer Society (ACS) HNC Survivorship Care Guideline was reviewed for developmental rigor by methodologists. An ASCO Expert Panel reviewed the content and recommendations, offering modifications and/or qualifying statements when deemed necessary. Results The ASCO Expert Panel determined that the ACS HNC Survivorship Care Guideline, published in 2016, is clear, thorough, clinically practical, and helpful, despite the limited availability of high-quality evidence to support many of the recommendations. ASCO endorsed the ACS HNC Survivorship Care Guideline, adding qualifying statements aimed at promoting team-based, multispecialty, multidisciplinary, collaborative head and neck survivorship care. Recommendations The ASCO Expert Panel emphasized that caring for HNC survivors requires a team-based approach that includes primary care clinicians, oncology specialists, otolaryngologists, dentists, and other allied professionals. The HNC treatment team should educate the primary care clinicians and patients about the type(s) of treatment received, the likelihood of potential recurrence, and the potential late and long-term complications. Primary care clinicians should recognize symptoms of recurrence and coordinate a prompt evaluation. They should also be prepared to manage late effects either directly or by referral to appropriate specialists. Health promotion is critical, particularly regarding tobacco cessation and dental care. Additional information is available at www.asco.org/HNC-Survivorship-endorsement and www.asco.org/guidelineswiki .