Treatment Decisions Research Articles

Predicting Epidural Hematoma Expansion in Traumatic Brain Injury: A Machine Learning Approach.

Traumatic brain injury (TBI) is a leading cause of disability and mortality worldwide, with epidural hematoma (EDH) being a severe consequence. This study focuses on identifying factors predicting EDH volume changes in TBI patients and developing a machine learning (ML) model to predict EDH expansion. The study includes patients with traumatic EDH between 2019 and 2021. Data were gathered from CT scans performed at the time of admission and 6hours later, and subsequently analyzed. The data was divided into three cohorts: all cases, adults, and pediatrics. To predict EDH volume changes, we used Logistic Regression (LR), Random Forest (RF), XGBoost, and K-Nearest Neighbors (KNN) models. Data was divided into an 80% training set and a 20% test set. Through a rigorous process of parameter optimization and K-fold cross-validation, focusing on the area under the receiving operating curve (AUROC), we identified the best models in all cohorts. The best models were evaluated on the test sets, reporting AUROC, recall, precision, and accuracy using the youden index threshold. Results show that age, initial EDH volume, swirl sign, intra-hematoma air bleb, contusion, otorrhagia, subarachnoid hemorrhage, location, and other side extra-axial hematoma have significant effects on changing EDH volume. Based on test AUROC, the best models were RF for adults (82.4%), KNN for pediatrics (90%), and LR for all cases (81.6%). In this study, we identified key features for predicting EDH expansion as well as developing ML models. Using high sensitive models, can assist clinicians in identifying high-risk patients early. This allows for enhanced monitoring and timely intervention, improving patient outcomes by facilitating quicker decisions for follow-up imaging or treatment.

Prognostic Significance of DSCC1, a Biomarker Associated with Aggressive Features of Breast Cancer

Background and Objectives: Invasive breast cancer (BC) was traditionally investigated visually, and no technique could identify the key molecular drivers of patient survival. However, essential molecular drivers of invasive BC have now been discovered using innovative genomic, transcriptomic, and proteomic methodologies. Nevertheless, few evaluations of the prognostic factors of BC in Saudi Arabia have been performed. Evaluating the biomarkers associated with the development of early-stage BC could help determine the risk of metastasis and guide treatment decisions. In a previous study, using large BC cohorts and artificial neural network techniques, DNA replication and sister chromatid cohesion 1 (DSCC1) was found to be one of the principal genes in invasive BC samples. To date, no studies have addressed the prognostic significance of DSCC1 in invasive BC and its association with aggressive tumor behavior. This research aimed to address this gap. Materials and Methods: The association of clinicopathological features and patient outcomes with DSCC1 expression at the mRNA level was assessed using the Molecular Taxonomy Breast Cancer International Consortium (METABRIC; n = 1980) and The Cancer Genome Atlas (TCGA; n = 854) cohorts. DSCC1 was also evaluated at the protein level using immunohistochemistry on samples from invasive BC patients (n = 100) presenting to King Abdul Aziz Specialist Hospital in Saudi Arabia. The association of clinicopathological parameters (including patient age, tumor grade, tumor size, and patient outcome) with protein level was also evaluated. Results: In both METABRIC and TCGA cohorts, high expression of DSCC1 was significantly associated with high histological grade, large tumor size, lymphovascular invasion positivity, and hormone receptor negativity (all p < 0.001). A high DSCC1 mRNA level was associated with poor outcomes (p < 0.001 for METABRIC, p = 0.23 for TCGA). At the protein level, high DSCC1 expression was associated with high histological grade (p = 0.001), lymph node presence (p = 0.008), hormone receptor negativity (p = 0.005), high Ki67 expression (p = 0.036), and shorter survival (p = 0.008). Conclusions: This study confirmed the prognostic significance of DSCC1 in invasive BC patients. DSCC1 could be a therapeutic target in BC cases with poor outcomes.

Otolaryngologists Demonstrate Low Agreement on Pediatric Airway Inflammation Assessment.

Microlaryngoscopy and bronchoscopy (MLB) are essential tools for evaluating airway inflammation, but the reliability of endoscopic assessments for this purpose remains unclear. The aim of this study was to assess surgeons' interrater reliability during endoscopic assessment of airway inflammation. The endoscopic factors used to determine overall airway inflammation were also assessed. We conducted a cross-sectional study involving 24 pediatric patients who underwent MLB and arytenoid biopsy. Surgeons rated airway inflammation based on endoscopic images, and interrater reliability was assessed using Fleiss' Kappa. Fleiss's Kappa demonstrated poor interrater reliability among all surgeons (0.111) and experienced surgeons (0.117). Surgeons varied in prioritizing visual features for assessing inflammation. Current subjective assessments of airway inflammation during MLB exhibit poor interrater reliability, necessitating further research for improved diagnostic accuracy and informed treatment decisions in pediatric airway interventions. Level 3 Laryngoscope, 2024.

Enhancing advanced cervical cell categorization with cluster-based intelligent systems by a novel integrated CNN approach with skip mechanisms and GAN-based augmentation

Cervical cancer is one of the biggest challenges in global health, thus it forms a critical need for early detection technologies that could improve patient prognosis and inform treatment decisions. This development in the form of an early detection mechanism increases the chances of successful treatment and survival, as early diagnosis promptly offers interventions that can dramatically reduce the rate of deaths attributed to this disease. Here, a customized Convolutional Neural Network (CNN) model is proposed for cervical cancerous cell detection. It includes three convolutional layers with increasing filter sizes and max-pooling layers, followed by dropout and dense layers for improved feature extraction and robust learning. By using ResNet models as inspiration, the model further innovates by incorporating skip connections into the CNN design. By enabling direct feature transmission from earlier to later layers, skip links enhance gradient flow and help preserve important spatial information. By boosting feature propagation, this integration increases the model’s ability to recognize minute patterns in cervical cell images, hence increasing classification accuracy. In our methodology, the SIPaKMeD dataset has been employed which contains 4049 cervical cell images that are arranged into five different categories. To address class imbalance, Generative Adversarial Networks (GANs) have been applied for data augmentation; that is, synthetic images have been created, that improve the diversity of the dataset and further enhance the robustness of the same. The present model is astonishingly accurate in classifying five cervical cell types: koilocytes, superficial-intermediate, parabasal, dyskeratotic, and metaplastic, thus significantly enhancing early detection and diagnosis of cervical cancer. The model gives an excellent performance because it has a validation accuracy of 99.11% and a training accuracy of 99.82%. It is a reliable model in the diagnosis of cervical cancerous cells because it ensures advancement in the computer-assisted cervical cancer detection system.

Cost-Utility Analysis of Multigene Assays to Guide Treatment Decisions for Node-Negative Early Breast Cancer.

Clinicopathologic and patient factors, such as tumor grade, size, age, and menopausal status, provide limited prognostic and predictive information in hormone receptor positive (HR +), human epidermal growth receptor 2 negative (HER2-), node-negative early-stage breast cancer, leading to potential over- or under-treatment. Multigene expression profile tests used in clinical practice in the USA, including the 21-gene assay, 70-gene assay, 12-gene assay, and 50-gene assay, offer prognostic information beyond traditional clinicopathologic features to improve treatment decisions. This study aimed to estimate the cost-effectiveness of these four multigene assays compared with clinicopathologic risk assessment alone. A decision tree categorized hypothetical patients with HR + /HER2- early-stage invasive breast cancer according to clinical and genomic risk, and integrated clinical expert insights for chemotherapy allocation with literature inputs. A Markov model simulated lifetime costs and outcomes of chemotherapy decisions over a patient's lifetime. The probability of distant breast cancer recurrence was derived from TAILORx (21-gene assay), MINDACT (70-gene assay), and TransATAC (12-gene assay, 50-gene assay) studies. Costs were calculated from a US societal perspective in 2021 US dollars, considering healthcare costs, lost productivity, and patient out-of-pocket expenses. The 21-gene assay and 50-gene assay were less costly ( -$12,189 and -$2410, respectively) and more effective [0.23 and 0.07 quality-adjusted life years (QALYs), respectively] compared with clinicopathologic risk alone. Similarly, the 70-gene assay and 12-gene assay are also cost-effective alternatives [incremental cost-effectiveness ratio (ICER): 27,760 and 7942, respectively]. All four multigene assays were cost-effective from a societal perspective, offering low net lifetime costs or savings with improved outcomes compared with clinicopathologic risk assessment alone. These assays can help refine treatment decisions by providing prognostic risk estimates. In the case of the 21-gene assay, it can also predict chemotherapy benefit leading to the highest lifetime cost savings and greatest QALY gain.

The role of combined FDG and SST PET/CT in neuroendocrine tumors.

Somatostatin receptor (SST) positron emission tomography with computed tomography (PET/CT) is the gold standard for functional imaging of neuroendocrine tumors (NETs), but FDG PET/CT is increasingly recognized for its prognostic value, particularly for higher-grade NETs and to detect disease heterogeneity. Despite the established role of pathological grading, clinical heterogeneity within the tumor burden often complicates accurate prognostication. Evidence suggests FDG PET/CT can outperform WHO grading in predicting outcomes by identifying aggressive, undifferentiated tumor clones that influence long-term prognosis and treatment decisions. Several grading systems integrating both SST and FDG PET/CT have been proposed to better capture tumor heterogeneity and guide clinical management. Studies demonstrate that FDG PET/CT can influence management in a significant subset of patients, although variably reported. Its use remains variable across centers, also affected by different reimbursement policies and local clinical practices. This review explores the indications to FDG PET/CT in NET and the clinical impact of combined SST and FDG PET/CT imaging.

Using Deep Learning to Suggest Treatment for Proximal Humerus Fractures.

Proximal humeral fractures are among the most common fractures seen in emergency departments. Accurately diagnosing and selecting the most appropriate treatment for these fractures can be challenging, and consultation with a senior orthopedic surgeon can be time-consuming for both the patient and the emergency unit. We developed a machine learning model for predicting the type of treatment based on injury radiographic images. The model distinguishes between nonoperative and operative treatment options, achieving an accuracy of 86% and an interobserver reliability (kappa) of 0.722 for test-dataset, which is more than the interobserver agreement between shoulder surgeons. This model has the potential to serve as a therapeutic decision support system for the practitioners in the emergency departments to expedite treatment decisions and to reduce patients' waiting time.

Management of Complications in Dental Traumatology.

Management of traumatic dental injuries is often challenging due to the complexity in diagnosis, concomitant injuries, and the interdisciplinary treatment planning. As a result, the clinicians are often confused and not confident over important treatment decisions. The guidelines of International Association of Dental Traumatology have improved the standard of dental trauma care globally and provide a roadmap for predictable prognosis. However, there are unique situations that require additional investigations such as the Cone Beam Computed Tomography and customized treatment and follow up protocol. An essential requisite for prevention of adverse late complications of dental injuries is clear understanding of their etiopathogenesis and the changes that occur after an injury. Additionally, it is prudent to understand the basic physiology behind the healing that is expected after a treatment protocol. This review presents the science behind the development of late complications of dental injuries and their management protocols in a simplified and clinical manner. An attempt has been made to highlight the clinical paradigms and decisions that reduce the chances of failures in traumatized teeth.

Communicating treatment options to older patients with advanced kidney disease: a conversation analysis study

BackgroundChoosing to have dialysis or conservative kidney management is often challenging for older people with advanced kidney disease. While we know that clinical communication has a major impact on patients’ treatment decision-making, little is known about how this occurs in practice. The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal disease) aimed to identify how clinicians present kidney failure treatment options in consultations with older patients and the implications of this for patient engagement.MethodsAn observational, multi-method study design was adopted. Outpatient consultations at four UK renal units were video-recorded, and patients completed a post-consultation measure of shared decision-making (SDM-Q-9). Units were sampled according to variable rates of conservative management. Eligible patients were ≥ 65 years old with an eGFR of ≤ 20 mls/min/1.73m2 within the last 6 months. Video-recordings were screened to identify instances where clinicians presented both dialysis and conservative management. These instances were transcribed in fine-grained detail and recurrent practices identified using conversation-analytic methods, an empirical, observational approach to studying language and social interaction.Results110 outpatient consultations were recorded (105 video, 5 audio only), involving 38 clinicians (doctors and nurses) and 94 patients: mean age 77 (65–97); 61 males/33 females; mean eGFR 15 (range 4–23). There were 21 instances where clinicians presented both dialysis and conservative management. Two main practices were identified: (1) Conservative management and dialysis both presented as the main treatment options; (2) Conservative management presented as a subordinate option to dialysis. The first practice was less commonly used (6 vs. 15 cases), but associated with more opportunities in the conversation for patients to ask questions and share their perspective, through which they tended to evaluate conservative management as an option that was potentially personally relevant. This practice was also associated with significantly higher post-consultation ratings of shared decision-making among patients (SDM-Q-9 median total score 24 vs. 37, p = 0.041).ConclusionsPresenting conservative management and dialysis as on an equal footing enables patient to take a more active role in decision-making. Findings should inform clinical communication skills training and education.Clinical trial numberNo trial number as this is not a clinical trial.

Patient and Caregiver Experience of Diagnosis, Treatment, and Living With Recurrent Oropharyngeal Cancer

The management of recurrent oropharyngeal cancer (rOPC) is complex. Curative options carry considerable risk of morbidity with overall poor prognosis. Little data exist on function and quality of life (QoL) outcomes for noncurative treatments. Even less is known about patient and carer experiences of function and QoL change over time when undergoing curative or noncurative treatment(s) for rOPC. To investigate the patient and caregiver experience of diagnosis, treatment, and living with recurrent oropharyngeal cancer and changes to function/QoL. A longitudinal prospective and retrospective qualitative study was carried out at a specialist cancer center in the United Kingdom. Participants with a biopsy proven diagnosis of recurrent OPC and their caregivers were included. Participants were recruited between December 2022 and November 2023. Concurrent data analysis took took place between November 2023 and January 2024. Curative salvage surgery or noncurative immunotherapy, chemotherapy, or clinical trials of investigational agents. A framework-approach thematic analysis of semistructured, in-depth interviews. Twenty-two patients and 7 caregivers were recruited. Demographic data was collected via medical record review. The longitudinal sample included 8 male and 2 female individuals, and the median age was 62 (range, 47-77) years. The retrospective sample included 11 male individuals and 1 female individual, and the median age was 64 (range, 59-70) years. Eleven participants (50%) underwent curative treatment, and 11 (50%) noncurative treatment.Treatments included salvage surgery, immunotherapy, chemotherapy, or clinical trials. Patients and their caregivers contextualize their experience of recurrent disease in their past experience of primary disease diagnosis and treatment. Patients want to survive and when the options to choose between are cure or functional outcomes impacting health-related QoL, cure appears to be favored. However, when cure is not an option, patients appear to want to survive as long as possible. However, as the prognosis gets shorter there appears to be a shift in priorities where function/QoL take precedence over survival. This qualitative study found that treatment decision-making is extremely complex in the setting of rOPC. Quite often, decisions are made based on what is perceived by health care professionals to be functionally "too morbid" with salvage surgery, or "kinder" with life-prolonging noncurative treatments. However, patients are not always fully involved in these decisions and so shared decision-making does not always happen. To facilitate shared decision-making and informed consent, patients need to be given clear and accurate information on survival and function/QoL outcomes for the various treatment modalities for rOPC.

Genomic profiling and expanded use of targeted anticancer drugs in solid cancers with exhausted evidence-based treatment options (PRECODE): study protocol of a prospective, non-randomized, cohort study

BackgroundGenomic profiling of advanced solid cancer in patients with no further evidence based standard treatment options is a novel approach to identify potential experimental treatment options based on specific genomic alterations. Due to the expected short survival of these patients timely assessment of potential druggable targets is critical to minimize the risk of deterioration during the analysis.The primary objective of this prospective study is to evaluate the turnaround time for genomic profiling and the clinical investigational procedures. The secondary objectives are to investigate how often genomic alterations in tumor tissue gives rise to a matched treatment offer and evaluate the clinical outcome.MethodsThe PRECODE study is a prospective, non-randomized, single-center cohort study conducted at Departments of Oncology and Pathology, Odense University Hospital, Denmark. Enrollment between March 1, 2019 and December 31, 2024. Eligibility criteria are age ≥ 18 years, written informed consent, advanced solid tumors, exhausted treatment options, ECOG performance status 0–2, adequate organ function and life expectancy ≥ 3 months. A core needle biopsy is analyzed by next generation sequencing using a pan-cancer comprehensive panel. Results are discussed weekly at institutional/local and national multidisciplinary tumor boards.DiscussionStrategies and methods for genomic profiling of advanced solid cancers differ. Rapid analysis and interpretation of sequencing data are key to avoiding delays in initiation potential experimental treatments, as these late-stage patients may quickly deteriorate.Although a highly optimized setup with fast-track clinical evaluation and genomic profiling has been established a subset will not be offered a targeted treatment due to deterioration. Local and national multidisciplinary teams have been established to optimize individualized treatment decisions. After genomic profiling a subset of patients will take part in clinical trials, which will constrain the reporting of overall survival or progression free survival.Trial registrationDanish Ethics Committee, Projekt-ID: S-2018014, date of approval: 27- FEB- 2019) Danish Data Protection Agency (Journal no: 18/58329, date of approval: 23-NOV-2018).ClinicalTrials.gov Identifier: NCT05385081 (retrospectively registered).

Relationship between [18F]FDG PET/CT findings and claudin 18.2 expression in metastatic gastric cancer.

Given that claudin 18.2 (CLDN18.2) is a cell surface protein specifically expressed by gastric cancer cells, anti-CLDN18.2 antibodies have demonstrated significant antitumor effects in patients with advanced gastric adenocarcinoma. The correlation of [18F]FDG PET/CT with CLDN18.2 expression remains unexplored. This study aimed to investigate whether CLDN18.2 expression was associated with [18F]FDG uptake and whether [18F]FDG PET/CT can be used to predict the CLDN18.2 status of gastric cancer. A retrospective analysis of [18F]FDG PET/CT images from 163 patients diagnosed with metastatic gastric cancer was conducted, and the expression of CLDN18.2 was assessed immunohistochemically. SUVmax, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were calculated in 3D mode using vendor-provided software. The relationship between PET metabolic parameters and CLDN18.2 status was analyzed. CLDN18.2-negative tumors showed a higher median SUVmax of 13.2 (1.8-46.7) compared to CLDN18.2-positive tumors at 7.55 (2.3-34.8), with a significant difference (p < 0.001). The median TLG was significantly higher in CLDN18.2-negative tumors (231.6) than in CLDN18.2-positive ones (81.14), indicating greater metabolic activity (p = 0.001). Multivariate analysis suggested that SUVmax remained significantly correlated with the status of CLDN18.2 (p = 0.01). CLDN18.2 expression was predicted with an accuracy of 69.9% when the SUVmax value of 10.9 was used as a cutoff point for analysis. Relatively reduced [18F]FDG uptake in metastatic gastric cancers correlates with positive CLDN18.2 expression compared to those with negative CLDN18.2 expression. [18F]FDG PET/CT may be useful for predicting the CLDN18.2 status of gastric cancer and thus aid in optimal treatment decisions. Question The study resolves the clinical issue of determining the correlation between [18F]FDG PET/CT imaging and claudin 18.2 expression in metastatic gastric cancer. Findings Claudin 18.2-positive metastatic gastric cancers exhibit relatively lower [18F]FDG uptake than negative ones. The SUVmax of 10.9 moderately predicts claudin 18.2 expression. Clinical relevance [18F]FDG PET/CT imaging could be a noninvasive way to predict claudin 18.2 status in metastatic gastric cancer, helping to improve personalized treatment plans.

Advancing precision in CT-guided bone biopsies: exploring the potential of dual-energy CT imaging.

This study aimed to investigate the integration of dual-energy CT (DECT) into CT-guided bone biopsy procedures, comparing it with conventional CT techniques. The focus was on technical aspects, accuracy and radiation dose exposure. A total of 51 bone biopsies were conducted, with 36 using conventional CT and 15 utilizing DECT. Patient data, lesion characteristics and biopsy techniques were analyzed. Statistical analyses, including Fisher's exact test and independent samples t-test, were performed to compare accuracy and radiation doses between the two methods. DECT-guided biopsies demonstrated a significantly higher accuracy (93.33%) compared to conventional CT biopsies (86.11%). The radiation dose exposure for DECT was comparable to conventional CT. DECT's ability to differentiate tissues, especially in bone marrow edema detection, led to higher precision. Integrating DECT into CT-guided bone biopsies enhances tissue differentiation and accuracy without significantly increasing radiation exposure. This advancement holds promise for improving musculoskeletal interventional radiology, leading to more precise diagnoses, informed treatment decisions and improved patient outcomes.

Pigmented Syringomatous Carcinoma/Sweat Gland Carcinoma of the Vulva With Melanocytic Colonization: An Uncommon Presentation of a Rare Sweat Gland Neoplasm

Abstract: Primary vulvar carcinomas are rare and constitute a diverse group of neoplasms. These primary tumors are typically classified based on their presumed tissue of origin or histological characteristics. Among these, carcinomas of sweat gland origin are particularly significant. They closely resemble similar malignancies in nonvulvar skin, including various cutaneous adnexal-type cancers such as apocrine and eccrine adenocarcinomas. Syringomatous carcinoma of the vulva is a rare malignant sweat gland neoplasm known for its infiltrative growth and tendency for local recurrence. Typically, these malignancies manifest as nonulcerated nodules or plaques, primarily in the head and neck region. The occurrence of syringomatous carcinoma in the vulvar region is exceptionally rare. Herein, we present a unique case of a 35-year-old woman with a dark mole measuring 1.5 × 1.0 cm on the vulva. Complete excision was performed to exhibit an infiltrative haphazard proliferation of elongated ductules and tubules, displaying significant cytologic atypia characterized by irregular nuclear contours and variably prominent nucleoli. Extensive melanocytic pigment deposition and stromal fibrosis were also observed. Immunohistochemical staining demonstrated positive expression of epithelial markers, including keratins (AE1/AE3) and epithelial membrane antigen, supporting the diagnosis of syringomatous carcinoma. CK7 and carcinoembryonic antigen were negative, whereas SOX10 and pan melanin highlighted admixed, cytologically bland melanocytes within the epidermis and neoplastic nests. This case represents a highly unusual presentation of syringomatous carcinoma associated with melanocyte colonization. Due to limited data on the optimal management strategies, a multidisciplinary approach involving gynecologic oncologists, dermatopathologists, and radiation oncologists is essential for treatment decisions. Long-term follow-up is crucial, considering the potential for local recurrence and metastatic spread, emphasizing the importance of comprehensive clinical management for favorable patient outcomes of this rare malignancy.

The Atopic Dermatitis Control Tool: Adaptation and Content Validation for Children and Caregivers of Children with Atopic Dermatitis.

The Atopic Dermatitis Control Tool (ADCT) assesses six concepts regarding patient-perceived control of atopic dermatitis (AD) in adults and adolescents with AD. This study aimed to develop two modified ADCT versions, one for children with AD aged 8-11years and another for caregivers of children with AD aged 6months to 11years. Following the US Food and Drug Administration patient-reported outcomes guidance, the ADCT was modified to produce draft Child and Caregiver ADCT versions, maintaining the original six concepts. The instruments were refined and finalized through an iterative process using input from children with AD and caregivers of children with AD via qualitative interviews. Inclusion criteria were clinician diagnosis of AD, prescription treatment use in the past 3months, and itching/scratching or rash in the past month. Interviews consisted of concept elicitation to identify perceptions of AD control and cognitive debriefing to test and refine the ADCT items. In total, 19 children (mean age 9.2years, 74% male) and 17 caregivers (mean age 36.3years, 100% female) were interviewed. During concept elicitation, children and caregivers reported similar symptoms and described the cycling and unpredictability of AD. Most participants reported that daily activities were impacted negatively by AD symptoms. The concept of AD control resonated with children and caregivers, and respondents were able to describe their experiences related to AD symptom severity. Children were unfamiliar with the term AD, so the Child ADCT version was named the Child Eczema Control Tool (ECT). Children and caregivers both reported that the instruments assessed relevant concepts, comprehensively measured AD control, and demonstrated content and face validity. The Child ECT and Caregiver ADCT were developed and qualitatively validated for assessing AD control in patients aged 6months to 11years and may offer simple ways to assess disease control and optimize treatment decisions. Video Abstract.

Assessing the role of conspiracy beliefs in oncological treatment decisions: An experimental approach.

Cancer is an important issue and a model topic for misinformatfion researchers. The present research experimentally investigates the effect of cancer-related conspiracy beliefs and misinformation on oncology treatment intentions in a cancer-free population. In three pre-registered studies (N total = 1020), participants were asked to put themselves in the shoes of a patient recommended for chemotherapy. Study 1 (N = 300) failed to experimentally manipulate cancer-related conspiracy beliefs with exposure to a health scandal not related to cancer. In Study 2 (N = 258), exposure to a pro-conspiracy (vs. anti-conspiracy) content related to cancer treatment was associated with more conspiracy beliefs, less intention to use chemotherapy and more intentions to use unconventional medicines. Exploratory analyses revealed that these effects were conditioned by the credibility of the misinformation. Study 3 (N = 462) replicated these findings using a full experimental design. Exposure (vs. no exposure) to a warning and accuracy prompt, prior to exposure to the pro-conspiracy content, was found to be effective in reducing its credibility and preventing its detrimental effects. These findings corroborate the existence of an effect of conspiracy beliefs on treatment intentions in oncology and also suggest several ways to mitigate them.

Tivozanib Monotherapy in the Frontline Setting for Patients with Metastatic Renal Cell Carcinoma and Favorable Prognosis.

In this review, we discuss which patients with metastatic clear cell renal cell carcinoma (mRCC) may be most suitable for frontline tyrosine kinase inhibitor (TKI) monotherapy, a treatment option supported by emerging long-term efficacy data including overall survival and quality of life. We specifically focus on tivozanib, a potent and selective inhibitor of vascular endothelial growth factor receptor, which has comparable efficacy to other single-agent TKIs in frontline treatment for mRCC while exhibiting fewer off-target side effects. Combination therapy with TKIs and checkpoint inhibitors (CPIs) and CPI/CPI combination therapies, as well as TKI monotherapy are recommended frontline treatment options for mRCC. Treatment decisions are complex and based on several factors, including the patient's International Metastatic RCC Database Consortium risk status, age, comorbidities, and personal preferences related to response, tolerability, and quality of life. TKIs not only serve as backbone of most combination therapies for mRCC, but also remain a viable monotherapy option in the first-line setting for patients in favorable risk groups and those with contraindications to CPI combination therapies. Given that overall survival benefits have not yet been confirmed for CPI-containing combination regimens in favorable risk patients, we argue that frontline single-agent TKI treatment remains a standard of care option for these patients. This is supported by treatment guidelines, even in the era of TKI/CPI combination therapies.

Q-Learning in Dynamic Treatment Regimes With Misclassified Binary Outcome.

The study of precision medicine involves dynamic treatment regimes (DTRs), which are sequences of treatment decision rules recommended based on patient-level information. The primary goal of the DTR study is to identify an optimal DTR, a sequence of treatment decision rules that optimizes the clinical outcome across multiple decision points. Statistical methods have been developed in recent years to estimate an optimal DTR, including Q-learning, a regression-based method in the DTR literature. Although there are many studies concerning Q-learning, little attention has been paid in the presence of noisy data, such as misclassified outcomes. In this article, we investigate the effect of outcome misclassification on identifying optimal DTRs using Q-learning and propose a correction method to accommodate the misclassification effect on DTR. Simulation studies are conducted to demonstrate the satisfactory performance of the proposed method. We illustrate the proposed method using two examples from the National Health and Nutrition Examination Survey Data I Epidemiologic Follow-up Study and the Population Assessment of Tobacco and Health Study.

Phelan-McDermid Syndrome-associated Psychosis: A Systematic Review.

Phelan-McDermid syndrome is a rare genetic disorder characterized by various neurodevelopmental, medical, and psychiatric issues. Although bipolar disorder-like presentations and catatonia are particularly common, psychosis has also been reported but is less well described. As such, this systematic review sought to characterize the phenomenology of psychosis in Phelan-McDermid syndrome, clarify the association of psychotic symptoms with other neuropsychiatric features of the disorder, and describe antipsychotic treatment response. A literature search was completed in July 2024 using PubMed and Scopus. Only English-language articles that reported the occurrence of psychotic symptoms in Phelan-McDermid syndrome were eligible for inclusion. 18 articles describing 35 individuals were included in the main analyses. Three additional articles of relevance are discussed separately, as they either provided limited clinical information or did not present data in a patient-specific manner. The average age of psychosis onset was ∼17 years, and 65% of individuals developed symptoms at or before age 15. ∼69% of individuals also experienced catatonia, ∼81% experienced mood symptoms, and 50% experienced both. Visual hallucinations were the most commonly reported psychotic symptom. Where reported, ∼76% (13/17) of individuals exhibited at least a partial and/or temporary response to antipsychotic therapy. Psychotic presentations in Phelan-McDermid syndrome may qualitatively differ from schizophrenia. Although numerous antipsychotics may be efficacious in the treatment of Phelan-McDermid syndrome-associated psychosis, this review most importantly highlights the paucity of available high-quality evidence to guide treatment decisions in this respect, and as such indicates the need for more reports to be published.

EUROVISCO Consensus Guidelines for the Use of Hyaluronic Acid Viscosupplementation in Knee Osteoarthritis Based on Patient Characteristics.

Viscosupplementation with hyaluronic acid (HA) is a commonly used intra-articular treatment for osteoarthritis (OA). We performed a Delphi consensus process to formulate guidelines for the use of intra-articular hyaluronic acid (IAHA) knee injection according to the patient's characteristics. The EUROVISCO group consists of 12 members who had expertise in clinical and/or research in the field of OA and IAHA treatment. This group drafted issues through an iterative process and subsequently voted according to a Delphi process on their level of agreement (LoA) on these recommendations. The scores were pooled to generate a median agreement score for each recommendation. The strength of the recommendation (SOR) was classified as strong if the median agreement score was ≥8. The level of consensus (LOC) was also obtained. The level of evidence was given for each recommendation. A total of 34 statements were evaluated by the expert group. A unanimous or high LoA was obtained in 16. IAHA can be considered irrespective of the age in patients with symptomatic knee OA. It can be used in patients with diabetes and/or moderate to severe obesity. It can also be used in knee OA patients with a history of gout, meniscocalcinosis and with mild-to-moderate varus/valgus malalignment. The group recommended against the use of VS in pregnant women and in OA flare. In summary, the working group provided strong recommendations for the use of IAHA injection that will facilitate individualized treatment decision algorithms in the management of knee OA.