Unequivocal Recommendations Research Articles

Oncologists’ communication about tobacco and alcohol use during treatment for esophagogastric cancer: a qualitative observational study of simulated consultations

PurposeTobacco and alcohol use influence cancer risk as well as treatment outcomes, specifically for esophageal and gastric cancer patients. Therefore, it is an important topic to discuss during consultations. This study aims to uncover medical, radiation, and surgical oncologists’ communication about substance use, i.e., tobacco and alcohol use, in simulated consultations about curative and palliative esophagogastric cancer treatment.MethodsSecondary analyses were performed on n = 40 standardized patient assessments (SPAs) collected in three Dutch clinical studies. Simulated patients with esophagogastric cancer were instructed to ask about smoking or alcohol use during treatment. The responses of the 40 medical, radiation, and surgical oncologists were transcribed verbatim, and thematic analysis was performed in MAXQDA.ResultsOncologists consistently advocated smoking cessation during curative treatment. There was more variation in their recommendations and arguments in the palliative compared to the curative setting and when addressing alcohol use instead of smoking. Overall, oncologists were less stringent regarding behavior change in the palliative than in the curative setting. Few oncologists actively inquired about the patient’s perspective on the substance use behavior, the recommended substance use change, or the support offered.ConclusionClear guidelines for oncologists on when and how to provide unequivocal recommendations about substance use behavior change and support to patients are needed. Oncologists might benefit from education on how to engage in a conversation about smoking or alcohol.

Residency in Long-Term Care Facilities: An Important Risk Factor for Respiratory Syncytial Virus Hospitalization.

Older age and comorbid conditions increase risk for severe for respiratory syncytial virus (RSV). Skilled nursing facilities (SNFs) and assisted living (AL) facilities represent an intersection of risk factors. In a 3-year prospective study in Rochester, New York, we compared the population-based incidence of RSV-associated hospitalization for community-dwelling (CD), SNF, and AL adults aged ≥65 years. Their median ages were 76, 83 and 86 years, respectively, and dementia and congestive heart failure (CHF) were more prevalent among SNF and AL residents. The average annual incidences were 117 (95% confidence interval, 104-132), 440 (307-629) and 740 per 100 000 persons (523-1045), respectively, for CD, SNF, and AL adults aged ≥65 years, demonstrating a need for unequivocal RSV vaccine recommendations in SNF and AL residents.

FRI111 Venous Thromboembolism In Cushing Syndrome - A Call For Standardized Anticoagulation Regimen In Hypercortisolism

Abstract Disclosure: M. Minasyan: None. A. Bryk-Wiazania: None. E. Rzepka: None. A. Bogusławska: None. A. Hubalewska-Dydejczyk: None. A. Gilis-Januszewska: None. Venous thromboembolism in Cushing Syndrome - a call for standardized anticoagulation regimen in hypercortisolism. Cushing Syndrome (CS) is associated with a 18-fold higher risk of venous thromboembolism (VTE) when compared to the general population with the similar demographic characteristics. Despite numerous studies on hypercoagulability in CS, the unequivocal recommendations regarding timing and dosing of thromboprophylaxis in hypercortisolism are still lacking. We present a case series of patients with CS and VTE, hospitalized in the Endocrinology Department of University Hospital in Krakow. Among 135 patients with CS, we found 7cases of VTE (5.19%), aged 35-65 years, mostly females (n=6). The etiology of CS was predominately pituitary (n=3), the other tissue origins of CS were: adrenal (n=2), ectopic(n=1) and adrenal carcinoma (n=1). Pulmonary embolism (PE) was found in 3 patients, deep venous thrombosis (DVT) in 2 patients, while 2 patients suffered from concomitant DVT and PE. We found that one patient had VTE 5 months before inducing the biochemical remission by a transsphenoidal surgery, while 2 patients within the 30 days after inducing the biochemical remission by either a transsphenoidal surgery in one, or metyrapone treatment in 2nd case. In the remaining 4 patients, VTE episode preceded the diagnosis of CS, ranging from 1 year to 2 months prior to the diagnosis. Among them, 2 PE episodes were associated with other predisposing factors, such as (1) postpartum PE in a 36-year-old women, who was subsequently diagnosed with Cushing disease, and (2) combined oral contraceptive in a 35-year-old woman, who suffered from the peripheral PE, and was eventually diagnosed with adrenal CS. Of note, at the time of VTE episode, 1 patient was treated with warfarin (international normalized ratio at the time of VTE, 1.66), another one took apixaban. One fatal PE occurred on the thromboprophylaxis with low molecular weight heparin, in the hypocortisolemia following metyrapone implementation. To summarize, VTE episode: 1. may be the first, life-threatening presentation of CS; 2. may occur after treatment of hypercortisolism; 3. may happen in patients on thromboprophylaxis or anticoagulant treatment; 4. should be included in the differential diagnosis of a thrombotic event despite coexisting transient factor (e.g. oral contraceptive, delivery). 5. Further multicenter studies are essential to understand the hypercoagulability in CS, and to create the recommendations on this topic. Presentation: Friday, June 16, 2023

Assessing the Level of Consumption by Children in Households

In the context of changing the demographic structure of the population (population aging) in order to determine the demand for goods and services and predict key socio-economic indexes, consumption age indexes are of practical interest for research. A feature of collecting information on the level of consumption is the conduct of surveys for the household as a whole, and not for a specific member of the household. At the same time, it should be noted that throughout the life cycle of a person, the level and structure of consumption differ. Methods for assessing the level of consumption in households of different generations are of greatest interest on the part of researchers. Current trends in developing and developed countries are characterized by a move away from multi-generational living. Thus, estimates of the level of consumption by children in households with parents are of practical interest.The purpose of the study. At present, there are no unequivocal recommendations on how to estimate the calculation of children’s consumption in households. At the same time, the available methods have been subjected to various criticisms from economists. It should be noted that most of the research on this topic was carried out at the end of the 20th century. At the same time, it is necessary to take into account possible cross-country features of consumption financing: the availability and development of medicine and education. If social services are available and provided at the expense of the state in a country, then the level of consumption by children will be lower. If the household finances the social sphere, the level of consumption by children in households will be higher. Thus, it is of practical interest to assess the level of consumption by children in Russian households.Materials and methods. Based on data from the Household Budget Survey (HBS) for 2020 conducted by Rosstat, households consisting of two adults and two adults with one child are selected. With the help of classical methods of statistical analysis, the construction of age profiles of consumption for each group of households is carried out. Based on the share of expenditures on food in the household and the scale effect of their consumption, the paper constructs age estimates for the redistribution of the level of consumption depending on the age of children. In addition, the sample size allows us to test the hypothesis about the age of birth of the child and the level of consumption.Results. The study made it possible to assess the differences in the level of consumption by children depending on the age at which a child was born. The average age of a child’s birth determines his/her further level of consumption throughout adulthood. Consumption is lowest among children who are born when parents are less than 26 years old. The obtained redistribution coefficients for ages under 15 are higher than in the estimates proposed by R. Lee, E. Mason, and Deaton, that confirms the possible consumption patterns of Russian households.Conclusion. This article draws two key conclusions. The age at which a child is born determines his/her level of future consumption: the birth of a child under the age of 24 indicates a relatively low level of consumption throughout their adulthood. The estimates obtained for the level of consumption by children depending on their age indicate higher consumption up to 14 years of age than in foreign methods that can be explained by the socio-economic characteristics of Russian households.

ALGORITHM OF A DIFFERENTIATED APPROACH TO MANAGEMENT OF PERSISTENT PULMONARY HYPERTENSION IN PREMATURE INFANTS

Introduction. Oxidative stress (OS) is recognized as a contributing factor to the development of persistent pulmonary hypertension (PPH) in premature infants. In the modern scientific literature, there is a lack of unequivocal recommendations for the management of PPH, considering the levels of OS, what determines the need for the development of a differentiated approach for management to infants with pulmonary hypertension.The aim of the study. To increase the efficacy of management of premature infants with persistent pulmonary hypertension with asphyxia and respiratory distress syndrome based on the development of the algorithm of a differentiated approach for management of pulmonary hypertension considering the levels of oxidative stress as determined by the urinary 8-hydroxy-2-deoxyguanosine (8-OHdG).Material and methods. Were analyzed the observations of 96 infants born prematurely at gestational age of 26/1–34/6 weeks: group I consisted of 50 infants with respiratory distress syndrome (RDS), group II - 50 infants with RDS associated with perinatal asphyxia. PPH was determined by echocardiography on the 1st and on the 3rd-5th day of life, and quantitative determination of the urinary 8-OHdG (ng/ml) was performed on 44 neonates on the 1st and in dynamics on the 3rd-5th day of life using enzyme-linked immunosorbent assay (ELISA). For comprehensive radiographic assessment of PPH, all infants received chest X-Ray with determination of Moore's, Schwedel's, and cardiothoracic indexes (CTI).Statistical analysis was performed using Microsoft Excel 2019 software. Under the conditions of normal distribution of quantities, parametric statistical methods were used to calculate the arithmetic mean (M) and the representativeness error of the mean (m). Using Fisher`s exact test (φ) we analyzed the quantitative parameters. Using the heterogeneous sequential Wald procedure, development of diagnostic criteria was performed. The essence of the procedure is to determine both diagnostic (DC), prognostic coefficients (PC) and diagnostic informativeness (I) of the investigated indicators. The minimum informativeness of the feature required for addition to the developed algorithm was considered I ≥ 0.25.The algorithm was developed on the basis of diagnostic coefficients of clinical and anamnestic data of the examined groups of children, echocardiographic criteria for the presence and determination of the degree of PPH, the dynamics of OS levels and their comparison with the indicators of a comprehensive radiological assessment of pulmonary hypertension in prematurely born infants with RDS and perinatal asphyxia in association with RDS in gestational age of 26-34 weeks.Design of a study was discussed and approved at a session of the Ethical commission of the Kharkiv Medical Academy of Postgraduate Education (Prot. № 5 from 18.12.2020). All parents gave an informed consent for examination of their children.The study was carried out in accordance to the plan of the research work of the Department of Neonatology of the Kharkiv Medical Academy of Postgraduate Education "Study of features of the course of oxidative stress diseases in newborns" (January 2022 - December 2024), state registration number 0122U000025.Results. Has been developed an algorithm of a differentiated approach to management of premature infants with RDS and asphyxia with PPH, the essence of which - is to improve and individualize the method of mechanical lung ventilation (MLV) for each individual case.Conclusions. For prematurely born infants at gestational age 26-34 weeks, is important to determine the level of the urinary 8-OHdG on the 1st and 3rd-5th days of life to decide the severity of OS. For management of newborns with PPH, in the case of an increase of the level of 8-OHdG by the 3rd-5th day of life, is recommended to increase the ventilator parameters; in the case of a decrease - diminish the ventilation parameters or extubate an infant.

Multidisciplinary Treatment in Toxic Epidermal Necrolysis.

Toxic epidermal necrolysis, Leyll's syndrome (TEN), is a rare mucocutaneous blistering disease burdened with high mortality rates. The diagnosis of TEN is based on clinical symptoms and histopathological findings. In approximately 90% of cases, it is a severe adverse reaction to drugs. In TEN, not only is the skin affected, but also mucosa and organs' epithelium. There are no unequivocal recommendations in regard to systemic and topical treatment of the patients. The aim of this paper is to review available literature and propose unified protocols to be discussed. Early management and multidisciplinary treatment are necessary to improve patients' outcome. Treatment of patients with TEN suspicions should be initiated with early drug withdrawal. TEN patients, like patients with burns, require intensive care and multidisciplinary management. Each patient with TEN should be provided with adequate fluid resuscitation, respiratory support, nutritional treatment, pain control, infection prophylaxis, anticoagulant therapy, and gastric ulcer prophylaxis. The key to local treatment of patients with TEN is the use of nonadherent dressings that do not damage the epidermis during the change. The aim of the systemic treatment is purification of the blood stream from the causative agent. The most efficient way to clarify serum of TEN patients' is the combination of plasmapheresis and IVIG. Immunomodulatory therapy can reduce the mortality five times in comparison with the patients with immunosuppression or lack of full protocol.

Current state of the problem of risk assessment and prevention of venous thromboembolic complications after thermal obliteration of superficial veins

Venous thromboembolic complications (VTEO) after modern minimally invasive superficial vein interventions are an infrequent but very dramatic event. This article presents a review of the literature, covering the issues of prevalence, prognosis and pharmacological prevention of VTEO. The performed studies demonstrate that the incidence of symptomatic thrombotic complications after endovenous thermal obliteration does not exceed 0,5%, but taking into account asymptomatic thermally induced thromboses and subclinical occlusions of the muscular veins of the lower leg, this figure can exceed 10%. There is a high heterogeneity of the data, possibly due to differences in the individual risk of VTEO. The most validated tool for assessing the latter is the Caprini Scale, which has not been sufficiently studied in the surgical treatment of varicose veins. The administration of prophylactic doses of anticoagulants after thermal obliteration of saphenous veins is widely used in routine clinical practice, despite the lack of convincing evidence for the appropriateness of this approach. In recent years, the use of direct oral anticoagulants against the official instruction (off-label) has gained great popularity as an alternative to heparin. The largest evidence base has accumulated for the use of rivaroxaban 10 mg, which is associated with high efficacy and safety. Based on completed clinical trials, it is not possible to formulate unequivocal recommendations for prophylactic anticoagulant doses after thermal obliteration of superficial veins at this time. Additional studies are required to identify patients with an individually increased risk of thrombosis in whom prophylactic doses of anticoagulants may be of maximum benefit.

Inpatient Specialist Palliative Care in Patients With Left Ventricular Assist Devices (LVAD): A Retrospective Case Series.

BackgroundRepeat hospitalizations, complications, and psychosocial burdens are common in patients with left ventricular assist devices (LVAD). Specialist palliative care (sPC) involvement supports patients during decision-making until end-of-life. In the United States, guidelines recommend early specialist palliative care (esPC) involvement prior to implantation. Yet, data about sPC and esPC involvement in Europe are scarce.Materials and MethodsThis is a retrospective descriptive study of deceased LVAD patients who had received sPC during their LVAD-related admissions to two university hospitals in Duesseldorf, Germany and Basel, Switzerland from 2010 to 2021. The main objectives were to assess: To which extent have LVAD patients received sPC, how early is sPC involved? What are the characteristics of those, how did sPC take place and what are key challenges in end-of-life care?ResultsIn total, 288 patients were implanted with a LVAD, including 31 who received sPC (11%). Twenty-two deceased LVAD patients (19 male) with sPC were included. Mean patient age at the time of implantation was 67 (range 49–79) years. Thirteen patients (59%) received LVAD as destination therapy, eight patients (36%) were implanted as bridge to transplantation (BTT), and one as an emergency LVAD after cardiogenic shock (5%). None of the eight BTT patients received a heart transplantation before dying. Most (n = 13) patients lived with their family and mean Eastern Cooperative Oncology Group (ECOG) performance status was three. Mean time between LVAD implantation and first sPC contact was 1.71 years, with a range of first sPC contact from 49 days prior to implantation to more than 6 years after. Two patients received esPC before implantation. In Duesseldorf, mean time between first sPC contact and in-hospital death was 10.2 (1–42) days. In Basel, patients died 16 (0.7–44) months after first sPC contact, only one died on the external sPC unit. Based on thorough examination of two case reports, we describe key challenges of sPC in LVAD patients including the necessity for sPC expertise, ethical and communicative issues as well as the available resources in this setting.ConclusionDespite unequivocal recommendations for sPC in LVAD patients, the integration of sPC for these patients is yet not well established.

The place of non-invasive brain stimulation in the RANZCP clinical practice guidelines for mood disorders.

Clinical practice guidelines are important documents as they have the capacity to significantly influence and shape clinical practice in important areas of therapeutics. As such, they need to be developed informed by comprehensive and quality-based systematic reviews, involve consensus deliberations representative of the appropriate experts in the field and be subject to thorough critical review. A revised clinical practice guideline for the management of patients with mood disorders was recently published under the auspices of the Royal Australian and New Zealand College of Psychiatrists. However, this clinical practice guideline was not developed in a manner that reflects the appropriate standards that should apply to clinical practice guideline development and it has critical flaws, especially as it pertains to the use of repetitive transcranial magnetic stimulation treatment for patients with depression. The revision of the college clinical practice guideline has explicitly removed clear and unequivocal evidence-based recommendations that were found in a previous version of the clinical practice guideline and replaced these with consensus-based recommendations. However, the consensus-based recommendations were developed without consultation of the appropriate expert body within the college and contradict the scientific literature. There is substantive and unequivocal evidence supporting the antidepressant use of repetitive transcranial magnetic stimulation in the treatment of patients with depression and its use after a patient with depression has failed a limited number (typically around two) of antidepressant medication trials. Readers should refer to the college Professional Practice Guidelines for repetitive transcranial magnetic stimulation published in 2018 for thorough information about the use of this important new treatment.

Statistical power: Implications for planning MEG studies

Statistical power is key for robust, replicable science. Here, we systematically explored how numbers of trials and subjects affect statistical power in MEG sensor-level data. More specifically, we simulated "experiments" using the MEG resting-state dataset of the Human Connectome Project (HCP). We divided the data in two conditions, injected a dipolar source at a known anatomical location in the "signal condition", but not in the "noise condition", and detected significant differences at sensor level with classical paired t-tests across subjects, using amplitude, squared amplitude, and global field power (GFP) measures. Group-level detectability of these simulated effects varied drastically with anatomical origin. We thus examined in detail which spatial properties of the sources affected detectability, looking specifically at the distance from closest sensor and orientation of the source, and at the variability of these parameters across subjects. In line with previous single-subject studies, we found that the most detectable effects originate from source locations that are closest to the sensors and oriented tangentially with respect to the head surface. In addition, cross-subject variability in orientation also affected group-level detectability, boosting detection in regions where this variability was small and hindering detection in regions where it was large. Incidentally, we observed a considerable covariation of source position, orientation, and their cross-subject variability in individual brain anatomical space, making it difficult to assess the impact of each of these variables independently of one another. We thus also performed simulations where we controlled spatial properties independently of individual anatomy. These additional simulations confirmed the strong impact of distance and orientation and further showed that orientation variability across subjects affects detectability, whereas position variability does not. Importantly, our study indicates that strict unequivocal recommendations as to the ideal number of trials and subjects for any experiment cannot be realistically provided for neurophysiological studies and should be adapted according to the brain regions under study.

Orally Administered NSAIDs-General Characteristics and Usage in the Treatment of Temporomandibular Joint Osteoarthritis-A Narrative Review.

Background: Temporomandibular joint osteoarthritis (TMJ OA) is a degenerative joint disease. The aim of this review was to present the general characteristics of orally administered nonsteroidal anti-inflammatory drugs (NSAIDs) and to present the efficacy of NSAIDs in the treatment of TMJ OA. Methods: PubMed database was analyzed with the keywords: “(temporomandibular joint) AND ((disorders) OR (osteoarthritis) AND (treatment)) AND (nonsteroidal anti-inflammatory drug)”. After screening of 180 results, 6 studies have been included in this narrative review. Results and Conclusions: Nonsteroidal anti-inflammatory drugs are one of the most commonly used drugs for alleviation of pain localized in the orofacial area. The majority of articles predominantly examined and described diclofenac sodium in the treatment of pain in the course of TMJ OA. Because of the limited number of randomized studies evaluating the efficacy of NSAIDs in the treatment of TMJ OA, as well as high heterogeneity of published researches, it seems impossible to draw up unequivocal recommendations for the usage of NSAIDs in the treatment of TMJ OA. However, it is highly recommended to use the lowest effective dose of NSAIDs for the shortest possible time. Moreover, in patients with increased risk of gastrointestinal complications, supplementary gastroprotective agents should be prescribed.

Drug-induced dyskinesias, can they be prevented?

Abstract Introduction: Dyskinesia is a symptom complex in the form of involuntary, repetitive movements of lips, lower jaw, tongue, less often the trunk and limbs. Despite the use of newer drugs in treatment neuroleptics, dyskinesia has not ceased to be a clinical problem. Method: The work is based on a research review for which the Google Scholar database was used as well PubMed. The search range was limited to 2008-2020. We have included descriptive publications tardive dyskinesia only as a consequence of antipsychotic medications. Material: We present the use of tetrabenazine analogues, deep brain stimulation, neuroleptics, benzodiazepines and botulinum toxin in late-suffering patients drug-induced dyskinesias, which may indicate an improvement in your health. Discussion: The first method of treating tardive dyskinesia are withdrawal antipsychotic medications, but for many patients this is impossible. Valbenazine and Deep Brain Stimulation are the most effective in treating Tardive Dyskinesia. Conclusions: There are not enough studies with the highest reliability to create unequivocal recommendations in the treatment of drug-induced tardive dyskinesia.

Patients with cardiac implantable electronic devices undergoing radiotherapy in Poland. Expert opinion of the Heart Rhythm Section of the Polish Cardiac Society and the Polish Society of Radiation Oncology.

Older age and high morbidity of the society contribute to a growing number of patients with cardiac implantable electronic devices (CIEDs) requiring effective cancer treatment, including radiotherapy (RT). The effect of RT on a CIED may vary depending on the type and physical parameters of radiation, location of the treated lesion, indications for electrotherapy, and the type of CIED. In the most dramatic scenarios, it may cause an irreversible damage to the CIED, with serious clinical consequences. The lack of precise guidelines may limit the access to RT for many patients with CIEDs who would otherwise benefit from the therapy or may lead to a therapy without taking the necessary precautions, which may worsen the prognosis. Therefore, clear and unequivocal recommendations for assessing patient eligibility for RT are aimed at ensuring that adequate precautions are taken as well as at providing patients with concomitant cardiovascular and oncologic diseases with access to safe and effective RT.

Consumption of Alcoholic Beverages and the Prevalence of Metabolic Syndrome and Its Components.

The relationship between alcohol consumption and the prevalence of metabolic syndrome is not consistent and may vary between populations, depending on age, sex, ethnicity, cultural traditions and lifestyle. We have hypothesized that moderate alcohol consumption will be associated with the lowest risk of the syndrome. The aim of the present study is to examine the relationship between the current consumption of alcohol and the prevalence of metabolic syndrome and its components. The research material includes data obtained from 12,285 men and women, in the age range of 37–66 years. Multiple logistic regression was used in the statistical analysis. Metabolic syndrome (MetS) was defined according to the International Diabetes Federation. In men, a current consumption of >30 g of alcohol/day was significantly associated with a higher risk of metabolic syndrome (OR = 1.73, 95% CI = 1.25–2.39), high blood pressure (OR = 2.76, 95% CI = 1.64–4.65), elevated glucose concentration (OR = 1.70, 95% CI = 1.24–2.32), and abdominal obesity (OR = 1.77; 95% CI = 1.07–2.92). In women, the consumption from 10.1 to 15.0 g of alcohol was associated only with a higher risk of abnormal glucose concentration (OR = 1.65; 95% CI = 1.14–2.38.) In both sexes, current alcohol consumption was associated with higher high-density lipoproteins (HDL)-cholesterol concentration (p < 0.05). No relationship was found between alcohol consumption and triglyceride concentration. It is difficult to formulate unequivocal recommendations regarding alcohol intake in MetS prophylaxis due to its different association with particular MetS components. In order to explain the causal relationship between alcohol consumption and MetS and its components, prospective studies are necessary.

Post Partum Hemorrhage – Mini Review

Background: Postpartum hemorrhage (PPH) remains a common cause of maternal mortality worldwide, mainly caused by uterine atony. Medical intervention plays an important part in prevention and therapies of PPH. Prophylactic interventions include the use of uterotonic drugs. We elaborated the consistency of national and international guidelines on those medical approaches. Materials and methods: Medical approaches in PPH were extracted from recent publications. Furthermore, the current guidelines of the World Health Organization, the FIGO and of the American, British,and Canadian of Obstetricians and Gynecologists on PPH were analyzed. Results: Use of oxytocin after delivery of the anterior shoulder is the most important and effective component of this practice. However, the examined guidelines fail to give unequivocal recommendations on further uterotonics in PPH, which may partially be attributed to differing publication dates of the guidelines. Conclusion: Appropriate management of postpartum hemorrhage requires prompt diagnosis and treatment . International guidelines on PPH are characterized by differing recommendations. However, recent publications suggest that adhering to local guidelines significantly reduces the prevalence of severe PPH.

Cause-effect analysis for sustainable development policy

The sustainable development goals (SDGs) launched by the United Nations (UN) set a new direction for development covering the environmental, economic, and social pillars. Given the complex and interdependent nature of the socioeconomic and environmental systems, however, understanding the cause-effect relationships between policy actions and their outcomes on SDGs remains as a challenge. We provide a systematic review of cause-effect analysis literature in the context of quantitative sustainability assessment. The cause-effect analysis literature in both social and natural sciences has significantly gained its breadth and depth, and some of the pioneering applications have begun to address sustainability challenges. We focus on randomized experiment studies, natural experiments, observational studies, and time-series methods, and the applicability of these approaches to quantitative sustainability assessment with respect to the plausibility of the assumptions, limitations and the data requirements. Despite the promising developments, however, we find that quantifying the sustainability consequences of a policy action, and providing unequivocal policy recommendations based on it is still a challenge. We recognize some of the key data requirements and assumptions necessary to design formal experiments as the bottleneck for conducting scientifically defensible cause-effect analysis in the context of quantitative sustainability assessment. Our study calls for the need of multi-disciplinary effort to develop an operational framework for quantifying the sustainability consequences of policy actions. In the meantime, continued efforts need to be made to advance other modeling platforms such as mechanistic models and simulation tools. We highlighted the importance of understanding and properly communicating the uncertainties associated with such models, regular monitoring and feedback on the consequences of policy actions to the modelers and decision-makers, and the use of what-if scenarios in the absence of well-formulated cause-effect analysis.

102 Evolution of european society of cardiology guidelines since 2000: a systematic appraisal

BackgroundGuidelines from the European Society of Cardiology (ESC) summarise the best available evidence in the management of cardiac disease. These guidelines are graded according to ESC-predefined scales of class of...

Cry Wolf or Equivocate? Credible Forecast Guidance in a Cost-Loss Game

What is the most credible way to convey the risk in expert forecasts to the nonexpert decision makers who use the forecast? We test two ways to communicate this information: provide an unequivocal recommendation or equivocate by providing the probability of the uncertain event of interest. We use a simple game in which human subjects (the forecast users) decide whether to take a risk of a loss or pay a cost to avoid the risk. We find that the influence of forecast information differs depending on whether the information implies that the decision maker should take the status quo action, the preforecast optimal action, or the siren action, optimal only if the period-by-period forecast implies it. Unequivocal recommendations are more successful at inducing the status quo action. Equivocating by providing probabilities is more successful at inducing the siren action. Unequivocal recommendations to take the siren action are less effective because the false certainty makes them more vulnerable to the “cry wolf” effect. A forecast that combines probabilities with recommendations captures most of the gains of the separate approaches. A follow-up study examines whether an explanation of how risk quantities inform recommendations can substitute for providing the risk quantities in the forecast. The study finds little evidence in support of this proposition. Data are available at https://doi.org/10.1287/mnsc.2016.2645 . This paper was accepted by Yuval Rottenstreich, judgment and decision making.

Management of salivary gland malignancies in the pediatric population

The management of pediatric salivary gland cancer (SGC) remains a challenge, and long-term outcome data are lacking for these rare tumors. The heterogeneity of histopathological features in 24 different SGCs further complicates unequivocal treatment recommendations across different age groups. This review aims to outline the management guidelines for pediatric SGC. Compared with adults, pediatric SGC is more often localized to the primary site and of low-grade histology. Surgery remains the treatment of choice accompanied by oncological treatment in selected patients. Elective neck dissection seems unnecessary as the occurrence of occult metastases is rare. This review provides information for clinicians to manage pediatric SGC highlighting the need for individually based treatment decisions at multidisciplinary head and neck centers.

Medical prevention and treatment of postpartum hemorrhage: a comparison of different guidelines

Postpartum hemorrhage (PPH) remains a common cause of maternal mortality worldwide, mainly caused by uterine atony. Medical intervention plays an important part in prevention and therapies of PPH. Prophylactic interventions include the use of uterotonic drugs. We elaborated the consistency of national and international guidelines on those medical approaches. Medical approaches in PPH were extracted from recent publications. Furthermore, the current guidelines of the World Health Organization, the FIGO and of the American, British, Canadian and German Societies of Obstetricians and Gynecologists on PPH were analyzed. Oxytocin is considered as therapy of first choice. However, the examined guidelines fail to give unequivocal recommendations on further uterotonics in PPH, which may partially be attributed to differing publication dates of the guidelines. International guidelines on PPH are characterized by differing recommendations. However, recent publications suggest that adhering to local guidelines significantly reduces the prevalence of severe PPH.