scholarly journals Classic cases revisited: Of hurricanes, cyanide and moral courage

2018 ◽  
Vol 21 (1) ◽  
pp. 2-6
Author(s):  
Piotr Szawarski
Keyword(s):  
Reflective Practice ◽  
Clinical Decision Making ◽  
Moral Distress ◽  
Clinical Decision ◽  
Moral Dimension ◽  
Usual Practice ◽  
Course Of Action ◽  
Burn Out ◽  
Moral Dimensions ◽  
The Individual

All decisions made by doctors have a moral dimension. When a moral judgement demands a different course of action to one that represents the usual practice, many doctors do struggle. The inability to embrace such decisions can represent moral negligence, as often the consequence is greater suffering for the individual in question or loss of utility for the population. On the other hand, it takes courage to make such decisions as the society fails to accept them, even though decisions made are rational and morally valid. Clinical practice that does not conform to moral judgements can result in moral distress, burn out and job-leave. Reflective practice evaluating moral dimensions of clinical decision making is an important aspect of nurturing humanity, empathy and professionalism in the therapeutic endeavour.

PATH-39. INTEGRATED MOLECULAR-MORPHOLOGICAL MENINGIOMA CLASSIFICATION: A MULTICENTER RETROSPECTIVE ANALYSIS, RETRO- AND PROSPECTIVELY VALIDATED

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi123-vi124
Author(s):  
Sybren Maas ◽  
Damian Stichel ◽  
Thomas Hielscher ◽  
Philipp Sievers ◽  
Anna Berghoff ◽  
...  
Keyword(s):  
Dna Methylation ◽  
Copy Number ◽  
Retrospective Cohort ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Molecular Data ◽  
Copy Number Variations ◽  
Who Grade ◽  
Risk Of Progression ◽  
The Individual

Abstract PURPOSE Meningiomas are the most frequent primary intracranial tumors. Patient outcome varies widely from cases with benign to highly aggressive, ultimately fatal courses. Reliable identification of risk of progression for the individual patient is of pivotal importance in clinical management. However, only biomarkers for highly aggressive tumors are established at present (CDKN2A/B and TERT), while no molecularly-based stratification exists for the broad spectrum of low- and intermediate-risk meningioma patients. PATIENTS AND METHODS DNA methylation data and copy-number information were generated for 3,031 meningiomas of 2,868 individual patients, with mutation data for 858 samples. DNA methylation subgroups, copy-number variations (CNV), mutations and WHO grading were comparatively analyzed. Prediction power for outcome of these parameters was assessed in an initial retrospective cohort of 514 patients, and validated on a retrospective cohort of 184, and on a prospective cohort of 287 multi-center cases, respectively. RESULTS Both CNV and methylation family- (MF)-based subgrouping independently resulted in an increase in prediction accuracy of risk of recurrence compared to the WHO classification (c-indexes WHO 2016, CNV, and MF 0.699, 0.706 and 0.721, respectively). Merging all independently powerful risk stratification approaches into an integrated molecular-morphological score resulted in a further, substantial increase in accuracy (c-index 0.744). This integrated score consistently provided superior accuracy in all three cohorts, significantly outperforming WHO grading (c-index difference p=0.005). Besides the overall stratification advantage, the integrated score separates more precisely for risk of progression at the diagnostically challenging interface of WHO grade 1 and grade 2 tumors (HR 4.56 [2.97;7.00], 4.34 [2.48;7.57] and 3.34 [1.28; 8.72] for discovery, retrospective, and prospective validation cohort, respectively). CONCLUSIONS Merging these layers of histological and molecular data into an integrated, three-tiered score significantly improves the precision in meningioma stratification. Implementation into diagnostic routine informs clinical decision-making for meningioma patients on the basis of robust outcome prediction.

Likelihood Ratio, Skull Roentgenograms, and Clinical Decision-Making

PEDIATRICS ◽  
1983 ◽  
Vol 71 (4) ◽  
pp. 673-674
Author(s):  
JOHN C. LEONIDAS ◽  
ANNA BINKIEWICZ ◽  
R. MICHAEL SCOTT ◽  
STEPHEN G. PAUKER
Keyword(s):  
Decision Making ◽  
Likelihood Ratio ◽  
Predictive Value ◽  
Clinical Finding ◽  
Posterior Probability ◽  
Clinical Decision Making ◽  
Skull Fracture ◽  
Clinical Decision ◽  
Negative Finding ◽  
The Individual

In Reply.— We appreciate the thoughtful comments of Leventhal and Lembo and concur with their conclusion that the clinician needs to know "the probability of skull fracture in a patient with head trauma." Unfortunately, their proposed "clinical likelihood ratio" (CR) will not further that end because it compares the predictive value (or, more precisely, the posterior probability) of a skull fracture after a positive clinical finding to the posterior probability after a negative finding. After the patient has been examined, the patient does not have both findings; thus, the CR cannot apply to the individual patient.

Pathogenesis of Peritoneal Sclerosis

2005 ◽  
Vol 28 (2) ◽  
pp. 90-96 ◽  
Author(s):  
C. Pollock
Keyword(s):  
Peritoneal Dialysis ◽  
Large Scale ◽  
Clinical Decision Making ◽  
Inflammatory Cells ◽  
Clinical Decision ◽  
Cumulative Exposure ◽  
Peritoneal Membrane ◽  
Peritoneal Fibrosis ◽  
Histological Data ◽  
The Individual

Peritoneal sclerosis is an almost invariable consequence of peritoneal dialysis. In most circumstances it is “simple” sclerosis, manifesting clinically with an increasing peritoneal transport rate and loss of ultrafiltration capacity. In contrast, encapsulating peritoneal sclerosis is a life threatening and usually irreversible condition, associated with bowel obstruction, malnutrition and death. It is unknown whether common etiological factors underlie the development of these 2 clinically and pathologically distinct forms of peritoneal sclerosis. The majority of studies to date have investigated factors that contribute to “simple” sclerosis, although it remains possible that similar mechanisms are amplified in patients who develop encapsulated peritoneal sclerosis. The cellular elements that promote peritoneal sclerosis include the mesothelial cells, peritoneal fibroblasts and inflammatory cells. Factors that stimulate these cells to promote peritoneal fibrosis and neoangiogenesis, both inherent in the development of peritoneal sclerosis, include cytokines that are induced by exposure of the peritoneal membrane to high concentrations of glucose, advanced glycation of the peritoneal membrane and oxidative stress. The cumulative exposure to bioincompatible dialysate is likely to have an etiological role as the duration of dialysis correlates with the likelihood of developing peritoneal sclerosis. Indeed peritoneal dialysis using more biocompatible fluids has been shown to reduce the development of peritoneal sclerosis. The individual contribution of the factors implicated in the development of peritoneal sclerosis will only be determined by large scale peritoneal biopsy registries, which will be able to prospectively incorporate clinical and histological data and support clinical decision making.

scholarly journals QOLP-03. MEASURING CHANGE IN HEALTH-RELATED QUALITY OF LIFE: THE ADDED VALUE OF ANALYSIS ON THE INDIVIDUAL PATIENT LEVEL IN GLIOMA PATIENTS IN CLINICAL DECISION MAKING

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi197-vi198 ◽  
Author(s):  
Marijke Coomans ◽  
Martin Taphoorn ◽  
Neil Aaronson ◽  
Brigitta Baumert ◽  
Martin van den Bent ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Scale Item ◽  
Individual Patient Level ◽  
Patient Level ◽  
Related Quality ◽  
The Individual ◽  
The Impact ◽  
Over Time

Abstract BACKGROUND: Health-related quality of life (HRQoL) is an important outcome in glioma research, reflecting the impact of disease and treatment on a patient’s functioning and wellbeing. Data on changes in HRQoL scores provide important information for clinical decision-making, but different analytical methods may lead to different interpretations of the impact of treatment on HRQoL. This study aimed to study whether different methods to evaluate change in HRQoL result in different interpretations. Methods: HRQoL and sociodemographical/clinical data from 15 randomized clinical trials were combined. Change in HRQoL scores was analyzed: (1)at the group level, comparing mean changes in scale/item scores between treatment arms over time, (2)at the patient level per scale/item by calculating the percentage of patients that deteriorated, improved or remained stable on a scale/item per scale/item, and (3)at the individual patient level combining all scales/items. Results: Data were available for 3727 patients. At the group scale/item level (method 1), only the item ‘hair loss’ showed a significant and clinically relevant change (i.e. ≥10 points) over time, whereas change scores on the other scales/items showed a statistically significant change only (all p< .001, range in change score:0.1–6.2). Analyses on the patient level per scale (method 2) indicated that, while a large proportion of patients had stable HRQoL over time (range:27–84%), many patients deteriorated (range:6–43%) or improved (range:8–32%) on a specific scale/item. At the individual patient level (method 3), the majority of patients (86%) showed both deterioration and improvement, while only 1% of the patients remained stable on all scales. Conclusion: Different analytical methods of changes in HRQoL result in distinct interpretations of treatment effects, all of which may be relevant for clinical decision-making. Additional information about the joint impact of treatment on all outcomes may help patients and physicians to make the best treatment decision.

scholarly journals A Qualitative Interpretation of Challenges Associated with Helping Patients with Multiple Chronic Diseases Identify Their Goals

2016 ◽  
Vol 6 (2) ◽  
pp. 120-126 ◽  
Author(s):  
Pauline Boeckxstaens ◽  
Sara Willems ◽  
Mieke Lanssens ◽  
Charlotte Decuypere ◽  
Guy Brusselle ◽  
...  
Keyword(s):  
Chronic Diseases ◽  
Goal Setting ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Chronic Obstructive ◽  
Personal Goals ◽  
Obstructive Pulmonary Disease ◽  
Clinical Method ◽  
The Individual ◽  
Multiple Chronic Diseases

Background Patients with multiple chronic diseases are usually treated according to disease-specific guidelines, with outcome measurements focusing mostly on biomedical indicators (e.g. blood sugar levels or lung function). However, for multimorbidity, a goal-oriented approach focusing on the goals defined by the individual patient, may be more suitable. Despite the clear theoretical and conceptual advantages of including patient-defined goals in clinical decision-making for multimorbidity, it is not clear how patients define their goals and which aspects play a role in the process of defining them. Objective To explore goal-setting in patients with multimorbidity. Design Qualitative analysis of interviews with 19 patients diagnosed with chronic obstructive pulmonary disease and comorbidities. Results Patients do not naturally present their goals. Their goals are difficult to elicit, even when different interviewing techniques are used. Four underlying hypotheses which may explain this finding were identified from the interviews: (1) patients cannot identify with the concept of goal-setting; (2) goal-setting is reduced due to acceptation; (3) actual stressors predominate over personal goal-setting; and (4) patients may consider personal goals as selfish. Conclusions Our findings advocate for specific attention to provider skills and strategies that help patients identify their personal goals. The hypotheses on why patients may struggle with defining goals may be useful to prompt patients in this process and support the development of a clinical method for goal-oriented care.

scholarly journals OS7.2 Measuring change in health-related quality of life: the added value of analysis on the individual patient level in glioma patients in clinical decision making

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii14-iii14
Author(s):  
M Coomans ◽  
M J B Taphoorn ◽  
N Aaronson ◽  
B G Baumert ◽  
M van den Bent ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Scale Item ◽  
Individual Patient Level ◽  
Patient Level ◽  
Related Quality ◽  
The Individual ◽  
The Impact ◽  
Over Time

Abstract BACKGROUND Health-related quality of life (HRQoL) is often used as an outcome in glioma research, reflecting the impact of disease and treatment on a patient’s functioning and wellbeing. Data on changes in HRQoL scores may provide important information for clinical decision-making, but different analytical methods may lead to different interpretations of the impact of treatment on HRQoL. This study aimed to examine three different methods to evaluate change in HRQoL, and to study whether these methods result in different interpretations. MATERIAL AND METHODS HRQoL and sociodemographical/clinical data from 15 randomized clinical trials were combined. Change in HRQoL scores was analyzed in three ways: (1) at the group level, comparing mean changes in scale/item scores between treatment arms over time, (2) at the patient level per scale/item by calculating the percentage of patients that deteriorated, improved or remained stable on a scale/item per scale/item, and (3) at the individual patient level combining all scales/items. RESULTS Baseline and first follow-up HRQoL data were available for 3727 patients. At the group scale/item level (method 1), only the item ‘hair loss’ showed a significant and clinically relevant change (i.e. ≥10 points) over time, whereas change scores on the other scales/items showed a statistically significant change only (all p<.001, range in change score: 0.1–6.2). Analyses on the patient level per scale (method 2) indicated that, while a large proportion of patients had stable HRQoL over time (range 27–84%), many patients deteriorated (range: 6–43%) or improved (range: 8–32%) on a specific scale/item. At the individual patient level (method 3), the majority of patients (86%) showed both deterioration and improvement, while only 1% of the patients remained stable on all scales. Clustering on clinical characteristics (WHO performance status, sex, tumor type, type of resection, newly diagnosed versus recurrent tumor and age) did not identify subgroups of patients with a specific pattern of change in their HRQoL score. CONCLUSION Different analytical methods of changes in HRQoL result in distinct interpretations of treatment effects, all of which may be relevant for clinical decision-making. Additional information about the joint impact of treatment on all outcomes, showing that most patients experience both deterioration and improvement, may help patients and physicians to make the best treatment decision.

Clinical Decision-Making for a Person Centered Medicine: the necessity of casuistic reasoning

2014 ◽  
Vol 2 (1) ◽  
pp. 71
Author(s):  
Mark Tonelli
Keyword(s):  
Decision Making ◽  
Clinical Judgment ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Patient Choice ◽  
Clinical Expertise ◽  
Patient Centered ◽  
Patient Centered Medicine ◽  
The Individual ◽  
Based Medicine

In their call to develop a consistent, coherent and comprehensive notion of person-centered medicine, Miles and Mezzich have elucidated several specific challenges that need to be urgently addressed. One of these foundational tasks is the development of a more complete understanding of person-centered clinical decision-making. Miles and Mezzich note that while the emphasis on clinical research in evidence-based medicine has served to de-emphasize the importance of the individual patient, the alternative of patient-centered medicine has the potential to de-emphasize the judgment of the clinician by making unfettered patient choice paramount. A practice of medicine that reduces professional healers to an informational role only, one where they lay out potential interventions devoid of context and allow patients to choose from amongst them, undervalues clinical expertise and will clearly not lead to better outcomes. Person-centered medicine (PCM), then, must be able to develop and defend a model of clinical judgment and practice that strikes the correct balance between the science of medicine and the personal experience of the individual in search of care.

scholarly journals Systematic Review: A Prevention-Based Model of Neuropsychological Assessment for Children With Medical Illness

2017 ◽  
Vol 42 (8) ◽  
pp. 815-822 ◽  
Author(s):  
Kristina K. Hardy ◽  
Katie Olson ◽  
Stephany M. Cox ◽  
Tess Kennedy ◽  
Karin S. Walsh
Keyword(s):  
Clinical Decision Making ◽  
Adaptive Functioning ◽  
Survival Rates ◽  
Clinical Decision ◽  
Medical Illness ◽  
Individual Level ◽  
Care Models ◽  
Neuropsychological Changes ◽  
The Central Nervous System ◽  
The Individual

Abstract Objective Many pediatric chronic illnesses have shown increased survival rates, leading to greater focus on cognitive and psychosocial issues. Neuropsychological services have traditionally been provided only after significant changes in the child’s cognitive or adaptive functioning have occurred. This model of care is at odds with preventative health practice, including early identification and intervention of neuropsychological changes related to medical illness. We propose a tiered model of neuropsychological evaluation aiming to provide a preventative, risk-adapted level of assessment service to individuals with medical conditions impacting the central nervous system based on public health and clinical decision-making care models. Methods Elements of the proposed model have been used successfully in various pediatric medical populations. We summarize these studies in association with the proposed evaluative tiers in our model. Results and Conclusions This model serves to inform interventions through the various levels of assessment, driven by evidence of need at the individual level in real time.

Defining the paramedic process

2015 ◽  
Vol 21 (1) ◽  
pp. 22 ◽  
Author(s):  
Holly Carter ◽  
James Thompson
Keyword(s):  
Process Model ◽  
Clinical Decision Making ◽  
Care Delivery ◽  
Clinical Decision ◽  
Nursing Process ◽  
Process Of Care ◽  
Ovid Medline ◽  
Hospital Practices ◽  
The Individual

The use of a ‘process of care’ is well established in several health professions, most evidently within the field of nursing. Now ingrained within methods of care delivery, it offers a logical approach to problem solving and ensures an appropriate delivery of interventions that are specifically suited to the individual patient. Paramedicine is a rapidly advancing profession despite a wide acknowledgement of limited research provisions. This frequently results in the borrowing of evidence from other disciplines. While this has often been useful, there are many concerns relating to the acceptable limit of evidence transcription between professions. To date, there is no formally recognised ‘process of care’-defining activity within the pre-hospital arena. With much current focus on the professional classification of paramedic work, it is considered timely to formally define a formula that underpins other professional roles such as nursing. It is hypothesised that defined processes of care, particularly the nursing process, may have features that would readily translate to pre-hospital practice. The literature analysed was obtained through systematic searches of a range of databases, including Ovid MEDLINE, Cumulative Index to Nursing and Allied Health. The results demonstrated that the defined process of care provides nursing with more than just a structure for practice, but also has implications for education, clinical governance and professional standing. The current nursing process does not directly articulate to the complex and often unstructured role of the paramedic; however, it has many principles that offer value to the paramedic in their practice. Expanding the nursing process model to include the stages of Dispatch Considerations, Scene Assessment, First Impressions, Patient History, Physical Examination, Clinical Decision-Making, Interventions, Re-evaluation, Transport Decisions, Handover and Reflection would provide an appropriate model for pre-hospital practices.

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