Towards an evidence-informed value scale for surgical and radiation oncology : a multi-stakeholder perspective

Surgery and radiotherapy, two locoregional cancer treatments, are essential to help improve cancer outcomes, control, and palliation. The continued evolution in treatment processes, techniques, and technologies-often at substantially increased costs-demands for direction on outcomes that are most valued by patients, and the evidence that is required before clinical adoption of these practices. Three recently introduced frameworks-the European Society for Medical Oncology Magnitude of Clinical Benefit Scale, the American Society of Clinical Oncology Value Framework, and the National Comprehensive Cancer Network Blocks-which all help define the value of oncology treatments, were appraised with a focus on their methods and definition of patient benefit. In this Review, we investigate the applicability of these frameworks to surgical and radiotherapy innovations. Findings show that these frameworks are not immediately transferable to locoregional cancer treatments. Moreover, the lack of emphasis on patient perspective and the reliance on traditional, trial-based endpoints such as survival, disease-free survival, and safety, calls for a new framework that includes real-world evidence with focus on the whole spectrum of patient-centred endpoints. Such an evidence-informed value scale would safeguard against the proliferation of low-value innovation while simultaneously increasing access to treatments that show significant improvements in the outcomes of cancer care

Effect of teriparatide in fracture healing of intertrochanteric fracture: a prospective study

Background: Intertrochanteric fracture is a relatively common and serious medical issue in geriatric trauma result in serious health problems and decrease health related quality of life. Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture-healing. The purpose of the present prospective, randomized, controlled study was to evaluate the effect of teriparatide on the course of intertrochanteric fracture-healing.Methods: Forty patients of intertrochanteric fractures who underwent surgical intervention between June 2016 and May 2017 were enrolled in this prospective study and followed for minimum of six months. Group A included patients who received only calcium supplementation; patients in Group B received teriparatide along with calcium supplementation postoperatively.Results: The mean time to fracture healing was between 8-12 weeks for the treatment group, compared with 12-16 weeks for the control group. There was also significant effectiveness with regards to Parker and Palmer mobility score at 6 months.Conclusions: Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with intertrochanteric fractures. However, because of the limited power of the study a large-scale cohort study is still required for determining the efficacy of teriparatide

Nifedipine versus nitroglycerin for acute tocolysis in preterm labour: a randomised controlled trial

Background: To compare the safety & efficacy of oral nifedipine with transdermal nitroglycerin in the inhibition of preterm labour.Methods: This study included 84 women in preterm labour, randomly divided into two groups, 43 receiving oral nifedipine and 41, transdermal nitroglycerin (NTG). Patients in preterm labour with a single gestation, between the 26th and the 34th week and no contraindication for tocolysis were selected. Women with fetal malformation and medical or obstetric diseases were excluded. The variables analyzed were: delay in delivery for 48 hours, 7 days or more than 7 days, period of gestation at delivery, side effect profile of drugs & neonatal outcomes.Results: Mean prolongation of pregnancy with NTG (29.04 days) was similar to that of nifedipine (34.46 days). Nifedipine was significantly more successful in prolonging pregnancy beyond 48 hours, especially in women with advanced cervical dilatation (>3 cm). Failure of acute tocolysis, defined as delivery within 48 hours, was significantly more common with NTG (31.7 %) as compared to nifedipine (11.6 %). Headache was significantly higher in the NTG group (41.5 %) compared to nifedipine group (4.7 %). The neonatal outcomes in terms of the mean birth weight, incidence of low birth weight and very low birth weight babies, need and duration of neonatal intensive care was similar in both groups.Conclusions: Oral nifedipine is a safe and effective tocolytic with a lower failure rate and better side effect profile as compared with transdermal nitroglycerin

Early cancer diagnosis: reaching targets across whole populations amidst setbacks.

Early diagnosis of cancer, followed by timely and appropriate therapy, are the cornerstones of the secondary prevention of cancer, thus the NHS has set a 2028 target to achieve 75% early stage (TNM I/II) at cancer diagnosis. In this context, Barclay et al. evaluated overall, sex, age and deprivation-group-specific progress towards this target based on 202,000 cancer patients diagnosis in 2015. Herein, we discuss their findings which form a valuable pre-COVID-19 pandemic status. We discuss the impact of the pandemic and the efforts being made in innovative early detection and diagnosis research

Looking For Niches In All The Right Places: Designing An MBA Program For The Next Decade

In an over-built, mature industry as is graduate management education it is increasingly important that schools find the right niche at which to target their MBA programs.  However, the literature is largely silent as to how a school might go about the process of finding the right niche for its MBA.  Using gap analysis and data from Occupational Outlook Handbook, we develop a process for identifying future employment trends as a means of identifying promising niches toward which to orient an MBA program.  This is an important exercise for those who design MBA programs, especially in light of the AACSB/International’s current focus upon continuous improvement among its member institutions.  Even if accreditation standards did not require it, the rapidly changing business climate makes continually upgrading MBA programs a necessity

Laproscopic intravesical vesicovaginal fistula repair after removal of an old vaginal drain tube-a rare case

The management of vesicovaginal fistula is difficult and challenging We are presenting a rare case of a 24-year-old unmarried girl with history of vaginoplasty and multiple surgeries done in the past, with a vaginal drain tube kept for 12 years and a Vesicovaginal fistula at the bladder trigone. Patient was successfully treated with a laproscopic Intravesical vesicovaginal Fistula repair. As advances in understanding the etiology of VVF have been made, the laproscopic approach has become the gold standard. Laparoscopy allows an excellent view, good exposure of pelvic structures, provides direct access to the fistula and for repair of complex VVF that may not be amenable to vaginal repair

Application of pediatric risk of mortality-III score to predict outcome in critically sick children admitted in a tertiary care pediatric unit in a developing country

Objective: The aim of this study is to assess the utilization of the pediatric risk of mortality-(PRISM)-III score to predict mortality in critically sick children and determination of mortality risk factors in a tertiary care pediatric unit. Materials and Methods: In this cross-sectional descriptive study, 100 children admitted during an 18-month period were enrolled in the study. PRISM-III score and mortality risk were calculated. Follow-up was noted as death or survival. Results: Of 100 patients, 27 died and 73 survived. The 47% of the patients were males. The PRISM-III score was 0-9 in 75%, 10-19 in 15% and 20-29 in 8%, ≥30 in 2% of patients. PRISM-III score showed an increase of mortality from 8% in 0-9 score patients to 100% in ≥20 score. PRISM-III score was significantly associated with study variables such as duration of hospital stay, mental status (Glasgow Coma scale <8), and blood pH <7.28 (p<0001). Conclusion: PRISM-III score showed good predictive value (94.5%) and adequate discriminatory capacity (area under receiver operating characteristics curve 90.8%), and thus constitutes a useful tool for the assessment of prognosis for pediatric patients

“Nudge” in the clinical consultation – an acceptable form of medical paternalism?

Background: Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities. Discussion. Evidence has shown that decision making is prone to bias and not necessarily rational or logical, particularly during ill health. Clinicians will usually have an opinion about what course of action represents the patient's best interests and thus may "frame" information in a way which "nudges" patients into making choices which are considered likely to maximise their welfare. This may be viewed as interfering with patient autonomy and constitute medical paternalism and appear in direct opposition to the tenets of modern practice. However, we argue that clinicians have a responsibility to try and correct "reasoning failure" in patients. Some compromise between patient autonomy and medical paternalism is justified on these grounds and transparency of how these techniques may be used should be promoted. Summary. Overall the extremes of autonomy and paternalism are not compatible in a responsive, responsible and moral health care environment, and thus some compromise of these values is unavoidable. Nudge techniques are widely used in policy making and we demonstrate how they can be applied in shared medical decision making. Whether or not this is ethically sound is a matter of continued debate but health care professionals cannot avoid the fact they are likely to be using nudge within clinical consultations. Acknowledgment of this will lead to greater self-awareness, reflection and provide further avenues for debate on the art and science of clinical communication