Uncertainty in Medical Decision Making: knowing how little you know

Making decisions about the care of individual patients is fundamental to health care. For each patient, many decisions have to be made. In the emergency room, for example, a doctor should decide which patient to see first, decide whether an x-ray should be made of an injured ankle, and decide how this specific ankle fracture of this specific patient should be treated. Medical training is focused on acquiring the knowledge and experience to make such decisions. Other factors that are essential for patient care, including empathy and technical abilities, also involve decision making. For example, in the outpatient clinic, a trade-off is needed when one patient needs more time and empathy, but the waiting room is packed and the physician is an hour behind schedule. In the operating room, a surgeon must decide whether to proceed with a complicated laparoscopic procedure to remove a gall bladder, to convert to an open procedure, or to ask a more experienced surgeon for help

Аналіз тенденцій рівня розвитку економічних процесів підприємства

Подано методичні розробки щодо визначення ймовірної зміни рівнів розвитку економічних процесів машинобудівних підприємств залежно від рівня ефективності матеріальної мотивації персоналу на період 2010 р. Імовірну зміну рівня розвитку економічного процесу визначено за допомогою ланцюгів Маркова, що передбачає реалізацію шести послідовних етапів. Ключові слова: підприємства машинобудування, ланцюги Маркова, економічні процеси.Представлены методические разработки по определению вероятного изменения уровня развития экономических процессов предприятий машиностроения в зависимости от уровня эффективности материальной мотивации персонала на период 2010 г. Вероятное изменение уровня развития экономического процесса определено с помощью цепей Маркова, что предусматривает реализацию шести последовательных этапов. Ключевые слова: предприятия машино-стро¬ения, цепи Маркова, экономические процессы.The paper presents methodical developments on determination of probable changes in the level of machine-build enterprises’ economic processes development depending on the level of personnel’s material motivation efficiency for the period of 2010. Probable changes in the level of economic processes development are determined by using Markov’s chains which provide six stages. Keywords: machine-building enterprises, Markov chains, economic processes

Intrahepatic cholangiocarcinoma: Current perspectives

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy arising from the liver. ICC makes up about 10% of all cholangiocarcinomas. It arises from the peripheral bile ducts within the liver parenchyma, proximal to the secondary biliary radicals. Histologically, the majority of ICCs are adenocarcinomas. Only a minority of patients (15%) present with resectable disease, with a median survival of less than 3 years. Multidisciplinary management of ICC is complicated by large differences in disease course for individual patients both across and within tumor stages. Risk models and nomograms have been developed to more accurately predict survival of individual patients based on clinical parameters. Predictive risk factors are necessary to improve patient selection for systemic treatments. Molecular differences between tumors, such as in the epidermal growth factor receptor status, are promising, but their clinical applicability should be validated. For patients with locally advanced disease, several treatment strategies are being evaluated. Both hepatic arterial infusion chemotherapy with floxuridine and yttrium-90 embolization aim to downstage locally advanced ICC. Selected patients have resectable disease after downstaging, and other patients might benefit because of postponing widespread dissemination and biliary obstruction

Current evidence of nutritional therapy in pancreatoduodenectomy: Systematic review of randomized controlled trials

Aim: Evidence of nutritional therapies in pancreatoduodenectomy (PD) has been shown. However, few studies focus on the association between different nutritional therapies and outcomes. The aim of this review was to summarize the current evidence of nutritional therapies such as enteral nutrition (EN), immunonutrition, and synbiotics on postoperative outcomes after PD. Methods: A systematic literature search of Embase, Medline Ovid, and Cochrane CENTRAL was done to summarize the available evidence, including randomized controlled trials, meta‐analyses and reviews, regarding nutritional therapy in PD. Results: A total of 20 randomized controlled trials were included in this review. Safety and tolerability of EN in PD was shown. Giving postoperative EN can shorten length of stay compared to parenteral nutrition; however, the effect of EN on postoperative complications remains controversial. Postoperative EN should be given only on selective indications rather than routinely used, and preoperative EN is indicated only in patients with severe malnutrition. Giving preoperative immunonutrition is considered to reduce the incidence of infectious complications; however, evidence level is moderate and recommendation grade is weak. The beneficial effect of perioperative synbiotics on postoperative infectious complications is limited. Furthermore, the effectiveness of other nutritional supplements remains unclear. Conclusion: Recently, evidence of enhanced recovery after surgery (ERAS) in PD has been increasing. Early oral intake with systematic nutritional support is an important aspect of the ERAS concept. Future well‐designed studies should investigate the impact of systematic nutritional therapies on outcomes following PD

Neoadjuvant Treatment in Patients With Resectable and Borderline Resectable Pancreatic Cancer

Approximately 20% of pancreatic ductal adenocarcinoma (PDAC) patients have (borderline) resectable pancreatic cancer [(B)RPC] at diagnosis. Upfront resection with adjuvant chemotherapy has long been the standard of care for these patients. However, although surgical quality has improved, still about 50% of patients never receive adjuvant treatment. Therefore, recent developments have focused on a neoadjuvant approach. Directly comparing results from neoadjuvant and adjuvant regimens is challenging due to differences in patient populations that influence outcomes. Neoadjuvant trials include all patients who have (B)RPC on imaging, while adjuvant-only trials include patients who underwent a complete resection and recovered to a good performance status without any evidence of residual disease. Guidelines recommend neoadjuvant treatment for BRPC patients mainly to improve negative resection margin (R0) rates. For resectable PDAC, upfront resection is still considered the standard of care. However, theoretical advantages of neoadjuvant treatment, including the increased R0 resection rate, early delivery of systemic therapy to all patients, directly addressing occult metastatic disease, and improved patient selection for resection, may also apply to these patients. A systematic review by intention-to-treat showed a superior median overall survival (OS) for any neoadjuvant approach (19 months) compared to upfront surgery (15 months) in (B)RPC patients. A neoadjuvant approach was recently supported by three randomized controlled trials (RCTs). For resectable PDAC, neoadjuvant treatment was superior in a Japanese RCT of neoadjuvant gemcitabine with S-1 vs. upfront surgery, with adjuvant S-1 in both arms (median OS: 37 vs. 27 months, p = 0.015). A Korean trial of neoadjuvant gemcitabine-based chemoradiotherapy vs. upfront resection in BRPC patients was terminated early due to superiority of the neoadjuvant group (median OS: 21 vs. 12 months, p = 0.028; R0 resection: 52 vs. 26%, p = 0.004). The PREOPANC-1 trial for (B)RPC patients also showed favorable outcome for neoadjuvant gemcitabine-based chemoradiotherapy vs. upfront surgery (median OS: 17 vs. 14 months, p = 0.07; R0 resection: 63 vs. 31%, p < 0.001). FOLFIRINOX is likely a better neoadjuvant regimen, because of superiority compared to gemcitabine in both the metastatic and adjuvant setting. Currently, five RCTs evaluating neoadjuvant modified or fulldose FOLFIRINOX are accruing patients

Efficacy of management and monitoring methods to prevent post-harvest losses caused by rodents

The presence of pest rodents around food production and storage sites is one of many underlying problems contributing to food contamination and loss, particularly influencing food and nutrition security in low-income countries. By reducing both pre- and post-harvest losses by rodents, millions of food-insecure people would benefit. As there are limited quantitative data on post-harvest rice losses due to rodents, our objectives were to assess stored rice losses in local households from eight rural communities and two rice milling factories in Bangladesh and to monitor the effect of different rodent control strategies to limit potential losses. Four treatments were applied in 2016 and 2017, (i) untreated control, (ii) use of domestic cats, (iii) use of rodenticides, (iv) use of snap-traps. In total, over a two-year period, 210 rodents were captured from inside people’s homes, with Rattus rattus trapped most often (n = 91), followed by Mus musculus (n = 75) and Bandicota bengalensis (n = 26). In the milling stations, 68 rodents were trapped, of which 21 were M. musculus, 19 R. rattus, 17 B. bengalensis, 8 Rattus exulans, and 3 Mus terricolor. In 2016, losses from standardised baskets of rice within households were between 13.6% and 16.7%. In 2017, the losses were lower, ranging from 0.6% to 2.2%. Daily rodent removal by trapping proved to be most effective to diminish stored produce loss. The effectiveness of domestic cats was limited

A preliminary prediction model for potentially guiding patient choices between breast conserving surgery and mastectomy in early breast cancer patients; a Dutch experience

Purpose: To guide early stage breast cancer patients to choose between breast conserving surgery (BCS) and mastectomy (MST) considering the predicted cosmetic result and quality of life (QoL). Methods: A decision model was built to compare QoL after BCS and MST. Treatment could result in BCS with good cosmesis, BCS with poor cosmesis, MST only, and MST with breast reconstruction. QoL for these treatment outcomes were obtained from a previous study and the literature and translated into EuroQoL-5D derived utilities. Chance of good cosmesis after BCS was predicted based on tumor location and tumor/breast volume ratio. The decision model determined whether the expected QoL was superior after BCS or MST based on chance of good cosmesis. Results: The mean utility for the treatments such as BCS with good cosmesis, BCS with poor cosmesis, MST only, and MST with breast reconstruction were 0.908, 0.843, 0.859, and 0.876, respectively. BCS resulted in superior QoL compared to MST in patients with a chance of good cosmesis above 36%. This 36% threshold is reached in case the tumor is located in the upper lateral, lower lateral, upper medial, lower medial, and central quadrant of the breast with a tumor/breast volume ratio below 21.6, 4.1, 15.1, 3.2, and 14.7, respectively. Conclusions: BCS results in superior QoL in patients with tumors in the upper breast quadrants or centrally and a tumor/breast volume ratio below 15. MST results in superior QoL in patients with tumors in the lower breast quadrants and a tumor/breast volume ratio above 4

Recreating tumour complexity in a dish: Organoid models to study liver cancer cells and their extracellular environment

Primary liver cancer, consisting predominantly of hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), remains one of the most lethal malignancies worldwide. This high malignancy is related to the complex and dynamic interactions between tumour cells, stromal cells and the extracellular environment. Novel in vitro models that can recapitulate the tumour are essential in increasing our understanding of liver cancer. Herein, primary liver cancer-derived organoids have opened up new avenues due to their patient-specificity, self-organizing ability and potential recapitulation of many of the tumour properties. Organoids are solely of epithelial origin, but incorporation into co-culture models can enable the investigation of the cellular component of the tumour microenvironment. However, the extracellular component also plays a vital role in cancer progression and representation is lacking within current in vitro models. In this review, organoid technology is discussed in the context of liver cancer models through comparisons to other cell culture systems. In addition, the role of the tumour extracellular environment in primary live

Achieving Near-Optimal Traffic Engineering Solutions for Current OSPF/IS-IS Networks

Traffic engineering is aimed at distributing traffic so as to optimize a given performance criterion. The ability to carry out such an optimal distribution depends on the routing protocol and the forwarding mechanisms in use in the network. In IP networks running the OSPF or IS-IS protocols, routing is along shortest paths, and forwarding mechanisms are constrained to distributing traffic uniformly over equal cost shortest paths. These constraints often make achieving an optimal distribution of traffic impossible. In this paper, we propose and evaluate an approach that is capable of realizing near optimal traffic distribution without any change to existing routing protocols and forwarding mechanisms. In addition, we explore the trade-off that exists between performance and the overhead associated with the additional configuration steps that our solution requires. The paper\u27s contributions are in formulating and evaluating an approach to traffic engineering for existing IP networks that achieves performance levels comparable to that offered when deploying other forwarding technologies such as MPLS