Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs

Tratamentos integrados em efluente metal-mecânico: precipitação química e biotratamento em reator do tipo air-lift Integrated treatments for metalworking effluent: chemistry precipitation and biotreatment in air-lift reactor type

Os objetivos deste trabalho foram: realizar a caracterização físico-química de um efluente metal-mecânico e efetuar o tratamento integrado (precipitação química e biotratamento), utilizando micro-organismos autóctones do efluente (FI e FV) e uma referência (A. niger). A caracterização indicou pH de 1,7; cor de 1.495 mg Pt.L-1; demanda química de oxigênio de 9.147 mgO2.L-1; 887 mg.L-1 de óleo e graxa, além de 2,5 mgO2.L-1 de oxigênio dissolvido. Com o tratamento por precipitação química, obteve-se, em pH = 7,5, a redução de todos os íons metálicos investigados. Após o biotratamento, a cor foi reduzida em 95%, utilizando o micro-organismos FV. As reduções da demanda química de oxigênio e de óleo e graxa foram mais significativas utilizando FI, que reduziu os mesmos em 52 e 62%, respectivamente. Estes resultados indicaram que os micro-organismos autóctones do efluente foram mais eficazes no tratamento do mesmo do que o organismo de referência A. niger.<br>The objectives of this paper were: to perform the physical-chemical characterization of a metalworking effluent and to carry out the integrated treatment (chemical precipitation and biotreatment), using effluent autochthonous microorganisms (FI and FV) and a reference (A. niger). The characterization indicated pH of 1.7; color, 1,495 mg Pt.L-1; chemical oxygen demand, 9,147 mgO2.L-1; oil and grease, 887 mg.L-1, and dissolved oxygen with 2.5 mgO2.L-1. With the chemical precipitation treatment, in pH = 7.5, the reduction of all the investigated metallic ions was obtained. The color was reduced 95% after the biotreatment using the FV microorganism. The chemical oxygen demand and oil and grease reductions were more significant when using FI, which reduced the same in 52 and 62%, respectively. These results indicated that the autochthonous microorganisms were more efficient in the effluent treatment than the reference organism A. niger

International eDelphi Study to Reach Consensus on the Methotrexate Dosing Regimen in Patients With Psoriasis.

A clear dosing regimen for methotrexate in psoriasis is lacking, and this might lead to a suboptimal treatment. Because methotrexate is affordable and globally available, a uniform dosing regimen could potentially optimize the treatment of patients with psoriasis worldwide. To reach international consensus among psoriasis experts on a uniform dosing regimen for treatment with methotrexate in adult and pediatric patients with psoriasis and identify potential future research topics. Between September 2020 and March 2021, a survey study with a modified eDelphi procedure that was developed and distributed by the Amsterdam University Medical Center and completed by 180 participants worldwide (55 [30.6%] resided in non-Western countries) was conducted in 3 rounds. The proposals on which no consensus was reached were discussed in a conference meeting (June 2021). Participants voted on 21 proposals with a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree) and were recruited through the Skin Inflammation and Psoriasis International Network and European Academy of Dermatology and Venereology in June 2020. Apart from being a dermatologist/dermatology resident, there were no specific criteria for participation in the survey. The participants worked mainly at a university hospital (97 [53.9%]) and were experienced in treating patients with psoriasis with methotrexate (163 [91.6%] had more than 10 years of experience). In a survey with eDelphi procedure, we tried to reach consensus on 21 proposals. Consensus was defined as less than 15% voting disagree (1-3). For the consensus meeting, consensus was defined as less than 30% voting disagree. Of 251 participants, 180 (71.7%) completed all 3 survey rounds, and 58 participants (23.1%) joined the conference meeting. Consensus was achieved on 11 proposals in round 1, 3 proposals in round 2, and 2 proposals in round 3. In the consensus meeting, consensus was achieved on 4 proposals. More research is needed, especially for the proposals on folic acid and the dosing of methotrexate for treating subpopulations such as children and vulnerable patients. In this eDelphi consensus study, consensus was reached on 20 of 21 proposals involving methotrexate dosing in patients with psoriasis. This consensus may potentially be used to harmonize the treatment with methotrexate in patients with psoriasis