Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis

Background/objectivesMinimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy.Methods714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher’s exact test, and Pearson’s correlation, as appropriate. P < 0.05 was accepted as statistically significant.Results115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5–7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3).ConclusionsNecrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.     

患者参与医疗决策期望量表的编制策略及条目筛选

目的编制适用于中国的患者参与医疗决策期望量表。方法采用德尔菲法建立初始条目池，对370例患者进行测评后，采用￡检验法、相关分析法、因子分析法等6种方法联合对条目进行筛选，建立量表测试版。结果编制了含12个条目的患者参与医疗决策量表，此量表与预期的理论构架相符，分为信息需求（3个条目），交流需求（6个条目），决策需求（3个条目）3个维度。结论患者参与医疗决策期望量表具有良好的内容效度，其所含的条目具有良好的敏感性、独立性和代表性。     

A Stochastic Model of Consensus Reaching in Committee Decisions for Faculty Advancement,Promotion and Tenure: Does Diversity Matter?

PurposeThere are considerable gender and racial disparities in academic promotions regardless of academic qualifications, suggesting bias. The investigators studied the academic promotions process by simulating the work of Advancement, Promotion and Tenure (APT) committees and applying a mathematical model to assess the impact of diversity on consensus reaching.MethodThe study targeted academic faculty during an annual Association of American Medical Colleges (AAMC) meeting. Participants evaluated the academic dossier of a male Assistant Professor with a focus on community engagement during four simulations. All dossiers were identical, with the singular exception of the candidate's race (white vs. black). Committee composition varied with respect to racial diversity. Participants scored the candidate before and after the deliberations. The DeGroot Model was used to compare individual scoring to group convergence.ResultsWhile there was no statistically significant difference in the candidate's overall scores between the groups, the least diverse groups rated the candidate the lowest (p = 0.0595). Participants ranked activities related to diversity and equity as the least important. Moreover, criteria deliberated more heavily showed significant score changes after deliberation. Lastly, ambiguity about the review process at various institutions was reported by project participants, increasing the opportunity for bias in real world situations.ConclusionsWhile there was not enough statistical power to measure intragroup differences, the model shows promise in illuminating how individual perceptions, committee composition and group dynamics sway consensus reaching. The model also suggests that social research, community engagement and diversity work do not carry the same weight as traditional scholarship, impacting the career trajectory of minority scholars. The model can be used to evaluate bias not only in academic promotions but also in admissions, hiring and grant review. This will allow improved methods and processes for equitable academic performance reviews, enhancing the career trajectory and retention of minority scholars.     

Values-based shared decision-making in the antenatal period

Despite advances in life-saving technology for critically ill neonates, challenges continue to arise for infants delivered with extreme prematurity, congenital anomalies, and genetic conditions that exceed the limits of currently available interventions. In these situations, parents are forced to make cognitively and emotionally difficult decisions, in discussion with a neonatologist, regarding how aggressively to provide supportive measures at the time of delivery and at what point burdens of therapy outweigh benefits. Current guidelines recommend that parents' values should guide these decisions; however, little is known about the values parents hold, and how those values are employed in the context of complexity, uncertainty, and emotionality of these situations. Systematic investigation of how parents derive their values and how clinicians should engage with parents about those values is necessary to guide the development of interventions to enhance shared decision-making processes, ultimately improving satisfaction, coping, and resilience and minimizing the potential for regret.     

Ethics and palliative care in the perinatal world

The perinatal world is unique in its dutiful consideration of two patients along the lines of decision-making and clinical management – the fetus and the pregnant woman. The potentiality of the fetus-newborn is intertwined with the absolute considerations for the woman as autonomous patient. From prenatal diagnostics, which may be quite extensive, to potential interventions prenatally, postnatal resuscitation, and neonatal management, the fetus and newborn may be anticipated to survive with or without special needs and technology, to have a questionable or guarded prognosis, or to live only minutes to hours. This review will address the ethical ramifications for prenatal diagnostics, parental values and goals clarification, birth plans, the fluidity of decision-making over time, and the potential role of prenatal and postnatal palliative care support.     

大学生自尊、无法忍受不确定性、职业决策困难与就业焦虑的关系

目的:探讨自尊、无法忍受不确定性、职业决策困难与就业焦虑的关系。方法:采用Rosenberg自尊问卷、无法忍受不确定性量表、职业决策困难量表和就业焦虑量表测量了376名大学生。结果:自尊与无法忍受不确定性、职业决策困难、就业焦虑呈显著负相关,相关系数r分别为:-0.254,-0.393,-0.280(P<0.001);无法忍受不确定性与职业决策困难(r=0.462,P<0.001)和就业焦虑(r=0.552,P<0.001)呈显著正相关;职业决策困难与就业焦虑呈显著正相关(r=0.496,P<0.001)。分层回归分析表明,当职业决策困难进入回归方程时,自尊对就业焦虑的预测效应不显著,回归系数从-0.280下降为-0.101;当无法忍受不确定进入回归方程时,自尊对职业决策困难的预测效应从-0.393下降为-0.295;自尊对就业焦虑的预测效应从-0.280下降为-0.150。结论:自尊以无法忍受不确定为部分中介影响着职业决策困难和就业焦虑。     

Predictive probability of success using surrogate endpoints

The predictive probability of success of a future clinical trial is a key quantitative tool for decision-making in drug development. It is derived from prior knowledge and available evidence, and the latter typically comes from the accumulated data on the clinical endpoint of interest in previous clinical trials. However, a surrogate endpoint could be used as primary endpoint in early development and, usually, no or limited data are collected on the clinical endpoint of interest. We propose a general, reliable, and broadly applicable methodology to predict the success of a future trial from surrogate endpoints, in a way that makes the best use of all the available evidence. The predictions are based on an informative prior, called surrogate prior, derived from the results of past trials on one or several surrogate endpoints. If available, in a Bayesian framework, this prior could be combined with data from past trials on the clinical endpoint of interest. Two methods are proposed to address a potential discordance between the surrogate prior and the data on the clinical endpoint. We investigate the patterns of behavior of the predictions in a comprehensive simulation study, and we present an application to the development of a drug in Multiple Sclerosis. The proposed methodology is expected to support decision-making in many different situations, since the use of predictive markers is important to accelerate drug developments and to select promising drug candidates, better and earlier.