Justifying Clinical Deception: Some Amendments to Brummett and Salter

In Abram Brummett and Erica K. Salter's excellent paper, “Mapping the Moral Terrain of Clinical Deception,” they rightly note that it is sometimes ethically appropriate for health care professionals to deceive patients and families. However, they also note that because doing so violates a prima facie duty of honesty, the ethical burden of proof falls upon the deceiver. Hence, they also provide a sophisticated framework for determining whether any given case is warranted. I applaud their overall approach but also critique some of their claims, in particular, their conclusion that lies of commission require greater justification than those of omission and their conflation of the principles of beneficence and nonmaleficence. I also urge them to give greater attention to how power asymmetries should be accounted for and to the impact such deceptive choices might have on the clinician's character.     

Outcomes of Fluoroscopy-Guided Percutaneous High Ligation of the Great Saphenous Vein Combined With Foam Sclerotherapy for Symptomatic Great Saphenous Veins

PurposeTo evaluate the effectiveness and safety of fluoroscopy-guided percutaneous high ligation (FPHL) combined with fluoroscopy-guided foam sclerotherapy (FGFS) to treat varicose veins of the great saphenous veins (GSVs).Materials and MethodsThis was a retrospective study of 113 patients (mean age, 62.1 ± 10.8 years; 60 men) with varicose veins of the GSVs (133 limbs) that were treated with FPHL combined with FGFS between April 1 and October 31, 2019. Demographic and clinical data were collected from these patients before the FPHL procedure, after which FGFS was performed. The preterminal GSV was ligated percutaneously by a percutaneously-positioned polypropylene ligature under fluoroscopic guidance. The outcome of ligation was confirmed by venography. Then, foam sclerotherapy was performed under fluoroscopy. At 1-year follow-up, GSV occlusion was evaluated by ultrasound. The venous clinical severity scores (VCSSs) were compared between the preoperative and 1-year follow-up periods.ResultsThe technical success rate was 100% (133 limbs). Complete 12-month follow-up was available for 112 limbs (84.2%) and 103 of these limbs (92.0%) remained occluded during this period. The VCSS improved from 4.71 ± 2.15 to 0.74 ± 0.60 (V = 6328, P < .001). During follow-up, there were 16 limbs with thrombophlebitis and 38 limbs with saphenous junction pain; these events were alleviated within 2 weeks of the procedure. There was no deep venous thrombosis or other severe adverse events.ConclusionsFPHL combined with FGFS to treat varicose veins in the GSVs achieved an occlusion rate of 92% and improved the clinical symptoms within 1 year; this minimally-invasive procedure was safe and effective.     

Neurodevelopmental outcomes of extremely preterm infants: theoretical and epidemiological perspectives to guide shared-care decision-making

Although births below 28 completed weeks' of gestation contribute to less than 1% of all preterm births globally, the impact of extreme prematurity (EPT) on neurodevelopmental outcomes across the life-course is disproportionately large. Higher rates and increased severity of neurodevelopmental impairments (NDIs) are reported among extremely preterm infants (EPIs). Cognitive skills, motor skills (manifesting as cerebral palsy) and vision are most commonly affected, with effects pervasive throughout school, adolescence and early adulthood. In addition, poorer academic outcomes and higher rates of psychiatric morbidity are seen among EPTs. Consistent improvements in EPI survival in recent years has not been matched with improvements in neurodevelopmental outcomes, especially for those born at less than 25 gestational weeks. However, over the last 20 years, several national and cross-national cohort studies have helped advance our understanding of extreme prematurity's developmental and life-course consequences. Here we provide an overview of the key findings from 13 multi-centre cohorts measuring neurodevelopmental outcomes and discuss the theoretical and epidemiological perspectives of NDIs in the context of extreme prematurity to guide communication with families and shared care decision-making.     

Redefining shared decision-making in the digital era

Perioperative shared decision-making can be improved through the development of novel patient-centered outcome measures made possible by digital phenotyping—“the moment-by-moment quantification of individual-level human phenotype in situ using data from personal digital devices, in particular smartphones.” This Short Report presents data from a patient with breast cancer that illustrates the opportunities of digital phenotyping to better inform patient quality of life while also discussing the challenges to its adoption. With time, effort, and physician engagement, digital phenotyping can help surgeons better understand the patient experience in the postoperative period and in turn, help them provide care that maximizes patient quality of life.     

Feasibility of open and percutaneous corrective osteotomies of the second phalanx of the great toe: An approach on a cadaveric model

BackgroundHaving had a previous experience of 4 open F2 osteotomies to correct interphalangeal hallux valgus, the aim of this study was to test the efficacy of a percutaneous approach for this correction.Methods3 open and 12 percutaneous F2 osteotomies in 15 cadaver feet were performed. Interphalangeal (IPH), F2 asymmetry (AF2) and joint deviation (JD) angles were measured on radiographs. The operated great toes were anatomically analyzed looking for possible lesions to surrounding tissues.ResultsMean IPH decreased from 10.7° to 2.9°, AF2 from 7.8° to 1°, and JD from 1.4° to 0.5°. Damage to the hallux extensor tendon was detected in 1 foot and a nail bed lesion was detected in 1 case, both operated percutaneously.ConclusionsF2 Valgus deformity can be corrected using open or percutaneous osteotomy. The authors consider the open correction worthwhile because percutaneous techniques may damage surrounding tissues and the incision length difference is minor.Level of clinical evidence: 3.     

Tracking Spinal Cord Injury Functional Outcomes Across the Lifespan: Validation of Linking Coefficients

ObjectiveValidation of linking coefficients to transform Pediatric Spinal Cord Injury Activity Measure (PEDI-SCI/AM) scores to adult Spinal Cord Injury-Functional Index (SCI-FI) scores.DesignThis cross-sectional study administered PEDI-SCI/AM and SCI-FI computerized adaptive tests (CATs) and short forms (SFs) to children with SCI and parents or caregivers.SettingHospitals, university, and rehabilitation institute.ParticipantsAbout 107 children with SCI and 96 parent or caregivers.InterventionsNot applicable.Main Outcome MeasuresLinking coefficients estimated SCI-FI (est-SCI-FI) scores from PEDI-SCI/AM scores for matched domains. Correlations between est-SCI-FI and actual SCI-FI scores were calculated. If correlations exceeded the criterion linking (0.866), the following analyses to compare est-SCI-FI and actual SCI-FI scores were conducted: paired t tests, intraclass correlation coefficients (ICCs 3, 1), percent of cases with absolute score differences at different thresholds.ResultsTwo matched domains, PEDI-SCI/AM Daily Routine/SCI-FI Self-Care and PEDI-SCI/AM General Mobility/SCI-FI Basic Mobility, met the linking criterion for both respondent-types (parent and child) and administration modes (CAT and SF). PEDI-SCI/AM Daily Routine and SCI-FI Fine Motor Function did not meet linking criterion for respondent type or mode. The linking criterion was met for wheelchair domains (child SF and CAT) and ambulation domains (child SF only). Significant differences between est-SCI-FI and actual SCI-FI scores were noted for all matched domains except Daily Routine/Self-Care (child SF only; parent SF and CAT). ICC values showed excellent agreement (range=0.75-0.89). Absolute differences between est-SCI-FI and actual SCI-FI scores were less than 1 standard deviation (except wheelchair CAT child).ConclusionsLinking coefficients applied to PEDI-SCI/AM scores can provide valid SCI-FI estimates that vary by domain, mode, and respondent type.     

Temporal Expectation Hastens Decision Onset But Does Not Affect Evidence Quality

The ability to predict the timing of forthcoming events, known as temporal expectation, has a strong impact on human information processing. Although there is growing consensus that temporal expectations enhance the speed and accuracy of perceptual decisions, it remains unclear whether they affect the decision process itself, or non-decisional (sensory/motor) processes. Here, healthy human participants (N = 21; 18 female) used predictive auditory cues to anticipate the timing of low-contrast visual stimuli they were required to detect. Modeling of the behavioral data using a prominent sequential sampling model indicated that temporal expectations speeded up non-decisional processes but had no effect on decision formation. Electrophysiological recordings confirmed and extended this result: temporal expectations hastened the onset of a neural signature of decision formation but had no effect on its build-up rate. Anticipatory α band power was modulated by temporal expectation and co-varied with intrinsic trial-by-trial variability in behavioral and neural signatures of the onset latency of the decision process. These findings highlight how temporal predictions optimize our interaction with unfolding sensory events.SIGNIFICANCE STATEMENT Temporal expectation enhances performance, but the locus of this effect remains debated. Here, we contrasted the two dominant accounts: enhancement through (1) expedited decision onset, or (2) an increase in the quality of sensory evidence. We manipulated expectations about the onset of a dim visual target using a temporal cueing paradigm, and probed the locus of the expectation effect with two complementary approaches: drift diffusion modeling (DDM) of behavior, and estimation of the onset and progression of the decision process from a supramodal accumulation-to-bound signal in simultaneously measured EEG signals. Behavioral modeling and neural data provided strong, converging evidence for an account in which temporal expectations enhance perception by speeding up decision onset, without affecting evidence quality.