Can reflective multicriteria be the new paradigm for healthcare decision-making? The EVIDEM journey

Background

Multiple technologies, procedures and programs call for fairly-based decisions for prioritization of healthcare interventions. There is a diversity of perspectives of what constitutes a legitimate decision, which depends on both the process and the reasoning applied. Current approaches focus on technical aspects while methods to support alignment of decisions with the compassionate impetus of healthcare systems is lacking.

Methods

The framework was developed based on an analysis of the foundations of healthcare systems, the reasoning underlying decisions and fair processes. The concept of reflective multicriteria was created: it assumes that decisionmakers guided by a generic interpretative frame rooted in the compassionate impetus of healthcare systems, can sharpen their reasoning, raise awareness of their motivation and increase legitimacy of decisions. The initial framework was made available through a not for profit organization (the EVIDEM Collaboration, 2006–2017) to stimulate its development with thought leaders and stakeholders in an open source philosophy. Development was tailored to the real-life needs of decisionmakers and drew on several domains of knowledge including healthcare ethics, evidenced-based medicine, health economics, health technology assessment and multicriteria approaches.

Results

The 10th edition framework builds on four dimensions: (1) the universal impetus of healthcare systems, (2) reasoning, values and ethics, (3) evidence and knowledge on interventions, and (4) a transformative process. Mathematical aspects of the framework are designed to help clarify, express and share individual reasoning; this non-conventional use of numbers requires a cultural change and needs to be phased in slowly. The framework includes four tools for easy adaptation and operationalization: (a) concepts and operationalization, (b) adapt and pilot, (c) evidence matrix, (d) mathematical representation of reasoning. Application is useful throughout all types of healthcare interventions, for all levels of decision, and across the globe.

Conclusion

By clarifying their reasoning while keeping decisionmakers aware of the impetus of healthcare systems, reflective multicriteria provides an effective approach to increase the legitimacy of decisions. Beyond a tool, reflective multicriteria pioneered by EVIDEM is geared to transform our vision of the value of healthcare interventions and how they might contribute to relevant, equitable and sustainable healthcare systems.

     

Occupational exposure to textile dust and lung cancer risk: Results from the ICARE Study

Background

To investigate the association of lung cancer with occupational exposure to textile dust and specifically to cotton dust in the population‐based case‐control study ICARE.

Methods

Lifelong occupational history of 2926 cases and 3555 controls was collected using standardized questionnaires, with specific questions for textile dust exposure. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using unconditional logistic regression models controlling for confounding factors including smoking and asbestos exposure.

Results

An inverse association between textile dust exposure and lung cancer was found among workers exposed ≥5% of their work time (OR = 0.80, 95%CI = 0.58‐1.09), more pronounced for distant exposures (40+ years; up to a 56% reduced risk, statistically significant). The OR of lung cancer was significantly decreased among workers exposed to cotton fibers (OR = 0.70, 95%CI = 0.48‐0.97).

Conclusions

Our results provide some evidence of a decreased risk of lung cancer associated with exposure to textile dust, particularly cotton.

     

Novel Virulent Bacteriophages Infecting Mediterranean Isolates of the Plant Pest Xylella fastidiosa and Xanthomonas albilineans

Xylella fastidiosa (Xf) is a plant pathogen causing significant losses in agriculture worldwide. Originating from America, this bacterium caused recent epidemics in southern Europe and is thus considered an emerging pathogen. As the European regulations do not authorize antibiotic treatment in plants, alternative treatments are urgently needed to control the spread of the pathogen and eventually to cure infected crops. One such alternative is the use of phage therapy, developed more than 100 years ago to cure human dysentery and nowadays adapted to agriculture. The first step towards phage therapy is the isolation of the appropriate bacteriophages. With this goal, we searched for phages able to infect Xf strains that are endemic in the Mediterranean area. However, as Xf is truly a fastidious organism, we chose the phylogenetically closest and relatively fast-growing organism X. albineans as a surrogate host for the isolation step. Our results showed the isolation from various sources and preliminary characterization of several phages active on different Xf strains, namely, from the fastidiosa (Xff), multiplex (Xfm), and pauca (Xfp) subspecies, as well as on X. albilineans. We sequenced their genomes, described their genomic features, and provided a phylogeny analysis that allowed us to propose new taxonomic elements. Among the 14 genomes sequenced, we could identify two new phage species, belonging to two new genera of the Caudoviricetes order, namely, Usmevirus (Podoviridae family) and Subavirus (Siphoviridae family). Interestingly, no specific phages could be isolated from infected plant samples, whereas one was isolated from vector insects captured in a contaminated area, and several from surface and sewage waters from the Marseille area.     

NMR characterization and solution structure determination of the oxidized cytochrome c7 from Desulfuromonas acetoxidans

The solution structure of the three-heme electron transfer protein cytochrome c₇ from Desulfuromonas acetoxidans is reported. The determination of the structure is obtained through NMR spectroscopy on the fully oxidized, paramagnetic form. The richness of structural motifs and the presence of three prosthetic groups in a protein of 68 residues is discussed in comparison with the four-heme cytochromes c₃ already characterized through x-ray crystallography. In particular, the orientation of the three hemes present in cytochrome c₇ is similar to that of three out of four hemes of cytochromes c₃. The reduction potentials of the individual hemes, which have been obtained through the sequence-specific assignment of the heme resonances, are discussed with respect to the properties of the protein matrix. This information is relevant for any attempt to understand the electron transfer pathway.     

Fibre-supplemented tube feeding in the hospitalised elderly

OBJECTIVES: To evaluate the effect of fibre supplementation in enteral feeding on bowel function in hospitalised geriatric patients, and to assess its metabolic and nutritional efficiency. DESIGN: Prospective randomised controlled trial with stratification for diabetes. SETTING: Department of Geriatrics at the University of Antwerp. SUBJECTS: During 30 months (January 2000-June 2002) every hospitalised patient requiring tube feeding was assessed for eligibility (n = 183). Finally 172 patients (19% diabetics) were randomised. METHODS: An enteral nutritional regimen consisting of 30 kcal/kg in 2000 ml with a calorie/nitrogen ratio of 156 with or without fibre was instituted. At weekly intervals, stool output was qualitatively evaluated by recording frequency, volume (small <1/2 cup, large >1/2 cup) and consistency (solid-formed, soft-pasty or liquid-watery). Nutritional and metabolic effects were evaluated through laboratory analysis. RESULTS: Overall mortality was 24% with a trend for excess mortality in diabetic patients (33.3% versus 21.6% in non-diabetics; P = 0.176). There was no difference in duration of feeding between the fibre group (27.5 days; 95% CI = 19.1-35.9) and the no fibre group (27.9 days; 95% CI = 20.2-35.5). In the fibre-supplemented group, stool frequency was lower (4.1 per week; 95% CI = 3.7-4.6) than in controls (6.3 per week; 95% CI = 5.6-6.9). Qualitatively, stool consistency was higher (P < 0.001) but no difference in volume was noted. There were no differences in final laboratory parameters between groups. CONCLUSIONS: Fibre supplementation improved bowel function with reduced stool frequency and more solid stool consistency. It did not affect the nutritional efficiency of enteral feeding in hospitalised geriatric patients. Diabetes may be a risk factor for mortality in malnourished patients requiring tube feeding.     

Biallelic loss of function variants in SYT2 cause a treatable congenital onset presynaptic myasthenic syndrome

Synaptotagmins are integral synaptic vesicle membrane proteins that function as calcium sensors and regulate neurotransmitter release at the presynaptic nerve terminal. Synaptotagmin‐2 (SYT2), is the major isoform expressed at the neuromuscular junction. Recently, dominant missense variants in SYT2 have been reported as a rare cause of distal motor neuropathy and myasthenic syndrome, manifesting with stable or slowly progressive distal weakness of variable severity along with presynaptic NMJ impairment. These variants are thought to have a dominant‐negative effect on synaptic vesicle exocytosis, although the precise pathomechanism remains to be elucidated. Here we report seven patients of five families, with biallelic loss of function variants in SYT2, clinically manifesting with a remarkably consistent phenotype of severe congenital onset hypotonia and weakness, with variable degrees of respiratory involvement. Electrodiagnostic findings were consistent with a presynaptic congenital myasthenic syndrome (CMS) in some. Treatment with an acetylcholinesterase inhibitor pursued in three patients showed clinical improvement with increased strength and function. This series further establishes SYT2 as a CMS‐disease gene and expands its clinical and genetic spectrum to include recessive loss‐of‐function variants, manifesting as a severe congenital onset presynaptic CMS with potential treatment implications.     

Relative stability of alexithymia and openness to emotions in one psychiatric day hospital setting

Alexithymia (literally, difficulty finding words for emotions) and openness to emotions (OE: referring to the cognitive representation, communication, regulation, perception of internal and external bodily sensations, and social restriction of emotions) are strongly linked to psychopathology. The absolute and relative stability hypotheses were tested in order to determine whether significant changes occurred on these constructs after therapy, a condition where changes were expected for both constructs. Negative attitudes toward treatment (NTI) and perceived social support (PSS) were expected to significantly predict alexithymia and OE. Patients (N = 179) who participated in this longitudinal study filled in the Toronto Alexithymia Scale, the Dimensions of Openness to Emotions Scale, the NTI subscale, the Multidimensional Scale of Perceived Social Support, and the Social Desirability Scale. After treatment, we observed significant decrease of all alexithymia scores and significant increases of three OE scores, that is, cognitive representation, communication, and regulation of emotions. Regression analyses revealed that gender, age, NTI, and PSS were significant predictors of alexithymia and OE. NTI strongly predicted lower OE levels and higher alexithymia levels, whereas PSS had opposite predicting effects on these constructs. In conclusion, the significant changes, and the moderate to high correlational levels observed between before and after alexithymia and OE scores, strengthen the relative stability hypothesis for both constructs. In addition, PSS represents a protective factor and NTI a vulnerability indicator for therapists. Our aim is to optimize treatment by providing therapists treating emotion difficulties a more concrete array of variables that potentially either promote or subvert recovery.