Kidney donors' interests and the prohibition on sales

I shall argue, first, that potential kidney donors may be subject to harmful pressure to donate. This pressure may take almost any form; people have diverse interests, and anything that could set them back may qualify as pressure. Given features of the context-the high stakes, the involvement of family, and the social meaning of donation-such pressure may be especially harmful. This problem is less tractable than the more familiar worry that pressure may compromise consent. Screening may ensure donors validly consent, but it provides no protection against harmful pressure. I shall argue, second, that the use of such pressure is the predictable consequence of the prohibition on kidney sales. Potential donors have something-a transplantable kidney-that is both valuable and scarce. Many of them, informed about donation, decide against it. Those in need of a transplant may seek to persuade the unwilling. Given the prohibition, the donation cannot be made more attractive in absolute terms by, say, the addition of money. However, it can be made more attractive in relative terms. If declining the option is made worse, then, by comparison, accepting it is made better. The application of harmful pressure has the desired effect. With so much at stake, and no good alternatives, its use is predictable. I conclude that potential donors' interests should figure more prominently in the discussion of transplant policy. Those who defend the prohibition have made virtually no attempt to account for its impact on that group.

Real-world treatment patterns and outcomes of triple-class treated patients with multiple myeloma in the United States

OBJECTIVES

Although multiple myeloma (MM) survival has improved following the introduction of proteosome inhibitors, immunomodulatory drugs, and anti-CD38 therapies, patients become refractory to these agents. Real-world outcomes of triple-class exposed patients are limited and were investigated in this study.

METHODS

The Integra Connect Database was used to assess the treatment patterns of triple-class exposed patients with relapsed/refractory MM (RRMM) (January 2016-December 2019).

RESULTS

During this period, patients (N = 501) reached triple exposure in a median of three lines of therapy (LOTs) over 995 days. A new LOT was started in a median of 18 (1-691) days after triple exposure; 71% of the patients started a new LOT within 30 days. Throughout the follow-up period, 8% of the patients had a therapy gap greater than 90 days. Following triple exposure, 103/501 patients (21%) received only triple-class agents in subsequent LOTs, while 24 (4.8%) patients received only non-triple-class agents. The median apparent survival from initiation of first therapy after triple exposure was 308 days.

CONCLUSION

These results indicate that recycling of triple-class agents after previous exposure is widespread and prognosis in the RRMM population remains poor, highlighting the continuing unmet need for new agents with novel mechanisms to improve patient outcomes.

Fostering Patient Choice Awareness and Presenting Treatment Options Neutrally: A Randomized Trial to Assess the Effect on Perceived Room for Involvement in Decision Making

Purpose

Shared decision making calls for clinician communication strategies that aim to foster choice awareness and to present treatment options neutrally, such as by not showing a preference. Evidence for the effectiveness of these communication strategies to enhance patient involvement in treatment decision making is lacking. We tested the effects of 2 strategies in an online randomized video-vignettes experiment.

Methods

We developed disease-specific video vignettes for rheumatic disease, cancer, and kidney disease showcasing a physician presenting 2 treatment options. We tested the strategies in a 2 (choice awareness communication present/absent) by 2 (physician preference communication present/absent) randomized between-subjects design. We asked patients and disease-naïve participants to view 1 video vignette while imagining being the patient and to report perceived room for involvement (primary outcome), understanding of treatment information, treatment preference, satisfaction with the consultation, and trust in the physician (secondary outcomes). Differences across experimental conditions were assessed using 2-way analyses of variance.

Results

A total of 324 patients and 360 disease-naïve respondents participated (mean age, 52 ± 14.7 y, 54% female, 56% lower educated, mean health literacy, 12 ± 2.1 on a 3–15 scale). The results showed that choice awareness communication had a positive (M_present = 5.2 v. M_absent = 5.0, P = 0.042, η²_partial = 0.006) and physician preference communication had no (M_present = 5.0 v. M_absent = 5.1, P = 0.144, η²_partial = 0.003) significant effect on perceived room for involvement in decision making. Physician preference communication steered patients toward preferring that treatment option (M_present = 4.7 v. M_absent = 5.3, P = 0.006, η²_partial = 0.011). The strategies had no significant effect on understanding, satisfaction, or trust.

Conclusions

This is the first experimental evidence for a small effect of fostering choice awareness and no effect of physician preference on perceived room to participate in decision making. Physician preference steered patients toward preferring that option.

Entropy and Wealth

While entropy was introduced in the second half of the 19th century in the international vocabulary as a scientific term, in the 20th century it became common in colloquial use. Popular imagination has loaded “entropy” with almost every negative quality in the universe, in life and in society, with a dominant meaning of disorder and disorganization. Exploring the history of the term and many different approaches to it, we show that entropy has a universal stochastic definition, which is not disorder. Hence, we contend that entropy should be used as a mathematical (stochastic) concept as rigorously as possible, free of metaphoric meanings. The accompanying principle of maximum entropy, which lies behind the Second Law, gives explanatory and inferential power to the concept, and promotes entropy as the mother of creativity and evolution. As the social sciences are often contaminated by subjectivity and ideological influences, we try to explore whether maximum entropy, applied to the distribution of a wealth-related variable, namely annual income, can give an objective description. Using publicly available income data, we show that income distribution is consistent with the principle of maximum entropy. The increase in entropy is associated to increases in society’s wealth, yet a standardized form of entropy can be used to quantify inequality. Historically, technology has played a major role in the development of and increase in the entropy of income. Such findings are contrary to the theory of ecological economics and other theories that use the term entropy in a Malthusian perspective.

Fabry Cardiomyopathy: Current Treatment and Future Options

Fabry disease is a multisystem X-linked lysosomal storage disorder caused by a mutation in the alpha-galactosidase A gene. Deficiency or reduced activity of alpha-galactosidase A (GLA) is leading to progressive intracellular accumulation of globotriaosylceramide (GL3) in various organs, including the heart, kidney and nerve system. Cardiac involvement is frequent and is evident as concentric left ventricular hypertrophy. Currently, the standard treatment is enzyme replacement therapy or chaperone therapy. However, early starting of therapy, before myocardial fibrosis has developed, is essential for long-term improvement of myocardial function. For future treatment options, various therapeutic approaches including gene therapy are under development. This review describes the current and potential future therapy options for Fabry cardiomyopathy.

Quorum sensing: a new prospect for the management of antimicrobial-resistant infectious diseases

INTRODUCTION

Quorum-sensing (QS) is a microbial cell-to-cell communication system that utilizes small signaling molecules to mediates interactions between cross-kingdom microorganisms, including Gram-positive and -negative microbes. QS molecules include N-acyl-homoserine-lactones (AHLs), furanosyl borate, hydroxyl-palmitic acid methylester, and methyl-dodecanoic acid. These signaling molecules maintain the symbiotic relationship between a host and the healthy microbial flora and also control various microbial virulence factors. This manuscript has been developed based on published scientific papers.

AREAS COVERED

Furanones, glycosylated chemicals, heavy metals, and nanomaterials are considered QS inhibitors (QSIs) and are therefore capable of inhibiting the microbial QS system. QSIs are currently being considered as antimicrobial therapeutic options. Currently, the low speed at which new antimicrobial agents are being developed impairs the treatment of drug-resistant infections. Therefore, QSIs are currently being studied as potential interventions targeting QS-signaling molecules and quorum quenching (QQ) enzymes to reduce microbial virulence.

EXPERT OPINION

QSIs represent a novel opportunity to combat antimicrobial resistance (AMR). However, no clinical trials have been conducted thus far assessing their efficacy. With the recent advancements in technology and the development of well-designed clinical trials aimed at targeting various components of the, QS system, these agents will undoubtedly provide a useful alternative to treat infectious diseases.

An update on options of therapy for aggressive mantle cell lymphoma

With the emerging application of novel targeted agents in the induction, maintenance and salvage strategies, management of aggressive mantle cell lymphoma is being transformed from high-intensity chemo-immunotherapy applicable to only selected patients, to more personalized treatment incorporating novel agents that are effective and accessible for the majority of the patients. This review summarizes risk-stratified management paradigm for aggressive mantle cell lymphoma, providing context for clinical applications of novel agents and cellular therapy including stem cell transplant and CAR-T.

Alternative option labeling impacts decision-making in noninvasive prenatal screening

Prenatal genetic screening should be an informed, autonomous patient choice. Extrinsic factors which influence patient decision-making threaten the ethical basis of prenatal genetic screening. Prior research in the area of medical decision-making has identified that labeling may have unanticipated effects on patient perceptions and decision-making processes. This Internet-administered study explored the impact of option labeling on the noninvasive prenatal screening (NIPS) selections of US adults. A total of 1,062 participants were recruited through Amazon Mechanical Turk (MTurk) and randomly assigned to one of three possible label sets reflecting provider-derived and industry-derived option labels used in prenatal screening. Multinomial logistic regression analysis showed option labeling had a statistically significant impact on the NIPS selections of study participants (p = .0288). Outcomes of the Satisfaction with Decision Scale (SWD) indicated option labels did not play a role in participant satisfaction with screening selection. The results of this study indicate a need for further evaluation of the impact NIPS option labeling has on patient screening decisions in real-world clinical interactions. Clinical providers and testing laboratories offering NIPS should give careful consideration to the option labels used with prenatal screening so as to minimize influence on patient screening selection and decision-making processes.

An Actuarial Pricing Method for Air Quality Index Options

Poor air quality has a negative impact on social life and economic production activities. Using financial derivatives to hedge risks is one of the important methods. Air quality index (AQI) options are designed to help enterprises cope with the operational risk caused by air pollution. First, the expanded Ornstein–Uhlenbeck model is established using an autoregressive-generalized autoregressive conditional heteroscedasticity (AR-GARCH) method to predict AQI for a city. Next, the average AQI is constructed to be as the underlying index for the AQI options. We then priced AQI options using an actuarial method with an Esscher transform. Meanwhile payoff functions for the options are established to let enterprises hedge against the operational risk caused by air pollution. Finally, we determined the price of AQI options using data from Xi’an, China, and the example of a tourism enterprise as a case study of how AQI options can be applied to hedge against operational risk for enterprises. With AQI options trading, enterprises can hedge against operational risks caused by air pollution. The applicability of AQI options is wide, it can also be applied in other cities or regions.

Shared Decision-making in Acute Myeloid Leukemia

OBJECTIVES

Shared decision-making (SDM) is the gold standard approach to cancer treatment decision-making in the 21^st century, but it is frequently misunderstood, and many clinicians do not know how to operationalize the SDM framework in their busy practices. Here we review the principles behind SDM, discuss unique aspects of acute myeloid leukemia (AML) that complicate the decision-making process, and provide one recommended framework for how to implement SDM into practice.

DATA SOURCES

Published literature and clinical experiences.

CONCLUSION

AML poses unique challenges to treatment decision-making. These challenges can be effectively addressed by following the SDM framework in practice.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play an important role in the AML treatment decision-making process. Being on the front lines of care, working most directly with patients and families, nurses are best positioned to assess understanding after treatment discussions take place, detect emotional distress, and provide empathic support as part of the SDM process.

How excluding some benefits from value assessment of new drugs impacts innovation

Payers often assess the benefits of new drugs relative to costs for reimbursement purposes, but they frequently exclude some drugs' option-related benefits, reducing their reimbursement chances, and making them less attractive R&D investments. We develop and test a real options model of R&D investment that shows that excluding option-related benefits heightens drug developers' incentives to avoid high-risk (volatile) R&D investments and instead encourages them to focus on "safer" (positively skewed) investments. Our model and empirical results could partly explain the decline in the number of risky new molecular entities.

Differences in attitudes to end-of-life care among patients, relatives and healthcare professionals

INTRODUCTION

This study explored and compared the differences in attitudes toward end-of-life care among patients, relatives and healthcare professionals, including doctors and nurses.

METHODS

We performed a descriptive study on a cross-section of the population of a tertiary hospital in Singapore. Data was collected using a questionnaire survey involving 50 participants from each of the four groups of patients, relatives, doctors and nurses.

RESULTS

Family members were the most commonly nominated surrogate decision-makers by the patient group (76%) and the majority of the relative group (74%) felt comfortable deciding on end-of-life care for their loved ones. However, the patient and relative groups differed significantly in their preferences on end-of-life care options, including cardiopulmonary resuscitation (CPR) (p = 0.001), intubation (p = 0.003), nasogastric tube feeding (p < 0.001) and the use of antibiotics (p = 0.023). Doctors, nurses and relatives demonstrated differences in preference between end-of-life care for themselves and for their loved ones, especially with regard to the use of nasogastric tube feeding. There was also a difference between patients and doctors in their decisions on CPR (p < 0.001) and intubation (p = 0.008).

CONCLUSION

This study demonstrated the importance of early planning for end-of-life care. This must be initiated proactively by healthcare professionals to engage patients in a culturally sensitive manner to discuss their preferences, in order to facilitate open communication between the patient and family.

AB101. Diversity and choice in the surgical techniques for benign prostatic hypertrophy

Benign prostatic hypertrophy (BPH) is still one of the most diseases that urologists need to deal with every day. Although conservative and medical therapy for BPH is now well established in terms of alpha-blocker and 5-alpha reductase inhibitor treatment, surgical intervention is still finally irreplaceable for many cases. Open prostectomy has more than 200 years of history since Doctor Guthrie first used the perineum incision to enucleate the hyperplastic prostate adenoma in the year of 1834. From then on, surgical techniques have been evolved and improved constantly and Guthrie’s perineum approach was superseded by Freyer’s suprapubic transvesical approach, Millin’s retropubic transcapsular prostectomy, and more recently laparoscopic and robotic-assisted approach. When it comes to surgical treatment options available for BPH, transurethral surgery of prostate (TUSP) have to be mentioned. Monopolar transurethral resection of the prostate (TURP) have been called for many years as the golden standard treatment for the surgical management of BPH. However, TURP rates have declined over the past two decades due to the significant benefits of medical therapy and, to a lesser extent, the proliferation of other transurethral surgical techniques. Transurethral vaporization and vaporesection of the prostate are reported to have the similar results compared to TURP. With the development of the monopolar to bipolar technique and many electrode designs available, TUSP is becoming more and more safety. In recent years, transurethral plasmakinetic resection of the prostate (TUPKRP/PKRP) is the more and more popular technique of TUSP and considered as the new golden standard procedure for surgical treatment of BPH. In the past 5 years, transurethral laser techniques have been used more and more in the surgical management of BPH. There are several types of lasers used for BPH surgery by either coagulating, vaporizing or enucleating the prostate. Laser techniques for treating BPH appears to have equivalent results to TURP and have superiority to TURP in anticoagulated patients where risks of bleeding and the need for post-operative blood transfusion remain low. Transurethral laser treatment of BPH seems to have a tendency to replace the TURP. In fact, surgical treatment options are far more than the above mentioned, for example, UroLift system can illustrate this point as the latest technique and new technology will appear constantly and apply to clinic. However, so many surgical options exist for BPH and indications are well defined, questions remain in this area. How much prostate volume reduction is necessary to relieve BOO or LUTS, how is bladder underactivity and its associated with LUTS after BPH surgery and which procedure is the best choice for each BPH patient. And more, cost effectiveness of any options should be considered, especially in developing country. It is clear that appropriate counseling is necessary in all patients who undergo BPH surgery.

Treating OCD: what to do when first-line therapies fail

OBJECTIVE

To provide a clinically-focused review of the biological treatment of treatment-resistant obsessive compulsive disorder (OCD).

CONCLUSIONS

There is a paucity of research on how to manage OCD patients who fail to respond adequately to first line therapies. High-dose selective serotonin reuptake inhibitors (SSRIs) and clomipramine have good evidence-based data. Combinations of SSRIs have little support in clinical trials, but the combination of SSRIs and clomipramine can be helpful: careful clinical and cardiac monitoring is required. Certain adjunctive antipsychotics have a reasonable evidence base in OCD, but their use also needs to be weighed against the potential side effect burden. In patients with substantial generalised anxiety symptoms, clonazepam is worth considering. Of the other augmenting strategies, memantine and ondansetron appear useful in some cases, and are well tolerated. Topiramate might ameliorate compulsions to some degree, but it is less well tolerated. If all these strategies, along with expert psychological therapy, fail, careful consideration should be given to deep brain stimulation (DBS), which has an emerging evidence base and which can result in dramatic benefits for some individuals. For some patients, gamma radiosurgery might also still have a place.

Patient perceptions on the subject of medical research

While performing medical research we often spend little time addressing patient’s views on how research participants perceive the trial will affect their own condition. This manuscript identifies various ways in which the field of medicine must approach the important subject of patient’s outlook. The described approach is vital to succeed at achieving meaningful patient’s involvement in research.

12. Selection of responses and interventions

Generally, there are a host of potential interventions available during a disaster. The selection of the most appropriate interventions/responses is dependent upon the goals elaborated in the strategic plan. All interventions selected must be aimed at meeting the defined needs of the affected population. In this Chapter, the process used for the selection of interventions is deconstructed into its component steps. The steps in selecting interventions include (but are not limited to): (1) identify objectives that have a likelihood of contributing to achievement of the strategic goal outlined in the strategic plan; (2) identify potential interventions likely to achieve these objectives; (3) assure compatibility with other interventions; (4) develop new options (if necessary); (5) identify available and other required resources; (6) match objectives with resources; (7) weight interventions for their ability to meet the objectives; (8) coordinate with ongoing/planned activities; (9) select most appropriate options; (10) codify the operational objectives for the intervention(s) selected; (11) provide timelines and reporting structure; (12) establish evaluation methods; and (13) complete contracts and/or memoranda of understanding. Understanding this process is essential for the identification of critical points of success and failure. Correction of critical points of failure should facilitate the process next time interventions must be selected.

The origins of options

Most research on decision making has focused on how human or animal decision makers choose between two or more options, posed in advance by the researchers. The mechanisms by which options are generated for most decisions, however, are not well understood. Models of sequential search have examined the trade-off between continued exploration and choosing one’s current best option, but still cannot explain the processes by which new options are generated. We argue that understanding the origins of options is a crucial but untapped area for decision making research. We explore a number of factors which influence the generation of options, which fall broadly into two categories: psycho-biological and socio-cultural. The former category includes factors such as perceptual biases and associative memory networks. The latter category relies on the incredible human capacity for culture and social learning, which doubtless shape not only our choices but the options available for choice. Our intention is to start a discussion that brings us closer toward understanding the origins of options.

Controlling Sickle Cell Disease in Ghana--ethics and options

Sickle Cell Disease (SCD) is a significant public health burden in Ghana. Recent studies indicate that 2% of Ghanaian newborns are affected by SCD; one in three Ghanaians has the hemoglobin S and/or C gene. As a means of controlling the disease, some authorities have recommended prenatal diagnosis (PND) and selective abortion. In the current era, SCD has a good prognosis and fairly reasonable quality of life. Advances in bone marrow transplantation have shown the disease is curable in selected patients. PND and selective abortion therefore raises a myriad of ethical dilemmas which are considered in this review. In the light of the demonstration of improved prognosis in recent times, PND and selective abortion appears to be applying capital punishment to the unborn child for "crimes" only the parents can be responsible for. In this review, we recommend control of SCD on three levels--preconception genetic testing and strategic reproductive choices, PND and education for carrier parents, and holistic management of persons with SCD. We emphasize the critical importance of self-management, especially self-awareness, in assuring a good quality of life for persons with SCD. We believe such an approach is cost-effective, and consistent with sound ethical principles and good conscience.