The role of time in involving patients with cancer in treatment decision making: A scoping review.

BACKGROUND: Time is often perceived as a barrier to shared decision making in cancer care. It remains unclear how time functions as a barrier and how it could be most effectively utilized. OBJECTIVE: This scoping review aimed to describe the role of time in patient involvement, and identify strategies to overcome time-related barriers. METHODS: Seven databases were searched for any publications on patient involvement in cancer treatment decisions, focusing on how time is used to involve patients, the association between time and patient involvement, and/or strategies to overcome time-related barriers. Reviewers worked independently and in duplicate to select publications and extract data. One coder thematically analyzed data, a second coder checked these analyses. RESULTS: The analysis of 26 eligible publications revealed four themes. Time was a resource 1) to process the diagnosis, 2) to obtain/process/consider information, 3) for patients and clinicians to spend together, and 4) for patient involvement in making decisions. DISCUSSION: Time is a resource throughout the treatment decision-making process, and generic strategies have been proposed to overcome time constraints. PRACTICE VALUE: Clinicians could co-create decision-making timelines with patients, spread decisions across several consultations, share written information with patients, and support healthcare redesigns that allocate the necessary time.

Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review.

INTRODUCTION: Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS: We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS: Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs

¿Ensayos clínicos de superioridad, equivalencia o no inferioridad? / ¿Clinical trials of superiority, non-inferiority or equivalence?

La eficacia de una nueva intervención se establece generalmente a través de ensayos clínicos (EC) con asignación aleatoria (AA). Sin embargo, entre otros tantos desafíos metodológicos, el especificar la hipótesis de un EC con AA, sigue siendo un problema complejo de resolver para los investigadores clínicos. En este manuscrito discutimos las características de tres variantes de los EC con AA: EC de superioridad (ECS), EC de no-inferioridad (ECNI), y EC de equivalencia (ECE). Estos tres tipos de EC tienen supuestos diferentes sobre los efectos de una intervención, por lo que plantear hipótesis y definir objetivos requiere conocer algunos supuestos subyacentes a estos EC, incluso hasta elementos relacionados con la estimación del tamaño de muestra para cada cual. El objetivo de este manuscrito fue describir las diferencias metodológicas entre ECS, ECNI y ECE.

Efficacy and effectivity of new interventions are generally established through randomized clinical trials (RCTs). However, among many other methodological challenges, specifying the hypothesis of a RCT remains complex problem for clinical researchers. In this manuscript we discuss the characteristics of three variants of RCTs: superiority RCT (SRCT), non-inferiority RCT (NIRCT), and equivalence RCT (ERCT). These three types of RCT have different assumptions about the effects of an intervention, so setting hypotheses and defining objectives requires knowing some assumptions underlying these RCTs, including elements related to the estimation of the sample size for each one. The aim of this manuscript was to describe methodological differences between SRCT, NIRCT and ERCT.

Does the duration of ambulatory consultations affect the quality of healthcare? A systematic review.

BACKGROUND: The objective is to examine and synthesise the best available experimental evidence about the effect of ambulatory consultation duration on quality of healthcare. METHODS: We included experimental studies manipulating the length of outpatient clinical encounters between adult patients and clinicians (ie, therapists, pharmacists, nurses, physicians) to determine their effect on quality of care (ie, effectiveness, efficiency, timeliness, safety, equity, patient-centredness and patient satisfaction). INFORMATION SOURCES: Using controlled vocabulary and keywords, without restriction by language or year of publication, we searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews and Scopus from inception until 15 May 2023. RISK OF BIAS: Cochrane Risk of Bias instrument. DATA SYNTHESIS: Narrative synthesis. RESULTS: 11 publications of 10 studies explored the relationship between encounter duration and quality. Most took place in the UK's general practice over two decades ago. Study findings based on very sparse and outdated evidence-which suggested that longer consultations improved indicators of patient-centred care, education about prevention and clinical referrals; and that consultation duration was inconsistently related to patient satisfaction and clinical outcomes-warrant low confidence due to limited protections against bias and indirect applicability to current practice. CONCLUSION: Experimental evidence for a minimal or optimal duration of an outpatient consultation is sparse and outdated. To develop evidence-based policies and practices about encounter length, randomised trials of different consultation lengths-in person and virtually, and with electronic health records-are needed. TRIAL REGISTRATION NUMBER: OSF Registration DOI:10.17605/OSF.IO/EUDK8.

Views of Multiple Sclerosis Patients About Key Elements for a Decision Aid: A Qualitative Study.

ABSTRACT: BACKGROUND: Patients with multiple sclerosis (MS) may experience decisional conflict during treatment choice. Shared decision making (SDM), whereby patients and health professionals, primarily nurses, collaborate in making decisions, reduces this decisional conflict. It requires understanding large amounts of information and may be complex, especially when decisions affect patients' autonomy and quality and prolongation of life. Patient decision aids are tools in facilitating SDM. This study aimed to identify the key elements from the perspective of patients with relapsing-remitting MS to create a patient decision aid in the Spanish sociocultural context. METHODS: This is a qualitative study using focus groups led by a clinical nurse specialist. Semistructured interviews included healthcare needs and demands, the SDM process, and general characteristics of a peer support program. After the transcription of interview recordings, data were analyzed by thematic analysis and a constructivist naturalistic approach. RESULTS: Patients with MS (27) from Spain participated in 4 focus groups of 90 to 120 minutes each. Three overarching themes were identified: information access to sufficient high-quality data; knowledge of available treatment options, including efficacy, adverse effects, frequency, administration route, and the impact on daily life; decision-making role, engaged versus nonengaged patients. The former require support in facilitating their active involvement in decisions, whereas the latter prefer more passive health models. CONCLUSION: The needs identified by patients with relapsing-remitting MS regarding treatment choice in the Spanish setting align with those reported by other studies. The identified themes provide valuable information to design and develop a virtual patient decision aid jointly by clinical MS nurses and patients according to the International Patient Decision Aid Standards Collaboration criteria. This aid will help improve understanding between nurses and patients during SDM and facilitate the process.

Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions.

Objective: To compare the agreement between patient and clinician perceptions of care-related financial issues. Patients and Methods: We surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient's level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings. Results: 58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (-0.051; 95% CI, -0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels. Conclusion: Even in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient's difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients.

Estudios de corte transversal: un diseño de investigación a considerar en ciencias morfológicas / Cross section studies: a research design to consider in morphological sciences

Los estudios de corte transversal (ECT) inician en la década de los 40 en países Europeos. Los ECT corresponden a investigaciones de tipo observacional que permiten estudiar prevalencia de enfermedad, determinar asociación entre variables y el desarrollo de un efecto de interés, conocer propiedades de una prueba diagnóstica, y censar poblaciones; describiendo las características de una población en un momento y lugar determinado. Esto implica, que no se requieren periodos de seguimiento, que no son prospectivos ni retrospectivos; características que permiten que sean más baratos y fáciles de realizar en relación a los estudios longitudinales. Por otro lado, al ser de carácter descriptivo sirven como insumo y evidencia preliminar para estudios de mayor complejidad metodológica, como estudios de cohortes. Sin embargo, tienen limitantes y sesgos que deben ser considerados por los investigadores. El objetivo de este manuscrito fue generar un documento de estudio para revisar características esenciales, fortalezas y debilidades; discutir cuestiones metodológicas de los ECT en ciencias de la salud; y proporcionar algunos ejemplos obtenidos de la literatura, para mejor comprensión del diseño.

SUMMARY: Cross-sectional studies (CSS) began European countries in the 1940s in. The CSSs correspond to observational-type investigations that allow studying the prevalence of disease, determining the association between variables and the development of an effect of interest, discovering the properties of a diagnostic test, and censusing populations, describing the characteristics of a population at a given time and place. This implies that follow-up periods are not required, and that they are neither prospective nor retrospective. These characteristics allow them to be cheaper and easier to perform in relation to longitudinal studies. On the other hand, being descriptive in nature, they serve as input and preliminary evidence for studies of greater methodological complexity, such as cohort studies. However, they have limitations and biases that must be considered by researchers. The aim of this manuscript was to generate a study document to review essential characteristics, strengths and weaknesses; discuss methodological issues of ECT in health sciences; and provide some examples obtained from the literature, for a better understanding of the design.

Women's preference to apply shared decision-making in breast cancer screening: a discrete choice experiment.

OBJECTIVE: To analyse women's stated preferences for establishing the relative importance of each attribute of shared decision-making (SDM) and their willingness to pay (WTP) for more participatory care in breast cancer screening programmes (BCSP). DESIGN: A discrete choice experiment was designed with 12 questions (choice tasks). It included three attributes: 'How the information is obtained', regarding benefits and harms; whether there is a 'Dialogue for scheduled mammography' between the healthcare professional and the woman; and, 'Who makes the decision', regarding participation in BCSP. Data were obtained using a survey that included 12 choice tasks, 1 question on WTP and 7 socioeconomic-related questions. The analysis was performed using conditional mixed-effect logit regression and stratification according to WTP. SETTING: Data collection related to BCSP was conducted between June and November 2021 in Catalonia, Spain. PARTICIPANTS: Sixty-five women aged between 50 and 60. MAIN OUTCOME MEASURES: Women's perceived utility of each attribute, trade-off on these attributes and WTP for SDM in BCSP. RESULT: The only significant attribute was 'Who makes the decision'. The decision made alone (coefficient=2.879; 95% CI=2.297 to 3.461) and the decision made together with a healthcare professional (2.375; 95% CI=1.573 to 3.177) were the options preferred by women. The former contributes 21% more utility than the latter. Moreover, 52.3% of the women stated a WTP of €10 or more for SDM. Women's preferences regarding attributes did not influence their WTP. CONCLUSIONS: The participant women refused a current paternalistic model and preferred either SDM or informed decision-making in BCSP.

[Moving toward personalized breast cancer screening: The role of Primary Care]. / Avances hacia el cribado personalizado del cáncer de mama: el papel de la Atención Primaria.

Breast cancer is the leading cause of death in the world among women. The Spanish National Health System (SNHS) introduced population-based breast cancer screening in 1990. As in most European programs, risk is identified on the basis of age and a mammogram is offered every two years to women aged 50-69 years. Scientific evidence is moving toward personalized screening, based on individual risk. This article presents the clinical trials that will evaluate the efficacy of personalized screening and some studies carried out in our environment on the effect of informing women of the benefits and adverse effects of screening or the acceptability and feasibility of offering personalized screening, in the Shared Decision Making context. The Preventive Activities and Health Promotion Program can help transform screening in our SNHS.

Views of health professionals on risk-based breast cancer screening and its implementation in the Spanish National Health System: A qualitative discussion group study.

BACKGROUND: With the aim of increasing benefits and decreasing harms, risk-based breast cancer screening has been proposed as an alternative to age-based screening. This study explores barriers and facilitators to implementing a risk-based breast cancer screening program from the perspective of health professionals, in the context of a National Health Service. METHODS: Socio-constructivist qualitative research carried out in Catalonia (Spain), in the year 2019. Four discussion groups were conducted, with a total of 29 health professionals from primary care, breast cancer screening programs, hospital breast units, epidemiology units, and clinical specialties. A descriptive-interpretive thematic analysis was performed. RESULTS: Identified barriers included resistance to reducing the number of screening exams for low-risk women; resistance to change for health professionals; difficulties in risk communication; lack of conclusive evidence of the benefits of risk-based screening; limited economic resources; and organizational transformation. Facilitators include benefits of risk-based strategies for high and low-risk women; women's active role in their health care; proximity of women and primary care professionals; experience of health professionals in other screening programs; and greater efficiency of a risk-based screening program. Organizational and administrative changes in the health system, commitment by policy makers, training of health professionals, and educational interventions addressed to the general population will be required. CONCLUSIONS: Despite the expressed difficulties, participants supported the implementation of risk-based screening. They highlighted its benefits, especially for women at high risk of breast cancer and those under 50 years of age, and assumed a greater efficiency of the risk-based program compared to the aged-based one. Future studies should assess the efficiency and feasibility of risk-based breast cancer screening for its transfer to clinical practice.

Barriers and Facilitators to the Implementation of a Personalized Breast Cancer Screening Program: Views of Spanish Health Professionals.

This study explored the barriers and facilitators to the implementation of a risk-based breast cancer screening program from the point of view of Spanish health professionals. A cross-sectional study with 220 Spanish health professionals was designed. Data were collected in 2020 via a web-based survey and included the advantages and disadvantages of risk-based screening and barriers and facilitators for the implementation of the program. Descriptive statistics and Likert scale responses analyzed as category-ordered data were obtained. The risk-based screening was considered important or very important to reduce breast cancer mortality and promote a more proactive role for women in breast cancer prevention, to increase coverage for women under 50 years, to promote a breast cancer prevention strategy for women at high risk, and to increase efficiency and effectiveness. Switching to a risk-based program from an age-based program was rated as important or very important by 85% of participants. As barriers for implementation, risk communication, the workload of health professionals, and limited human and financial resources were mentioned. Despite the barriers, there is good acceptance, and it seems feasible, from the perspective of health professionals, to implement a risk-based breast cancer screening program in Spain. However, this poses a number of organizational and resource challenges.

Development of support material for health professionals who are implementing Shared Decision-making in breast cancer screening: validation using the Delphi technique.

BACKGROUND: The Literature is no report support material on Shared Decision-making applied to breast cancer screening that is intended for Spanish health professionals. The researcher created both a handbook and a guide for this topic using an adaption of the Three-talk model. OBJECTIVE: A Delphi method will be used to reach an agreement among experts on the contents and design of a manual and guide, designed by the research team, and to be used by health professionals in the application of SDM in breast cancer screening. DESIGN: A qualitative study. The content and design of the handbook and the guide was discussed by 20 experts. The Delphi techniques was in an online mode between July and October 2020 and researchers used Google forms in three rounds with open and closed questions. The criterion established for consensus was a coefficient of concordance (Cc) above 75, for questions using a Likert scale of 1-6-in which 1 meant 'completely disagree' and 6 'completely agree'-with a cut-off point equal to or higher than 4. RESULTS: Participants considered the Three-talk model suitable for the screening context. The handbook sections and level of detail were considered satisfactory (Cc=90). The summary provided by the clinical practice guide was considered necessary (Cc=75), as it was the self-assessment tool for professionals (Cc=85). Content was added: addressing the limitations of the SDM model; extending the number of sample dialogues for health professionals; providing supplementary resources on using Patient Decisions aids and adding references on communication skills. CONCLUSIONS AND APPLICATIONS: The first handbook and clinical practice guide providing unique SDM support material for health professionals have been developed. The handbook and guide are useful and innovative as supporting material for health professionals, but training strategies for SDM and a piloting plan for the use of materials are requested, in order to facilitate its implementation.

[Validation of the Informed Choice instrument for Chilean women facing a mammography decision in primary care]. / Validación del instrumento Informed Choice para medir la decisión informada de mamografía en mujeres chilenas usuarias de atención primaria.

OBJECTIVE: To adapt and validate for the Chilean context the instrument Informed Choice (IC) to measure informed decision for mammography. LOCATION: Primary Health Care Center in southeast Santiago, Chile. DESIGN: Individual, transversal, analytical and psychometric adaptation and validation study. METHODS: We 1) translated and back-translated IC; 2) conducted a focus group for cultural/linguistic relevance; 3) reviewed content validity; 4) piloted the instrument; 5) applied IC for validation. Analysis was performed by using Cronbach alpha, correlation, Bartlett's test of sphericity, Kaiser-Meyer-Olkin measure and factor analysis. RESULTS: Three versions of the IC were developed, which included changes according to the views of users and experts. Validation was conducted in a sample of 70 women. Mean age was 54,4 years, 47,1% had completed secondary school and 92,9% have had at least one mammography. After factor analysis item 1 was removed and the final Cronbach Alpha was 0,79. CONCLUSIONS: The Chilean IC is reliable to measure decision women for mammography, this evaluate knowledge, attitude and intention towards the screening. The validation of an instrument to the cultural context is necessary and may have any variations to the original version according to local needs.

Healthcare professionals' behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review.

OBJECTIVE: To explore the barriers to and facilitators of healthcare professionals' implementation of SDM regarding screening programmes. METHOD: A systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves. RESULTS: Eight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes. CONCLUSION: The results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts. PRACTICAL IMPLICATIONS: The authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals' behaviour within the context of the uncertainty of screening programmes.

La confianza en la relación profesional de la salud y paciente / Confidence in the health professional and patient relation

Introducción: Las condiciones crónicas de salud demandan un cuidado continuo con enfoque en el método clínico centrado en la persona, que incluye la relación médico-paciente como un elemento transversal, siendo la confianza el eje principal. Esta confianza podría mediar entre el manejo de las condiciones crónicas de los pacientes y sus efectos. Objetivo: Identificar el efecto de la confianza en la relación paciente-proveedor de salud en los diversos contextos de salud. Métodos: Se efectuó una revisión crítica de la literatura durante los meses de junio a agosto del 2017, para comprender el rol de la confianza en la relación entre el paciente-proveedor de salud y su relación con los resultados en salud. La búsqueda inicial fue con las palabras clave: confianza, médico, proveedor de salud, paciente y sus variantes en inglés y francés, en las bases de datos electrónicas JSTOR (Filosofía), Race Relations Abstracts, SocIndex with Full Text, Social Science Database, PubMed Central, CINAHL, Nursing & Allied Health Database, Web of Science, Academic Search Complete y ProQuest Central. Se aplicaron diferentes estrategias de búsqueda con las palabras claves y el operador boleano AND. Conclusiones: La confianza es una variable de la relación paciente-proveedor de salud que tiene un rol estratégico en los procesos terapéuticos. De ahí que sea fundamental considerarla como parte de la atención en salud, en especial como una instancia de colaboración y compromiso del paciente con su salud. Por lo que se hace necesario crear instrumentos que midan esta variable de acuerdo a las características culturales de los países latinoamericanos y que se extienda a todos los que tienen un rol asistencial en el contacto directo con el paciente(AU)

ABSTRACT Introduction: Health's chronic conditions demand continuous care with an approach to the clinical method focused in the person, which includes physician-patient relation as a cross-sectional element where confidence is the core. This confidence would mediate between the management of the patient's chronic conditions and their effects. Objective: To identify the effect of confidence in health provider/professional-patient relation in different health contexts. Methods: It was carried out a critical review of related literature from June to August, 2017 in order to understand the role of confidence in health provider- patient relation, and its relation with the results in health. The initial search was with the keywords: ´confidence, physician, health provider, patient and their equivalents in English and French, in the electronic databases JSTOR (Philosophy), Race Relations Abstracts, SocIndex with Full Text, Social Science Database, PubMed Central, CINAHHL, Nursing & Allied Health Database, Web of Science, Academic Search Complete and ProQuest Central. There were carried out different search strategies with the keywords and the boolean operator AND. Conclusions: Confidence is a variable of the atient-health provider relation that has a strategic role in therapeutic processes. Then, it is important to consider it as a part of health care, specially as a point of collaboration and commitment of the patient with his/her health. Thus, it is necessary to create instruments that measure this variable in accordance with the cultural characteristics of Latin American countries and this can be extended to all having a care role in the direct contact with patients(AU)

Experiencia de alumnos de pregrado en el V encuentro internacional de autocuidado en salud: beneficios y dificultades al asistir a eventos de carácter científico / Undergrad student's experience on the V international gathering of selfcare in health: benefits and difficulties in attending scientific events

En este documento de reflexión, tres estudiantes de la Escuela de Enfermería de la Pontificia Universidad Católica de Chile relatan su experiencia como asistentes al V Encuentro Internacional de Autocuidado, actividad de difusión de carácter científico organizada por la Escuela, en donde se busca generar un espacio de diálogo respecto a e-health y literacidad en salud con profesionales y estudiantes relacionados con la temática. Este artículo tiene por objetivo relatar los beneficios y las problemáticas obtenidos por los autores, quienes resaltan aspectos positivos de esta instancia para el alumnado de pregrado, ya que favorece en la sección de nuevos conocimientos, desarrollo de un pensamiento crítico, generación de redes de apoyo y motivación para introducirse en el área de la investigación. Este último elemento es fundamental para la formación de enfermeros, ya que permite desenvolver nuevos conocimientos y contribuir de esta forma a la práctica clínica y beneficiar a los usuarios en cuidados costo-efectivos, Finalmente mencionar que no hay evidencia de publicaciones anteriores respecto a la importancia de ser partícipe como oyente a congresos, puesto que solo se menciona la relevancia que poseen estos al participar como expositor en los mismos.

Three students from Pontifical Catholic University of Chile Nurse's School describe their experience in the fifth International Encounter of self-care, diffusion activities with a scientific interest that are usually organized by The school of nurses UC. In which they are creating instances the students raise reflections in e-health and health literacy along with professional and students related to the matter. The article purpose is to describe the mayor benefits and problematics obtained by the authors, who emphasize positive aspects of this instance to undergraduate students, as it encourages the gain of knowledge, development of critical thinking, generating networks of support and motivating them to enter the area of research. This last element is crucial to the training of nurses, allowing to develop knowledge and thus contribute to clinical practice and benefit users in cost-efectives care', Finally mentioning that there is no evidence of previous publications about the importance of being a participant as a listener to these kind conferences, since only the relevance of these is known once we participate as exhibitors.