Ethics of Implementing US Preventive Services Task Force Recommendations for Childhood Obesity.

Childhood obesity represents a serious and growing concern for the United States. Its negative consequences for health and well-being can be far-reaching, devastating, and intergenerational. In 2017, the US Preventive Services Task Force (USPSTF) issued a grade B recommendation for screening children and adolescents for obesity and offering or referring to comprehensive, intensive behavioral interventions as indicated. However, many communities in the United States have limited access to such interventions. The USPSTF's mission is to review and grade research evidence for clinical preventive services and does not include cost or population-based operationalization and implementation logistics considerations for its recommendations. Yet implementing recommendations without considering cost and operationalization may lead to equity and access challenges. These are essential considerations, but oversight of the implementation of these recommendations is not standardized or assigned to any one agency or organization. As such, a central ethical feature inherent to the implementation of USPSTF recommendations calls for stakeholder collaborations to take on the next step beyond the establishment of evidence-based recommendations: to ensure the ethical application of such guidelines across diverse populations. Furthermore, the screening-intervention relationship inherent to this USPSTF recommendation raises ethical concerns regarding US societal norms surrounding obesity, particularly when contrasted against other screening-intervention modalities. More efforts, such as increased incentives or expansion of clinical services in low-resource areas, should be taken to facilitate this recommended intervention by expanding access to childhood obesity interventions to fulfill ethical responsibilities to equity and to ensure the right to open futures for children.

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review.

BACKGROUND: Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation. METHODS: This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected. RESULTS: Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications. CONCLUSION: No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

Analysis of diagnosis announcements in Abidjan pediatric oncology unit 2 years after introduction of the African Pediatric Cancer Announcement Guideline.

INTRODUCTION: Announcing the diagnosis allows the therapeutic alliance between physicians and patients to be sealed and it prevents abandonment of treatment. To compensate for the deficit in information received by the families, the Franco-African Group of Pediatric Oncology (FAGPO) has published an "African Pediatric Cancer Announcement Guide" for the group's pediatric oncology units. OBJECTIVE: To analyze the announcements made to parents and children 2 years after the provision of this guide. METHODS: Cross-sectional survey conducted from March to July 2016. In total, 69 parents of children followed up in the pediatric oncology unit of Abidjan were interviewed regarding the characteristics of the announcement that was made to them and the information given to the sick child. RESULTS: Of all the accompanying individuals, 91% reported having benefited from the announcement made with empathy, mainly by a physician. In approximately one quarter of the cases the information had been given to a third party. The main barriers to information were: the negative experiences of parents, the medical terminology, and communication problems. The sick child was rarely informed. DISCUSSION: The information given was in accordance, in content and form, with the data from Western and African literature. The lack of information given to the child has a dual explanation: the primacy of the community over the individual advocated by African culture and the non-integration of the rights of children in the current code of ethics. CONCLUSION: The information provided could be improved by practical training of physicians in the technique of breaking bad news to patients and their families and the use of a code of ethics in accordance with the principle of autonomy.

Ethical considerations for modern molecular pathology.

Molecular pathology is becoming an increasingly important discipline in oncology as molecular tumor characteristics will increasingly determine targeted clinical cancer care. In recent years, many technological advances have taken place that contributed to the development of molecular pathology. However, attention to ethical aspects has been lagging behind as illustrated by the lack of publications or professional guidelines. Existing guidelines or publications on ethical aspects of DNA sequencing are mostly aimed at germline or tumor sequencing in clinical genetics or biomedical research settings. As a result, large differences have been demonstrated in the process of tumor sequencing analysis between laboratories. In this perspective we discuss the ethical issues to consider in molecular pathology by following the process of tumor DNA sequencing analysis from the preanalytical to postanalytical phase. For the successful and responsible use of DNA sequencing in clinical cancer care, several moral requirements must be met, for example, those related to the interpretation and returning of genetic results, informed consent, and the retrospective as well as future use of genetic data for biomedical research. Many ethical issues are new to pathology or more stringent than in current practice because DNA sequencing could yield sensitive and potentially relevant data, such as clinically significant unsolicited findings. The context of molecular pathology is unique and complex, but many issues are similar to those applicable to clinical genetics. As such, existing scholarship in this discipline may be translated to molecular pathology with some adaptations and could serve as a basis for guideline development. For responsible use and further development of clinical cancer care, we recommend that pathologists take responsibility for the adequate use of molecular analyses and be fully aware and capable of dealing with the diverse, complex, and challenging aspects of tumor DNA sequencing, including its ethical issues. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Applicant Interview Experiences and Postinterview Communication of the 2016 Radiation Oncology Match Cycle.

PURPOSE: To characterize applicant interview experiences at radiation oncology residency programs during the 2016 match cycle and to assess applicant opinions regarding postinterview communication (PIC) after recent attention to gamesmanship noted in prior match cycles. METHODS AND MATERIALS: An anonymous, institutional review board-approved, 29-question survey was deployed following the rank order list deadline to all 2016 radiation oncology residency applicants applying to a single institution. RESULTS: Complete surveys were returned by 118 of 210 applicants, for a 56% response rate. Regarding possible match violation questions, 84% of respondents were asked at least once about where else they were interviewing (occurred at a median of 20% of program interviews); 51% were asked about marital status (6% of interviews); and 22% were asked about plans to have children (1% of interviews). Eighty-three percent of applicants wrote thank-you notes, with 55% reporting fear of being viewed unfavorably if such notes were not communicated. Sixty percent of applicants informed a program that they had ranked a program highly; 53% felt this PIC strategy would improve their standing on the rank order list, yet 46% reported feeling distressed by this obligation. A majority of applicants stated that they would feel relieved if programs explicitly discouraged PIC (89%) and that it would be preferable if programs prohibited applicants from notifying the program of their rank position (66%). CONCLUSIONS: Potential match violations occur at a high rate but are experienced at a minority of interviews. Postinterview communication occurs frequently, with applicants reporting resultant distress. Respondents stated that active discouragement of both thank-you notes/e-mails and applicants' notification to programs of their ranking would be preferred.

Guidelines or gospels?

In the interest of advancing evidenced-based medicine, enthusiasm for clinical practice guidelines has skyrocketed. They have a genuine impact on clinical practice and are frequently referenced in the literature. Their construction is complex and labor intensive, and has significant limitations given the necessary process as well as the data available. There has been less focus on their appropriate clinical application as dictated by these inherent limitations. It is worthwhile taking a step back and considering how we know what we think we know based on statistical analysis of biomedical data sets and the real implications of those population data for making predictions about the individual patient we encounter in the clinic. These data as used to establish guidelines for care should be the foundation and starting point for our thoughtful recommendations and decision making, not the final word. The importance of nuance in clinical judgment remains even in this "evidence-based" world.

Integrity of the National Resident Matching Program for Radiation Oncology: National Survey of Applicant Experiences.

PURPOSE: The aim of this study was to examine the experiences of radiation oncology applicants and to evaluate the prevalence of behaviors that may be in conflict with established ethical standards. METHODS AND MATERIALS: An anonymous survey was sent to all 2013 applicants to a single domestic radiation oncology residency program through the National Resident Matching Program (NRMP). Questions included demographics, survey of observed behaviors, and opinions regarding the interview and matching process. Descriptive statistics were presented. Characteristics and experiences of respondents who matched were compared with those who did not match. RESULTS: Questionnaires were returned by 87 of 171 applicants for a 51% response rate. Eighty-two questionnaires were complete and included for analysis. Seventy-eight respondents (95.1%) reported being asked at least 1 question in conflict with the NRMP code of conduct. When asked where else they were interviewing, 64% stated that this query made them uncomfortable. Forty-five respondents (54.9%) reported unsolicited post-interview contact by programs, and 31 (37.8%) felt pressured to give assurances. Fifteen respondents (18.3%) reported being told their rank position or that they were "ranked to match" prior to Match day, with 27% of those individuals indicating this information influenced how they ranked programs. Half of respondents felt applicants often made dishonest or misleading assurances, one-third reported that they believed their desired match outcome could be improved by deliberately misleading programs, and more than two-thirds felt their rank position could be improved by having faculty from their home institutions directly contact programs on their behalf. CONCLUSIONS: Radiation oncology applicants report a high prevalence of behaviors in conflict with written NRMP policies. Post-interview communication should be discouraged in order to enhance fairness and support the professional development of future radiation oncologists.

[A case report of the difficulty treating an endstage oncologic ENT patient with parenteral nutrition]. / Ein Fallbericht über die Problematik der Ernährung am Lebensende eines onkologischen HNO-Patienten.

The occurrence of cachexia at the end of life of patients suffering from cancer is a common seen problem. Within the last years new definitions, diagnostic criteria and classification systems of cachexia have been developed to improve the clinical practice. Still therapeutic interventions are limited; the role of parenteral nutrition (PN) remains controversial. PN cannot be generally recommended in patients with incurable malignancies, not even in ill-nourished patients with inadequate oral or enteral nutrition due to a changed metabolism. Treating a cachectic endstage patient suffering from head-neck-cancer we were faced with different problems.