The field of clinical decision making is polarized by two predominate views. One holds that treatment recommendations should conform with guidelines; the other emphasizes clinical expertise in reaching case-specific judgments. Previous work developed a test for a proposed alternative, that clinical judgment should systematically incorporate both general knowledge and patient-specific information. The test was derived from image theory’s two phase-account of decision making and its “simple counting rule”, which describes how possible courses of action are pre-screened for compatibility with standards and values. The current paper applies this rule to clinical forecasting, where practitioners indicate how likely a specific patient will respond favorably to a recommended treatment. Psychiatric trainees evaluated eight case vignettes that exhibited from 0 to 3 incompatible attributes. They made two forecasts, one based on a guideline recommendation, the other based on their own alternative. Both forecasts were predicted by equally- and unequally-weighted counting rules. Unequal weighting provided a better fit and exhibited a clearer rejection threshold, or point at which forecasts are not diminished by additional incompatibilities. The hypothesis that missing information is treated as an incompatibility was not confirmed. There was evidence that the rejection threshold was influenced by clinician preference. Results suggests that guidelines may have a de-biasing influence on clinical judgment. Subject to limitations pertaining to the subject sample and population, clinical paradigm, guideline, and study procedure, the data support the use of a compatibility test to describe how clinicians make patient-specific forecasts.

Bien que les cliniciens français restent majoritairement prudents et attentifs aux recommandations concernant la prescription de médicaments psychotropes chez l’enfant et l’adolescent, celle-ci augmente depuis quelques années. Antipsychotiques, antidépresseurs, mais aussi psychostimulants, mélatonine, ocytocine…la palette s’élargit, les indications se diversifient et les effets indésirables sont de mieux en mieux étudiés. Afin d’apporter aux praticiens des informations concrètes et démontrées, pour les aider dans leur appréciation du rapport « bénéfices-risques » d’une prescription médicamenteuse, la Société française de psychiatrie de l’enfant et de l’adolescent (SFPEADA) propose, au cours de cette rencontre avec l’expert :

– dans un premier temps une mise au point sur les données actualisées et démontrées pouvant être utiles aux médecins amenés à prescrire chez des jeunes de moins de 18 ans : indications, AMM, éléments pouvant guider vers le choix de telle ou telle molécule au sein d’une même famille thérapeutique, examens à pratiquer avant mise sous traitement et modalités de surveillance en pratique clinique, mesures d’accompagnement de la prescription, articulation avec les autres formes d’interventions thérapeutiques…

– Dans un second temps une discussion avec les participants sous la forme « questions-réponses » et de « partage d’expériences ».

La rencontre avec l’expert sera modérée par le professeur Jean-Philippe Raynaud (Toulouse), président du conseil scientifique de la SFPEADA.

The practice of emergency medicine (EM) has been intertwined with emergency medical services (EMS) for more than 40 years. In this commentary, we explore the practice of translating hospital based evidence into the prehospital setting. We will challenge both EMS and EM dogma—bringing hospital care to patients in the field is not always better. In providing examples of therapies championed in hospitals that have failed to translate into the field, we will discuss the unique prehospital environment, and why evidence from the hospital setting cannot necessarily be translated to the prehospital field. Paramedicine is maturing so that the capability now exists to conduct practice-specific research that can inform best practices. Before translation from the hospital environment is implemented, evidence must be evaluated by people with expertise in three domains: critical appraisal, EM, and EMS. Scientific evidence should be assessed for: quality and bias; directness, generalizability, and validity to the EMS population; effect size and anticipated benefit from prehospital application; feasibility (including economic evaluation, human resource availability in the mobile environment); and patient and provider safety.

The update course in foetal cardiology held by the Fetal Working Group of the Association for European Paediatric and Congenital Cardiology in Istanbul in May 2012 included a session on foetal cardiac therapy. In the introductory overview to this symposium, we critically examine the level of evidence supporting or refuting proposed foetal cardiac therapies including transplacental treatment of foetal tachyarrhythmias, steroid treatment in foetal atrioventricular block, and foetal aortic valvuloplasty. In summary, the evidence for the efficiency and safety of currently available foetal cardiac therapies is low, with no therapy based on a randomised controlled trial. Transplacental treatment of foetal tachycardia is generally accepted as effective and safe, based on extensive and widespread clinical experience; however, there is no consensus on which drugs are the most effective in different electrophysiological situations. Randomised studies may be able to resolve this, but this is complicated because tachyarrhythmias are relatively rare conditions, the foetus is not accessible for direct treatment, and it is the healthy mother who accepts treatment she does not need on behalf of her foetus. The indications for steroid treatment in foetal atrioventricular block and for foetal valvuloplasty are even more controversial. Although randomised trials would be desirable, the practical issues of recruiting sufficient sample sizes and controlling for variation in practice across multiple sites is not to be underestimated. Multicentre registries, analysed free of bias, may be an alternative way to improve the evidence base of foetal cardiac therapy.

The Cochrane Collaboration represents a quite successful example of a grass roots international effort aimed at contributing the growing demand for valid and reliable information on the effects of health care intervention, eagerly sought by consumers, patients, doctors and policy makers worldwide. The Cochrane Collaboration is fully aware that part of its success is due to the originality of its founding principles and that the challenge ahead is to maintain its ‘Cochrane Collaboration brand’ while understanding how a mature organisation can cope with the expectations of the relevant stakeholders with whom it seeks to collaborate. In this editorial reference is made to the strategic reflections emerged from the internal review that the organisation has recently completed to guide its years ahead.

Objectives: The aim of this study was to review the history of health technology assessment (HTA) in Italy.

Methods: Founded in 1978, the Italian National Health Service (NHS) has been strongly regionalized mainly after a constitutional reform, which started a devolution process. HTA started in the 1980s at the National Institute of Health and in a few University Hospitals, with a focus on big ticket technology: that process was driven by clinical engineers.

Results: In recent years, HTA is becoming an important tool for decision-making processes at central, regional, and local levels. In particular, the National Agency for Regional Health Services (AGENAS) and five regions (of twenty-one) are strongly committed to develop HTA initiatives connected with the planning process.

Conclusions: At the local level, the hospital-based HTA activity is probably the most important peculiarity of the country and the real driver of the HTA movement.

There is a large evidence base around prostate cancer. Most of this concentrates on which stages of the disease to treat with which modality. The purpose of this study is to try and determine from the literature an evidence based radiotherapy treatment technique. The evidence is examined on prostate and patient motion, the effect of bladder and rectum filling, patient positioning and error detection with portal imaging. The technique derived is patient supine or prone with empty bladder and bowel. A simple leg immobilisation device is recommended, with set-up to couch height. The required margins are 13.2 mm laterally, 18 mm anterior-posteriorly and 21.3 mm cranio-caudally using a three-dimensional margin recipe. It is shown that an intensive portal imaging routine is required to demonstrate that systematic set-up errors are below 5 mm.

Objectives: The aim of the Consensus on Health Economic Criteria (CHEC) project is to develop a criteria list for assessment of the methodological quality of economic evaluations in systematic reviews. The criteria list resulting from this CHEC project should be regarded as a minimum standard.

Methods: The criteria list has been developed using a Delphi method. Three Delphi rounds were needed to reach consensus. Twenty-three international experts participated in the Delphi panel.

Results: The Delphi panel achieved consensus over a generic core set of items for the quality assessment of economic evaluations. Each item of the CHEC-list was formulated as a question that can be answered by yes or no. To standardize the interpretation of the list and facilitate its use, the project team also provided an operationalization of the criteria list items.

Conclusions: There was consensus among a group of international experts regarding a core set of items that can be used to assess the quality of economic evaluations in systematic reviews. Using this checklist will make future systematic reviews of economic evaluations more transparent, informative, and comparable. Consequently, researchers and policy-makers might use these systematic reviews more easily. The CHEC-list can be downloaded freely from http://www.beoz.unimaas.nl/chec/.