Tacit Consensus

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The question of primary prophylaxis of varices remains one of the more complex and contentious issues in pediatric hepatology. There are strong proponents for active endoscopic screening for and treatment of high-risk varices in children (1). Others question the benefit of this intervention (2). The decision is significant. Unproven but potential benefits include diminishing morbidity and mortality, whereas potential risks relate to repeated endoscopic treatments and general anesthesia exposure. Costs are an entirely separate issue. Unfortunately, none of these matters are well-characterized in children, leading to difficulties in clinical decision making. Calls for randomized trials to answer these critical questions are likely to go unanswered due to pragmatic issues in the conduct of such an investigation (3).
In the absence of clear evidence, experts make clinical determinations based upon their best assessment of risks and benefits. Gathering experienced clinicians for discussion and development of expert-guided recommendations is one way to address the lack of evidence (4). An alternative method is to survey clinical practice as a means of establishing an “accepted” approach to the clinical problem. Jeanniard-Malet et al (5) have recently published the results of their survey related to this important question. They conclude based upon their survey results, “… there is a tacit consensus” in favor of screening and primary prophylaxis. A key question is a tacit consensus by whom and how generally applicable is this tacit consensus?
There have been several surveys of clinical practice vis-a-vis the issue of primary prophylaxis of varices, although these are not cited in the present work (6–8). Surveys are valuable instruments, which provide unique insights. The Journal of Pediatric Gastroenterology and Nutrition has recently published a number of surveys (9–11). These have been useful additions to the medical literature. They spark dialogue, potentially establish “norms” of current care, and open the door to important clinical trials. Consensus guidelines of validity for the publication of surveys of clinical practice in the biomedical literature are not readily available. Perhaps our societies should consider developing these guidelines for The Journal of Pediatric Gastroenterology and Nutrition. A major presumption in a survey is that respondents provide and/or recall an accurate version of their clinical practice. Theoretical cases can be used in a survey and respondents are expected to state what they would do in a specific context. Prospective recording of clinical practice may be a more accurate assessment of actual clinical practice. In a recent prospective multicenter report of the experience of the Childhood Liver Disease Research Network, only 4 of 137 infants with biliary atresia (62% of whom had splenomegaly) underwent screening endoscopy (12). Presumably, the “tacit” consensus among these clinicians was that screening and primary prophylaxis were not indicated.
We will continue to struggle with the question of screening and primary prophylaxis of varices in children. We should continue to collect information and interpret it in the context of the scope of existing data in the field. A systematic and prospective multinational recording of clinical practice and outcomes is likely essential to understand this issue and make progress. Fundamental high-quality clinical data are lacking, in particular the clinical consequence of a primary variceal hemorrhage in children. It is imperative that we demonstrate the value of prospective careful clinical observation to funding agencies and the pharmaceutical industry, so we can make further advances in solving the difficult clinical problems our subspecialty faces.
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