Stress potentiates decision biases: A stress induced deliberation-to-intuition (SIDI) model

Habitual behavioural control moderates the relation between daily perceived stress and purging

OBJECTIVE

Evidence suggests that interpersonal stress plays a role in maintaining binge eating and purging (e.g., self-induced vomiting, misuse of laxatives). Stress is especially likely to promote engagement in maladaptive behaviour if the behaviour is habitual; therefore, individuals whose binge eating and/or purging are habitual may be particularly likely to engage in these behaviours in the context of interpersonal stress. We aimed to investigate this hypothesis in a sample of women with binge eating and/or purging using ecological momentary assessment (EMA).

METHOD

Women (N = 81) with binge-eating and/or purging symptoms completed a self-report measure assessing habit strength of binge eating and purging followed by a 14-day EMA protocol assessing daily perceived interpersonal stress and binge-eating and purging episodes.

RESULTS

Habit strength of purging moderated the within-person effect of interpersonal stress on purging frequency, such that higher daily stress was associated with greater same-day purging frequency when purging was more habitual. Contrary to expectations, the interactive effect of habit strength of binge eating and daily interpersonal stress on same-day binge-eating frequency was non-significant.

CONCLUSIONS

Findings suggest that individuals with habitual purging may be vulnerable to engaging in purging when they are experiencing high levels of interpersonal stress.

Workflow analysis of breast cancer treatment decision-making: challenges and opportunities for informatics to support patient-centered cancer care

Objective

Decision support can improve shared decision-making for breast cancer treatment, but workflow barriers have hindered widespread use of these tools. The goal of this study was to understand the workflow among breast cancer teams of clinicians, patients, and their family caregivers when making treatment decisions and identify design guidelines for informatics tools to better support treatment decision-making.

Materials and Methods

We conducted observations of breast cancer clinicians during routine clinical care from February to August 2022. Guided by the work system model, a human factors engineering model that describes the elements of work, we recorded all aspects of clinician workflow using a tablet and smart pencil. Observation notes were transcribed and uploaded into Dedoose. Two researchers inductively coded the observations. We identified themes relevant to the design of decision support that we classified into the 4 components of workflow (ie, flow of information, tasks, tools and technologies, and people).

Results

We conducted 20 observations of breast cancer clinicians (total: 79 hours). We identified 10 themes related to workflow that present challenges and opportunities for decision support design. We identified approximately 48 different decisions discussed during breast cancer visits. These decisions were often interdependent and involved collaboration across the large cancer treatment team. Numerous patient-specific factors (eg, work, hobbies, family situation) were discussed when making treatment decisions as well as complex risk and clinical information. Patients were frequently asked to remember and relay information across the large cancer team.

Discussion and Conclusion

Based on these findings, we proposed design guidelines for informatics tools to support the complex workflows involved in breast cancer care. These guidelines should inform the design of informatics solutions to better support breast cancer decision-making and improve patient-centered cancer care.

Heightened SAM- and HPA-axis activity during acute stress impairs decision-making: A systematic review on underlying neuropharmacological mechanisms

Individuals might be exposed to intense acute stress while having to make decisions with far-reaching consequences. Acute stress impairs processes required for decision-making by activating different biological stress cascades that in turn affect the brain. By knowing which stress system, brain areas, and receptors are responsible for compromised decision-making processes, we can effectively find potential pharmaceutics that can prevent the deteriorating effects of acute stress. We used a systematic review procedure and found 44 articles providing information on this topic. Decision-making processes could be subdivided into 4 domains (cognitive, motivational, affective, and predictability) and could be referenced to specific brain areas, while mostly being impaired by molecules associated with the sympathetic-adrenal-medullar and hypothalamic-pituitary-adrenal axes. Potential drugs to alleviate these effects included α1 and β adrenoceptor antagonists, α2 adrenoceptor agonists, and corticotropin releasing factor receptor1/2 antagonists, while consistent stress-like effects were found with yohimbine, an α2 adrenoceptor antagonist. We suggest possible avenues for future research.

Personality systems interactions theory: an integrative framework complementing the study of the motivational and volitional dynamics underlying adjustment to chronic pain

In the endeavor to advance our understanding of interindividual differences in dealing with chronic pain, numerous motivational theories have been invoked in the past decade. As they focus on relevant, yet different aspects of the dynamic, multilevel processes involved in human voluntary action control, research findings seem fragmented and inconsistent. Here we present Personality Systems Interactions theory as an integrative meta-framework elucidating how different motivational and volitional processes work in concert under varying contextual conditions. PSI theory explains experience and behavior by the relative activation of four cognitive systems that take over different psychological functions during goal pursuit. In this way, it may complement existing content-related explanations of clinical phenomena by introducing a functional, third-person perspective on flexible goal management, pain acceptance and goal maintenance despite pain. In line with emerging evidence on the central role of emotion regulation in chronic pain, PSI theory delineates how the self-regulation of positive and negative affect impacts whether behavior is determined by rigid stimulus-response associations (i.e., habits) or by more abstract motives and values which afford more behavioral flexibility. Along with testable hypotheses, multimodal interventions expected to address intuitive emotion regulation as a central process mediating successful adaptation to chronic pain are discussed.

Testing the hormesis hypothesis on motor behavior under stress

While much research has focused on the deleterious effects of stress on goal-directed behavior in recent decades, current views increasingly discuss growth under stress, often assuming dose-dependent effects of stress in a curvilinear association. This is based on the concept of hormesis, which postulates a strengthening effect of stress at low-to-moderate doses. Leveraging this approach, hormetic curves indicate under which stress dose an individual is able to maintain or even increase goal-directed behavior. The present study aimed to test the hormetic effect of low-to-moderate stress on tactical movement performance in the context of police operational scenarios in virtual reality. In teams of three to four, 37 riot police officers had to search a building for a potentially aggressive perpetrator in three scenarios with escalating stress potential (i.e., increasing weapon violence and number of civilians). Tactical movement performance as behavioral response was quantified by the sample entropy of each officer's velocity derived from positional data. To account for inter-individuality in response to the scenarios, we assessed self-reported stress, anxiety, mental effort, and vagally mediated heart rate variability. Specifically, we tested the quadratic associations between tactical movement performance and stress parameters, respectively. Random-intercept-random-slope regressions revealed neither significant linear nor quadratic associations between any of the stress parameters and performance. While we did not find evidence for hormesis in the present study, it stimulates theoretical discussions about the definition of "baseline" functioning and how the understanding of hormesis can move from psychological to behavioral adaptations to stressors.

How a pilot's brain copes with stress and mental load? Insights from the executive control network

In aviation, mental workload and stress are two major factors that can considerably impact a pilot's flight performance and decisions. Their consequences can be even more dramatic in single-pilot aircraft or with the forthcoming single-pilot operations where the pilot will fly alone and will not be able to be assisted in case of difficulty. An accurate and automatic monitoring of the pilot's mental state could help to prevent the potentially dangerous effects of an excess mental workload and stress. For example, some tasks could be allocated to automation or to a ground-based flight crew if a mental overload or significant stress is detected. In the current study, the brain activity of 20 private pilots was recorded with a fNIRS device during two realistic flight simulator scenarios. The mental workload was manipulated with the added difficulty of a secondary task and stress was induced by a social stressor. Our results confirmed the sensitivity of the fNIRS readings to variations in the mental workload, with increased HbO2 concentration in regions of the executive control network (ECN), in particular in the dorsolateral prefrontal cortex and in lateral parietal regions, when the difficulty of the secondary task was high. The social stressor also triggered an HbO2 increase in the ECN, especially when it was combined with high mental workload. This latter result suggests that mental workload and stress together can have cumulative effects, and coping with both factors is possible at the expense of an extra recruitment of the ECN. Finally, results also revealed a time-on-task effect, with a progressive reduction of the HbO2 signal in the ECN during the flight scenario, suggesting that these regions are sensitive to short term habituation to the tasks. Overall, fNIRS efficiently indexed mental load, stress, and practice effects.

Non-technical skills and teamwork in trauma: from the emergency department to the operating room

Management of a trauma patient is a challenging process. Swift and accurate clinical assessment is required and time-sensitive decisions and life-saving procedures must be performed in an unstable patient. This requires a coordinated response by both the emergency room (ER) and operating room (OR) teams. However, a team of experts does not necessarily make an expert team. Root cause analysis of adverse events in surgery has shown that failures in coordination, planning, task management and particularly communication are the main causes for medical errors. While most research is focused on the ER trauma team, the trauma OR team also deserves attention. In fact, OR team dynamics may resemble more the ER team than the elective OR team. ER and OR trauma teams assemble on short notice, and their members, who are from different specialties and backgrounds, may not train regularly together or even know each other beforehand. And yet, they have to perform high-risk procedures and make high stake decisions, in a time-sensitive manner. The airline industry has long recognized the role of team training and non-technical skills (NTS) in reducing hazards. The implementation of the so called crew resource management or crisis resource management (CRM) has significantly made airline travel safer and the transposition to the medical context, with specific training in non-technical skills, has also brought great benefits. In fact, it is clear that adoption of non-technical skills (NTS) in healthcare has led to an increase in patient safety. In this narrative review we recapitulate some of the key non-technical skills and their relevance in trauma, with a focus on both the emergency department (ER) and the operating room (OR) teams, as well as on the transition of care from one to the other. Also, we explore the use of debriefing the team, as well as the roles of NTS training in both undergraduate and postgraduate settings. We review some of the existing trauma training courses and their roles in developing NTS. Finally, we briefly address the challenges posed by the development of trauma hybrid operating rooms.

Artificial Intelligence Screening of Medical School Applications: Development and Validation of a Machine-Learning Algorithm

PURPOSE

To explore whether a machine-learning algorithm could accurately perform the initial screening of medical school applications.

METHOD

Using application data and faculty screening outcomes from the 2013 to 2017 application cycles (n = 14,555 applications), the authors created a virtual faculty screener algorithm. A retrospective validation using 2,910 applications from the 2013 to 2017 cycles and a prospective validation using 2,715 applications during the 2018 application cycle were performed. To test the validated algorithm, a randomized trial was performed in the 2019 cycle, with 1,827 eligible applications being reviewed by faculty and 1,873 by algorithm.

RESULTS

The retrospective validation yielded area under the receiver operating characteristic (AUROC) values of 0.83, 0.64, and 0.83 and area under the precision-recall curve (AUPRC) values of 0.61, 0.54, and 0.65 for the invite for interview, hold for review, and reject groups, respectively. The prospective validation yielded AUROC values of 0.83, 0.62, and 0.82 and AUPRC values of 0.66, 0.47, and 0.65 for the invite for interview, hold for review, and reject groups, respectively. The randomized trial found no significant differences in overall interview recommendation rates according to faculty or algorithm and among female or underrepresented in medicine applicants. In underrepresented in medicine applicants, there were no significant differences in the rates at which the admissions committee offered an interview (70 of 71 in the faculty reviewer arm and 61 of 65 in the algorithm arm; P = .14). No difference in the rate of the committee agreeing with the recommended interview was found among female applicants (224 of 229 in the faculty reviewer arm and 220 of 227 in the algorithm arm; P = .55).

CONCLUSIONS

The virtual faculty screener algorithm successfully replicated faculty screening of medical school applications and may aid in the consistent and reliable review of medical school applicants.

The acute effects of stress on dishonesty are moderated by individual differences in moral default

In daily life we regularly must decide whether to act dishonestly for personal gain or to be honest and maintain a positive image of ourselves. While evidence suggests that acute stress influences moral decisions, it is unclear whether stress increases or decreases immoral behavior. Here, we hypothesize that stress, through its effects on cognitive control, has different effects on moral decision making for different individuals, depending on their moral default. We test this hypothesis by combining a task which allows for inconspicuously measuring spontaneous cheating with a well-established stress induction task. Our findings confirm our hypothesis, revealing that effects of stress on dishonesty are not uniform, but instead depend on the individual: for those who are relatively dishonest, stress increases dishonesty, whereas for participants who are relatively honest stress makes them more honest. These findings go a long way in resolving the conflicting findings in the literature on the effects of stress on moral decisions, suggesting that stress affects dishonesty differently for different individuals, depending on their moral default.

Anticipatory Stress Increases Deontological Inclinations: The Mediating Role of Emotional Valence

Previous studies have explored the differences in moral judgments under normal situations and acute stress using the Trier Social Stress Test (TSST). The present study examined whether anticipatory stress (i.e., induced by an anticipated speech) could elicit similar effects and further explored the mediation of emotional responses between acute stress and moral judgments with a process-dissociation approach. Fifty-three undergraduate students (20 males and 33 females) were randomly assigned to the stress and control groups. In the first stage, they were instructed to prepare a public speech (the stress group) or just recall events during the previous vacation (the control group). In the second stage, they reported emotional valence and arousal for each moral dilemma in a set of 12 moral dilemmas, followed by judgments on moral acceptability of the agent's action. The manipulation check confirmed that anticipatory stress was reliably induced, as indicated in both self-reported and physiological data. The traditional dilemma analysis revealed that participants in the stress group would make fewer utilitarian judgments than those in the control group. The process dissociation (PD) analyses further revealed that the stress group exhibited higher deontological inclinations than the control group, but no significant differences in utilitarian inclinations. Emotional valence played a mediating role in the association between stress and deontological inclinations. To sum up, our study extended the investigation of the relationship between acute stress and moral judgment to anticipatory stress, clarified its distinct impact on deontological and utilitarian inclinations, and revealed the mediating effect of emotional valence.

Institution and gender-related differences in publication speed before and during COVID-19

The COVID-19 pandemic elicited a substantial hike in journal submissions and a global push to get medical evidence quickly through the review process. Editorial decisions and peer-assessments were made under intensified time constraints, which may have amplified social disparities in the outcomes of peer-reviewing, especially for COVID-19 related research. This study quantifies the differential impact of the pandemic on the duration of the peer-review process for women and men and for scientists at different strata of the institutional-prestige hierarchy. Using mixed-effects regression models with observations clustered at the journal level, we analysed newly available data on the submission and acceptance dates of 78,085 medical research articles published in 2019 and 2020. We found that institution-related disparities in the average time from manuscript submission to acceptance increased marginally in 2020, although half of the observed change was driven by speedy reviews of COVID-19 research. For COVID-19 papers, we found more substantial institution-related disparities in review times in favour of authors from highly-ranked institutions. Descriptive survival plots also indicated that scientists with prestigious affiliations benefitted more from fast-track peer reviewing than did colleagues from less reputed institutions. This difference was more pronounced for journals with a single-blind review procedure compared to journals with a double-blind review procedure. Gender-related changes in the duration of the peer-review process were small and inconsistent, although we observed a minor difference in the average review time of COVID-19 papers first authored by women and men.

Cognitive control and dishonesty

Dishonesty is ubiquitous and imposes substantial financial and social burdens on society. Intuitively, dishonesty results from a failure of willpower to control selfish behavior. However, recent research suggests that the role of cognitive control in dishonesty is more complex. We review evidence that cognitive control is not needed to be honest or dishonest per se, but that it depends on individual differences in what we call one's 'moral default': for those who are prone to dishonesty, cognitive control indeed aids in being honest, but for those who are already generally honest, cognitive control may help them cheat to occasionally profit from small acts of dishonesty. Thus, the role of cognitive control in (dis)honesty is to override the moral default.

Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic

Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.

“Compared to COVID, HIV Is Nothing”: Exploring How Onshore East Asian and Sub-Saharan African International Students in Sydney Navigate COVID-19 versus BBVs/STIs Risk Spectrum

Background: While a large body of evidence indicates changes in alcohol and other drug use among young people as a result of the COVID-19 pandemic, there is a lack of evidence around changes in sexual practices and how the pandemic may be impacting the potential spread of blood-borne viruses and sexually transmissible infections (BBVs/STIs). Most of what we know about sex during COVID-19 lockdowns is largely based on solitary sexual practices, which may not answer the critical question around how the pandemic may be shaping sexual practices among young people. Against this backdrop, this study explored how the COVID-19 pandemic may be shaping BBVs/STIs risk and protective practices among a sample of onshore African and Asian international students in Sydney, Australia. Methods: This phenomenological qualitative study involved semi-structured telephone and face-to-face interviews with 16 international university students in Sydney, between September 2020–March 2021. Generated data were coded using NVivo and analysis was guided by reflexive thematic analysis. Results: Participants reported elevated mental health distress because of the COVID-19 pandemic. Some participants reported engaging in casual sexual hook-ups as a strategy to mitigate the mental health distress they were experiencing. Some of these sexual hook-ups were condomless partly because COVID-related disruptions impacted condom accessibility. Additionally, the preventive practices of some participants who were sexually active during the lockdowns were focused on preventing COVID-19, while the risk of BBVs/STIs were downplayed. Conclusions: This study indicates a need for a comprehensive public health response to the evolving and near-endemic COVID-19 situation. Such a comprehensive approach should focus on empowering young people to prevent both SARS-CoV-2 and BBVs/STIs.

Empathy Modulates the Effect of Stress Reactivity on Generous Giving

How does acute stress influence the degree to which we cooperate with others? Research on the effects of stress on social decision-making is guided by two seemingly contrasting theories. Acute stress may trigger a Fight-or-Flight response, manifested by increased anxiety, and more egocentric or selfish behavior. Alternatively, according to the Tend-and-Befriend model, acute stress may induce affiliative behaviors, marked by increased prosociality in an effort to seek and receive social support and protection. Extant studies on the topic do not provide consistent support for either pattern of behavior, with studies showing evidence for both Fight-or-Flight or Tend-and-Befriend like responses. One possibility, may be the nature of social responses to stressful situations differ as a function of the individual. In the current study, we demonstrate an example of such a person-by-situation interaction, showing that acute stress can cause either pro-social or selfish responses, contingent on individual differences in trait empathy. One hundred and twenty three participants (60 F) were assessed for trait empathy using the Interpersonal Reactivity Index; consequently, they underwent either the Trier Social Stress Test-a well-validated paradigm for eliciting acute psychosocial stress-or a non-stress inducing control condition. Following exposure to either the stress or control condition, participants played a one-shot Dictator Game to evaluate their generosity levels. Statistical analyses revealed that acute stress by itself did not affect the amount transferred in the Dictator Game. Rather, individual differences in trait empathy moderated the effects of stress on giving. Elevations in stress-induced cortisol resulted in more generous behavior, but only in individuals high in empathy. In contrast, in individuals low in empathy, a greater rise in stress-induced cortisol resulted in more selfish behavior. Effects were more pronounced in females than males. Our findings highlight the necessity of integrating personality traits as important moderators of the link between stress and sociality.

Guiding Efficient, Effective, and Patient-Oriented Electrolyte Replacement in Critical Care: An Artificial Intelligence Reinforcement Learning Approach

Both provider- and protocol-driven electrolyte replacement have been linked to the over-prescription of ubiquitous electrolytes. Here, we describe the development and retrospective validation of a data-driven clinical decision support tool that uses reinforcement learning (RL) algorithms to recommend patient-tailored electrolyte replacement policies for ICU patients. We used electronic health records (EHR) data that originated from two institutions (UPHS; MIMIC-IV). The tool uses a set of patient characteristics, such as their physiological and pharmacological state, a pre-defined set of possible repletion actions, and a set of clinical goals to present clinicians with a recommendation for the route and dose of an electrolyte. RL-driven electrolyte repletion substantially reduces the frequency of magnesium and potassium replacements (up to 60%), adjusts the timing of interventions in all three electrolytes considered (potassium, magnesium, and phosphate), and shifts them towards orally administered repletion over intravenous replacement. This shift in recommended treatment limits risk of the potentially harmful effects of over-repletion and implies monetary savings. Overall, the RL-driven electrolyte repletion recommendations reduce excess electrolyte replacements and improve the safety, precision, efficacy, and cost of each electrolyte repletion event, while showing robust performance across patient cohorts and hospital systems.

Moral judgment and hormones: A systematic literature review

This systematic review of the literature aims to evaluate possible associations between moral judgment and hormones. The electronic databases PsycINFO, PubMed, Scielo, Web of Science, Scopus, and LILACS were used. Twenty studies with different methodological designs were reviewed, covering the hormones cortisol, oxytocin, and testosterone, assessing aspects related to polymorphisms in receptor genes, endogenous levels, and exogenous administration. Taken together, the reviewed studies showed a trend towards an association between hormones and moral judgment, with important specificities involving biological, environmental, and individual aspects. Endogenous levels of cortisol, released under stress, showed negative associations with altruistic and utilitarian decisions only in highly emotionally charged dilemmas. Oxytocin receptor gene polymorphisms (rs2268498, rs237889, and rs2254298) and acute administration of this hormone were associated with variability in moral judgment, with sex as an important moderating variable. Testosterone studies have tended to show a positive association with utilitarian moral judgments, particularly in female and in individuals with low prenatal exposure to this hormone. Knowing how hormones influence moral judgment may help expand our understanding of the plurality of human behavior. However, this area of research is new and still little explored, which does not allow for conclusions with a high level of evidence. Subsequent research will benefit from methodological improvements to extend current findings.

Social Value Orientation Moderated the Effect of Acute Stress on Individuals' Prosocial Behaviors

Acute stress is believed to lead to prosocial behaviors via a "tend-and-befriend" pattern of stress response. However, the results of the effect of acute stress on prosocial behavior are inconsistent. The current study explores the moderating effect of gender and social value orientation on the relationship between acute stress and individuals' pure prosocial behaviors (i.e., pure prosociality and prosocial third-party punishment). Specifically, eighty-one participants were selected and underwent the Trier Social Stress Test (or were in the control group), followed by the third-party punishment task and the dictator game. The results showed that, in general, the main effect of condition or respiratory sinus arrhythmia (RSA) reactivity on individual prosocial behaviors was significant and did not vary between genders. Furthermore, social value orientation (i.e., prosocial or self-orientation) might moderate the impact of RSA reactivity on the amount of punishment in the third-party punishment task. That is, individuals with self-orientation exhibited more prosocial third-party punishment as RSA reactivity decreased, while the effect did not occur for individuals with prosocial orientation. Taken together, the findings of the current study provide further evidence for the "tend-and-befriend" hypothesis and highlight the underlying physical mechanisms as well as the individual dependence of the effect of psychosocial stress on individuals' pure prosocial behaviors.

A trans-diagnostic cognitive behavioural conceptualisation of the positive and negative roles of social media use in adolescents’ mental health and wellbeing

Whilst research into the association between social media and mental health is growing, clinical interest in the field has been dominated by a lack of theoretical integration and a focus on pathological patterns of use. Here we present a trans-diagnostic cognitive behavioural conceptualisation of the positive and negative roles of social media use in adolescence, with a focus on how it interacts with common mental health difficulties. Drawing on clinical experience and an integration of relevant theory/literature, the model proposes that particular patterns of social media use be judged as helpful/unhelpful to the extent that they help/hinder the adolescent from satisfying core needs, particularly those relating to acceptance and belonging. Furthermore, it introduces several key interacting processes, including purposeful/habitual modes of engagement, approach/avoidance behaviours, as well as the potential for social media to exacerbate/ameliorate cognitive biases. The purpose of the model is to act as an aide for therapists to collaboratively formulate the role of social media in young people’s lives, with a view to informing treatment, and ultimately, supporting the development of interventions to help young people use social media in the service of their needs and values.

Key learning aims

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Holistic View of Intuition and Analysis in Leadership Decision-Making and Problem-Solving

Making decisions is a key task for leaders and managers. Senior leaders are currently exposed to increasing amounts of data which they must process quickly in our current dynamic world. Complex factors in the business world are not always best approached through an analytical framework. Using tacit knowledge gained through intuition can enable a more holistic understanding of the deep nature of today’s problems. This paper takes an expansive view of decision-making with intuition right at the centre and canvasses understandings of intuition arising from philosophy, psychology, Western and Eastern beliefs; and proposes a model that relates intuition to other problem-solving approaches. The paper presents the results of interviews with senior leaders who must make difficult decisions in complex turbulent environments. The interview schedule is based on questions raised in a prior literature search concerning the relationship between intuition and analysis in complexity decision-making and problem-solving, the usefulness to this group of respondents, the possibilities of combining both approaches and any conflict arising from that combination, and understandings of the concept of intuition by these respondents. The resultant model presents a visual description of a process that moves from exterior assessment achieved via sensing and analysis, through to deeper understandings and a more holistic discernment gained through intuition. The model has the potential to assist leaders faced with difficult-to-solve problems in providing a better understanding of the steps involved in tackling problems of increasing levels of complexity.

The Impact of Delayed Symptomatic Treatment Implementation in the Intensive Care Unit

We estimated the harm related to medication delivery delays across 12,474 medication administration instances in an intensive care unit using retrospective data in a large urban academic medical center between 2012 and 2015. We leveraged an instrumental variables (IV) approach that addresses unobserved confounds in this setting. We focused on nurse shift changes as disruptors of timely medication (vasodilators, antipyretics, and bronchodilators) delivery to estimate the impact of delay. The average delay around a nurse shift change was 60.8 min (p < 0.001) for antipyretics, 39.5 min (p < 0.001) for bronchodilators, and 57.1 min (p < 0.001) for vasodilators. This delay can increase the odds of developing a fever by 32.94%, tachypnea by 79.5%, and hypertension by 134%, respectively. Compared to estimates generated by a naïve regression approach, our IV estimates tend to be higher, suggesting the existence of a bias from providers prioritizing more critical patients.

Impact of Perceived Stress and Immune Status on Decision-Making Abilities during COVID-19 Pandemic Lockdown

The ability to make risky decisions in stressful contexts has been largely investigated in experimental settings. We examined this ability during the first months of COVID-19 pandemic, when in Italy people were exposed to a prolonged stress condition, mainly caused by a rigid lockdown. Participants among the general population completed two cognitive tasks, an Iowa Gambling Task (IGT), which measures individual risk/reward decision-making tendencies, and a Go/No-Go task (GNG), to test impulsivity, together with two questionnaires, the Perceived Stress Scale and the Depression, Anxiety and Stress Scales. The Immune Status Questionnaire was additionally administered to explore the impact of the individual health status on decision making. The effect of the questionnaires scores on task performance was examined. The results showed that higher levels of perceived stress and a more self-reported vulnerable immune status were associated, separately, with less risky/more advantageous choices in the IGT in young male participants but with more risky/less advantageous choices in older male participants. These effects were not found in female participants. Impulsivity errors in the GNG were associated with more anxiety symptoms. These findings bring attention to the necessity of taking into account decision-making processes during stressful conditions, especially in the older and more physically vulnerable male population.

Cognitive Control Promotes Either Honesty or Dishonesty, Depending on One's Moral Default

Cognitive control is crucially involved in making (dis)honest decisions. However, the precise nature of this role has been hotly debated. Is honesty an intuitive response, or is will power needed to override an intuitive inclination to cheat? A reconciliation of these conflicting views proposes that cognitive control enables dishonest participants to be honest, whereas it allows those who are generally honest to cheat. Thus, cognitive control does not promote (dis)honesty per se; it depends on one's moral default. In the present study, we tested this proposal using electroencephalograms in humans (males and females) in combination with an independent localizer (Stroop task) to mitigate the problem of reverse inference. Our analysis revealed that the neural signature evoked by cognitive control demands in the Stroop task can be used to estimate (dis)honest choices in an independent cheating task, providing converging evidence that cognitive control can indeed help honest participants to cheat, whereas it facilitates honesty for cheaters.SIGNIFICANCE STATEMENT Dishonesty causes enormous economic losses. To target dishonesty with interventions, a rigorous understanding of the underlying cognitive mechanisms is required. A recent study found that cognitive control enables honest participants to cheat, whereas it helps cheaters to be honest. However, it is evident that a single study does not suffice as support for a novel hypothesis. Therefore, we tested the replicability of this finding using a different modality (EEG instead of fMRI) together with an independent localizer task to avoid reverse inference. We find that the same neural signature evoked by cognitive control demands in the localizer task can be used to estimate (dis)honesty in an independent cheating task, establishing converging evidence that the effect of cognitive control indeed depends on a person's moral default.

Changes in Depressive Symptoms, Physical Symptoms, and Sleep-Wake Problems from before to during the COVID-19 Pandemic among Emerging Adults: Inequalities by Gender, Socioeconomic Position, and Race

The impact of the COVID-19 pandemic on emerging adults is of global concern. We examine changes in depressive symptoms, physical symptoms, and sleep-wake problems from before to during the pandemic among college students, and examine inequalities by gender, socioeconomic status (SES), and race (N=263, 52% Black, 48% White, 53% female). As compared to pre-pandemic levels, increases were evident in depressive symptoms, physical symptoms, and sleep problems. Females had greater increases than males in depressive symptoms, sleep problems, and physical symptoms. Students from disadvantaged SES backgrounds had greater increases in physical symptoms. Among White students, those from disadvantaged backgrounds also had greater increases in sleep problems. Lastly, daytime sleepiness increased more among Black male than White male students. Overall, findings suggest notable shifts in sleep and health during the early phase of the pandemic among emerging adults, and that attention to inequality by gender, SES, and race is warranted.

Differential chronic social stress models in male and female mice

Chronic stress creates an allostatic overload that may lead to mood disorders such as anxiety and depression. Modern causes of chronic stress in humans are mostly social in nature, relating to work and relationship stress. Research into neural and molecular mechanisms of vulnerability and resilience following chronic social stress (CSS) is ongoing and uses animal models to discover efficient prevention strategies and treatments. To date, most CSS studies have neglected the female sex and used male-focused aggression-based animal models such as chronic social defeat stress (CSDS). Accumulating evidence on sex differences suggests differences in the stress response, the prevalence of stress-related illness and in response to treatment, indicating that researchers should expand CSS investigation to include female-focused protocols alongside the popular CSDS protocols. Here, we describe a novel female mouse model of CSS and a parallel modified male mouse model of CSDS in C57BL/6 mice. These new models enable the investigation of vulnerability, coping and downstream effectors mediating short-term and long-term consequences of CSS in both sexes. Our data demonstrate differential effects on male and female mice during, soon after, and many weeks after CSS. Female mice are more prone to body weight loss during CSS and hyperactive anxious behaviour following CSS. Both sexes show reduced social interaction, but only stressed male mice show long-term changes in emotional memory and neuroendocrine function. We further discuss future avenues of research using these models to investigate mechanisms pertaining to sensitivity to CSS and treatment response profiles, in a sex-appropriate manner.

Effect of Cold Stress on Neurobehavioral and Physiological Parameters in Rats

Objective: Cold stress is an important current issue and implementing control strategies to limit its sometimes harmful effects is crucial. Cold is a common stressor that can occur in our work and our occupational or leisure time activities every day. There are substantial studies on the effects of chronic stress on memory and behavior, although, the cognitive changes and anxiety disorders that can occur after exposure to chronic intermittent cold stress are not completely characterized. Therefore, the present study was undertaken with an aim to investigate the effects of chronic intermittent cold stress on body weight, food intake and working memory, and to elucidate cold stress related anxiety disorders using cognitive and behavioral test batteries. Methods: We generated a cold stress model by exposing rats to chronic intermittent cold stress for 5 consecutive days and in order to test for the potential presence of sex differences, a comparable number of male and female rats were tested in the current study. Then, we measured the body weights, food intake and the adrenal glands weight. Working memory and recognition memory were assessed using the Y maze and the Novel Object Recognition (NOR) tasks. While, sex differences in the effects of chronic stress on behavior were evaluated by the elevated plus maze (EPM), open field maze (OF), and Marble burying (MB) tests. Results: We found that 2 h exposure to cold (4°C) resulted in an increase in the relative weight of the adrenal glands in male rats. Given the same chronic stress 5 days of cold exposure (2 h per day), increased weight gain in male rats, while females showed decreased food intake and no change in body weight. Both sexes successfully performed the Y maze and object recognition (OR) tasks, indicating intact spatial working memory performance and object recognition abilities in both male and female rats. In addition, we have shown that stress caused an increase in the level of anxiety in male rats. In contrast, the behavior of the female rats was not affected by cold exposure. Conclusion: Overall, the current results provide preliminary evidence that chronic intermittent cold stress model may not be an efficient stressor to female rats. Females exhibit resilience to cold exposure that causes an increase in the level of anxiety in male rats, which demonstrates that they are affected differently by stress and the gender is an important consideration in experimental design.

Mental Resilience and Coping With Stress: A Comprehensive, Multi-level Model of Cognitive Processing, Decision Making, and Behavior

Aversive events can evoke strong emotions that trigger cerebral neuroactivity to facilitate behavioral and cognitive shifts to secure physiological stability. However, upon intense and/or chronic exposure to such events, the neural coping processes can be maladaptive and disrupt mental well-being. This maladaptation denotes a pivotal point when psychological stress occurs, which can trigger subconscious, "automatic" neuroreactivity as a defence mechanism to protect the individual from potential danger including overwhelming unpleasant feelings and disturbing or threatening thoughts.The outcomes of maladaptive neural activity are cognitive dysfunctions such as altered memory, decision making, and behavior that impose a risk for mental disorders. Although the neurocognitive phenomena associated with psychological stress are well documented, the complex neural activity and pathways related to stressor detection and stress coping have not been outlined in detail. Accordingly, we define acute and chronic stress-induced pathways, phases, and stages in relation to novel/unpredicted, uncontrollable, and ambiguous stressors. We offer a comprehensive model of the stress-induced alterations associated with multifaceted pathophysiology related to cognitive appraisal and executive functioning in stress.

Acute stress amplifies experienced and anticipated regret in counterfactual decision-making

Previous research has shown that stress can affect emotion processing in a variety of settings. However, little attention has been paid to the effects of stress on emotional decision-making. The present study addressed this question by exposing healthy young participants either to a stressor (n = 30)-socially evaluated cold pressor task- or a non-stressful control task (n = 30). Subsequently, participants completed a computerized decision-making task in which they could compare the obtained factual outcome with a non-obtained counterfactual outcome. Saliva samples were taken at four time points over the course of the experiment and used to analyze cortisol levels. Results revealed that acute stress induced reliable salivary cortisol increase over the experimental task. At the outcome delivery stage, acute stress amplified negative emotions induced by the counterfactual comparison. At the choice stage, under stress, participants were more likely to make regret-averse decisions. The findings that acute stress amplifies both experienced and anticipated regret is consistent with dual process frameworks such that stress tilts decision-making toward more emotional and intuitive processing.Lay summaryStress is thought to affect emotional processing. The present study investigated the effects of acute stress on emotional decision making using a typical counterfactual decision making task. Acute stress amplified both experience and anticipation of regret, consistent with the dual process frame that stress tilts decision-making toward more emotional and intuitive processing.

Acute psychosocial stress increases third-party helping but not punishing behavior

Despite extensive research on the effects of stress on the brain and behaviors, there is a debate whether stress promotes prosocial behaviors, especially acute stress due to intricate costly punishment in the ultimatum game. Therefore, the present study introduced an irrelevant third party to examine how acute stress and the triggered cortisol influence third parties' punishing and helping behaviors as more convincing altruistic behaviors. The 65 participants were exposed to a psychosocial stressor (n = 33) or a control condition (n = 32). Afterwards, two third-party intervention tasks (a token allocation task and criminal scenario judgment task) were completed, during which the participants, as an "irrelevant" third party, could choose whether to sacrifice their own interests to help the victim or punish the transgressor. Participants' affective states, heart rate, and salivary cortisol were repeatedly measured throughout the experiment. Results showed that acute stress can lead to more third-party helping behaviors but not more punishing behaviors. Specifically, participants under stress tended to transfer more monetary units to the victim in the token allocation task than the control-group participants, and they tended to help the victim in the scenario task. In contrast, there was no significant difference in punishing behavior between the stressed and control participants. These findings reveal that acute psychosocial stress triggers the "tend and befriend" response, which might reflect the prosocial intuition under acute stress.

Regression I. Experimental approaches to regression

The concept of regression is considered with an emphasis on the differences between the positions of Freud and Jung regarding its significance. The paper discusses the results of experimental analyses of individual experience dynamics (from gene expression changes and impulse neuronal activity in animals to prosocial behaviour in healthy humans at different ages, and humans in chronic pain) in those situations where regression occurs: stress, disease, learning, highly emotional states and alcohol intoxication. Common mechanisms of regression in all these situations are proposed. The mechanisms of regression can be described as reversible dedifferentiation, which is understood as a relative increase of the representation of low-differentiated (older) systems in the actualized experience. In all of the cases of dedifferentiation mentioned above, the complexity of the systemic organization of behaviour significantly decreases.

Effects of subclinical depression on prefrontal-striatal model-based and model-free learning

Depression is characterized by deficits in the reinforcement learning (RL) process. Although many computational and neural studies have extended our knowledge of the impact of depression on RL, most focus on habitual control (model-free RL), yielding a relatively poor understanding of goal-directed control (model-based RL) and arbitration control to find a balance between the two. We investigated the effects of subclinical depression on model-based and model-free learning in the prefrontal-striatal circuitry. First, we found that subclinical depression is associated with the attenuated state and reward prediction error representation in the insula and caudate. Critically, we found that it accompanies the disrupted arbitration control between model-based and model-free learning in the predominantly inferior lateral prefrontal cortex and frontopolar cortex. We also found that depression undermines the ability to exploit viable options, called exploitation sensitivity. These findings characterize how subclinical depression influences different levels of the decision-making hierarchy, advancing previous conflicting views that depression simply influences either habitual or goal-directed control. Our study creates possibilities for various clinical applications, such as early diagnosis and behavioral therapy design.

Evidence of Racial Bias Using Immersive Virtual Reality: Analysis of Head and Hand Motions During Shooting Decisions

Shooter bias is the tendency to more quickly shoot at unarmed Black suspects compared to unarmed White suspects. The primary goal of this research was to investigate the efficacy of shooter bias simulation studies in a more realistic immersive virtual scenario instead of the traditional methodologies using desktop computers. In this paper we present results from a user study (N=99) investigating shooter and racial bias in an immersive virtual environment. Our results highlight how racial bias was observed differently in an immersive virtual environment compared to previous desktop-based simulation studies. Latency to shoot, the standard shooter bias measure, was not found to be significantly different between race or socioeconomic status in our more realistic scenarios where participants chose to raise a weapon and pull a trigger. However, more nuanced head and hand motion analysis was able to predict participants' racial shooting accuracy and implicit racism scores. Discussion of how these nuanced measures can be used for detecting behavior changes for body-swap illusions, and implications of this work related to racial justice and police brutality are discussed.

Effects of acute psychosocial stress on interpersonal cooperation and competition in young women

Although tend-and-befriend is believed to be the dominant stress response in women, little is known regarding the effects of acute psychosocial stress on different dynamic social interactions. To measure these effects, 80 female participants were recruited, paired into the dyads, and instructed to complete cooperative and competitive key-pressing tasks after experiencing acute stress or a control condition. Each dyad of participants should press the key synchronously when the signal was presented in the cooperative task and as fast as possible in the competitive task. During the tasks, brain activities of prefrontal and right temporo-parietal areas were recorded from each dyad using functional near-infrared spectroscopy (fNIRS). The results showed that acute psychosocial stress evidently promoted competitive behavior, accompanied by increased interpersonal neural synchronization (INS) in the right dorsolateral prefrontal cortex. Despite the lack of a significant difference in the overall cooperation rate, the response time difference between two stressed participants markedly declined over time with more widespread INS in the prefrontal cortex, suggesting that there ensued cooperative improvement among stressed women. These findings behaviorally and neurologically revealed context-dependent response patterns to psychosocial stress in women during dynamic social interactions.

Decision-making by laypersons equipped with an emergency response smartphone app for opioid overdose

BACKGROUND

Targeted naloxone distribution to potential lay responders increases the timeliness of overdose response and reduces mortality. Little is known, however, about the patterns of decision-making among overdose lay responders. This study explored heuristic decision-making among laypersons equipped with an emergency response smartphone app.

METHODS

UnityPhilly, a smartphone app that connects lay responders equipped with naloxone to overdose victims, was piloted in Philadelphia from March 2019 to February 2020. Participants used the app to signal overdose alerts to peer app users and emergency medical services, or respond to alerts by arriving at overdose emergency sites. This study utilised in-depth interviews, background information, and app use data from a sample of 18 participants with varying histories of opioid use and levels of app use activity.

RESULTS

The sample included 8 people who used opioids non-medically in the past 30 days and 10 people reporting no opioid misuse. Three prevailing, not mutually exclusive, heuristics were identified. The heuristic of unconditional signalling ("Always signal for help or backup") was used by 7 people who valued external assistance and used the app as a replacement for a 911 call; this group had the highest number of signalled alerts and on-scene appearances. Nine people, who expressed confidence in their ability to address an overdose themselves, followed a heuristic of conditional signalling ("Rescue, but only signal if necessary"); these participants had the highest frequency of prior naloxone administrations. Eleven participants used the heuristic of conditional responding ("Assess if I can make a difference"), addressing an alert if they carried naloxone, were nearby, or received a signal before dark hours.

CONCLUSION

The deployment of specific heuristics was influenced by prior naloxone use and situational factors. Success of overdose prevention interventions assisted by digital technologies may depend on the involvement of people with diverse overdose rescue backgrounds.

The Psychological Impact of the COVID-19 Pandemic Affected Decision-Making Processes

A sample of 641 participants were presented with four decision-making tasks during the first stages of the COVID–19 lockdown in Spain: The dictator game, framing problems, utilitarian/deontological and altruistic/egoistic moral dilemmas. Participants also completed questionnaires on mental health status and experiences related to the COVID–19 pandemic. We used boosted regression trees (an advanced form of regression analysis based on machine learning) to model relationships between responses to the questionnaires and decision-making tasks. Results showed that the psychological impact of the COVID–19 pandemic predicted participants’ responses to the framing problems and utilitarian/deontological and altruistic/egoistic moral dilemmas (but not to the dictator game). More concretely, the more psychological impact participants suffered, the more they were willing to choose the safest response in the framing problems, and the more deontological/altruistic were their responses to moral dilemmas. These results suggest that the psychological impact of the COVID–19 pandemic might prompt automatic processes.

Food Acquisition and Daily Life for U.S. Families with 4-to 8-Year-Old Children during COVID-19: Findings from a Nationally Representative Survey

Evidence of short-term impacts of the coronavirus disease 2019 (COVID-19) pandemic on family life is emerging. Continued research can shed light on potential longer-term impacts. An online survey of U.S. parents with 4- to 8-year-old children (n = 1000) was administered in October 2020. The survey examined parent-reported impacts of COVID-19 on lifestyle (e.g., work, child-care, grocery shopping), as well as current family food acquisition and eating behaviors (e.g., cooking, restaurant use). Descriptive statistics were calculated, incorporating sampling weights based on sociodemographics. In terms of COVID-19 impacts, parents reported increases in working from home, decreased work hours, and increased child care and instruction, with most children attending school or receiving care at home. Parents reported increased home cooking and online grocery shopping; only 33% reported increased take-out or delivery from restaurants. About half of parents reported that their child dined at restaurants, 62% reported getting take-out, and 57% reported delivery from restaurants at least 2–3 times per month. About half viewed dining at restaurants as safe, while take-out and delivery were seen as safe by around three-quarters. Approximately two-thirds reported recent food insecurity. These nationally-representative results illustrate possible longer-lasting shifts in family life, with the potential to impact health and well-being. Sociodemographic differences and research and policy implications are discussed.

A systematic review and realist synthesis on toilet paper hoarding: COVID or not COVID, that is the question

OBJECTIVE

To explore whether the coronavirus disease 2019 (COVID-19) pandemic is associated with toilet paper hoarding and to assess which risk factors are associated with the risk of toilet paper hoarding.

DESIGN

A systematic review and realist review were conducted.

DATA SOURCES

PubMed, Web of Science, Scopus and PsycINFO were searched (systematic review). PubMed, pre-prints and grey literature were also searched (realist review). The databases were searched from inception until October 2020.

STUDY SELECTION

There were no restrictions on the study design.

OUTCOMES AND MEASURES

For the systematic review, toilet paper hoarding was the main outcome, and pathological use of toilet paper was the secondary outcome. For the realist review, the context-mechanisms-outcome (CMO) scheme included the COVID-19 pandemic (context), four proposed mechanisms, and one outcome (toilet paper hoarding). The four potential mechanisms were (1) gastrointestinal mechanisms of COVID-19 (e.g. diarrhoea), (2) social cognitive biases, (3) stress-related factors (mental illnesses, personality traits) and (4) cultural aspects (e.g. differences between countries).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

All studies of human populations were considered (including general population studies and clinical studies of patients suffering from mental health problems).

RESULTS

The systematic review identified 14 studies (eight studies for the main outcome, six studies for the secondary outcome). Three surveys identified the role of the COVID-19 threat in toilet paper hoarding in the general population. One study pointed to an association between a personality trait (conscientiousness) and toilet paper buying and stockpiling as well as an additional significant indirect effect of emotionality through the perceived threat of COVID-19 on toilet paper buying and stockpiling. Six case reports of pathological use of toilet paper were also identified, although none of them were associated with the COVID-19 pandemic. The realist review suggested that of all the mechanisms, social cognitive biases and a bandwagon effect were potential contributors to toilet paper hoarding in the general population. The stressful situation (COVID-19 pandemic) and some personality traits (conscientiousness) were found to be associated with toilet paper hoarding. Cultural differences were also identified, with relatively substantial effects of toilet paper hoarding in several Asian regions (Australia, Japan, Taiwan and Singapore).

CONCLUSIONS

The COVID-19 pandemic has been associated with a worldwide increase in toilet paper hoarding. Social media and social cognitive biases are major contributors and might explain some differences in toilet paper hoarding between countries. Other mental health-related factors, such as the stressful situation of the COVID-19 pandemic, fear of contagion, or particular personality traits (conscientiousness), are likely to be involved.

REGISTRATION

PROSPERO CRD42020182308.

Decision Outcomes in Sport: Influence of Type and Level of Stress

In two experiments, the authors investigated the influence of stress type (i.e., low/no stress, mental, and physical), level (i.e., low, moderate, and high), and Type × Level interaction on intuitive decision frequency, decision quality, and decision speed. Participants were exposed to mental (i.e., color word task, mental arithmetic) and/or physical stress (i.e., running) and then required to make decisions regarding videotaped offensive situations in basketball. Intuitive decision frequency, decision quality, and decision speed were measured for each trial. Study 1 used a between-subjects design whereby 20 participants were randomly assigned to each of the five stress conditions. Results revealed that moderate stress was associated with faster decisions. Study 2 replicated the design and aim of Study 1 using a within-subject methodology (n = 42). Results suggested that moderate stress levels produced better, faster decisions. In conclusion, moderate levels of stress were associated with the most desirable decision outcomes.

Mechanisms Underlying Unconscious Processing and Their Alterations in Post-traumatic Stress Disorder: Neuroimaging of Zero Monetary Outcomes Contextually Framed as "No Losses" vs. "No Gains"

Although unconscious processing is a key element of mental operation, its neural correlates have not been established. Also, clinical observations suggest that unconscious processing may be involved in the pathophysiology of post-traumatic stress disorder (PTSD), but the neurobiological mechanisms underlying such impairments remain unknown. The purpose of the present study was to examine putative mechanisms underlying unconscious processing by healthy participants and to determine whether these mechanisms may be altered in PTSD patients. Twenty patients with PTSD and 27 healthy individuals were administered a validated wheel of fortune-type gambling task during functional magnetic resonance imaging (fMRI). Unconscious processing was elicited using unconscious contextual framing of the zero monetary outcomes as "no loss," "no gain" or as "neutral." Brief passive visual processing of the "no loss" vs. "no gain" contrast by healthy participants yielded bilateral frontal-, temporal- and insular cortices and striatal activations. Between-group comparison revealed smaller activity in the left anterior prefrontal-, left dorsolateral prefrontal-, right temporal- and right insular cortices and in bilateral striatum in PTSD patients with the left dorsolateral prefrontal cortex activity been more pronounced in those with greater PTSD severity. These observations implicate frontal-, temporal-, and insular cortices along with the striatum in the putative mechanisms underlying unconscious processing of the monetary outcomes. Additionally, our results support the hypothesis that PTSD is associated with primary cortical and subcortical alterations involved in the above processes and that these alterations may be related to some aspects of PTSD symptomatology.

An Integrative Framework of Appraisal and Adaptation in Serious Medical Illness

Multiple randomized clinical trials have demonstrated that palliative care improves the quality of life of individuals with serious medical illness. Research also suggests that in patients with advanced cancer, palliative care's focus on symptom management, coping with illness, goals of care, and treatment decisions may be associated with improved patient quality of life in part by increasing patients' use of active (vs. passive) and approach-oriented (vs. avoidant) coping strategies. However, without a framework outlining the process that individuals with serious medical illness and their loved ones undergo, it is challenging to discern exactly where, how, and why palliative care may affect the serious medical illness experience. To address this gap, we propose a clinically applicable framework, derived from existing theory and research in the social and behavioral sciences. This framework, called the Integrative Framework of Appraisal and Adaptation in Serious Medical Illness, describes how patients and their loved ones cognitively and emotionally process the various events that may occur as they navigate serious medical illness and the end of life. The framework also describes how individuals and their loved ones use that event processing to determine next steps, while considering the impact of their surrounding external environment, their individual social roles, and their connections on this decision making. The framework presented in this article is intended to improve our ability to understand and care for individuals with serious medical illness and their loved ones, while stimulating further discussion and research to test and refine these ideas.

The Effect of Information Formats and Incidental Affect on Prior and Posterior Probability Judgments

Background. Interpreting medical test results involves judging probabilities, including making Bayesian inferences such as judging the positive and negative predictive values. Although prior work has shown that experience formats (e.g., slide shows of representative patient cases) produce more accurate Bayesian inferences than description formats (e.g., verbal statistical summaries), there are disadvantages of using the experience format for real-world medical decision making that may be solved by presenting relevant information in a 2 × 2 table format. Furthermore, medical decisions are often made in stressful contexts, yet little is known about the influence of acute stress on the accuracy of Bayesian inferences. This study aimed to a) replicate the description-experience format effect on probabilistic judgments; b) examine judgment accuracy across description, experience, and a new 2 × 2 table format; and c) assess the effect of acute stress on probability judgments. Method. The study employed a 2 (stress condition) × 3 (format) factorial between-subjects design. Participants (N = 165) completed a Bayesian inference task in which information about a medical screening test was presented in 1 of 3 formats (description, experience, 2 × 2 table), following a laboratory stress induction or a no-stress control condition. Results. Overall, the 2 × 2 table format produced the most accurate probability judgments, including Bayesian inferences, compared with the description and experience formats. Stress had no effect on judgment accuracy. Discussion. Given its accuracy and practicality, a 2 × 2 table may be better suited than description or experience formats for communicating probabilistic information in medical contexts.

Evidence-Loving Rockstar Chief Medical Officers: Female Leadership Amidst COVID-19 in Canada

This article presents a feminist poststructuralist inquiry perspective on how news and social media discourse around the COVID‐19 pandemic is presenting a potential shift in hegemonic representations of masculine leadership. I am informed by organizational rules and sensemaking theories, and consider how Canadian and international female leaders are showing resilience, emotion and vulnerability as they help lead their countries through these uncertain times. I reflexively ground my observations in my own sensemaking and personal experiences. Despite reservations, I am hopeful. There are indications that the ‘rules of the game’ are starting to be challenged, and feminine frameworks that question traditional gender roles are disrupting conceptions around ‘business as usual’.

Neuroenhancement in surgeons: benefits, risks and ethical dilemmas

Background

Surgeons traditionally aim to reduce mistakes in healthcare through repeated training and advancement of surgical technology. Recently, performance-enhancing interventions such as neurostimulation are emerging which may offset errors in surgical practice.

Methods

Use of transcranial direct-current stimulation (tDCS), a novel neuroenhancement technique that has been applied to surgeons to improve surgical technical performance, was reviewed. Evidence supporting tDCS improvements in motor and cognitive performance outside of the field of surgery was assessed and correlated with emerging research investigating tDCS in the surgical setting and potential applications to wider aspects of healthcare. Ethical considerations and future implications of using tDCS in surgical training and perioperatively are also discussed.

Results

Outside of surgery, tDCS studies demonstrate improved motor performance with regards to reaction time, task completion, strength and fatigue, while also suggesting enhanced cognitive function through multitasking, vigilance and attention assessments. In surgery, current research has demonstrated improved performance in open knot-tying, laparoscopic and robotic skills while also offsetting subjective temporal demands. However, a number of ethical issues arise from the potential application of tDCS in surgery in the form of safety, coercion, distributive justice and fairness, all of which must be considered prior to implementation.

Conclusion

Neuroenhancement may improve motor and cognitive skills in healthcare professions with impact on patient safety. Implementation will require accurate protocols and regulations to balance benefits with the associated ethical dilemmas, and to direct safe use for clinicians and patients.

Investigating the temporal dynamics of electroencephalogram (EEG) microstates using recurrent neural networks

Electroencephalogram (EEG) microstates that represent quasi‐stable, global neuronal activity are considered as the building blocks of brain dynamics. Therefore, the analysis of microstate sequences is a promising approach to understand fast brain dynamics that underlie various mental processes. Recent studies suggest that EEG microstate sequences are non‐Markovian and nonstationary, highlighting the importance of the sequential flow of information between different brain states. These findings inspired us to model these sequences using Recurrent Neural Networks (RNNs) consisting of long‐short‐term‐memory (LSTM) units to capture the complex temporal dependencies. Using an LSTM‐based auto encoder framework and different encoding schemes, we modeled the microstate sequences at multiple time scales (200–2,000 ms) aiming to capture stably recurring microstate patterns within and across subjects. We show that RNNs can learn underlying microstate patterns with high accuracy and that the microstate trajectories are subject invariant at shorter time scales (≤400 ms) and reproducible across sessions. Significant drop in the reconstruction accuracy was observed for longer sequence lengths of 2,000 ms. These findings indirectly corroborate earlier studies which indicated that EEG microstate sequences exhibit long‐range dependencies with finite memory content. Furthermore, we find that the latent representations learned by the RNNs are sensitive to external stimulation such as stress while the conventional univariate microstate measures (e.g., occurrence, mean duration, etc.) fail to capture such changes in brain dynamics. While RNNs cannot be configured to identify the specific discriminating patterns, they have the potential for learning the underlying temporal dynamics and are sensitive to sequence aberrations characterized by changes in metal processes. Empowered with the macroscopic understanding of the temporal dynamics that extends beyond short‐term interactions, RNNs offer a reliable alternative for exploring system level brain dynamics using EEG microstate sequences.

Neural correlates of enhanced response inhibition in the aftermath of stress

Life stress has been shown to impact cognitive functions, including inhibitory control. However, the immediate effects of acute stress on inhibitory control and the underlying neural mechanisms remain unclear. In a behavioral pilot study (N = 30) and a within-subject functional magnetic resonance imaging study (N = 30), we examined how acute stress induced by Trier Social Stress Test influenced inhibitory control in a stop signal task. Behavioral results across two studies showed that stress consistently improved inhibitory control. Shorter stop signal reaction time (SSRT) in stress as compared with control condition was associated with stronger connectivity between the superior/middle frontal gyrus (SFG/MFG) and striatum. Dynamic causal modeling revealed distinct best models under stress and control condition, with an enhanced interaction between the SFG/MFG and the striatum after stress exposure. This research identified the SFG/MFG-striatum network as a key circuit underlying acute stress-elicited enhancement of inhibitory control in a stop signal task.