Do some prefer to pay? Identifying bias against free COVID-19 tests

Objectives

In the United States, a federal emergency program has made SARS-CoV-2 self-test kits available at no cost. It is unclear how widely free tests are preferred. We conducted a survey to estimate the proportion of respondents who do not prefer a free test. We hypothesized that free tests would not be preferred universally, and that a preference for paying would be more common among those with conservative politics than with liberal politics, regardless of income.

Design

Observational study design.

Methods

A national sample of US adults completed an online survey. To reduce potential enrollment bias, the survey's focus was not specified beforehand. To prioritize a high-risk group, participation was limited to those who were unvaccinated or were incompletely vaccinated in the primary series against COVID-19. Participants reported their testing preferences and socio-demographic characteristics, including political affiliation. The main outcome assessed if a participant preferred to pay for a self-test or receive a free one (subsidized by the US government).

Results

Among 1215 participants, (73%, n = 886) preferred free self-testing, while 27% (n = 329) preferred to pay for the same testing. After adjusting for income, the odds of preferring to pay for self-testing were 66% higher in "strong" Republicans compared to "strong" Democrats (odds ratio = 1.66, 95% confidence interval = 1.07-2.62).

Conclusions

More than a quarter of individuals preferred paying for these tests. This preference was more likely among those with right-wing politics. Policy implications are discussed, along with future research directions.

Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

The convergence approach may be critical to improving early situational awareness in hostile radioactive environments

This study explores the impact of a simulated radiological dispersal device (RDD) event in an urban area on young adults around 20 years old. The RDD releases radioactive Cs-137 (7.0E+3 Ci), a common industrial sterilization source. The study aims to demonstrate that combining computational codes and epidemiological models can produce valuable data to guide initial actions when confronting a hostile radioactive environment. The HotSpot Health Physics and RESRAD-RDD codes were used in the simulation to evaluate the event's initial phase. The codes were executed together, and the HotSpot output data was input into RESRAD-RDD. Based on simulated radiation dose levels, estimated doses were incorporated into radioepidemiological models proposed by the Committee on Biological Effects of Ionizing Radiation (BEIR V or VII report). Despite limitations, data transfer between the models revealed no discontinuities or antagonisms. Radiation doses were simulated under three exposure conditions and two atmospheric release modes (day or night), suggesting that atmospheric conditions, sex, and exposure routine can strongly influence the perception of radiation impacts. This combination of methods can increase situational awareness and help with decision-making and developing coping strategies.

Accuracy of ChatGPT in head and neck oncological board decisions: preliminary findings

OBJECTIVES

To evaluate the ChatGPT-4 performance in oncological board decisions.

METHODS

Twenty medical records of patients with head and neck cancer were evaluated by ChatGPT-4 for additional examinations, management, and therapeutic approaches. The ChatGPT-4 propositions were assessed with the Artificial Intelligence Performance Instrument. The stability of ChatGPT-4 was evaluated through regenerated answers at 1-day interval.

RESULTS

ChatGPT-4 provided adequate explanations for cTNM staging in 19 cases (95%). ChatGPT-4 proposed a significant higher number of additional examinations than practitioners (72 versus 103; p = 0.001). ChatGPT-4 indications of endoscopy-biopsy, HPV research, ultrasonography, and PET-CT were consistent with the oncological board decisions. The therapeutic propositions of ChatGPT-4 were accurate in 13 cases (65%). Most additional examination and primary treatment propositions were consistent throughout regenerated response process.

CONCLUSIONS

ChatGPT-4 may be an adjunctive theoretical tool in oncological board simple decisions.

Current principles for the establishment of the virological "cutoff points" in transfusion science and medicine: A short concise overview

Establishing the virological cutoff point, during epidemics, such as the COVID-19 Pandemic, is crucially important as inadequate standardization and the false qualitative results, have enormous clinical and economic consequences when screening for SARS-CoV-2. Moreover, a cutoff point is a crucial step in ensuring a minimal risk of clinical misclassification. Therefore complying with such statutory requirements is an essential part of obligatory good laboratory and clinical practices. In this concise report, we propose a novel methodology for establishing cutoff points for all samples exhibiting detectable levels of the measured parameter, even those from the disease-free group. Based on target specificity and sensitivity levels of 100 % and 95 %, a value of 1209 A is identified as the "best cutoff". In fact, the ROC decision matrixes play a crucial role in determining optimal cutoff points. The most effective discriminators are those that meet specified accuracy criteria. The selection process is influenced by finding the right clinical sensitivity/specificity trade-off.

Determinants of childbearing intentions among pregnant women with a suspected fetal congenital heart disease

BACKGROUND

The Saudi population is characterized by a high fertility rate, a conservative sociocultural context, and an ongoing societal and lifestyle transition. Yet, data regarding childbearing intentions and the associated factors is scarce. Furthermore, childbearing intention may be impacted by abnormal pregnancy events, such as the clinical suspicion or diagnosis of a fetal congenital disease and the negative experience that may result from it.

OBJECTIVES

The present study explored childbearing intention and determined the sociodemographic and health-related factors discouraging from future pregnancies among women visiting the cardiology clinic for antenatal screening of congenital heart diseases (CHD).

METHODS

A one-year cross-sectional study involved 150 consecutive pregnant women aged between 18 and 47 years old, who presented for antenatal screening of CHD at the fetal echocardiography clinic for, of a teaching hospital in Jeddah, Saudi Arabia. An interview-based questionnaire was administered before the clinic visit and collected sociodemographic data, obstetrical history, risk factors of congenital diseases, mothers' knowledge about fetal echocardiography and CHDs, and childbearing intention (the primary outcome).

RESULTS

Fetal echocardiography and CHD were correctly described by 60 % and 31.3 % of the participants respectively, while 40.7 % and 12 % recognized the association of congenital diseases with consanguinity and advanced maternal age respectively. Childbearing intentions showed 68.0 % of the participants declared desiring a future baby while the remaining 32.0 % declared having no further pregnancy expectations. Attitudes towards a hypothetical baby with CHD were positive in 97.3 % of the participants, and only 30 % declared that the fetal echocardiography results will impact their future childbearing decision. However, childbearing intention showed no significant association with knowledge or attitudes towards CHD. On the other hand, childbearing intention was independently associated with the number of children (OR=0.34; p<0.001), consanguinity with husband (OR=3.64; p = 0.010), and history of gestational diabetes (OR=0.28; p = 0.040).

CONCLUSION

Fertility expectations among Saudi mothers are more likely to be impacted by the personal experience and judgment of own pregnancy fitness, while no significant impact of fetal risks and events. This demonstrates a certain level of autonomy balanced with deeply rooted religious ethics yet combined with a lack of awareness about fetal and maternal risks associated with advanced maternal age and consanguinity. We emphasize the unmet need of education and family planning.

Twelve-Month Outcomes after Metabolic and Bariatric Surgery among Youths Participating in a Structured Preparation and Follow-Up Program: Results of the Youth with Extreme Obesity Study

INTRODUCTION

While invasive and associated with risks, metabolic and bariatric surgery (MBS) can promote sustained weight loss and substantial health benefits in youths with extreme obesity. The path toward informed decision making for or against MBS is poorly characterized and postoperative follow-up to assess risks and benefits is inconsistent. In youths with extreme obesity, we aimed to evaluate decision making toward MBS, as well as MBS outcomes and adherence with follow-up and recommendations in the setting of a structured pre- and post-MBS program.

METHODS

Participants were recruited in the setting of the multicenter "Youth with Extreme Obesity Study" (YES). YES is a cohort study in adolescents and young adults aged 14-24 years with obesity (BMI ≥30.0 kg/m2) who were recruited at four medical centers and one job center in Germany between 2012 and 2018. Participants at two medical centers with BMI ≥35 kg/m2, aged 14-24 years, and interested in pursuing MBS were included in the subproject 3 "Safety and effectiveness of weight loss surgery in adolescents with severe obesity within a structured pre- and post-surgery treatment program - an observational study" that comprised a 2-months pre- and 12-months post-MBS program.

RESULTS

Twenty-eight of 169 youths (17%) with BMI ≥35 kg/m2 were interested in MBS. Twenty-six fulfilled published eligibility criteria for MBS and participated in the structured pre-MBS preparation program. Of these, 9 participants (2 females) decided against, and 17 (n = 11 females) decided for MBS (sleeve gastrectomy). The 12-month follow-up rate was high (16/17 [94%]) and all participants achieved significant weight reduction (ΔBMI: -16.1 ± 5.6 kg/m2). Eleven of 16 participants (69%) reported taking the prescribed dietary supplements in the first year after MBS, but only five of them (31%) did so daily. In contrast to the high 12-month retention rate, follow-up after completion of the structured program was low at 24-months (9/16 [56%]) and at 36-months (5/15 [36%]), respectively.

CONCLUSION

Participants demonstrated active decision making for or against MBS and high adherence with the structured pre- and 12 months post-MBS program, but participation was low thereafter. These findings endorse the need for longer term structured post-MBS programs to capture long-term outcomes and provide adequate care in this vulnerable group at the transition to adulthood.

Ventrolateral prefrontal neurons of the monkey encode instructions in the 'pragmatic' format of the associated behavioral outcomes

The prefrontal cortex plays an important role in coding rules and producing context-appropriate behaviors. These processes necessarily require the generation of goals based on current context. Indeed, instructing stimuli are prospectively encoded in prefrontal cortex in relation to behavioral demands, but the coding format of this neural representation is, to date, largely unknown. In order to study how instructions and behaviors are encoded in prefrontal cortex, we recorded the activity of monkeys (Macaca mulatta) ventrolateral prefrontal neurons in a task requiring to perform (Action condition) or withhold (Inaction condition) grasping actions on real objects. Our data show that there are neurons responding in different task phases, and that the neuronal population discharge is stronger in the Inaction condition when the instructing cue is presented, and in the Action condition in the subsequent phases, from object presentation to action execution. Decoding analyses performed on neuronal populations showed that the neural activity recorded during the initial phases of the task shares the same type of format with that recorded during the final phases. We propose that this format has a pragmatic nature, that is instructions and goals are encoded by prefrontal neurons as predictions of the behavioral outcome.

A framework to explain the in-match decision-making of elite Australian football coaches

The ability to make effective decisions is an important function of any football coach, whether during training, team selection, match-day performance or post-match player evaluation. It is not yet known how elite Australian football coaches make decisions during matches, in time-constrained but well-resourced environments. This study is the first to explore the decision-making of elite Australian football coaches during matches, in pursuit of identifying opportunities to improve the translation and implementation of research findings into the competitive match environment. Using semi-structured interviews and thematic analysis, a six-stage framework of the decision-making of elite Australian football coaches during matches was developed. The stages include (1) Opportunity trigger, (2) Understand the opportunity, (3) Determine the need for action, (4) Explore options, (5) Take action and (6) Evaluate the decision. Coaches relied on subjective and objective sources of information and consulted with assistant coaches, performance analysts, and sport scientists. The findings enable researchers to ensure future interventions to improve decision-making during matches are well integrated. They also provide an opportunity for coaches to reflect on their own decision-making process, identifying targeted areas for improvement in their own practice.

Enhancing decision-making support by mining social media data with social network analysis

This paper explores the use of social network analysis (SNA) on airlines' online social networks (OSNs) to extract valuable information for decision support, by analyzing interactions and discursive exchanges between users. The research is focused on fostering customer service of an airline company during a strike period, namely by detecting influential customers (whether satisfied or dissatisfied), address pending requests, and enhancing customer satisfaction, thus promoting issue-solving, and increasing responsiveness. The methodology involves analyzing data from the Facebook account of an airline company, using SNA to structure the data, and calculating metrics to detect possible situations to be addressed by customer service. The research concludes that it is possible to extract valuable information for decision support by analyzing the metrics that were built over the interactions and discursive exchanges between OSN users. SNA metrics enable to measure airline's call-center performance in terms of speed of answer and customer satisfaction, to identify active users requiring additional support, as well as highly influential customers who may impact on the overall customer satisfaction, thus helping to resolve issues more efficiently. This study provides both theoretical and practical implications: it contributes to the existing literature by integrating social interaction and SNA for decision support in airline's service context; and it provides practical insights into how companies can use SNA metrics to improve customer service. The research also highlights and corroborates the importance of monitoring social media interactions for decision-making and improving customer service.

A Quality Improvement Study Designed to Optimize Scheduling Geographic/Site Preferences Among Anesthesia Professionals Utilizing Decision Support Tool Assistance

This is a quality improvement pilot study comparing percentages of anesthesia professionals receiving their first choice of workplace location both pre-, and post-implementation of an electronic decision support tool for anesthesia-in-charge schedulers. The study evaluates anesthesia professionals who use the electronic decision support tool and scheduling system at four hospitals and two surgical centers within NorthShore University HealthSystem. The subjects in the study are those anesthesia professionals that work at NorthShore University HealthSystem and are subject to being placed in their desired location by anesthesia schedulers who use the electronic decision support tool. The primary author developed the current software system enabling the electronic decision support tool implementation into clinical practice. All anesthesia-in-charge schedulers were educated during a three-week time period via administrative discussions and demonstrations on how to effectively operate the tool in real time. The total numbers and percentage of 1st choice of location selection by anesthesia professionals were summarized each week using interrupted time series Poisson regression. Slope before intervention, slope after intervention, level change, and slope change were all measured over 14-week pre- and post- implementation periods. The level of change (difference in percentage of anesthesia professionals who received their first choice) was statistically (P<0.0001) and clinically significant when comparing the historical cohorts of 2020 and 2021 to the 2022 intervention group weeks. Therefore, the implementation of an electronic decision support scheduling tool resulted in a statistically significant increase in those anesthesia professionals receiving their first-choice workplace location. This study provides the basis for further investigating whether this specific tool may improve anesthesia professional satisfaction within their work-life balance by enhancing workplace geographic/site choice.

Origins and consequences of mood flexibility: a computational perspective

A stable and neutral mood (euthymia) is commended by both economic and clinical perspectives, because it enables rational decisions and avoids mental illnesses. Here we suggest, on the contrary, that a flexible mood responsive to life events may be more adaptive for natural selection, because it can help adjust the behavior to fluctuations in the environment. In our model (dubbed MAGNETO), mood represents a global expected value that biases decisions to forage for a particular reward. When flexible, mood is updated every time an action is taken, by aggregating incurred costs and obtained rewards. Model simulations show that, across a large range of parameters, flexible agents outperform cold agents (with stable neutral mood), particularly when rewards and costs are correlated in time, as naturally occurring across seasons. However, with more extreme parameters, simulations generate short manic episodes marked by incessant foraging and lasting depressive episodes marked by persistent inaction. The MAGNETO model therefore accounts for both the function of mood fluctuations and the emergence of mood disorders.

Why and when choosing child-free life in Sweden? Reasons, influencing factors and personal and societal factors: Individual interviews during 2020-2021

OBJECTIVE

Few studies have examined a voluntarily child-free life in the Nordic countries. The aim of this study was to explore reasons, influencing factors, and personal and social factors in individuals who chose to lead a child-free life in Sweden.

METHODS

Twenty-three individual interviews were conducted during 2020-2021, and data were analysed through thematic network analysis.

RESULTS

The organising themes captured how the informants discovered pathways and managed social structures to feel certain in their decision to lead a child-free life. The informants highlighted freedom, independence and governing their own time in everyday life and acknowledged the younger generation as being more open-minded towards child-free individuals.

CONCLUSIONS

All the informants, who had chosen to lead a child-free life, were confident in their decision. They appreciated living in a country where it was possible to make this personal and important life choice independently. Further knowledge is needed about remaining child-free.

From Natural Behavior to Drug Screening: Invertebrates as Models to Study Mechanisms Associated with Alcohol Use Disorders

Humans consume ethanol-containing beverages, which may cause an uncontrollable or difficult-to-control intake of ethanol-containing liquids and may result in alcohol use disorders. How the transition at the molecular level from "normal" ethanol-associated behaviors to addictive behaviors occurs is still unknown. One problem is that the components contributing to normal ethanol intake and their underlying molecular adaptations, especially in neurons that regulate behavior, are not clear. The fruit fly Drosophila melanogaster and the earthworm Caenorhabditis elegans show behavioral similarities to humans such as signs of intoxication, tolerance, and withdrawal. Underlying the phenotypic similarities, invertebrates and vertebrates share mechanistic similarities. For example in Drosophila melanogaster, the dopaminergic neurotransmitter system regulates the positive reinforcing properties of ethanol and in Caenorhabditis elegans, serotonergic neurons regulate feeding behavior. Since these mechanisms are fundamental molecular mechanisms and are highly conserved, invertebrates are good models for uncovering the basic principles of neuronal adaptation underlying the behavioral response to ethanol. This review will focus on the following aspects that might shed light on the mechanisms underlying normal ethanol-associated behaviors. First, the current status of what is required at the behavioral and cellular level to respond to naturally occurring levels of ethanol is summarized. Low levels of ethanol delay the development and activate compensatory mechanisms that in turn might be beneficial for some aspects of the animal's physiology. Repeated exposure to ethanol however might change brain structures involved in mediating learning and memory processes. The smell of ethanol is already a key component in the environment that is able to elicit behavioral changes and molecular programs. Minimal networks have been identified that regulate normal ethanol consumption. Other environmental factors that influence ethanol-induced behaviors include the diet, dietary supplements, and the microbiome. Second, the molecular mechanisms underlying neuronal adaptation to the cellular stressor ethanol are discussed. Components of the heat shock and oxidative stress pathways regulate adaptive responses to low levels of ethanol and in turn change behavior. The adaptive potential of the brain cells is challenged when the organism encounters additional cellular stressors caused by aging, endosymbionts or environmental toxins or excessive ethanol intake. Finally, to underline the conserved nature of these mechanisms between invertebrates and higher organisms, recent approaches to identify drug targets for ethanol-induced behaviors are provided. Already approved drugs regulate ethanol-induced behaviors and they do so in part by interfering with cellular stress pathways. In addition, invertebrates have been used to identify new compounds targeting molecules involved in the regulation in ethanol withdrawal-like symptoms. This review primarily highlights the advances of the last 5 years concerning Drosophila melanogaster, but also provides intriguing examples of Caenorhabditis elegans and Apis mellifera in support.

Supporting consumers' informed food choices: Sources, channels, and use of information

Information about food is available from several sources using a variety of communication channels. Following an overview of the different types on food information, the most important source/channel combinations are discussed. The key steps in processing the information toward making a food choice are discussed: consumer's exposure to such information, the attention the consumer pays to it, the understanding and/or liking of the information, as well as the importance of motivation, knowledge, and trust. To support consumers in making informed food choices, it is recommended to ensure that food information is easy to understand and targeted to consumers with a specific need or interest, align the information on the food label with the communication about the food elsewhere ("off label"), provide (non-expert) influencers with transparent information to enable an increase in the trustworthiness of their communications on the web in on social media. Furthermore, increase cooperation between authorities and food producers to create standards that fulfill the legal requirements and are feasible as label elements. Improving food literacy among consumers by including it in formal education would provide consumers with better nutrition knowledge and skills to interpret food-related information in a manner that supports informed choices.

A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport

Return-to-sport (RTS) decisions are critical to clinical sports medicine and are often characterised by uncertainties, such as re-injury risk, time pressure induced by competition schedule and social stress from coaches, families and supporters. RTS decisions have implications not only for the health and performance of an athlete, but also the sports organisation. RTS decision-making is a complex process, which relies on evaluating multiple biopsychosocial factors, and is influenced by contextual factors. In this narrative review, we outline how RTS decision-making of clinicians could be evaluated from a decision analysis perspective. To begin with, the RTS decision could be explained as a sequence of steps, with a decision basis as the core component. We first elucidate the methodological considerations in gathering information from RTS tests. Second, we identify how decision-making frameworks have evolved and adapt decision-making theories to the RTS context. Third, we discuss the preferences and perspectives of the athlete, performance coach and manager. We conclude by proposing a framework for clinicians to improve the quality of RTS decisions and make recommendations for daily practice and research.

Patient age at time of reverse shoulder arthroplasty remains stable over time: a 7.5-year trend evaluation

PURPOSE

There is a common belief among some shoulder surgeons that the increased utilization of reverse shoulder arthroplasty (RSA) is driven by the operation being performed in younger patients. The primary purpose of this study was to evaluate the change in patient age at the time of primary RSA in the USA.

METHODS

All patients undergoing primary RSA (January 2011-June 2018) were identified in the Mariner database. The mean age at the time of primary RSA was evaluated for each patient and assessed in 6-month intervals. A longitudinal comparison over time was performed for all patients.

RESULTS

A total of 56,141 primary RSA were evaluated, with the mean age increasing from 69 in the 2011 to 71 in 2018 (p < 0.001). The largest increase in RSA utilization occurred in patients > 70 (1092 in 2011 to 3499 in 2018), with patients < 50 years demonstrating the slowest growth (13 in 2011 to 65 in 2018). However, when evaluated by percentage increase from 2011 to 2018, RSA volumes for patients < 60 have increased 390% compared to 220% for those > 70 years (p < 0.001).

CONCLUSION

RSA continues to be performed at a similar mean age despite expanded indications and surgeon comfort. However, patients < 60 years have had a greater increase in utilization compared to patients > 70 years. The volumetric growth of RSA has largely been driven by the older population, but younger patients have shown a higher percentage of growth, which may explain the generalized observation that RSA is performed in younger patients.

LEVEL OF EVIDENCE

Level III; Retrospective comparative study; Treatment study.

Delay in making decision to seek care on institutional delivery and associated factors among postpartum mothers in South Gondar zone hospitals, 2020: A cross-sectional study

Background

Delay in seeking emergency obstetric care contributes to high maternal mortality and morbidity in developing countries. One of the major factors contributing to maternal death in developing countries is a delay in seeking emergency obstetric care. This study aimed to assess the proportion and associated factors of delay in deciding to seek emergency obstetric care on institutional delivery among postpartum mothers in the South Gondar zone hospitals, Ethiopia, 2020.

Methods

An institution-based cross-sectional study design was conducted from September to October 2020. A total of 650 postpartum mothers were recruited using a systematic random sampling technique. We collected the data through personal interviews with pretested semi-structured questionnaires. We used a logistic regression model to identify statistically significant independent variables, and entered the independent variables into multivariable logistic regression. The Adjusted Odds Ratio was used to identify associated variables with delay in deciding to seek emergency obstetric care, with a 95% confidence interval at P-value < 0.05.

Results

The proportion of delay in deciding to seek emergency obstetric care on institutional delivery was 36.3% (95% CI: 32.6–40.1). The mean age of the respondents was 27.23, with a standard deviation of 5.67. Mothers who reside in rural areas (AOR = 3.14,95%, CI:2.40–4.01), uneducated mothers (AOR = 3.62, 95%, CI:2.45–5.52), unplanned pregnancy (AOR: 2.01, 95% CI: 1.84–7.96), and no health facilities in Kebele (AOR: 1.62, 95% CI: 1.43–6.32) were significantly associated with delay in a decision to seek emergency obstetric care.

Conclusion

The proportion of delay in deciding to seek emergency obstetric care was 36.3% among postpartum mothers in the South Gondar zone hospitals. One of the factors contributing to maternal death is a delay in seeking emergency obstetric care in South Gondar zone. Pregnant mothers living in the rural area, unplanned pregnancy, uneducated mothers, no health facilities in Kebele were associated factors in the study area. Therefore, stakeholders must address them to reduce the proportion of delay in deciding to receive on-time obstetric care as per the standards.

Sign tracking predicts suboptimal behavior in a rodent gambling task

RATIONALE

Reward-associated cues can promote maladaptive behavior, including risky decision-making in a gambling setting. A propensity for sign tracking over goal tracking-i.e., interaction with a reward-predictive cue rather than the site of reward-demonstrates an individual's tendency to transfer motivational value to a cue. However, the relationship of sign tracking to risky decision-making remains unclear.

OBJECTIVES

To determine whether sign tracking predicts risky choice, we used a Pavlovian conditioned approach task to evaluate the tendency of male rats to sign track to a lever cue and then trained rats on a rodent gambling task (rGT) with win-associated cues. We also tested the effects of D-amphetamine, quinpirole (a D₂/D₃ receptor agonist), and PD128907 (a D₃ receptor agonist) on gambling behavior in sign tracker and goal tracker individuals.

RESULTS

Increased sign tracking relative to goal tracking was associated with suboptimal performance on the rGT, including decreased selection of the optimal choice, increased selection of a high-risk/high-reward option, and increased impulsive premature choices. Amphetamine increased choices of a low-risk/low-reward option at the expense of optimal and high-risk choices, whereas quinpirole and PD128907 had little effect on choice allocation, but reduced impulsivity. Drug effects were similar across sign tracker and goal tracker individuals.

CONCLUSIONS

Cue reactivity, as measured by sign tracking, is predictive and may be an important driver of risky and impulsive choices in a gambling setting laden with salient audiovisual cues. Evaluating an individual's sign tracking behavior may be an avenue to predict vulnerability to pathological gambling and the efficacy of treatments.

Impact of the affected population size assessment on the decision-making after a nuclear event

In this study an improvised nuclear device (IND) is simulated using a software called HotSpot. The explosion took place in a theoretical central business district (CBD), for the major issue addressed in this paper is the comparison of two methods used for estimating the size of the potentially affected population. The first method estimates the size by multiplying the local average demographic density by the area of the zone of interest. The second method uses the population density gradient model developed by Colin Clark in 1951. The comparison of the two methods enables authorities to better estimate the allocation of resources. The conservative approach allocates the maximum resources possible. However, the Clark model enables a more realistic approach which allocates minimum resources to the emergency response. This study shows how accurate information can be quintessential for authorities to maximize the efficiency of their decisions.

The Sound of Noise in Decision-making: An Illustration with Management of Male Lower Urinary Tract Symptoms

High-quality patient care depends on the accuracy and efficacy of clinical decision-making, which can be affected by both cognitive bias and the risk of judgment variability, which is called noise. Deep learning algorithms, artificial intelligence, and robots could improve the reliability of decision-making, but until these become a reality, clinical practice guidelines are of great value in reducing this noise.

Conscious intention and human action: Review of the rise and fall of the readiness potential and Libet's clock

Is consciousness-the subjective awareness of the sensations, perceptions, beliefs, desires, and intentions of mental life-a genuine cause of human action or a mere impotent epiphenomenon accompanying the brain's physical activity but utterly incapable of making anything actually happen? This article will review the history and current status of experiments and commentary related to Libet's influential paper (Brain 106:623-664, 1983) whose conclusion "that cerebral initiation even of a spontaneous voluntary act …can and usually does begin unconsciously" has had a huge effect on debate about the efficacy of conscious intentions. Early (up to 2008) and more recent (2008 on) experiments replicating and criticizing Libet's conclusions and especially his methods will be discussed, focusing especially on recent observations that the readiness potential (RP) may only be an "artifact of averaging" and that, when intention is measured using "tone probes," the onset of intention is found much earlier and often before the onset of the RP. Based on these findings, Libet's methodology was flawed and his results are no longer valid reasons for rejecting Fodor's "good old commonsense belief/desire psychology" that "my wanting is causally responsible for my reaching.".

Feedback moderates the effect of prevalence on perceptual decisions

How does the prevalence of a target influence how it is perceived and categorized? A substantial body of work, mostly in visual search, shows that a higher proportion of targets are missed when prevalence is low. This classic low prevalence effect (LPE) involves a shift to a more conservative decision criterion that makes it less likely that observers will call an ambiguous item a target. In contrast, Levari et al. (Science, 360[6396], 1465-1467, 2018) recently reported the opposite effect in a simple categorization task. In their hands, at low prevalence, observers adopted a more liberal criterion, making observers more likely to label ambiguous dots on a blue-purple continuum "blue." They called this "prevalence-induced concept change" (PICC). Here, we report that the presence or absence of feedback is critical. With feedback, observers become more conservative at low prevalence, as in the LPE. Without feedback, they become more liberal, identifying a wider range of stimuli as targets, as in Levari's PICC studies. Stimuli from a shape continuum ranging from rounded ("Bouba") to bumpy ("Kiki") shapes produced similar results. Other variables: response type (2AFC vs. go/no-go), color (blue-purple vs. red-green), and stimuli type (solid color vs. texture) did not influence the criterion shifts. Understanding these effects of prevalence and ways they can be controlled illuminates the context-specific nature of perceptual decisions and may be useful in socially important, low prevalence tasks like cancer screening, airport security, and disease diagnosis in pathology.

Forensic science and the principle of excluded middle: "Inconclusive" decisions and the structure of error rate studies

In a paper published recently in this journal, Dror and Scurich (2020) [20] critically discuss the notions of "inconclusive evidence" (i.e., test items for which it is difficult to render a categorical response) and "inconclusive decisions" (i.e., experts' conclusions or responses) in the context of forensic science error rate studies. They expose several ways in which the understanding and use of "inconclusives" in current forensic science research and practice can adversely affect the outcomes of error rate studies. A main cause of distortion, according to Dror and Scurich, is what they call "erroneous inconclusive" decisions, in particular the lack of acknowledgment of this type of erroneous conclusion in the computation of error rates. To overcome this complication, Dror and Scurich call for a more explicit monitoring of "inconclusives" using a modified error rate study design. Whilst we agree with several well-argued points raised by the authors, we disagree with their framing of "inconclusive decisions" as potential errors. In this paper, we argue that referring to an "inconclusive decision" as an error is a contradiction in terms, runs counter to an analysis based on decision logic and, hence, is questionable as a concept. We also reiterate that the very term "inconclusive decision" disregards the procedural architecture of the criminal justice system across modern jurisdictions, especially the fact that forensic experts have no decisional rights in the criminal process. These positions do not ignore the possibility that "inconclusives" - if used excessively - do raise problems in forensic expert reporting, in particular limited assertiveness (or, overcautiousness). However, these drawbacks derive from inherent limitations of experts rather than from the seemingly erroneous nature of "inconclusives" that needs to be fixed. More fundamentally, we argue that attempts to score "inconclusives" as errors amount to philosophical claims disguised as forensic methodology. Specifically, these attempts interfere with the metaphysical substrate underpinning empirical research. We point this out on the basis of the law of the excluded middle, i.e. the principle of "no third possibility being given" (tertium non datur).

Predictive brain: Addressing the level of representation by reviewing perceptual hysteresis

In recent years, the idea that the prediction of sensory input is one of the major computational goals of the nervous system led to the development of several large-scale theories of brain functioning, such as different versions of the Bayesian approach to brain functions, predictive coding theories of cognition and the Free-energy principle. During the years, various empirical phenomena have been re-interpreted within such frames, and have been considered as consequences of predictive processing. Here we focus on perceptual hysteresis, or serial dependence, as an exemplary case. We unravel a potential gap in the predictive frameworks and raise the idea that alternative explanations of this effect can solve this issue, as they address the type of cognitive and neural representations involved.

Confidence in action: Differences between perceived accuracy of decision and motor response

Each of our decisions is associated with a degree of confidence. This confidence can change once we have acted because we might start doubting our choice or even become convinced that we have made a mistake. In this study, we explore the relations between action and our confidence that our decision was correct or erroneous. Fifty-four volunteers took part in a perceptual decision task in which their decisions could either lead to action or not. At the end of each trial, participants rated their confidence that their decision was correct, or they reported that they had made an error. The main results showed that when given after a response, confidence ratings were higher and more strongly related to decision accuracy, and post-response reports of errors more often indicated actual errors. The results support the view that error awareness and confidence might be partially based on postaction processing.

Is investment in Climate-Smart-agricultural practices the option for the future? Cost and benefit analysis evidence from Ghana

A majority of smallholder farmers in sub-Saharan Africa (SSA) countries depend to a large extent on agriculture for food security and income. Efforts aimed at improving farm-related profitability are therefore important to improving livelihoods among smallholder farmers. In Ghana, for example, smallholder farmers that depend on agriculture face serious risks especially those related to climate change and variability and soil degradation. Notwithstanding these dangers, evidence of the published literature on how best to tackle these challenges is limited. Over the recent decades, however, there has been advancement by programs channelling resources into Climate-Smart Agricultural (CSA) practices to improving smallholder livelihoods and food security. The interest in advancing investment in CSA practices is a key pathway that has the potential to significantly reduce the negative effect of climate change and variability risks on smallholder farmers livelihoods. Investing in CSA practices is also a key pathway to improving farm yield per unit area. Consequently, smallholder farmers are adopting and implementing CSA practices. Despite that, a gap still exists on the profitability of undertaking such an investment, as this is key in determining the sustainability of CSA practices. On this basis, the present study undertook a detailed cost-benefit analysis (CBA) of seven CSA practices identified with smallholder farmers in the coastal savannah agro-ecological zone of Ghana. A total of 48 smallholder farmers that had adopted these practices were studied. Three CBA indicators namely the net present value (NPV), internal rate of return (IRR) and payback period (PP) were assessed for each of the seven CSA practices. The results showed that out of the seven CSA practices examined, six of them were profitably suitable for adoption and scaling up from the perspective of smallholder farmers as well as the public perspective. The finding from this study, therefore, fill the current information gap in the literature on the costs and benefits of adopting CSA practices on household livelihoods in Ghana. Such a finding is critical to the promotion and scaling up the adoption of CSA practices by smallholder farmers and serve as a basis of formulating appropriate guidelines and policies for supporting CSA practices.

How to predict choice using eye-movements data?

In recent decades, eye-movement detection technology has improved significantly, and eye-trackers are available not only as standalone research tools but also as computer peripherals. This rapid spread gives further opportunities to measure the eye-movements of participants. The current paper provides classification models for the prediction of food choice and selects the best one. Four choice sets were presented to 112 volunteered participants, each choice set consisting of four different choice tasks, resulting in altogether sixteen choice tasks. The choice sets followed the 2-, 4-, 6- and 8-alternative forced-choice paradigm. Tobii X2-60 eye-tracker and Tobii Studio software were used to capture and export gazing data, respectively. After variable filtering, thirteen classification models were elaborated and tested; moreover, eight performance parameters were computed. The models were compared based on the performance parameters using the sum of ranking differences algorithm. The algorithm ranks and groups the models by comparing the ranks of their performance metrics to a predefined gold standard. Techniques based on decision trees were superior in all cases, regardless of the choice tasks and food product categories. Among the classifiers, Quinlan's C4.5 and cost-sensitive decision trees proved to be the best-performing ones. Future studies should focus on the fine-tuning of these models as well as their applications with mobile eye-trackers.

Evidence accumulation under uncertainty - a neural marker of emerging choice and urgency

To interact meaningfully with its environment, an agent must integrate external information with its own internal states. However, information about the environment is often noisy. In this study, we identify a neural correlate that tracks how asymmetries between competing alternatives evolve over the course of a decision. In our task participants had to monitor a stream of discrete visual stimuli over time and decide whether or not to act, on the basis of either strong or ambiguous evidence. We found that the classic P3 event-related potential evoked by sequential evidence items tracked decision-making processes and predicted participants' categorical choices on a single trial level, both when evidence was strong and when it was ambiguous. The P3 amplitudes in response to evidence supporting the eventually selected option increased over trial time as decisions evolved, being maximally different from the P3 amplitudes evoked by competing evidence at the time of decision. Computational modelling showed that both the neural dynamics and behavioural primacy and recency effects can be explained by a combination of (a) competition between mutually inhibiting accumulators for the two categorical choice outcomes, and (b) a context-dependant urgency signal. In conditions where evidence was presented at a low rate, urgency increased faster than in conditions when evidence was very frequent. We also found that the readiness potential, a classic marker of endogenously initiated actions, was observed preceding movements in all conditions - even when those were strongly driven by external evidence.

Understanding factors affecting breastfeeding practices in one city in the Kingdom of Saudi Arabia: an interpretative phenomenological study

Background

Breastfeeding duration has declined in the Kingdom of Saudi Arabia (KSA) in recent decades, although accurate national data about different breastfeeding indicators by infant age are lacking. This qualitative study, the first in KSA, aimed to understand the factors affecting mothers’ decisions and experiences regarding any breastfeeding practices.

Methods

A qualitative phenomenological approach was used to investigate mothers’ experiences of breastfeeding. Non-probability convenience sampling and snowballing strategies were designed to recruit participants. Semi-structured interviews were conducted with 16 mothers, from two hospitals and three primary health clinics in Al-Madinah city, from December 2017 to March 2018. Interpretative phenomenological analysis was the analysis framework.

Results

Three themes were identified: 1) ‘Up against the system’: policies, staff and systems were the main barriers to exclusive breastfeeding; 2) ‘Social support and negativity’: family support in the first 40 postpartum days protected breastfeeding continuation and was highly appreciated, but negative comments limited breastfeeding practices thereafter; and 3) ‘Managing tensions’: mothers’ religious beliefs about breastfeeding boosted their decisions; however, the challenge of managing tensions influenced mothers to stop breastfeeding earlier than they wished. The study revealed that mothers had no doubts about wanting to breastfeed their babies; but continuation was adversely affected by unhelpful hospital policies and staff actions, the lack of ongoing social support, and by others people’s negativity, rather than by the mothers’ own views. Stopping breastfeeding earlier than planned was a complex decision for most mothers. However, mothers said that they intended to breastfeed their next baby successfully.

Conclusions

Healthcare professionals (maternity staff, paediatricians and pharmacists) need education and training to support exclusive breastfeeding effectively. Increasing the number of hospitals with Baby Friendly Hospital Initiative accreditation, which includes staff practice changes, is needed to protect and support exclusive breastfeeding. Ongoing professional and peer support, and improving conditions at workplaces and universities, are needed to help mothers to continue breastfeeding successfully. Effective, coordinated national policies can support mothers’ decisions in relation to breastfeeding. Such changes will reduce the tensions experienced by women and help them to achieve their breastfeeding goals and to breastfeed for longer.

[Prenatal path of care following the diagnosis of a malformation for which a novel prenatal therapy is available]

OBJECTIVES

Fetal therapy is part of the available care offer for several severe malformations. The place of these emergent prenatal interventions in the prenatal path of care is poorly known. The objective of this study is to describe the decision-making process of patients facing the option of an emergent in utero intervention.

METHODS

We have conducted a retrospective monocentric descriptive study in the department of maternal-fetal medicine of Necker Hospital. We collected data regarding eligibility or not for fetal surgery and the pregnancy outcomes of patients referred for myelomeningocele, diaphragmatic hernia, aortic stenosis and low obstructive uropathies.

RESULTS

All indications combined, 70% of patients opted for fetal surgery. This rate was lower in the case of myelomeningocele with 21% consent, than in the other pathologies: 69% for diaphragmatic hernias, 90% for aortic stenoses and 76% for uropathy. When fetal intervention was declined, the vast majority of patients opted for termination of pregnancy: 86%. In 14% of the considering fetal surgery, the patient was referred too far.

CONCLUSION

The acceptance rate for fetal surgeries depends on condition. It offers an additional option and is an alternative for couples for which termination of pregnancy (TOP) is not an option. Timely referral to an expert center allows to discuss the place of a fetal intervention and not to deprive couples of this possibility.

Urban critical infrastructure disruption after a radiological dispersive device event

This study aims to evaluate the impacts of the activation of a hypothetical radiological dispersal device (RDD) on the urban critical infrastructure (health facilities and public transport). A densely populated urban region was chosen as a scenery. Additionally, the influence of local environmental factors in the post-detonation process was verified. The source term was Cs-137 due to its mobility in the environment and relative ease of access. The approach used for the evaluation of the consequences was a computer simulation by Gaussian modeling. The HotSpot Health Physics Codes software was applied in conjunction with the RESRAD-RDD software. The results suggest that there is a strong influence of the local atmospheric stability classes (Pasquill-Gifford classes) on both the total equivalent effective dose (TEDE) and soil contamination. Consequently, the impacts on critical urban infrastructure follow the same trend. The method used for comparing the simulated and reference limits was the proportional ratio. All calculated values for radioactive contamination were divided by the reference value adopted by the RESRAD-RDD model for urban critical infrastructure. The results indicate that the information compiled is useful to support the decision-making process, although it is not sufficient to provide care and support for longer periods than those considered in the initial response phase.

[The attitude of patients in geriatric rehabilitation towards nursing homes]

Hintergrund

Mit Erreichen des höheren Lebensalters nehmen unterstützende Wohnformen eine immer wichtigere Rolle ein. Eingeschränkte Selbstständigkeit kann dazu führen, dass ein Umzug in ein Pflegeheim unabdingbar ist. Die Einstellung zu Pflegeheimen ist von großer Bedeutung sowohl für die Vorbereitung auf diesen Fall als auch für die psychische Reaktion auf sein Eintreten, wurde allerdings bisher kaum näher beforscht.

Ziel der Arbeit (Fragestellung)

Das Ziel dieser Untersuchung ist herauszufinden, wie Pflegeheime von älteren Menschen je nach ihrem subjektiven Kontrollerleben, ihrem Informationsstand und ihren Erfahrungen bewertet werden.

Material und Methoden

Zu Einstellungen gegenüber Pflegeheimen wurden insgesamt 150 geriatrische Rehabilitationspatienten mit einer ersten Fragebogenversion (n = 64) oder einer revidierten Fassung (n = 86) befragt.

Ergebnisse

Mittels Polaritätsprofil konnte eine eher positive Einstellung zu Pflegeheimen beobachtet werden, jedoch wurden bei freiem Antwortformat überwiegend negative Assoziationen geäußert. Der Großteil der Probanden hat eine ängstliche Haltung zu einem Umzug in ein Pflegeheim. Stärkeres Kontrollerleben, ein besserer Informationsstand und positive Erfahrungen mit Pflegeheimen stehen mit einer positiven Haltung zum Umzug in ein Pflegeheim im Zusammenhang.

Diskussion

Mit Blick auf geäußerte Ängste, einen verbreitet geringen Informationsstand und die starke Abwehrhaltung einiger Befragter gilt es, die Betroffenen proaktiv zu informieren und stärker in die Entscheidungen für eine Wohnoption einzubinden. Neueste Entwicklungen zu aussagekräftigerer Qualitätsdarstellung der Pflegeheime können dabei unterstützen.

The impact of adult trauma triage training on decision-making skills and accuracy of triage decision at emergency departments in Malaysia: A randomized control trial

INTRODUCTION

Patients who visit emergency departments need to undergo a precise assessment to determine their priority and accurate triage category to ensure they receive the right treatment.

AIM

To identify the effect of triage training on the skills and accuracy of triage decisions for adult trauma patients.

METHOD

A randomized controlled trial design was conducted in ten emergency department of public hospitals. A total of 143 registered nurses and medical officer assistants who performed triage roles were recruited for the control group (n = 74) and the intervention group (n = 69). The skill and accuracy of triage decisions were measured two weeks and four weeks after the intervention group were exposed to the intervention.

RESULTS

There was a significant effect on the skill of triage decision-making between the control and the intervention group p < 0.001, η²_partial = 0.31. Concerning the accuracy of triage decisions, the effect was significantly different between the control group and the intervention group p < 0.001, η²_partial = 0.66 across time.

CONCLUSION

The triage training improved the skills of the participants and the accuracy of triage decision-making across time.

Artificial Intelligence-Based Clinical Decision Support Systems Using Advanced Medical Imaging and Radiomics

Artificial intelligence (AI) is poised to make a veritable impact in medicine. Clinical decision support (CDS) is an important area where AI can augment the clinician's capability to collect, understand and make inferences on an overwhelming volume of patient data to reach the optimal clinical decision. Advancements in medical image analysis, such as Radiomics, and data computation, such as machine learning, have expanded our understanding of disease processes and their management. In this article, we review the most relevant concepts of AI as applicable to advanced imaging-based clinical decision support systems.

Do patient factors influence embryologists' decisions to freeze borderline blastocysts?

RESEARCH QUESTION

To investigate whether patient factors influence the decision to freeze a blastocyst with low implantation potential.

DESIGN

This experimental study assessed 170 practicing embryologists from a variety of countries who were recruited via an online survey. Participants were currently practicing embryologists, who grade blastocysts as part of this role. The survey presented decision-making 'vignettes' to participants. These included specific patient information, as well as an image of an expanded blastocyst that was of borderline quality for inner cell mass and trophectoderm, for which the embryologist selected whether or not to freeze. High/low maternal age, the presence/absence of other top quality blastocysts, and the presence/absence of previously unsuccessful IVF cycles were systematically varied within the patient information in a 2 × 2 × 2 design. Participants reported how likely they would be to freeze a particular blastocyst on a scale of 1 (Extremely Unlikely) to 7 (Extremely Likely), and whether or not they would ultimately freeze each blastocyst (Yes or No).

RESULTS

Lower maternal age, no other high-quality blastocysts within the cohort, and multiple unsuccessful IVF cycles were associated with greater likelihood of recommending to freeze (P < .001). Furthermore, significant interactions among all three patient factors were noted.

CONCLUSION

This study provides evidence suggesting that when faced with an uncertain blastocyst, factors pertaining to the patient (maternal age, the presence/absence of other top quality blastocysts, and the presence/absence of previously unsuccessful IVF cycles) influence the decision to freeze.

Decision-to-delivery interval of emergency cesarean section in Uganda: a retrospective cohort study

Background

In many low and medium human development index countries, the rate of maternal and neonatal morbidity and mortality is high. One factor which may influence this is the decision-to-delivery interval of emergency cesarean section. We aimed to investigate the maternal risk factors, indications and decision-to-delivery interval of emergency cesarean section in a large, under-resourced obstetric setting in Uganda.

Methods

Records of 344 singleton pregnancies delivered at ≥24 weeks throughout June 2017 at Mulago National Referral Hospital were analysed using Cox proportional hazards models and multivariate logistic regression models.

Results

An emergency cesarean section was performed every 104 min and the median decision-to-delivery interval was 5.5 h. Longer interval was associated with preeclampsia and premature rupture of membranes/oligohydramnios. Fetal distress was associated with a shorter interval (p < 0.001). There was no association between decision-to-delivery interval and adverse perinatal outcomes (p > 0.05). Mothers waited on average 6 h longer for deliveries between 00:00–08:00 compared to those between 12:00–20:00 (p < 0.01). The risk of perinatal death was higher in neonates where the decision to deliver was made between 20:00–02:00 compared to 08:00–12:00 (p < 0.01).

Conclusion

In this setting, the average decision-to-delivery interval is longer than targets adopted in high development index countries. Decision-to-delivery interval varies diurnally, with decisions and deliveries made at night carrying a higher risk of adverse perinatal outcomes. This suggests a need for targeting the improvement of service provision overnight.

The rise of one anastomosis gastric bypass: insights from surgeons and dietitians

One anastomosis gastric bypass/Mini Gastric Bypass (OAGB/MGB) is an emerging bariatric surgery (BS) technique. We evaluated and compared attitudes of bariatric surgeons and dietitians towards the considerations for choosing BS-type ("Decision-making"), the contributing factors to the rise of OAGB/MGB in Israel ("OAGB/MGB-rise") and notions regarding the occurrence of gastrointestinal (GI) symptoms and nutritional deficiencies following OAGB/MGB. Anonymous online surveys were distributed. The participants were asked to rate by a 10-point Likert scale (0 = not at all; 100 = very much/often) their attitudes towards "Decision-making", "OAGB/MGB-rise" and occurrence of GI symptoms and nutritional deficiencies following OAGB/MGB. For "Decision-making" and "OAGB/MGB-rise", items were considered prioritized where ≥ 50% of the group considered them as 'very-important' (rating ≥ 80). Data on age, sex, years-in-practice and main workplace were also collected. A total of 106 professionals participated in the survey (42 surgeons; 64 dietitians). The respective mean age, years-in-practice and sex were 52.3 ± 8.7 vs. 42.3 ± 9.0 years, 21.0 ± 10.8 vs. 15.5 ± 9.2 years and 85.7% vs. 3.1% males. The inter-observer agreement for prioritized items related to "Decision-making" was fair (Kappa = 0.250; P = 0.257) and both groups prioritized patient's BMI, comorbidities and compliance. The inter-observer agreement for prioritized items related to "OAGB/MGB-rise" was moderate (Kappa = 0.550; P = 0.099) and both groups prioritized ease of performance, shorter operation duration and failure of former restrictive BS. Surgeons reported lower occurrence of nutritional deficiencies and GI symptoms as adverse effects of OAGB/MGB (P ≤ 0.033). The study highlights the views of bariatric surgeons and dietitians concerning factors that underpin the rise of OABG/MGB in Israel and possible rates of GI symptoms and nutritional deficiencies associated with this modality.

Ethical challenges in family caregivers of patients with advanced cancer - a qualitative study

Background

Caring for patients with advanced or terminal diseases can confront family caregivers (FC) with ethical challenges. The present study aims at tracing paths connected to ethical challenges among FC of advanced cancer patients by exploring morally troubling situations and related burden, as well as strategies to handle the situation and experience of moral distress from the grieving FC’s perspective.

Methods

Within a qualitative design, interviews with 12 grieving FC were conducted using a semi-structured interview guide. Data were analysed using grounded theory and abductive reasoning.

Results

Core phenomena identified were two paths connected to ethical challenges among FC. Ethical challenges occurred in the context of difficult decision-making (Path 1) and in the context of lacking decision-making options when no decision was to be made by FC (Path 2). We found each path to be triggered by distinct sets of morally troubling situations that occurred during the patient’s disease trajectory. In the course of difficult decision-making (Path 1), detrimental external factors could add emotional stress, thus making the decision-making process burdensome. FC used various proactive strategies to overcome those detrimental factors and/or to make the decision. Decisions in conflict with FCs' own moral expectations and values led to moral distress, generating painful emotions. When no decision was to be made by FC (Path 2), FC felt powerless and overrun, which was associated with major emotionality in terms of anxiety and confusion. Either detrimental factors aggravated these feelings to paralyzing shock, or internal resources enabled FC to accept the situation. While acceptance prevented moral distress, paralyzing shock often caused a sense of not meeting their their own moral expectations and values, resulting in moral distress. In both paths, factors were identified that helped FC finding closure and prevented moral residue. Nevertheless, some FC experienced residual moral distress months after the morally troubling situation had occurred.

Conclusion

Findings provide first information towards understanding paths leading to ethical challenges in FC and can help clinicians to minimize associated emotional burden and moral distress.

Cancer patients, physicians, and nurses differ in their attitudes toward the decisional role in do-not-resuscitate decision-making

PURPOSE

Do-not-resuscitate (DNR) decision-making in severely ill patients presents many difficult medical, ethical, and legal challenges. The primary aim of this study was to explore cancer patients' and health care professionals' attitudes regarding DNR decision-making authority and timing of the decision.

METHODS

This study was a questionnaire survey among Danish cancer patients and their attending physicians and nurses in an oncology outpatient setting. Potential differences between patients', physicians', and nurses' answers to the questionnaire were analyzed using Fisher's exact test.

RESULTS

Responses from 904 patients, 59 physicians, and 160 nurses were analyzed. The majority in all three groups agreed that DNR decisions should be made in collaboration between physician and patient. However, one-third of the patients answered that the patient alone should make the decision regarding DNR, which contrasts with the physicians' and nurses' attitudes, 0% and 6% pointing to the patient as sole decision-maker, respectively. In case of disagreement between patient and physician, a majority of both patients (66%) and physicians (86%) suggested themselves as the ultimate decision-maker. Additionally, 43% of patients but only 19% of physicians preferred the DNR discussion being brought up early in the course of the disease.

CONCLUSIONS

With regard to the decisional role of patient vs. physician and the timing of the DNR discussion, we found a substantial discrepancy between the attitudes of cancer patients and physicians. This discrepancy calls for a greater awareness and discussion of this sensitive topic among both health care professionals and the public.

Implementation of a Standardized Patient/Family Communication Bundle

During critical illness, active discussions about a person's preferences are linked with better patient outcomes. Our intensive care unit implemented an evidence-based standardized communication bundle that included education to providers on effective family communication, focused patient/family discussions to identify Durable Power of Attorney/surrogate decision maker and obtaining advanced directive documents, and documenting conversations in the electronic medical record and appropriately updating the patient's code status. The aim of the bundle was to increase compliance with conducting and documenting family discussions, clearly identifying and documenting surrogate decisions makers, and to improve patient/family satisfaction and caregiver satisfaction.

Decomposing the neural pathways in a simple, value-based choice

Understanding the neural implementation of value-based choice has been an important focus of neuroscience for several decades. Although a consensus has emerged regarding the brain regions involved, including ventromedial prefrontal cortex (vmPFC), posterior parietal cortex (PPC), and the ventral striatum (vSTR), the multifaceted nature of decision processes is one cause of persistent debate regarding organization of the value-based choice network. In the current study, we isolate neural activity related to valuation and choice selection using a gambling task where expected gains and losses are dissociated from choice outcomes. We apply multilevel mediation analysis to formally test whether brain regions identified as part of the value-based choice network mediate between perceptions of expected value and choice to accept or decline a gamble. Our approach additionally makes predictions regarding interregional relationships to elucidate the chain of processing events within the value-based decision network. Finally, we use dynamic causal modelling (DCM) to compare plausible models of interregional relationships in value-based choice. We observe that activity in vmPFC does not predict take/pass choices, but rather is highly associated with outcome evaluation. By contrast, both PPC and bilateral vSTR (bilaterally) mediate the relationship between expected value and choice. Interregional mediation analyses reveal that vSTR fully mediates between PPC and choice, and this is supported by DCM. Together these results suggest that vSTR, and not vmPFC nor PPC, functions as an important driver of choice.

Consent for newborn screening: screening professionals' and parents' views

OBJECTIVES

Expansion of newborn bloodspot screening (NBS) within England, which practices an informed consent model, justified examining acceptability and effectiveness of alternative consent models.

STUDY DESIGN

Qualitative focus groups.

METHODS

Forty-five parents and 37 screening professionals (SPs) participated. Data were analysed using thematic analysis.

RESULTS

Parents and SPs initially appeared to have differing views about appropriate consent models. Most parents accepted assumed consent, if adequately informed; however, once aware of bloodspot storage, informed consent was wanted. SPs valued informed consent, but acknowledged it was difficult to obtain. Both samples wanted parents to be informed but were unclear how this could be achieved. Most parents felt NBS was not presented as optional.

CONCLUSION

The simultaneous exploration of parents and SPs views, in real time is original. This rigour avoided the reliance on retrospective accounts which make it difficult to establish how decisions were made at the time. It is also unique in providing pre-interview consent models to drive the depth of data. It was rigorous in member checking. Findings suggested a preference for full disclosure of all information with some parents valuing this more than choice. Both samples queried whether current consent was sufficiently informed and voluntary. Results suggest differing tolerances of consent type if screening is solely for diagnostic purposes vs bloodspot storage. Results highlight the need for caution when examining consent model preferences without also checking knowledge, as opinions may be based on incomplete knowledge. Future research is needed to examine efficacy of proposed changes.

FUNDING

National Institute for Health Research Health Technology Assessment HTAProgramme (11/62/02).

TRIAL REGISTRATION

ISRCTN70227207.

Static magnetic field stimulation of the supplementary motor area modulates resting-state activity and motor behavior

Focal application of a strong static magnetic field over the human scalp induces measurable local changes in brain function. Whether it also induces distant effects across the brain and how these local and distant effects collectively affect motor behavior remains unclear. Here we applied transcranial static magnetic field stimulation (tSMS) over the supplementary motor area (SMA) in healthy subjects. At a behavioral level, tSMS increased the time to initiate movement while decreasing errors in choice reaction-time tasks. At a functional level, tSMS increased SMA resting-state fMRI activity and bilateral functional connectivity between the SMA and both the paracentral lobule and the lateral frontotemporal cortex, including the inferior frontal gyrus. These results suggest that tSMS over the SMA can induce behavioral aftereffects associated with modulation of both local and distant functionally-connected cortical circuits involved in the control of speed-accuracy tradeoffs, thus offering a promising protocol for cognitive and clinical research.

A comparative study on decision and documentation of refraining from resuscitation in two medical home care units in Sweden

Background

A decision to refrain from cardiopulmonary resuscitation (CPR) in the case of cardiac arrest is recommended in terminally ill patients to avoid unnecessary suffering at time of death. The aim of this study was to describe the frequency of decisions and documentation of “do not attempt cardiopulmonary resuscitation” (DNACPR) in two Medical Home Care Units in Stockholm. Unit A had written guidelines about how to document CPR-decisions in the medical records, including a requirement for a decision to be taken (CPR: yes/no) while Unit B had no such requirement.

Method

The medical records for all patients in palliative phase of their disease at the two Units were reviewed. Data was collected on documentation of decisions about CPR (yes/no), DNACPR-decisions and documentation regarding whether the patient or next-of-kin had been informed about the DNACPR-decision.

Results

In the two Units, 316 and 219 patients in palliative phase were identified. In Unit A 100% of the patients had a CPR-decision (yes/no) compared to 79% in Unit B (p < 0.001). There was no statistically significant difference in DNACPR-decisions between the two Units, 43 and 37%. Documentation about informing the patient regarding the decision was significantly higher in Unit A, 53% compared to 14% at Unit B (p < 0.001). Documentation about informing the next-of-kin was also significantly higher at Unit A; 42% compared to 6% at Unit B (p < 0.001).

Conclusion

Less than 50% of patients in palliative phase had a decision of DNACPR in two Medical Home Care Units in Stockholm. The presence of written guidelines and a requirement for a CPR-decision did not increase the frequency of DNACPR-decisions but was associated with a higher frequency of documentation of decisions and of information given to both the patients and the next-of-kin.

Factors Influence the Acceptance of Surgical Treatment in Chinese Bariatric Surgery Candidates

Background

The prevalence of obesity and obesity-related disorders is rapidly increasing among the Chinese populations. Bariatric surgery is becoming more and more popular in China, yet little cases were performed compared with western countries. The acceptance of this new treatment modality in Chinese bariatric surgery candidates was seldom studied.

Objective

To investigate the factors affecting the choice of bariatric surgery in Chinese patients with obesity and metabolic disorders, so as to promote the popularization of bariatric surgery in developing countries like China

Methods

Patients with obesity and related metabolic disorders meet the indications for bariatric surgery in the Department of Metabolic and Bariatric Surgery in the First Affiliated Hospital of Jinan University between January 2016 and April 2017 were asked to answer a questionnaire about the demographics of the patients, social economic status, present and past history, family history, etc. The data collected and the relationship of the acceptance of bariatric surgery were analyzed.

Results

There were 157 patients (51 males, 32.5%; 106 females, 67.5%) with mean BMI 38.7 ± 8.1 kg/m² answered the questionnaire. One hundred twenty-three of them (78%) accepted bariatric surgery. By univariate analysis, it was found that patients’ weight, BMI, family support, medical insurance, past surgical history, family history of T2DM, and obesity-related comorbidities and symptoms are correlated with the acceptance of bariatric surgery. By multivariate analysis, it was found that patients’ weight (P = 0.024), BMI (P = 0.007), family support (P < 0.001), medical insurance (P < 0.001), past surgical history (P = 0.011), family history of T2DM (P = 0.020), and obesity-related comorbidities and symptoms (P = 0.030) are statistically significant and were positively correlated with the acceptance of bariatric surgery. Age, height, gender, history of smoking and alcohol consumption, family history of obesity, history of hypertension and T2DM, education level, and marital status were not statistically significant (P < 0.05).

Conclusions

Patients with heavier weight, higher BMI, family support, medical insurance reimbursement, past surgical history, family history of T2DM, and obesity-related comorbidities and symptoms are more likely to consider bariatric surgery in Chinese bariatric surgery candidates. It will be important to provide appropriate healthcare education and support to patients focusing on both obesity-related health risks and options of surgical treatment so to improve their acceptance of bariatric surgery.

Concurrent evaluation of independently cued features during perceptual decisions and saccadic targeting in visual search

Simultaneous search for one of two targets is slower and less accurate than search for a single target. Within the Signal Detection Theoretic (SDT) framework, this can be attributed to the division of resources during the comparison of visual input against independently cued targets. The current study used one or two cues to elicit single- and dual-target searches for orientation targets among similar and dissimilar distractors. In Experiment 1, the accuracy of target discrimination in brief displays was compared at setsizes of 1, 2 and 4. Results revealed a reduction in accuracy that scaled with the product of set size and the number of cued targets. In Experiment 2, the accuracy and latency of observers’ saccadic targeting were compared. Fixations on single-target searches were highly selective towards the target. On dual-target searches, the requirement to detect one of two targets produced a significant reduction in target fixations and equivalent rates of fixations to distractors with opposite orientations. For most observers, the dual-target cost was predicted by an SDT model that simulated increases in decision-noise and the distribution of capacity-limited resources during the comparison of selected input against independently cued targets. For others, search accuracy was consistent with a single-item limit on perceptual decisions and saccadic targeting during search. These findings support a flexible account of the dual-target cost based on different strategies to resolve competition between independently cued targets.

Trust in Group Decisions: a scoping review

BACKGROUND

Trust is a critical component of competency committees given their high-stakes decisions. Research from outside of medicine on group trust has not focused on trust in group decisions, and "group trust" has not been clearly defined. The purpose was twofold: to examine the definition of trust in the context of group decisions and to explore what factors may influence trust from the perspective of those who rely on competency committees through a proposed group trust model.

METHODS

The authors conducted a literature search of four online databases, seeking articles published on trust in group settings. Reviewers extracted, coded, and analyzed key data including definitions of trust and factors pertaining to group trust.

RESULTS

The authors selected 42 articles for full text review. Although reviewers found multiple general definitions of trust, they were unable to find a clear definition of group trust and propose the following: a group-directed willingness to accept vulnerability to actions of the members based on the expectation that members will perform a particular action important to the group, encompassing social exchange, collective perceptions, and interpersonal trust. Additionally, the authors propose a model encompassing individual level factors (trustor and trustee), interpersonal interactions, group level factors (structure and processes), and environmental factors.

CONCLUSIONS

Higher degrees of trust at the individual and group levels have been associated with attitudinal and performance outcomes, such as quality of group decisions. Developing a deeper understanding of trust in competency committees may help these committees implement more effective and meaningful processes to make collective decisions.

Enhanced decision-making through multimodal training

A central aim of research in the psychological and decision sciences is to establish interventions that enhance performance, investigating the efficacy of modern approaches to improve human inference and decision-making. Whereas the decision sciences have established interventions to reduce decision biases by promoting strategies for critical thought and reasoning, methods from psychology have instead focused on enhancing cognition through skill-based training of executive functions. Contemporary research in psychology has engaged these operations through multi-modal interventions designed to enhance cognition and physical health through training of executive functions, mindfulness meditation, and physical fitness. Despite the comparable aims of research in the psychological and decision sciences, the efficacy of multi-modal interventions to enhance decision-making remain to be established. We therefore conducted a comprehensive, 16-week, randomized controlled trial (RCT) to investigate this issue, enrolling 160 healthy adults in one of four interventions: (1) high-intensity cardioresistance fitness training (HICRT); (2) HICRT and cognitive training of core executive functions; (3) HICRT and cognitive training, along with mindfulness meditation training; or (4) active control training. The results of our RCT demonstrate that HICRT training and multi-modal interventions that also incorporate cognitive training and mindfulness meditation have beneficial effects on decision-making competence. The observed pattern of findings motivate the application of modern interventions from psychology and cognitive neuroscience to enhance human judgment and decision-making in complex, real-world environments.

Why neuroscience does not disprove free will

While the question whether free will exists or not has concerned philosophers for centuries, empirical research on this question is relatively young. About 35 years ago Benjamin Libet designed an experiment that challenged the common intuition of free will, namely that conscious intentions are causally efficacious. Libet demonstrated that conscious intentions are preceded by a specific pattern of brain activation, suggesting that unconscious processes determine our decisions and we are only retrospectively informed about these decisions. Libet-style experiments have ever since dominated the discourse about the existence of free will and have found their way into the public media. Here we review the most important challenges to the common interpretation of Libet-style tasks and argue that the common interpretation is questionable. Brain activity preceding conscious decisions reflects the decision process rather than its outcome. Furthermore, the decision process is configured by conditional intentions that participants form at the beginning of the experiment. We conclude that Libet-style tasks do not provide a serious challenge to our intuition of free will.