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Uncertainty in clinical decision making

Karen Luetsch, Judith Burrows
BACKGROUND: Graduate and post-graduate education for health professionals is increasingly delivered in an e-learning environment, where automated, continuous formative testing with integrated feedback can guide students' self-assessment and learning. Asking students to rate the certainty they assign to the correctness of their answers to test questions can potentially provide deeper insights into the success of teaching, with test results informing course designers whether learning outcomes have been achieved...
October 14, 2016: BMC Medical Education
Andrew Skeggs, Tricia McKeever, Lelia Duley, Eleanor Mitchell, Lucy Bradshaw, Kevin Mortimer, Samantha Walker, Steve Parrott, Andrew Wilson, Ian Pavord, Chris Brightling, Mike Thomas, David Price, Graham Devereux, Bernard Higgins, Tim Harrison, Rebecca Haydock
BACKGROUND: Asthma is one of the commonest chronic diseases in the UK. Acute exacerbations of asthma are unpredictable, disruptive and frightening. They cause considerable morbidity and account for a large component of the health service costs of asthma. The widespread use of an asthma self-management plan, designed to encourage disease monitoring and timely intervention, can reduce exacerbations and is, therefore, recommended for all patients with asthma. Unfortunately, the majority of patients are not provided with such a plan...
October 13, 2016: Trials
P M Down, A J Bradley, J E Breen, W J Browne, T Kypraios, M J Green
Importance of the dry period with respect to mastitis control is now well established although the precise interventions that reduce the risk of acquiring intramammary infections during this time are not clearly understood. There are very few intervention studies that have measured the clinical efficacy of specific mastitis interventions within a cost-effectiveness framework so there remains a large degree of uncertainty about the impact of a specific intervention and its costeffectiveness. The aim of this study was to use a Bayesian framework to investigate the cost-effectiveness of mastitis controls during the dry period...
October 1, 2016: Preventive Veterinary Medicine
Shiu-Yu C Katie Lee
The decision-making process that is used by cancer patients to determine their treatment has become more multi-foci, difficult and complicated in recent years. This has in part been attributed to the increasing incidence rate of cancer in Taiwan and the rapid development of medical technologies and treatment modalities. Oncology nurses must assist patients and family to make informed and value-based treatment decisions. Decision-making is an information process that involves appraising one's own expectation and values based on his/her knowledge on cancer and treatment options...
October 2016: Hu Li za Zhi the Journal of Nursing
Emily C Williams, Jessica P Young, Carol E Achtmeyer, Christian S Hendershot
BACKGROUND: Efforts to identify genetic moderators of pharmacotherapy response have generated interest in clinical applications of pharmacogenetic tests in alcohol use disorder (AUD) treatment. To date, no research on providers' interest in using pharmacogenetic tests in the context of AUD treatment has been reported. We conducted qualitative interviews with primary care providers from 5 clinics in the Veterans Health Administration (VA) to assess their interest in using a hypothetical genetic test to inform treatment of AUD with pharmacotherapy...
November 2016: Journal of Substance Abuse Treatment
Honey Calebrant, Marie Sandh, Inger Jansson
PURPOSE: To determine the factors that affect how nurse anesthetists in a county in Sweden decide how to manage perioperative fluid status. DESIGN: A cross-sectional qualitative study was conducted at two surgical wards in a county hospital. METHODS: Sixteen nurse anesthetists were interviewed to explore how nurse anesthetists assess patients' intraoperative fluid requirements and the subsequent measures adopted. FINDING: Three categories emerged through content analysis: clinical criteria and the thought process that drives decision making, interdependence in decision making, and uncertainty in decision making...
October 2016: Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses
Chloe Shaw, Elizabeth Stokoe, Katie Gallagher, Narendra Aladangady, Neil Marlow
The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed...
September 25, 2016: Sociology of Health & Illness
Alyssa Power, Jean-Francois Lemay, Suzette Cooke
: Construct: Clinical reasoning assessment is a growing area of interest in the medical education literature. Script concordance testing (SCT) evaluates clinical reasoning in conditions of uncertainty and has emerged as an innovative tool in the domain of clinical reasoning assessment. SCT quantifies the degree of concordance between a learner and an experienced clinician and attempts to capture the breadth of responses of expert clinicians, acknowledging the significant yet acceptable variation in practice under situations of uncertainty...
September 23, 2016: Teaching and Learning in Medicine
Tingting Wu, Alexander J Dufford, Melissa-Ann Mackie, Laura J Egan, Jin Fan
Cognitive control refers to the processes that permit selection and prioritization of information processing in different cognitive domains to reach the capacity-limited conscious mind. Although previous studies have suggested that the capacity of cognitive control itself is limited, a direct quantification of this capacity has not been attempted. In this behavioral study, we manipulated the information rate of cognitive control by parametrically varying both the uncertainty of stimul measured as information entropy and the exposure time of the stimuli...
September 23, 2016: Scientific Reports
Allana Austin, Jean-Pierre Lin, Richard Selway, Keyoumars Ashkan, Tamsin Owen
BACKGROUND: Dystonia is characterised by involuntary movements and postures. Deep Brain Stimulation (DBS) is effective in reducing dystonic symptoms in primary dystonia in childhood and to lesser extent in secondary dystonia. How families and children decide to choose DBS surgery has never been explored. AIMS: To explore parental decision-making for DBS in paediatric secondary dystonia. METHODS: Data was gathered using semi-structured interviews with eight parents of children with secondary dystonia who had undergone DBS...
September 6, 2016: European Journal of Paediatric Neurology: EJPN
C Gale, M J Hyde, N Modi
OBJECTIVE: Randomised controlled trials, a gold-standard approach to reduce uncertainties in clinical practice, are growing in cost and are often slow to recruit. We determined whether methodological approaches to facilitate large, efficient clinical trials were acceptable to UK research ethics committees (RECs). DESIGN: We developed a protocol in collaboration with parents, for a comparative-effectiveness, randomised controlled trial comparing two widely used blood transfusion practices in preterm infants...
September 14, 2016: Archives of Disease in Childhood. Fetal and Neonatal Edition
G Hirsch, M Trusheim, E Cobbs, M Bala, S Garner, D Hartman, K Isaacs, M Lumpkin, R Lim, K Oye, E Pezalla, P Saltonstall, H Selker
The current system of biomedical innovation is unable to keep pace with scientific advancements. We propose to address this gap by re-engineering innovation processes to accelerate reliable delivery of products that address unmet medical needs. Adaptive Biomedical Innovation (ABI) provides an integrative, strategic approach for process innovation. While the term ABI is new, it encompasses fragmented "tools" that have been developed across the global pharmaceutical industry, and that could accelerate the evolution of the system through more coordinated application...
September 14, 2016: Clinical Pharmacology and Therapeutics
Junya Fujino, Kimito Hirose, Shisei Tei, Ryosaku Kawada, Kosuke Tsurumi, Noriko Matsukawa, Jun Miyata, Genichi Sugihara, Yujiro Yoshihara, Takashi Ideno, Toshihiko Aso, Kazuhisa Takemura, Hidenao Fukuyama, Toshiya Murai, Hidehiko Takahashi
When making decisions in everyday life, we often have to choose between uncertain outcomes. Economic studies have demonstrated that healthy people tend to prefer options with known probabilities (risk) than those with unknown probabilities (ambiguity), which is referred to as "ambiguity aversion." However, it remains unclear how patients with schizophrenia behave under ambiguity, despite growing evidence of their altered decision-making under uncertainty. In this study, combining economic tools and functional magnetic resonance imaging (fMRI), we assessed the attitudes toward risk/ambiguity and investigated the neural correlates during decision-making under risk/ambiguity in schizophrenia...
September 9, 2016: Schizophrenia Research
Victoria Shepherd
BACKGROUND: Society is failing in its moral obligation to improve the standard of healthcare provided to vulnerable populations, such as people who lack decision making capacity, by a misguided paternalism that seeks to protect them by excluding them from medical research. Uncertainties surround the basis on which decisions about research participation is made under dual regulatory regimes, which adds further complexity. Vulnerable individuals' exclusion from research as a result of such regulation risks condemning such populations to poor quality care as a result of 'evidence biased' medicine...
2016: BMC Medical Ethics
Paramala J Santosh, Laura Bell, Federico Fiori, Jatinder Singh
Antipsychotic (ATP) prescription rates have increased in children and adolescents despite concern regarding the safety and effectiveness of ATP usage in community populations. Rising safety concerns and uncertainty regarding ATP effectiveness in children stress the need for improvement in routine clinical outcome monitoring and research. Due to the growing number of children exposed to atypical ATPs, studies assessing the risk/benefit ratio of administering ATPs in this age group-especially in off-label conditions-become of high importance...
September 8, 2016: Journal of Child and Adolescent Psychopharmacology
Stef M Shuster
To alleviate uncertainty in the specialized field of transgender medicine, mental and physical healthcare providers have introduced the rhetoric of evidence-based medicine (EBM) in clinical guidelines to help inform medical decision making. However there are no diagnostic tests to assess the effectiveness of transgender medical interventions and no scientific evidence to support the guidelines. Using in-depth interviews with a purposive sample of 23 healthcare providers, I found that providers invoked two strategies for negotiating the guidelines...
September 2016: Journal of Health and Social Behavior
E L McGoldrick, T Crawford, J A Brown, K M Groom, C A Crowther
BACKGROUND: Active participation of consumers in health care decision making, policy and clinical research is increasingly encouraged by governments, influential bodies and funders. Identifying the best way to achieve this is difficult due to the paucity of evidence. Consumers have mixed feelings towards clinical practice guidelines (CPG) demonstrating scepticism towards their purpose and applicability to their needs. There is no information pertaining to consumers' views and attitudes on the receipt of antenatal corticosteroids (ACS)...
2016: BMC Pregnancy and Childbirth
Stella K Kang, Kayte Spector-Bagdady, Arthur L Caplan, R Scott Braithwaite
Incidental and secondary findings have become an important by-product of diagnostic testing, and their ramifications affect clinical care, research, and policy. Given parallels in the reporting and management of such findings on diagnostic imaging, radiologists may draw from ongoing discussions in medical genetics to rethink more patient-centered approaches to analogous clinical, ethical, and medicolegal dilemmas. Low-risk incidental findings in particular may be drivers of unnecessary testing, invasive procedures, and overtreatment, with associated financial, psychological, and clinical consequences...
August 25, 2016: Journal of the American College of Radiology: JACR
Himanshu Gupta, Chun G Schiros, Oleg F Sharifov, Apurva Jain, Thomas S Denney
BACKGROUND: Recently released American College of Cardiology/American Heart Association (ACC/AHA) guideline recommends the Pooled Cohort equations for evaluating atherosclerotic cardiovascular risk of individuals. The impact of the clinical input variable uncertainties on the estimates of ten-year cardiovascular risk based on ACC/AHA guidelines is not known. METHODS: Using a publicly available the National Health and Nutrition Examination Survey dataset (2005-2010), we computed maximum and minimum ten-year cardiovascular risks by assuming clinically relevant variations/uncertainties in input of age (0-1 year) and ±10 % variation in total-cholesterol, high density lipoprotein- cholesterol, and systolic blood pressure and by assuming uniform distribution of the variance of each variable...
2016: BMC Cardiovascular Disorders
R B Den, M Santiago-Jimenez, J Alter, M Schliekelman, J R Wagner, J F Renzulli Ii, D I Lee, C G Brito, K Monahan, B Gburek, N Kella, G Vallabhan, F Abdollah, E J Trabulsi, C D Lallas, L G Gomella, T L Woodlief, Z Haddad, L L C Lam, S Deheshi, Q Wang, V Choeurng, M du Plessis, J Jordan, B Parks, H Shin, C Buerki, K Yousefi, E Davicioni, V R Patel, N L Shah
BACKGROUND: Currently, there are multiple commercially available RNA-based biomarkers that are Medicare approved and suggested for use by the National Comprehensive Cancer Network guidelines. There is uncertainty as to which patients benefit from genomic testing and for whom these tests should be ordered. Here, we examined the correlation patterns of Decipher assay to understand the relationship between the Decipher and patient tumor characteristics. METHODS: De-identified Decipher test results (including Decipher risk scores and clinicopathologic data) from 2 342 consecutive radical prostatectomy (RP) patients tested between January and September 2015 were analyzed...
August 30, 2016: Prostate Cancer and Prostatic Diseases
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