Decision making and response inhibition as predictors of heavy alcohol use: a prospective study

Background: Very few studies have investigated the “real world” prospective, predictive value of behavioral instruments used in laboratory studies to test decision‐making abilities or impulse control. The current study examines the degree to which 2 commonly used decision‐making/impulse control measures prospectively predict (heavy) alcohol use in a sample of college students. Methods: Two hundred healthy young adults (50% women) performed the Iowa Gambling Task (IGT) and a StopSignal inhibition task in the second college year. At testing and at the end of the fourth college year, heavy alcohol use was assessed. Results: Disadvantageous performance on the IGT was associated with higher scores on a heavy drinking measure and higher quantity/frequency of alcohol use 2 years past neurocognitive testing in male students even after controlling for prior drinking. These results were corrected for heavy drinking and alcohol use in the period before neurocognitive testing. Interactions with gender indicated that this general pattern held for male but not for female students. Level of response inhibition was not associated with either of the alcohol use measures prospectively. Conclusion: These findings indicate that a neurocognitive decision‐making task is predictive of maladaptive alcohol use. Advantageous decision makers appear to show adaptive real‐life decision making, changing their drinking habits to the changing challenges of early adulthood (e.g., finishing college), whereas disadvantageous decision makers do not, and continue to drink heavily. These findings extend earlier findings of neurocognitive predictors of relapse in clinical substance‐dependent groups, to subclinical alcohol use and abuse.     

Optimum duration of transtelephonic ECG monitoring when used for transient symptomatic event detection

Transtelephonic electrocardiographic monitoring (TTM) has been used for postpacemaker follow-up study, postmyocardial infarction monitoring, and transient symptomatic event detection (TSED). For postpacemaker follow-up study, TTM is continued indefinitely. For postmyocardial infarction monitoring, TTM is continued for 1 year or more. For TSED, the appropriate duration for TTM has not yet been adequately assessed. Accordingly, the authors determined the yield, by week, of TTM for TSED. Five thousand fifty-two patients who made 20,590 calls were analyzed for this investigation. Ninety-five percent of patients making symptomatic calls or making a call in which an arrhythmia was documented did so within 5 weeks. Shorter periods would sacrifice yield, longer periods may not be cost-effective.     

A health economic model to assess the long term effects and cost-effectiveness of PEG IFN alpha-2a in hepatitis C virus infected patients

OBJECTIVES: Chronic Hepatitis C (CHC) is associated with long-term complications. Treating CHC with Pegylated interferon alpha-2a (PEG IFN alpha-2a) improves response rates and may contribute to less morbidity and mortality compared to standard interferon therapy. The objectives of this study were to estimate the long-term clinical consequences of such treatment as well as the resulting cost-effectiveness. RESEARCH DESIGN AND METHODS: A Markov model was developed in order to predict the clinical and economic outcomes over a 25 year period. Three analyses were conducted: 1. for all Hepatitis C Virus (HCV) genotypes where PEG IFN alpha-2a was compared to interferon alpha-2a (IFN alpha-2a) in monotherapy for 48 weeks; 2. for the HCV genotypes 1-4-5-6 comparing PEG IFN alpha-2a with interferon alpha-2b (IFN alpha-2b) both combined with ribavirin 1000/1200 mg for 48 weeks; and 3, where PEG IFN alpha-2a with 800 mg ribavirin was compared to IFN alpha-2b with ribavirin 1000/1200 mg for 24 weeks in genotypes 2 and 3. RESULTS: In analysis one the cost-effectiveness of PEG IFN alpha-2a is 4,569/quality adjusted life year (QALY) gained. In the second analysis, the result was 14,763 euros/QALY, while for the 24 weeks therapy (analysis 3) the result was 903 per QALY gained. In an extensive sensitivity analysis cost-effectiveness was confirmed within reasonable assumptions. CONCLUSIONS: These results suggest that PEG IFN alpha-2a is cost-effective in the management of all CHC patients. Real life evidence about longer term benefits of PEG IFN alpha-2a will be of importance for future decision making.     

Adapting community based participatory research (CBPR) methods to the implementation of an asthma shared decision making intervention in ambulatory practices

Objective: Translating research findings into clinical practice is a major challenge to improve the quality of healthcare delivery. Shared decision making (SDM) has been shown to be effective and has not yet been widely adopted by health providers. This paper describes the participatory approach used to adapt and implement an evidence-based asthma SDM intervention into primary care practices. Methods: A participatory research approach was initiated through partnership development between practice staff and researchers. The collaborative team worked together to adapt and implement a SDM toolkit. Using the RE-AIM framework and qualitative analysis, we evaluated both the implementation of the intervention into clinical practice, and the level of partnership that was established. Analysis included the number of adopting clinics and providers, the patients’ perception of the SDM approach, and the number of clinics willing to sustain the intervention delivery after 1 year. Results: All six clinics and physician champions implemented the intervention using half-day dedicated asthma clinics while 16% of all providers within the practices have participated in the intervention. Themes from the focus groups included the importance of being part the development process, belief that the intervention would benefit patients, and concerns around sustainability and productivity. One year after initiation, 100% of clinics have sustained the intervention, and 90% of participating patients reported a shared decision experience. Conclusions: Use of a participatory research process was central to the successful implementation of a SDM intervention in multiple practices with diverse patient populations.     

Methods of the elaboration of data of the cardiological importance

This paper deals with some introductory topics of signal processing and decision making in cardiology. In both instances the matter is referred to general schemes well suited to host different applications. Signal processing is divided in some phases: acquisition, storing, analysis and each of them is described with applications to specific signals. In a similar manner the methods for decision making have been simplified to a scheme including a "knowledge base" and an "inference method". The scheme is used to classify various implementations. Bayes analysis and expert systems have been introduced with some details.     

Risk preference following adolescent alcohol use is associated with corrupted encoding of costs but not rewards by mesolimbic dopamine

Several emerging theories of addiction have described how abused substances exploit vulnerabilities in decision-making processes. These vulnerabilities have been proposed to result from pharmacologically corrupted neural mechanisms of normal brain valuation systems. High alcohol intake in rats during adolescence has been shown to increase risk preference, leading to suboptimal performance on a decision-making task when tested in adulthood. Understanding how alcohol use corrupts decision making in this way has significant clinical implications. However, the underlying mechanism by which alcohol use increases risk preference remains unclear. To address this central issue, we assessed dopamine neurotransmission with fast-scan cyclic voltammetry during reward valuation and risk-based decision making in rats with and without a history of adolescent alcohol intake. We specifically targeted the mesolimbic dopamine system, the site of action for virtually all abused substances. This system, which continuously develops during the adolescent period, is central to both reward processing and risk-based decision making. We report that a history of adolescent alcohol use alters dopamine signaling to risk but not to reward. Thus, a corruption of cost encoding suggests that adolescent alcohol use leads to long-term changes in decision making by altering the valuation of risk.     

Case for folic acid and vitamin B12 fortification in Europe

The number of pregnancies affected by neural tube defects has been estimated to be 4000/year in Europe, with a higher prevalence in Celtic populations and in women of low socioeconomic status. Since the 1980s, it has been shown that supplementation with folic acid during the periconceptual period reduces the risk of neural tube defects in the fetus. However, in view of the period during which supplementation should be taken (< 4 weeks before conception until 8-10 weeks after) and the fact that in some countries 30-50% of pregnancies are unplanned, a public health initiative based solely on increasing dietary folate intake or recommendations on use of folic acid supplements is likely to be insufficient. Mandatory fortification has been started in 38 countries throughout the world. Several European countries have advocated mandatory flour folic acid fortification over the last 6 years, but none has introduced it. A recent public health decision in Hungary stimulated flour fortification on a voluntary basis, but it remains the only European country to take this action. Many European countries have deferred a decision to introduce fortification because of concerns about possible masking of vitamin B (12) deficiency. This review advocates a proposal for combined fortification of folic acid and vitamin B (12) to address possible hazards of fortification with folic acid alone.     

Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda

Background Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults. Objective This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD. Results While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD. Conclusions More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.     

The complete blood count and leukocyte differential count. An approach to their rational application

The complete blood count and leukocyte differential count have no value in screening asymptomatic members of the general population. The complete blood count may be useful for screening infants in the first year of life, institutionalized elderly persons, pregnant women, and recent immigrants from Third World countries, if poor nutrition or inadequate iron intake is suspected. These tests are not useful for hospitalized patients, unless an abnormality is suspected or surgery with major blood loss is anticipated. It is appropriate to obtain the tests when a hematologic or infectious disorder is suspected, but they may not affect decision making if the diagnosis is clinically evident. The leukocyte differential count is unnecessary to confirm an infection in most cases in which leukocytosis is present. Repeat tests should be limited to situations where the clinical course is unclear, and at intervals long enough such that the results might affect clinical decision making.     

Decision-making deficits linked to real-life social dysfunction in crack cocaine-dependent individuals

Crack cocaine-dependent individuals (CCDI) present abnormalities in both social adjustment and decision making, but few studies have examined this association. This study investigated cognitive and social performance of 30 subjects (CCDI × controls); CCDI were abstinent for 2 weeks. We used the Social Adjustment Scale (SAS), Wisconsin Card Sorting Test (WCST), and Iowa Gambling Task (IGT). Disadvantageous choices on the IGT were associated with higher levels of social dysfunction in CCDI, suggesting the ecological validity of the IGT. Social dysfunction and decision making may be linked to the same underlying prefrontal dysfunction, but the nature of this association should be further investigated.     

Where now with Do Not Attempt Resuscitation decisions?

Geriatricians are often asked to make decisions about withholding cardiopulmonary resuscitation. This seems to be becoming more difficult and more controversial. There has been increased public concern about this subject recently and a recognition within the profession of the need for more openness and transparency in decision making. The implementation of The Human Rights Act led to updated guidelines from professional bodies, but these are likely to need careful interpretation in light of local circumstances before they can become a practical tool for decision making.     

THE CESSATION OF DIALYSIS IN PATIENTS WITH END‐STAGE RENAL DISEASE: DEVELOPING AN APPROPRIATE EVIDENCE BASE FOR PRACTICE

Recently there has been a growing awareness that not all patients with Established Renal Failure will benefit from dialysis treatment, and it has been recognised that this patient population requires an enhanced approach to assessment and control of symptoms, as well as supportive management, including effective and high‐quality palliative care. This overview of the literature examines supportive care for the patient with Established Renal Failure and how conscious decision‐making in this group of patients can be best facilitated. It highlights recommendations, which have been produced to assist in the decision‐making process regarding withholding and withdrawing dialysis, and is a starting point prior to establishing supportive care programmes for the renal population. Patients who decide to abstain from dialysis or for whom such a decision is made should be offered appropriate supportive and palliative care.     

Determinants of Survival Following Hospitalization for Acute Heart Failure

Heart failure constitutes a major public health concern in the United States and is one of the leading causes of hospitalization, readmission, and death. Due to an aging U.S. population, it is estimated that the prevalence of heart failure will increase by 25 % over the coming decades, affecting approximately 3.5 % of the population by the year 2030. The ability to discriminate patients admitted with acute heart failure syndromes who are at increased risk for poor post-hospitalization outcomes is thus critical to guide therapeutic decision making for healthcare providers. This review paper will discuss clinical, hemodynamic, as well as biochemical markers that have been demonstrated to predict post-discharge outcomes among patients hospitalized with acute heart failure.     

Decision making and binge drinking: a longitudinal study

BACKGROUND: Behavioral decision making, as measured by the Iowa Gambling Task (IGT) is found to be diminished in individuals with substance dependence and other types of disinhibitory psychopathology. However, little is known regarding the relation between heavy alcohol use and decision-making skills in young adults. This study therefore investigated whether binge drinking is related to disadvantageous decision making, as measured by the IGT. We also examined the relation between decision making and impulsivity. METHODS: Latent class growth analysis was used to classify college students into 4 groups (each group n=50, 50% male), based on their binge drinking trajectories over a 2-year time period (precollege through second year of college). Participants were 200 college students, divided in 4 subgroups: (1) low binge drinkers, (2) stable moderate binge drinkers, (3) increasing binge drinkers, and (4) stable high binge drinkers. A measure of decision making, the IGT, impulsivity questionnaires, and multiple indicators of heavy alcohol use were included. RESULTS: The stable high binge-drinking group made less advantageous choices on the IGT than the low binge-drinking group. Impulsivity was not related to decision-making performance. Decision-making performance did not differ by gender, but deck preferences and decision time patterns did differ; women preferred low frequency, high amount punishments to a greater extent than men. CONCLUSIONS: Although disadvantageous decision making is related to binge-drinking patterns in emerging adulthood, this relation is independent of impulsivity. Additionally, the association appears attributable to those who engage in heavy (binge) drinking at an early age, but not to age of onset of drinking in general.     

A diabetes-specific measure of patient desire to participate in medical decision making

PURPOSE: The goal of this study was to develop a diabetes-specific scale of patient desire to participate in medical decision making (DPMD) and examine its internal consistency reliability, stability, and validity (content, discriminant, convergent, and construct). METHODS: In a cross-sectional study, 65 patients with type 2 diabetes from a teaching hospital's general medical clinic were interviewed at baseline and 2 weeks later to measure their DPMD scores. Data were collected on demographic/clinical features, health value, social support, desire to make a final decision, and value of patient autonomy. RESULTS: Of the 11 DPMD items, 2 distinct factors emerged representing desire for discussion and desire for information. The DPMD scale had high internal consistency reliability, was stable over 2 weeks and demonstrated good content validity. DPMD scale items were more correlated with each other than with health value or social support. Overall, patients who obtained diabetes education reported greater desire to participate in decisions. Younger patients had a greater overall desire for discussion. The DPMD desire for discussion subscale correlated with patients' desire to make the final treatment decision but not with patients' value of autonomy. CONCLUSIONS: The DPMD is a brief, reliable, valid measure for assessing patient desire to participate in diabetes medical decision making.     

Decision analysis in patient care

To help patients to fully participate in shared decision making is becoming an important goal in clinical practice and one which is receiving increasing attention in terms of the requisite skills and technological development. We discuss the potential application of decision analysis-a specific technology that has been introduced into clinical practice but to date only within research contexts-and examine the usefulness and feasibility of the technique for patients, particularly in settings where clinical presentations are diverse and characterised by uncertainty.     

Quality of life and autonomy preferences in stable asthmatics: A developing country scenario

Background and objective: The quality of life (QOL) and autonomy preferences of asthmatics in developing countries have been sparingly researched, with a resulting lack of management strategies. This study determined the asthma‐specific QOL and autonomy preferences of a population of asthmatics in a developing country and their association with relevant sociodemographic and clinical characteristics. Methods: A cross‐sectional study using the Asthma Quality of Life Questionnaire and the Asthma Autonomy Questionnaire was performed on a population of stable asthmatics recruited from a tertiary care centre in India. Severity of the disease was assessed by spirometry. Results: The study population comprised 80 asthmatics. The mean (SD) overall QOL score was 5.04 (0.97). This was significantly associated with history of hospitalization during the previous year for an asthma attack (P < 0.01) and with FEV₁ (P < 0.05) on univariate analysis; on multivariate analysis, only history of hospitalization was significant. Autonomy preferences of the patients showed higher scores for information‐seeking (mean (SD) = 78.95 (16.35) ) than decision‐making (mean (SD) = 38.21 (14.6)). The information‐seeking preferences had a negative correlation with age (P < 0.01) and a positive correlation with education status (P < 0.01) and decision‐making correlated with education status (P < 0.05). A minority of patients (19%) indicated a preference for a greater say in decision‐making than their physicians. There was a lower tendency for decision‐making when given a ‘severe exacerbation’ scenario than in ‘mild exacerbation’ (P < 0.001) or ‘stable disease’ (P < 0.001). Conclusions: Hospitalization history and FEV₁ values are the parameters having the most significant impact on the QOL of asthmatics. There is a clear desire to obtain more information about the disease but most patients do not endorse the idea of making independent disease‐related decisions.     

Hypoxemia without persistent right-to-left pressure gradient across a patent foramen ovale:A clinical challenge

Patent foramen ovale (PFO) closure for systemic hypoxemia is controversial. The first systematic, albeit retrospective, study was recently presented which showed good procedural and clinical success for PFO closure for this indication. We present a case of acute right to left intra-cardiac shunt across PFO where the shunting is not persistent. Hence making a decision on PFO closure based on the aforementioned promising trial may not have been the right decision for the patient. This case highlights that the decision on PFO closure for such indication needs to be individualized. We also review the sparse literature on PFO closure for this indication and discuss how the decision making for such indication needs to be individualized.     

Health care professionals and family involvement in care-related decisions concerning older patients

This article examines care-related decision making within the context of in-home family care. It also uses the Andersen-Newman model to identify the correlates of physician involvement and centrality in decision making and the impact that it has on family members' caregiving satisfaction. Analysis of data from 244 family caregivers shows that elders (40%) and nuclear kin (53%) are key decision makers, indicating that families prefer to control care-related decisions. However, physicians are part of the decision-making process for nearly one fourth of the families in this study. The patient's impairment and the caregiver's education correlate with physician involvement in decision making. Shared residence and caregiver's overall satisfaction with the caregiving process correlate with physician centrality on the network. Discussion centers on implications for physician interactions with caregiving families around decision making. Included are indications for improved communication in decision-making contexts.