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Sample records for driven treatment decisions

  1. SU-E-J-04: A Data-Driven, Response-Based, Multi-Criteria Decision Support System for Personalized Lung Radiation Treatment Planning

    SciTech Connect

    Luo, Y; McShan, D; Schipper, M; Matuszak, M; Ten Haken, R; Kong, F

    2014-06-01

    Purpose: To develop a decision support tool to predict a patient's potential overall survival (OS) and radiation induced toxicity (RIT) based on clinical factors and responses during the course of radiotherapy, and suggest appropriate radiation dose adjustments to improve therapeutic effect. Methods: Important relationships between a patient's basic information and their clinical features before and during the radiation treatment are identified from historical clinical data by using statistical learning and data mining approaches. During each treatment period, a data analysis (DA) module predicts radiotherapy features such as time to local progression (TTLP), time to distant metastases (TTDM), radiation toxicity to different organs, etc., under possible future treatment plans based on patient specifics or responses. An information fusion (IF) module estimates intervals for a patient's OS and the probabilities of RIT from a treatment plan by integrating the outcomes of module DA. A decision making (DM) module calculates “satisfaction” with the predicted radiation outcome based on trade-offs between OS and RIT, and finds the best treatment plan for the next time period via multi-criteria optimization. Results: Using physical and biological data from 130 lung cancer patients as our test bed, we were able to train and implement the 3 modules of our decision support tool. Examples demonstrate how it can help predict a new patient's potential OS and RIT with different radiation dose plans along with how these combinations change with dose, thus presenting a range of satisfaction/utility for use in individualized decision support. Conclusion: Although the decision support tool is currently developed from a small patient sample size, it shows the potential for the improvement of each patient's satisfaction in personalized radiation therapy. The radiation treatment outcome prediction and decision making model needs to be evaluated with more patients and demonstrated for

  2. A Decision Fusion Framework for Treatment Recommendation Systems.

    PubMed

    Mei, Jing; Liu, Haifeng; Li, Xiang; Xie, Guotong; Yu, Yiqin

    2015-01-01

    Treatment recommendation is a nontrivial task--it requires not only domain knowledge from evidence-based medicine, but also data insights from descriptive, predictive and prescriptive analysis. A single treatment recommendation system is usually trained or modeled with a limited (size or quality) source. This paper proposes a decision fusion framework, combining both knowledge-driven and data-driven decision engines for treatment recommendation. End users (e.g. using the clinician workstation or mobile apps) could have a comprehensive view of various engines' opinions, as well as the final decision after fusion. For implementation, we leverage several well-known fusion algorithms, such as decision templates and meta classifiers (of logistic and SVM, etc.). Using an outcome-driven evaluation metric, we compare the fusion engine with base engines, and our experimental results show that decision fusion is a promising way towards a more valuable treatment recommendation. PMID:26262059

  3. Bayesian Decision Support for Adaptive Lung Treatments

    NASA Astrophysics Data System (ADS)

    McShan, Daniel; Luo, Yi; Schipper, Matt; TenHaken, Randall

    2014-03-01

    Purpose: A Bayesian Decision Network will be demonstrated to provide clinical decision support for adaptive lung response-driven treatment management based on evidence that physiologic metrics may correlate better with individual patient response than traditional (population-based) dose and volume-based metrics. Further, there is evidence that information obtained during the course of radiation therapy may further improve response predictions. Methods: Clinical factors were gathered for 58 patients including planned mean lung dose, and the bio-markers IL-8 and TGF-β1 obtained prior to treatment and two weeks into treatment along with complication outcomes for these patients. A Bayesian Decision Network was constructed using Netica 5.0.2 from Norsys linking these clinical factors to obtain a prediction of radiation induced lung disese (RILD) complication. A decision node was added to the network to provide a plan adaption recommendation based on the trade-off between the RILD prediction and complexity of replanning. A utility node provides the weighting cost between the competing factors. Results: The decision node predictions were optimized against the data for the 58 cases. With this decision network solution, one can consider the decision result for a new patient with specific findings to obtain a recommendation to adaptively modify the originally planned treatment course. Conclusions: A Bayesian approach allows handling and propagating probabilistic data in a logical and principled manner. Decision networks provide the further ability to provide utility-based trade-offs, reflecting non-medical but practical cost/benefit analysis. The network demonstrated illustrates the basic concept, but many other factors may affect these decisions and work on building better models are being designed and tested. Acknowledgement: Supported by NIH-P01-CA59827

  4. Data-Driven Decision Making 2016

    ERIC Educational Resources Information Center

    Ligon, Glynn D.

    2006-01-01

    Educators base many of their most significant decisions on what they think will happen in the future. This article on education technology begins by outlining six notable advances in education information technology that have already occurred. Ten predictions are made concerning general advances in education information technology for the next…

  5. Group decision support system for customer-driven product design

    NASA Astrophysics Data System (ADS)

    Lin, Zhihang; Chen, Hang; Chen, Kuen; Che, Ada

    2000-10-01

    This paper describes the work on the development of a group decision support system for customer driven product design. The customer driven is to develop products, which meet all customer requirements in whole life cycle of products. A process model of decision during product primary design is proposed to formulate the structured, semi-structured and unstructured decision problems. The framework for the decision support system is presented that integrated both advances in the group decision making and distributed artificial intelligent. The system consists of the product primary design tool kit and the collaborative platform with multi-agent structure. The collaborative platform of the system and the product primary design tool kit, including the VOC (Voice of Customer) tool, QFD (Quality Function Deployment) tool, the Conceptual design tool, Reliability analysis tool and the cost and profit forecasting tool, are indicated.

  6. Guarding against discriminatory treatment decisions.

    PubMed

    Griffith, Richard

    2013-10-01

    This article studies a case in which a 52-year-old male patient has early onset dementia, Down's syndrome and an associated heart condition, for which he is prescribed warfarin and digoxin. A district nurse, who is an independent prescriber, monitors and adjusts his medication and takes the required blood sample. The staff at the care home where the patient lives report that the patient is spitting out his medication and they have not been able to persuade him to swallow his tablets for a week. Despite the patient being assessed as lacking capacity to decide treatment decisions, the care home staff argue that his refusal to take medication should be respected and the medication discontinued. Although withdrawing the medication would make caring for the patient less challenging, the district nurse assesses the legal obligations that must be considered before this decision can be considered lawful. PMID:24471220

  7. Outcome-driven Evaluation Metrics for Treatment Recommendation Systems.

    PubMed

    Mei, Jing; Liu, Haifeng; Li, Xiang; Yu, Yiqin; Xie, Guotong

    2015-01-01

    Treatment recommendation systems aim to providing clinical decision supports, e.g. with integration of Computerized Physician Order Entry (CPOE). One of the most significant issue is the quality of recommendations which needs to be quantified, before getting the acceptance from physicians. In computer science, such evaluations are typically performed by applying appropriate metrics that provides a comparison of different systems. However, a big challenge for evaluating treatment recommendation systems is that ground truth is only partially observed. In this paper, we propose an outcome-driven evaluation methodology, and present five metrics (i.e. precision, recall, accuracy, relative risk and odds ratio) with highlight of their statistic meanings in clinical context. The experimental results are based on the comparison of two well-developed treatment recommendation systems (one is knowledge-driven and based on clinical practice guidelines, while the other is data-driven and based on patient similarity analysis), using our proposed evaluation metrics. As a conclusion, physicians are less prone to comply with clinical guidelines, but once following guideline recommendations, it is much more likely to get good outcomes than not following. PMID:25991128

  8. A Middle School Principal's and Teachers' Perceptions of Leadership Practices in Data-Driven Decision Making

    ERIC Educational Resources Information Center

    Godreau Cimma, Kelly L.

    2011-01-01

    The purpose of this qualitative case study was to describe one Connecticut middle school's voluntary implementation of a data-driven decision making process in order to improve student academic performance. Data-driven decision making is a component of Connecticut's accountability system to assist schools in meeting the requirements of the No…

  9. Parental involvement in paediatric cancer treatment decisions

    PubMed Central

    McKenna, K; Collier, J; Hewitt, M; Blake, H

    2010-01-01

    This study investigated parents' information needs and involvement in decision-making processes affecting the care of children diagnosed with cancer. Interviews and questionnaires were used to assess parental satisfaction in 50 mothers and 16 fathers responsible for 58 children in an English Paediatric Oncology Unit. Parents reported that doctors contributed almost twice as much to the decision-making process as they did, but parental satisfaction was positively correlated with the amount of information provided when giving informed consent. Satisfaction about their involvement in this process relied heavily upon the level of support received from others. Parents consenting to their child's involvement in non-randomised trials perceived themselves to be under greater pressure from others during the decision-making process while those whose children were further along the treatment trajectory were more uncertain about decisions previously made. Findings indicate that the accessibility, support, information and degree of control afforded to parents by healthcare professionals impacts upon their satisfaction with both the decision-making process and their confidence in the decisions thus made. Information and support tailored to parents' specific needs may therefore enhance satisfaction with clinical decision making and reassure parents about decisions made in the long-term interest of their child's health. PMID:19807776

  10. SIDEKICK: Genomic data driven analysis and decision-making framework

    PubMed Central

    2010-01-01

    Background Scientists striving to unlock mysteries within complex biological systems face myriad barriers in effectively integrating available information to enhance their understanding. While experimental techniques and available data sources are rapidly evolving, useful information is dispersed across a variety of sources, and sources of the same information often do not use the same format or nomenclature. To harness these expanding resources, scientists need tools that bridge nomenclature differences and allow them to integrate, organize, and evaluate the quality of information without extensive computation. Results Sidekick, a genomic data driven analysis and decision making framework, is a web-based tool that provides a user-friendly intuitive solution to the problem of information inaccessibility. Sidekick enables scientists without training in computation and data management to pursue answers to research questions like "What are the mechanisms for disease X" or "Does the set of genes associated with disease X also influence other diseases." Sidekick enables the process of combining heterogeneous data, finding and maintaining the most up-to-date data, evaluating data sources, quantifying confidence in results based on evidence, and managing the multi-step research tasks needed to answer these questions. We demonstrate Sidekick's effectiveness by showing how to accomplish a complex published analysis in a fraction of the original time with no computational effort using Sidekick. Conclusions Sidekick is an easy-to-use web-based tool that organizes and facilitates complex genomic research, allowing scientists to explore genomic relationships and formulate hypotheses without computational effort. Possible analysis steps include gene list discovery, gene-pair list discovery, various enrichments for both types of lists, and convenient list manipulation. Further, Sidekick's ability to characterize pairs of genes offers new ways to approach genomic analysis that

  11. The structural basis for cancer treatment decisions

    PubMed Central

    Nussinov, Ruth; Jang, Hyunbum; Tsai, Chung-Jung

    2014-01-01

    Cancer treatment decisions rely on genetics, large data screens and clinical pharmacology. Here we point out that genetic analysis and treatment decisions may overlook critical elements in cancer development, progression and drug resistance. Two critical structural elements are missing in genetics-based decision-making: the mechanisms of oncogenic mutations and the cellular network which is rewired in cancer. These lay the foundation for the structural basis for cancer treatment decisions, which is rooted in the physical principles of the molecular conformational behavior of single molecules and their interactions. Improved tumor mutational analysis platforms and knowledge of the redundant pathways which can take over in cancer, may not only supplement known actionable findings, but forecast possible cancer progression and resistance. Such forward-looking can be powerful, endowing the oncologist with mechanistic insight and cancer prognosis, and consequently more informed treatment options. Examples include redundant pathways taking over after inhibition of EGFR constitutive activation, mutations in PIK3CA p110α and p85, and the non-hotspot AKT1 mutants conferring constitutive membrane localization. PMID:25277176

  12. Data-Driven Decision Making: Teachers' Use of Data in the Classroom

    ERIC Educational Resources Information Center

    Moriarty, Tammy Wu

    2013-01-01

    Data-driven decision making has become an important educational issue in the United States, primarily because of federal and state emphasis on school accountability and achievement. Data use has been highlighted as a key factor in monitoring student progress and informing decision making at various levels of the education system. Federal and state…

  13. Co-Constructing Distributed Leadership: District and School Connections in Data-Driven Decision-Making

    ERIC Educational Resources Information Center

    Park, Vicki; Datnow, Amanda

    2009-01-01

    The purpose of this paper is to examine leadership practices in school systems that are implementing data-driven decision-making employing the theory of distributed leadership. With the advent of No Child Left Behind Act of 2001 (NCLB) in the US, educational leaders are now required to analyse, interpret and use data to make informed decisions in…

  14. Decision support for redesigning wastewater treatment technologies.

    PubMed

    McConville, Jennifer R; Künzle, Rahel; Messmer, Ulrike; Udert, Kai M; Larsen, Tove A

    2014-10-21

    This paper offers a methodology for structuring the design space for innovative process engineering technology development. The methodology is exemplified in the evaluation of a wide variety of treatment technologies for source-separated domestic wastewater within the scope of the Reinvent the Toilet Challenge. It offers a methodology for narrowing down the decision-making field based on a strict interpretation of treatment objectives for undiluted urine and dry feces and macroenvironmental factors (STEEPLED analysis) which influence decision criteria. Such an evaluation identifies promising paths for technology development such as focusing on space-saving processes or the need for more innovation in low-cost, energy-efficient urine treatment methods. Critical macroenvironmental factors, such as housing density, transportation infrastructure, and climate conditions were found to affect technology decisions regarding reactor volume, weight of outputs, energy consumption, atmospheric emissions, investment cost, and net revenue. The analysis also identified a number of qualitative factors that should be carefully weighed when pursuing technology development; such as availability of O&M resources, health and safety goals, and other ethical issues. Use of this methodology allows for coevolution of innovative technology within context constraints; however, for full-scale technology choices in the field, only very mature technologies can be evaluated. PMID:25225855

  15. Patient age and general dentists' treatment decisions.

    PubMed

    Dolan, T A; McNaughton, C A; Davidson, S N; Mitchell, G S

    1992-01-01

    To test whether a patient's age plays a role in dentists' treatment planning decisions, a convenience sample of 159 general dentists attending a state dental society annual meeting was presented a vignette including intra-oral photographs, a brief case history and clinical diagnosis of a patient. The patient was partially dentate, and was described as having irreversible pulpitis of tooth #19. Three versions of the vignette were developed, with identical materials and information except for the patient's age (either 44, 65, or 84 years), and were randomly assigned to the participating dentists who were asked to develop a treatment plan for the patient's mandibular arch. The dentists planned limited therapy for the 84 year old because of their assumptions about the patient's brief life expectancy, cost, concern about the inability of the patient to tolerate extensive treatment, and a low cost/benefit ratio. These findings suggest that a patient's age influences general dentists' treatment planning decisions, perhaps limiting the treatment options offered to older adults. Additional research is necessary to further test these associations. PMID:10895734

  16. Data-Driven Decision-Making: Mission Accomplished

    ERIC Educational Resources Information Center

    Weinstock, Jeff

    2009-01-01

    When the author and his colleagues last left Chicago Public Schools (CPS) and Texas' Plano Independent School District in April 2008, both school districts were immersed in the long and labored advance toward becoming a fully matured data-driven operation, one that uses sophisticated technologies to gather data, sort and interpret it, and…

  17. Data-Driven Decision Making: The "Other" Data

    ERIC Educational Resources Information Center

    Villano, Matt

    2007-01-01

    Data is a daily reality for school systems. Between standardized tests and tools from companies that offer data warehousing services, educators and district superintendents alike are up to their eyeballs in facts and figures about student performance that they can use as the basis for curricular decisions. Still, there is more to assessment than…

  18. Data Use: Data-Driven Decision Making Takes a Big-Picture View of the Needs of Teachers and Students

    ERIC Educational Resources Information Center

    Bernhardt, Victoria L.

    2009-01-01

    Data-driven decision making is the process of using data to inform decisions to improve teaching and learning. Schools typically engage in two kinds of data-driven decision making--at the school level and at the classroom level. The first leads to the second. In this article, the author describes how Marylin Avenue Elementary School successfully…

  19. Creating a System for Data-Driven Decision-Making: Applying the Principal-Agent Framework

    ERIC Educational Resources Information Center

    Wohlstetter, Priscilla; Datnow, Amanda; Park, Vicki

    2008-01-01

    The purpose of this article is to improve our understanding of data-driven decision-making strategies that are initiated at the district or system level. We apply principal-agent theory to the analysis of qualitative data gathered in a case study of 4 urban school systems. Our findings suggest educators at the school level need not only systemic…

  20. Design and Data in Balance: Using Design-Driven Decision Making to Enable Student Success

    ERIC Educational Resources Information Center

    Fairchild, Susan; Farrell, Timothy; Gunton, Brad; Mackinnon, Anne; McNamara, Christina; Trachtman, Roberta

    2014-01-01

    Data-driven approaches to school decision making have come into widespread use in the past decade, nationally and in New York City. New Visions has been at the forefront of those developments: in New Visions schools, teacher teams and school teams regularly examine student performance data to understand patterns and drive classroom- and…

  1. Data-Driven Decision-Making: Facilitating Teacher Use of Student Data to Inform Classroom Instruction

    ERIC Educational Resources Information Center

    Schifter, Catherine C.; Natarajan, Uma; Ketelhut, Diane Jass; Kirchgessner, Amanda

    2014-01-01

    Data-driven decision making is essential in K-12 education today, but teachers often do not know how to make use of extensive data sets. Research shows that teachers are not taught how to use extensive data (i.e., multiple data sets) to reflect on student progress or to differentiate instruction. This paper presents a process used in an National…

  2. Data-Driven Decision Making in Practice: The NCAA Injury Surveillance System

    ERIC Educational Resources Information Center

    Klossner, David; Corlette, Jill; Agel, Julie; Marshall, Stephen W.

    2009-01-01

    Putting data-driven decision making into practice requires the use of consistent and reliable data that are easily accessible. The systematic collection and maintenance of accurate information is an important component in developing policy and evaluating outcomes. Since 1982, the National Collegiate Athletic Association (NCAA) has been collecting…

  3. Data-Driven Decision Making--Not Just a Buzz Word

    ERIC Educational Resources Information Center

    Kadel, Rob

    2010-01-01

    In education, data-driven decision making is a buzz word that has come to mean collecting absolutely as much data as possible on everything from attendance to zero tolerance, and then having absolutely no idea what to do with it. Most educational organizations with a plethora of data usually call in a data miner, or evaluator, to make some sense…

  4. A Perfect Time for Data Use: Using Data-Driven Decision Making to Inform Practice

    ERIC Educational Resources Information Center

    Mandinach, Ellen B.

    2012-01-01

    Data-driven decision making has become an essential component of educational practice across all levels, from chief state school officers to classroom teachers, and has received unprecedented attention in terms of policy and financial support. It was included as one of the four pillars in the American Recovery and Reinvestment Act (2009),…

  5. A communication model of shared decision making: accounting for cancer treatment decisions.

    PubMed

    Siminoff, Laura A; Step, Mary M

    2005-07-01

    The authors present a communication model of shared decision making (CMSDM) that explicitly identifies the communication process as the vehicle for decision making in cancer treatment. In this view, decision making is necessarily a sociocommunicative process whereby people enter into a relationship, exchange information, establish preferences, and choose a course of action. The model derives from contemporary notions of behavioral decision making and ethical conceptions of the doctor-patient relationship. This article briefly reviews the theoretical approaches to decision making, notes deficiencies, and embeds a more socially based process into the dynamics of the physician-patient relationship, focusing on cancer treatment decisions. In the CMSDM, decisions depend on (a) antecedent factors that have potential to influence communication, (b) jointly constructed communication climate, and (c) treatment preferences established by the physician and the patient. PMID:16045427

  6. What Is Known about Parents’ Treatment Decisions? A Narrative Review of Pediatric Decision Making

    PubMed Central

    Lipstein, Ellen A.; Brinkman, William B.; Britto, Maria T.

    2013-01-01

    Background With the increasing complexity of decisions in pediatric medicine, there is a growing need to understand the pediatric decision-making process. Objective To conduct a narrative review of the current research on parent decision making about pediatric treatments and identify areas in need of further investigation. Methods Articles presenting original research on parent decision making were identified from MEDLINE (1966–6/2011), using the terms “decision making,” “parent,” and “child.” We included papers focused on treatment decisions but excluded those focused on information disclosure to children, vaccination, and research participation decisions. Results We found 55 papers describing 52 distinct studies, the majority being descriptive, qualitative studies of the decision-making process, with very limited assessment of decision outcomes. Although parents’ preferences for degree of participation in pediatric decision making vary, most are interested in sharing the decision with the provider. In addition to the provider, parents are influenced in their decision making by changes in their child’s health status, other community members, prior knowledge, and personal factors, such as emotions and faith. Parents struggle to balance these influences as well as to know when to include their child in decision making. Conclusions Current research demonstrates a diversity of influences on parent decision making and parent decision preferences; however, little is known about decision outcomes or interventions to improve outcomes. Further investigation, using prospective methods, is needed in order to understand how to support parents through the difficult treatment decisions. PMID:21969136

  7. Visualization-based decision support for value-driven system design

    NASA Astrophysics Data System (ADS)

    Tibor, Elliott

    In the past 50 years, the military, communication, and transportation systems that permeate our world, have grown exponentially in size and complexity. The development and production of these systems has seen ballooning costs and increased risk. This is particularly critical for the aerospace industry. The inability to deal with growing system complexity is a crippling force in the advancement of engineered systems. Value-Driven Design represents a paradigm shift in the field of design engineering that has potential to help counteract this trend. The philosophy of Value-Driven Design places the desires of the stakeholder at the forefront of the design process to capture true preferences and reveal system alternatives that were never previously thought possible. Modern aerospace engineering design problems are large, complex, and involve multiple levels of decision-making. To find the best design, the decision-maker is often required to analyze hundreds or thousands of combinations of design variables and attributes. Visualization can be used to support these decisions, by communicating large amounts of data in a meaningful way. Understanding the design space, the subsystem relationships, and the design uncertainties is vital to the advancement of Value-Driven Design as an accepted process for the development of more effective, efficient, robust, and elegant aerospace systems. This research investigates the use of multi-dimensional data visualization tools to support decision-making under uncertainty during the Value-Driven Design process. A satellite design system comprising a satellite, ground station, and launch vehicle is used to demonstrate effectiveness of new visualization methods to aid in decision support during complex aerospace system design. These methods are used to facilitate the exploration of the feasible design space by representing the value impact of system attribute changes and comparing the results of multi-objective optimization formulations

  8. Cognitive Imaging in Visual Data-Driven Decision-Support Systems

    NASA Astrophysics Data System (ADS)

    Gorohov, V.; Vitkovskiy, V.

    2010-12-01

    Within data-driven types of decision-support systems (DDDSS, DSS), visual decision-support systems are those that try to inspire operator to find solution (decision) by producing visual representation of the data. Traditional approaches, that utilize traditional scientific visualization techniques such as 2D and 3D plots, vector fields, surface maps etc, works well when subject to represent is relatively simply structured data, low-dimensioned and weak interconnected. However, modern scientific experiments, as those in astrophysics observations, generate huge volumes of multidimensional complicated data. More sophisticated approach for visualizing of big volumes of multidimensional data is that based on the cognitive machine graphics techniques, which, for example, are used in visualization system Space Walker (SW). In contrast to illustrative ones, the cognitive images are aimed to make clear and evident some difficult scientific concepts and promote us with a new knowledge.

  9. Projection in surrogate decisions about life-sustaining medical treatments.

    PubMed

    Fagerlin, A; Ditto, P H; Danks, J H; Houts, R M; Smucker, W D

    2001-05-01

    To honor the wishes of an incapacitated patient, surrogate decision makers must predict the treatment decisions patients would make for themselves if able. Social psychological research, however, suggests that surrogates' own treatment preferences may influence their predictions of others' preferences. In 2 studies (1 involving 60 college student surrogates and a parent, the other involving 361 elderly outpatients and their chosen surrogate decision maker), surrogates predicted whether a close other would want life-sustaining treatment in hypothetical end-of-life scenarios and stated their own treatment preferences in the same scenarios. Surrogate predictions more closely resembled surrogates' own treatment wishes than they did the wishes of the individual they were trying to predict. Although the majority of prediction errors reflected inaccurate use of surrogates' own treatment preferences, projection was also found to result in accurate prediction more often than counterprojective predictions. The rationality and accuracy of projection in surrogate decision making is discussed. PMID:11403214

  10. Dubious delegation: Article III limits on mental health treatment decisions.

    PubMed

    Teitelbaum, Adam

    2012-06-01

    A common condition of supervised release requires a defendant, post-incarceration, to participate in a mental health treatment program. Federal district courts often order probation officers to make certain decisions ancillary to these programs. However, Article III delegation doctrine places limits on such actions. This Note addresses the constitutionality of delegating the "treatment program" decision, in which a probation officer decides which type of treatment the defendant must undergo; the choice is often between inpatient treatment and other less restrictive alternatives. The resolution of this issue ultimately depends on whether this decision constitutes a "judicial act." Finding support in lower court case law, this Note argues that a "judicial act" encompasses decisions affecting the defendant's significant liberty interests. The Supreme Court case law and the mental health literature make clear that significant liberty interests are at stake in these "treatment program" decisions. Thus, delegating the "treatment program" decision to probation officers is unconstitutional under Article III. The Note concludes by suggesting a constitutionally permissible scheme whereby the judge orders a maximally intrusive treatment while giving the probation officer the discretion to choose a less restrictive program. PMID:22708137

  11. Model-driven decision support for monitoring network design: methods and applications

    NASA Astrophysics Data System (ADS)

    Vesselinov, V. V.; Harp, D. R.; Mishra, P. K.; Katzman, D.

    2012-12-01

    A crucial aspect of any decision-making process for environmental management of contaminated sites and protection of groundwater resources is the identification of scientifically defensible remediation scenarios. The selected scenarios are ranked based on both their protective and cost effectiveness. The decision-making process is facilitated by implementation of site-specific data- and model-driven analyses for decision support (DS) taking into account existing uncertainties to evaluate alternative characterization and remedial activities. However, due to lack of data and/or complex interdependent uncertainties (conceptual elements, model parameters, measurement/computational errors, etc.), the DS optimization problem is ill posed (non unique) and the model-prediction uncertainties are difficult to quantify. Recently, we have developed and implemented several novel theoretical approaches and computational algorithms for model-driven decision support. New and existing DS tools have been employed for model analyses of the fate and extent of a chromium plume in the regional aquifer at Sandia Canyon Site, LANL. Since 2007, we have performed three iterations of DS analyses implementing different models, decision-making tools, and data sets providing guidance on design of a subsurface monitoring network for (1) characterization of the flow and transports processes, and (2) protection of the water users. The monitoring network is augmented by new wells at locations where acquired new data can effectively reduce uncertainty in model predicted contaminant concentrations. A key component of the DS analyses is contaminant source identification. Due to data and conceptual uncertainties, subsurface processes controlling the contaminant arrival at the top of the regional aquifer are not well defined. Nevertheless, the model-based analyses of the existing data and conceptual knowledge, including respective uncertainties, provide constrained probabilistic estimates of the

  12. Integrating complex business processes for knowledge-driven clinical decision support systems.

    PubMed

    Kamaleswaran, Rishikesan; McGregor, Carolyn

    2012-01-01

    This paper presents in detail the component of the Complex Business Process for Stream Processing framework that is responsible for integrating complex business processes to enable knowledge-driven Clinical Decision Support System (CDSS) recommendations. CDSSs aid the clinician in supporting the care of patients by providing accurate data analysis and evidence-based recommendations. However, the incorporation of a dynamic knowledge-management system that supports the definition and enactment of complex business processes and real-time data streams has not been researched. In this paper we discuss the process web service as an innovative method of providing contextual information to a real-time data stream processing CDSS. PMID:23366138

  13. Sim•TwentyFive: An Interactive Visualization System for Data-Driven Decision Support

    PubMed Central

    Stubbs, Brendan; Kale, David C.; Das, Amar

    2012-01-01

    Clinicians at the bedside are increasingly overwhelmed by an inundation of information and must rely largely on pattern recognition and professional experience to comprehend complex clinical data and treat their patients in a timely manner. Traditional decision support systems are based on rules and predictive models and often fail to take advantage of increasingly large digital clinical data stores available in real-time. We propose an alternative approach to delivering data-driven decision support based on an interactive system for exploring and visualizing a context of physiologically similar patients from a database. Here we present Sim•TwentyFive, a highly flexible, responsive, intuitive prototype with a comprehensive set of interaction techniques that effectively reduces the cognitive burden of querying, exploring, analyzing and comparing similar past patient episodes. Quantitative performance tests and anonymous summative evaluations from PICU physicians indicated that Sim•TwentyFive is an efficient, intuitive and clinically-useful tool. PMID:23304364

  14. Medulloblastoma development: tumor biology informs treatment decisions.

    PubMed

    Gopalakrishnan, Vidya; Tao, Rong-Hua; Dobson, Tara; Brugmann, William; Khatua, Soumen

    2015-01-01

    Medulloblastoma is the most common malignant pediatric brain tumor. Current treatments including surgery, craniospinal radiation and high-dose chemotherapy have led to improvement in survival. However, the risk for recurrence as well as significant long-term neurocognitive and endocrine sequelae associated with current treatment modalities underscore the urgent need for novel tumor-specific, normal brain-sparing therapies. It has also provided the impetus for research focused on providing a better understanding of medulloblastoma biology. The expectation is that such studies will lead to the identification of new therapeutic targets and eventually to an increase in personalized treatment approaches. PMID:25768332

  15. Development and initial evaluation of a treatment decision dashboard

    PubMed Central

    2013-01-01

    Background For many healthcare decisions, multiple alternatives are available with different combinations of advantages and disadvantages across several important dimensions. The complexity of current healthcare decisions thus presents a significant barrier to informed decision making, a key element of patient-centered care. Interactive decision dashboards were developed to facilitate decision making in Management, a field marked by similarly complicated choices. These dashboards utilize data visualization techniques to reduce the cognitive effort needed to evaluate decision alternatives and a non-linear flow of information that enables users to review information in a self-directed fashion. Theoretically, both of these features should facilitate informed decision making by increasing user engagement with and understanding of the decision at hand. We sought to determine if the interactive decision dashboard format can be successfully adapted to create a clinically realistic prototype patient decision aid suitable for further evaluation and refinement. Methods We created a computerized, interactive clinical decision dashboard and performed a pilot test of its clinical feasibility and acceptability using a multi-method analysis. The dashboard summarized information about the effectiveness, risks of side effects and drug-drug interactions, out-of-pocket costs, and ease of use of nine analgesic treatment options for knee osteoarthritis. Outcome evaluations included observations of how study participants utilized the dashboard, questionnaires to assess usability, acceptability, and decisional conflict, and an open-ended qualitative analysis. Results The study sample consisted of 25 volunteers - 7 men and 18 women - with an average age of 51 years. The mean time spent interacting with the dashboard was 4.6 minutes. Mean evaluation scores on scales ranging from 1 (low) to 7 (high) were: mechanical ease of use 6.1, cognitive ease of use 6.2, emotional difficulty 2

  16. Becoming Data Driven: The Influence of Teachers' Sense of Efficacy on Concerns Related to Data-Driven Decision Making

    ERIC Educational Resources Information Center

    Dunn, Karee E.; Airola, Denise T.; Lo, Wen-Juo; Garrison, Mickey

    2013-01-01

    Data-driven decision-making (DDDM) reform has proven to be an effective means for improving student learning. However, little DDDM reform has happened at the classroom level, and little research has explored variables that influence teacher adoption of DDDM. The authors propose a model in which teachers' sense of efficacy for the skills that…

  17. Patients' and parents' concerns and decisions about orthodontic treatment

    PubMed Central

    Aydoğan, Cihan; Alkan, Özer

    2016-01-01

    Objective Patients' and parents' expectations are important in orthodontic treatment decision making. The literature generally demonstrates the perceived benefits of orthodontic treatment, but patients' and their parents' concerns about orthodontic treatment have not been investigated comprehensively. The aim of this study was to identify patients' and parents' concerns about orthodontic treatment and compare them according to sex, age, and treatment demand level. Methods One hundred and eighty-nine children and their parents were interviewed about concerns related to orthodontic treatment. Patients and parents were asked about orthodontic treatment decisions. Answers were recorded as "yes," "no," or "don't know." Chi-squared and Fisher's exact tests were used to compare concerns between age groups, sexes, and treatment demand levels. Kappa statistics were used to assess agreement between patients and their parents. Results Concerns about orthodontic treatment were gathered under 10 items as follows: "feeling pain," "the appearance of braces," "being teased," "avoiding smiling," "speech problems," "dietary changes," "problems with transportation," "economic problems," "long treatment duration," and "missing school." There was no statistically significant difference in concerns between the sexes or age groups. Some concern items and treatment demand were inversely related in patients. Conclusions The results of this study demonstrate patients' and parents' concerns about orthodontic treatment. Differences between the concerns of patients with different treatment demands imply that children might reject orthodontic treatment because of their concerns. Appropriate consultation of patients addressing their concerns may help reduce anxiety and improve the acceptance of treatment. PMID:26877979

  18. Japanese physicians’ preferences for decision making in rheumatoid arthritis treatment

    PubMed Central

    Aoki, Akiko; Ohbu, Sadayoshi

    2016-01-01

    Background Rheumatoid arthritis (RA) is a complex chronic illness requiring continued medical care. During the past decade, the therapeutic options for RA have increased significantly; these often have a higher risk of adverse effects and are more expensive than traditional drugs. Rheumatologists may hence face difficulties when deciding on the optimal modality in initiating or changing treatment. The aim of this study was to explore the Japanese physicians’ usual style of and preferences for decision making regarding RA treatment. Methods This was a cross-sectional study conducted using an Internet survey. Respondents were asked about their usual style of making treatment decisions (perceived style), and their perception of the importance of physicians’ actions and patients’ attitudes. Results Of the 485 physicians who were sent the questionnaire, 157 responded completely (response rate: 32.3%). Ninety-two percent of the respondents were men, and 57% were clinicians with more than 20 years of experience. Their specialties were general medicine (29%), rheumatology (27%), orthopedics (31%), and rehabilitation (12%). Sixty-one (39%) stated that they usually presented multiple treatment options to their patients and selected a decision for them, 42 (27%) shared the decision making with their patients, 34 (22%) let their patients choose the treatment, and 20 (13%) made the treatment decision for the patients. Physicians using the shared decision making (SDM) style desired for their patients to have supportive family and friends, to discuss with nurses, and to follow the doctors’ directions more strongly compared with physicians using the other styles. There were no significant differences in sex, duration of clinical experience, major place of clinical work, and number of patients per month by the styles. More number of rheumatologists and physicians with specialist qualifications stated that they practiced SDM. Conclusion To enhance patient participation

  19. Understanding and Utilizing Patient Preferences in Cancer Treatment Decisions.

    PubMed

    Ubel, Peter A

    2016-05-01

    Shared decision-making is a complex endeavor that should take into account the patient's personal preferences regarding treatment options. To truly empower patients to be partners in decision-making, especially in situations in which their preferences are important, physicians must learn to communicate better and to distinguish between what is "medical fact" versus a "value judgement." Knowing what are, when to ask, and how to ask the right questions will help physicians be effective in guiding patients toward the right treatments. PMID:27226516

  20. Treatment Decisions for Children with Speech-Sound Disorders

    ERIC Educational Resources Information Center

    Kamhi, Alan G.

    2006-01-01

    PURPOSE: In this article, I consider how research, clinical expertise, client values, a clinician's theoretical perspective, and service delivery considerations affect the decisions that clinicians make to treat children with speech-sound disorders (SSD). METHOD: After reviewing the research on phonological treatment, I discuss how a clinician's…

  1. Decision Support System Development for the Treatment of Maladaptive Behaviors.

    ERIC Educational Resources Information Center

    Hile, Matthew G.; Desrochers, Marcie N.

    The Mental Retardation-Expert (MR-E) is a microcomputer based expert decision support system that provides practitioners with state of the art assistance in the treatment of aggressive, self injurious, and destructive behaviors displayed by individuals with mental retardation or developmental disabilities. This system, based on human experts and…

  2. Redefining self: patients' decision making about treatment for multiple sclerosis.

    PubMed

    Lowden, Diane; Lee, Virginia; Ritchie, Judith A

    2014-08-01

    The treatment of multiple sclerosis (MS) has become possible with the advent of disease-modifying therapies, but little is known about patients' experiences when faced with a complex array of treatment options. The purpose of this phenomenological study was to explore the lived experience of making a first decision about treatment with disease-modifying therapies for relapsing-remitting MS. Nine participants shared their perspectives on negotiating the decision to accept, refuse, or delay treatment. All individuals described a core theme in which decision making about treatment was part of a process of coming to a "redefined self." This core theme included reflections about self-image, quality of life, goals, and being a person with MS. Six common themes supporting this core theme were (a) weighing and deciding what's important, (b) acknowledging the illness as part of oneself, (c) playing the mental game, (d) seeking credible resources, (e) evaluating symptoms and fit with quality of life, and (f) managing the roles and involvement of family. The findings of this study provide a greater understanding about the experience of making a therapeutic choice for those with MS and offer insights for nurses when supporting patients faced with options about treatment. PMID:24875289

  3. Online Produced Water Treatment Catalog and Decision Tool

    SciTech Connect

    J. Arthur

    2012-03-31

    The objective of this project was to create an internet-based Water Treatment Technology Catalog and Decision Tool that will increase production, decrease costs and enhance environmental protection. This is to be accomplished by pairing an operator's water treatment cost and capacity needs to specific water treatments. This project cataloged existing and emerging produced water treatment technologies and allows operators to identify the most cost-effective approaches for managing their produced water. The tool captures the cost and capabilities of each technology and the disposal and beneficial use options for each region. The tool then takes location, chemical composition, and volumetric data for the operator's water and identifies the most cost effective treatment options for that water. Regulatory requirements or limitations for each location are also addressed. The Produced Water Treatment Catalog and Decision Tool efficiently matches industry decision makers in unconventional natural gas basins with: 1) appropriate and applicable water treatment technologies for their project, 2) relevant information on regulatory and legal issues that may impact the success of their project, and 3) potential beneficial use demands specific to their project area. To ensure the success of this project, it was segmented into seven tasks conducted in three phases over a three year period. The tasks were overseen by a Project Advisory Council (PAC) made up of stakeholders including state and federal agency representatives and industry representatives. ALL Consulting has made the catalog and decision tool available on the Internet for the final year of the project. The second quarter of the second budget period, work was halted based on the February 18, 2011 budget availability; however previous project deliverables were submitted on time and the deliverables for Task 6 and 7 were completed ahead of schedule. Thus the application and catalog were deployed to the public Internet

  4. Treatment limitation decisions under uncertainty: the value of subsequent euthanasia.

    PubMed

    Savulescu, Julian

    1994-01-01

    This paper examines how decisions to limit treatment to critically ill patients under uncertainty can be made rationally. Expected utility theory offers one way of making rational decisions under uncertainty. One problem with using this approach is that we may not know the value of each option. One rational course open is to treat until further information becomes available. However, treatment can limit the range of options open. With treatment, a patient may recover such that he no longer requires life-supporting treatment. However, his life may be not worth living. If active euthanasia of 'non-terminal' conditions is prohibited, the option of dying will no longer be available. Taking a rational 'wait and see' course may result in being trapped within an unbearable life. On the other hand, sometimes present practice 'lets nature take its course'. Critically ill patients are allowed to die because it is believed that their lives will be not worth living. It is likely that some patients are allowed to die when there is some objective chance of worthwhile future life. This paper argues that a policy of treating critically ill patients until the nature of future options can be better evaluated, in company with an offer of subsequent euthanasia where appropriate, allows a more rational and humane approach to treatment limitation decisions under uncertainty. PMID:11657375

  5. Teacher Capacity for and Beliefs about Data-Driven Decision Making: A Literature Review of International Research

    ERIC Educational Resources Information Center

    Datnow, Amanda; Hubbard, Lea

    2016-01-01

    Data-driven decision making continues to be a growing educational reform initiative across the globe. The effective use of data requires that teachers develop the knowledge and skills to analyze and use data to improve instruction. The purpose of this article is to examine teachers' capacity for and beliefs about data use. These issues are…

  6. Examining Data Driven Decision Making via Formative Assessment: A Confluence of Technology, Data Interpretation Heuristics and Curricular Policy

    ERIC Educational Resources Information Center

    Swan, Gerry; Mazur, Joan

    2011-01-01

    Although the term data-driven decision making (DDDM) is relatively new (Moss, 2007), the underlying concept of DDDM is not. For example, the practices of formative assessment and computer-managed instruction have historically involved the use of student performance data to guide what happens next in the instructional sequence (Morrison, Kemp, &…

  7. Data-Driven Decision Making: Vision to Know and Do. Backgrounder Brief. CoSN Essential Leadership Skills Series

    ERIC Educational Resources Information Center

    Consortium for School Networking (NJ1), 2005

    2005-01-01

    This Backgrounder Brief is an executive summary of "Data-Driven Decision Making: Vision to Know and Do," a component of CoSN's Essential Leadership Skills Series. Collecting student achievement data is nothing new in schools. But for all of the data gathered, many schools remain information poor. Educators are challenged to understand how to best…

  8. Educational Psychology's Instructional Challenge: Pre-Service Teacher Concerns Regarding Classroom-Level Data-Driven Decision-Making

    ERIC Educational Resources Information Center

    Dunn, Karee E.

    2016-01-01

    Data-driven decision-making (DDDM) is a difficult topic to cover, but typically required, in the applied educational psychology course or other courses required for teacher licensure in the United States. While a growing body of literature indicates in-service teachers are resistant to DDDM and underprepared to engage in it, little has been done…

  9. Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration.

    PubMed

    Pieterse, A H; Baas-Thijssen, M C M; Marijnen, C A M; Stiggelbout, A M

    2008-09-16

    Patient participation in treatment decision-making is being increasingly advocated, although cancer treatments are often guideline-driven. Trade-offs between benefits and side effects underlying guidelines are made by clinicians. Evidence suggests that clinicians are inaccurate at predicting patient values. The aim was to assess what role oncologists and cancer patients prefer in deciding about treatment, and how they view patient participation in treatment decision-making. Seventy disease-free cancer patients and 60 oncologists (surgical, radiation, and medical) were interviewed about their role preferences using the Control Preferences Scale (CPS) and about their views on patient participation using closed- and open-ended questions. Almost all participants preferred treatment decisions to be the outcome of a shared process. Clinicians viewed participation more often as reaching an agreement, whereas 23% of patients defined participation exclusively as being informed. Of the participants, > or = 81% thought not all patients are able to participate and > or = 74% thought clinicians are not always able to weigh the pros and cons of treatment for patients, especially not quality as compared with length of life. Clinicians seemed reluctant to share probability information on the likely impact of adjuvant treatment. Clinicians should acknowledge the legitimacy of patients' values in treatment decisions. Guidelines should recommend elicitation of patient values at specific decision points. PMID:18781148

  10. Breast cancer diagnosis and factors influencing treatment decisions in Ghana.

    PubMed

    Aziato, Lydia; Clegg-Lamptey, Joe Nat A

    2015-01-01

    Researchers in this study explored the reactions of women with breast cancer and identified factors influencing treatment decisions. A qualitative exploratory approach was employed. Participants were recruited from a tertiary hospital and a breast cancer support group. Purposive sampling recruited 12 women. It was found that women identified breast lesions accidentally or intentionally and that diagnosis was delayed. Emotional reactions to diagnosis included shock and sadness. Factors that influenced treatment were the influence of other people, alternative sources of treatment, faith and support, knowledge, "tuning the mind," and effects on intimacy. Health professionals should develop effective communication and counseling skills for clients. PMID:24750095

  11. Data-Driven Geospatial Visual Analytics for Real-Time Urban Flooding Decision Support

    NASA Astrophysics Data System (ADS)

    Liu, Y.; Hill, D.; Rodriguez, A.; Marini, L.; Kooper, R.; Myers, J.; Wu, X.; Minsker, B. S.

    2009-12-01

    Urban flooding is responsible for the loss of life and property as well as the release of pathogens and other pollutants into the environment. Previous studies have shown that spatial distribution of intense rainfall significantly impacts the triggering and behavior of urban flooding. However, no general purpose tools yet exist for deriving rainfall data and rendering them in real-time at the resolution of hydrologic units used for analyzing urban flooding. This paper presents a new visual analytics system that derives and renders rainfall data from the NEXRAD weather radar system at the sewershed (i.e. urban hydrologic unit) scale in real-time for a Chicago stormwater management project. We introduce a lightweight Web 2.0 approach which takes advantages of scientific workflow management and publishing capabilities developed at NCSA (National Center for Supercomputing Applications), streaming data-aware semantic content management repository, web-based Google Earth/Map and time-aware KML (Keyhole Markup Language). A collection of polygon-based virtual sensors is created from the NEXRAD Level II data using spatial, temporal and thematic transformations at the sewershed level in order to produce persistent virtual rainfall data sources for the animation. Animated color-coded rainfall map in the sewershed can be played in real-time as a movie using time-aware KML inside the web browser-based Google Earth for visually analyzing the spatiotemporal patterns of the rainfall intensity in the sewershed. Such system provides valuable information for situational awareness and improved decision support during extreme storm events in an urban area. Our further work includes incorporating additional data (such as basement flooding events data) or physics-based predictive models that can be used for more integrated data-driven decision support.

  12. Three-dimensional brain magnetic resonance imaging segmentation via knowledge-driven decision theory

    PubMed Central

    Verma, Nishant; Muralidhar, Gautam S.; Bovik, Alan C.; Cowperthwaite, Matthew C.; Burnett, Mark G.; Markey, Mia K.

    2014-01-01

    Abstract. Brain tissue segmentation on magnetic resonance (MR) imaging is a difficult task because of significant intensity overlap between the tissue classes. We present a new knowledge-driven decision theory (KDT) approach that incorporates prior information of the relative extents of intensity overlap between tissue class pairs for volumetric MR tissue segmentation. The proposed approach better handles intensity overlap between tissues without explicitly employing methods for removal of MR image corruptions (such as bias field). Adaptive tissue class priors are employed that combine probabilistic atlas maps with spatial contextual information obtained from Markov random fields to guide tissue segmentation. The energy function is minimized using a variational level-set-based framework, which has shown great promise for MR image analysis. We evaluate the proposed method on two well-established real MR datasets with expert ground-truth segmentations and compare our approach against existing segmentation methods. KDT has low-computational complexity and shows better segmentation performance than other segmentation methods evaluated using these MR datasets. PMID:26158060

  13. Ontology driven decision support for the diagnosis of mild cognitive impairment.

    PubMed

    Zhang, Xiaowei; Hu, Bin; Ma, Xu; Moore, Philip; Chen, Jing

    2014-03-01

    In recent years, mild cognitive impairment (MCI) has attracted significant attention as an indicator of high risk for Alzheimer's disease (AD), and the diagnosis of MCI can alert patient to carry out appropriate strategies to prevent AD. To avoid subjectivity in diagnosis, we propose an ontology driven decision support method which is an automated procedure for diagnosing MCI through magnetic resonance imaging (MRI). In this approach, we encode specialized MRI knowledge into an ontology and construct a rule set using machine learning algorithms. Then we apply these two parts in conjunction with reasoning engine to automatically distinguish MCI patients from normal controls (NC). The rule set is trained by MRI data of 187 MCI patients and 177 normal controls selected from Alzheimer's Disease Neuroimaging Initiative (ADNI) using C4.5 algorithm. By using a 10-fold cross validation, we prove that the performance of C4.5 with 80.2% sensitivity is better than other algorithms, such as support vector machine (SVM), Bayesian network (BN) and back propagation (BP) neural networks, and C4.5 is suitable for the construction of reasoning rules. Meanwhile, the evaluation results suggest that our approach would be useful to assist physicians efficiently in real clinical diagnosis for the disease of MCI. PMID:24468160

  14. A systematic review of decision aids for patients making a decision about treatment for early breast cancer.

    PubMed

    Nicholas Zdenkowski; Butow, Phyllis; Tesson, Stephanie; Boyle, Frances

    2016-04-01

    Several complex treatment decisions may be offered to women with early stage breast cancer, about a range of treatments from different modalities including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids can facilitate shared decision-making and improve decision-related outcomes. We aimed to systematically identify, describe and appraise the literature on treatment decision aids for women with early breast cancer, synthesise the data and identify breast cancer decisions that lack a decision aid. A prospectively developed search strategy was applied to MEDLINE, the Cochrane databases, EMBASE, PsycINFO, Web of Science and abstract databases from major conferences. Data were extracted into a pre-piloted form. Quality and risk of bias were measured using Qualsyst criteria. Results were synthesised into narrative format. Thirty-three eligible articles were identified, evaluating 23 individual treatment decision aids, comprising 13 randomised controlled trial reports, seven non-randomised comparative studies, eight single-arm pre-post studies and five cross-sectional studies. The decisions addressed by these decision aids were: breast conserving surgery versus mastectomy (+/- reconstruction); use of chemotherapy and/or endocrine therapy; radiotherapy; and fertility preservation. Outcome measures were heterogeneous, precluding meta-analysis. Decisional conflict decreased, and knowledge and satisfaction increased, without any change in anxiety or depression, in most studies. No studies were identified that evaluated decision aids for neoadjuvant systemic therapy, or contralateral prophylactic mastectomy. Decision aids are available and improved decision-related outcomes for many breast cancer treatment decisions including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids for neoadjuvant systemic therapy and contralateral prophylactic mastectomy could not be found, and may be warranted. PMID:27017240

  15. Comprehensive Risk-Based Diagnostically Driven Treatment Planning: Developing Sequentially Generated Treatment.

    PubMed

    Kois, Dean E; Kois, John C

    2015-07-01

    The clinical example presented in this article demonstrates a risk-based, diagnostically driven treatment planning approach by focusing on 4 key categories: periodontal, biomechanical, functional, dentofacial. In addition, our unique approach allowed the comprehensive clinical management of a patient with complex restorative needs. A full-mouth rehabilitation was completed sequentially without sacrificing the amount of dentistry necessary to restore health, comfort, function, and esthetics. The result exceeded the patient's expectation and was made financially possible by extending treatment over numerous years. PMID:26140967

  16. Unbiased estimation in seamless phase II/III trials with unequal treatment effect variances and hypothesis-driven selection rules.

    PubMed

    Robertson, David S; Prevost, A Toby; Bowden, Jack

    2016-09-30

    Seamless phase II/III clinical trials offer an efficient way to select an experimental treatment and perform confirmatory analysis within a single trial. However, combining the data from both stages in the final analysis can induce bias into the estimates of treatment effects. Methods for bias adjustment developed thus far have made restrictive assumptions about the design and selection rules followed. In order to address these shortcomings, we apply recent methodological advances to derive the uniformly minimum variance conditionally unbiased estimator for two-stage seamless phase II/III trials. Our framework allows for the precision of the treatment arm estimates to take arbitrary values, can be utilised for all treatments that are taken forward to phase III and is applicable when the decision to select or drop treatment arms is driven by a multiplicity-adjusted hypothesis testing procedure. © 2016 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd. PMID:27103068

  17. Data Science and its Relationship to Big Data and Data-Driven Decision Making.

    PubMed

    Provost, Foster; Fawcett, Tom

    2013-03-01

    Companies have realized they need to hire data scientists, academic institutions are scrambling to put together data-science programs, and publications are touting data science as a hot-even "sexy"-career choice. However, there is confusion about what exactly data science is, and this confusion could lead to disillusionment as the concept diffuses into meaningless buzz. In this article, we argue that there are good reasons why it has been hard to pin down exactly what is data science. One reason is that data science is intricately intertwined with other important concepts also of growing importance, such as big data and data-driven decision making. Another reason is the natural tendency to associate what a practitioner does with the definition of the practitioner's field; this can result in overlooking the fundamentals of the field. We believe that trying to define the boundaries of data science precisely is not of the utmost importance. We can debate the boundaries of the field in an academic setting, but in order for data science to serve business effectively, it is important (i) to understand its relationships to other important related concepts, and (ii) to begin to identify the fundamental principles underlying data science. Once we embrace (ii), we can much better understand and explain exactly what data science has to offer. Furthermore, only once we embrace (ii) should we be comfortable calling it data science. In this article, we present a perspective that addresses all these concepts. We close by offering, as examples, a partial list of fundamental principles underlying data science. PMID:27447038

  18. Capturing Treatment Decision Making Among Patients With Solid Tumors and Their Caregivers

    PubMed Central

    Jones, Randy A.; Steeves, Richard; Ropka, Mary E.; Hollen, Patricia

    2013-01-01

    Purpose/Objectives To examine the feasibility and acceptability of using a decision aid with an interactive decision-making process in patients with solid tumors and their caregivers during cancer-related treatment. Research Approach A phenomenologic approach was used to analyze qualitative data, with a focus on the meaning of participants’ lived experiences. Interviews were conducted by telephone or in person. Setting Outpatient clinics at two regional cancer centers. Participants 160 total individuals; 80 patients with newly diagnosed breast (n = 22), advanced-stage prostate (n = 19), or advanced-stage lung (n = 39) cancer, and their caregivers (n = 80). Methodologic Approach Twenty-seven of the 80 pairs engaged in audio recorded interviews that were conducted using a semistructured interview guide. Continuous text immersion revealed themes. Validity of qualitative analysis was achieved by member checking. Findings Significant findings included three themes: (a) the decision aid helped patients and caregivers understand treatment decisions better, (b) the decision aid helped patients and caregivers to be more involved in treatment decisions, and (c) frequent contact with the study nurse was valuable. Conclusions Decision making was more complex than participants expected. The decision aid helped patients and caregivers make satisfying treatment decisions and become integral in a shared treatment decision-making process. Interpretation Decision aids can help patients and their caregivers make difficult treatment decisions affecting quantity and quality of life during cancer treatment. The findings provide valuable information for healthcare providers helping patients and their caregivers make treatment decisions through a shared, informed, decision-making process. Knowledge Translation Decision aids can be helpful with treatment choices. Caregivers’ understanding about treatment is just as important in the decision-making process as the patients

  19. Dental caries: A complete changeover, PART III: Changeover in the treatment decisions and treatments

    PubMed Central

    Carounanidy, Usha; Sathyanarayanan, R

    2010-01-01

    Comprehensive management of dental caries should involve the management of disease as well as the lesion. Current decision making process in cariology is influenced by numerous factors such as the size/ depth/ activity of the carious lesion and age/ the caries risk status of the patient. Treatment decisions should involve planning the non-operative/ preventive treatment for non-cavitated or early cavitated lesions and also formulating operative treatment for cavitated lesions. Apart from these two responsibilities, a clinician should also be knowledgeable enough to decide when not to interfere in the caries dynamics and how frequently to recall the patient for follow-ups. The non-operative treatment prescriptions vary in dose, intensity and mode of delivery according to the caries risk status. Minimal invasion and maximal conservation of tooth structure has become the essence of current operative treatments. This part of the series elaborates on the paradigm shift in the management of dental caries. PMID:21217948

  20. Emotion and decision-making: affect-driven belief systems in anxiety and depression

    PubMed Central

    Paulus, Martin P.; Yu, Angela J.

    2012-01-01

    Emotion processing and decision-making are integral aspects of daily life. However, our understanding of the interaction between these constructs is limited. In this review, we summarize theoretical approaches to the link between emotion and decision-making, and focus on research with anxious or depressed individuals that reveals how emotions can interfere with decision-making. We integrate the emotional framework based on valence and arousal with a Bayesian approach to decision-making in terms of probability and value processing. We then discuss how studies of individuals with emotional dysfunctions provide evidence that alterations of decision-making can be viewed in terms of altered probability and value computation. We argue that the probabilistic representation of belief states in the context of partially observable Markov decision processes provides a useful approach to examine alterations in probability and value representation in individuals with anxiety and depression and outline the broader implications of this approach. PMID:22898207

  1. In Light of the Limitations of Data-Driven Decision Making

    ERIC Educational Resources Information Center

    Loeb, Susanna

    2012-01-01

    Students' experiences and the opportunities they have to learn rest on the quality of education decisions made in each classroom, in each school, in each district, and in each state, federal legislature, and department of education. The role of research and scholarship more broadly in education finance and policy is to inform these decisions for…

  2. Nonadjunctive Use of Continuous Glucose Monitoring for Diabetes Treatment Decisions.

    PubMed

    Castle, Jessica R; Jacobs, Peter G

    2016-09-01

    While self-monitoring of blood glucose (SMBG) is the current standard used by people with diabetes to manage glucose levels, recent improvements in accuracy of continuous glucose monitoring (CGM) technology are making it very likely that diabetes-related treatment decisions will soon be made based on CGM values alone. Nonadjunctive use of CGM will lead to a paradigm shift in how patients manage their glucose levels and will require substantial changes in how care providers educate their patients, monitor their progress, and provide feedback to help them manage their diabetes. The approval to use CGM nonadjunctively is also a critical step in the pathway toward FDA approval of an artificial pancreas system, which is further expected to transform diabetes care for people with type 1 diabetes. In this article, we discuss how nonadjunctive CGM is expected to soon replace routine SMBG and how this new usage scenario is expected to transform health outcomes and patient care. PMID:26880390

  3. Generalized Tumor Dose for Treatment Planning Decision Support

    NASA Astrophysics Data System (ADS)

    Zuniga, Areli A.

    Modern radiation therapy techniques allow for improved target conformity and normal tissue sparing. These highly conformal treatment plans have allowed dose escalation techniques increasing the probability of tumor control. At the same time this conformation has introduced inhomogeneous dose distributions, making delivered dose characterizations more difficult. The concept of equivalent uniform dose (EUD) characterizes a heterogeneous dose distribution within irradiated structures as a single value and has been used in biologically based treatment planning (BBTP); however, there are no substantial validation studies on clinical outcome data supporting EUD's use and therefore has not been widely adopted as decision-making support. These highly conformal treatment plans have also introduced the need for safety margins around the target volume. These margins are designed to minimize geometrical misses, and to compensate for dosimetric and treatment delivery uncertainties. The margin's purpose is to reduce the chance of tumor recurrence. This dissertation introduces a new EUD formulation designed especially for tumor volumes, called generalized Tumor Dose (gTD). It also investigates, as a second objective, margins extensions for potential improvements in local control while maintaining or minimizing toxicity. The suitability of gTD to rank LC was assessed by means of retrospective studies in a head and neck (HN) squamous cell carcinoma (SCC) and non-small cell lung cancer (NSCLC) cohorts. The formulation was optimized based on two datasets (one of each type) and then, model validation was assessed on independent cohorts. The second objective of this dissertation was investigated by ranking the probability of LC of the primary disease adding different margin sizes. In order to do so, an already published EUD formula was used retrospectively in a HN and a NSCLC datasets. Finally, recommendations for the viability to implement this new formulation into a routine treatment

  4. Exploring Data-Driven Decision-Making in the Field: How Faculty Use Data and Other Forms of Information to Guide Instructional Decision-Making. WCER Working Paper No. 2014-3

    ERIC Educational Resources Information Center

    Hora, Matthew T.; Bouwma-Gearhart, Jana; Park, Hyoung Joon

    2014-01-01

    A defining characteristic of current U.S. educational policy is the use of data to inform decisions about resource allocation, teacher hiring, and curriculum and instruction. Perhaps the biggest challenge to data-driven decision making (DDDM) is that data use alone does not automatically result in improved teaching and learning. Research indicates…

  5. Federal Policy to Local Level Decision-Making: Data Driven Education Planning in Nigeria

    ERIC Educational Resources Information Center

    Iyengar, Radhika; Mahal, Angelique R.; Felicia, Ukaegbu-Nnamchi Ifeyinwa; Aliyu, Balaraba; Karim, Alia

    2015-01-01

    This article discusses the implementation of local level education data-driven planning as implemented by the Office of the Senior Special Assistant to the President of Nigeria on the Millennium Development Goals (OSSAP-MDGs) in partnership with The Earth Institute, Columbia University. It focuses on the design and implementation of the…

  6. An MPEG-21-driven multimedia adaptation decision-taking engine based on constraint satisfaction problem

    NASA Astrophysics Data System (ADS)

    Feng, Xiao; Tang, Rui-chun; Zhai, Yi-li; Feng, Yu-qing; Hong, Bo-hai

    2013-07-01

    Multimedia adaptation decision-taking techniques based on context are considered. Constraint satisfaction problem-Based Content Adaptation Algorithm (CBCAA) is proposed. First the algorithm obtains and classifies context information using MPEG-21; then it builds the constraint model according to different types of context information, constraint satisfaction method is used to acquire Media Description Decision Set (MDDS); finally a bit-stream adaptation engine performs the multimedia transcoding. Simulation results prove that the presented algorithm offers an efficient solution for personalized multimedia adaptation in heterogeneous environments.

  7. The Call for Data-Driven Decision Making in the Midwest's Schools: NCREL's Response.

    ERIC Educational Resources Information Center

    Cromey, Allison; van der Ploeg, Arie; Masini, Blase

    This report describes the efforts of the North Central Regional Educational Laboratory (NCREL) during the last several years to respond to direct requests from educational stakeholders to help integrate data into their decision-making processes related to school improvement. In some cases, NCREL cooperated in the development of educational…

  8. Data-Driven Decision Making in Community Colleges: An Integrative Model for Institutional Effectiveness

    ERIC Educational Resources Information Center

    Callery, Claude Adam

    2012-01-01

    This qualitative study identified the best practices utilized by community colleges to achieve systemic and cultural agreement in support of the integration of institutional effectiveness measures (key performance indicators) to inform decision making. In addition, the study identifies the relevant motives, organizational structure, and processes…

  9. Keeping Teachers in the Center: A Framework of Data-Driven Decision-Making

    ERIC Educational Resources Information Center

    Light, Daniel; Wexler, Dara H.; Heinze, Juliette

    2004-01-01

    The Education Development Center's Center for Children and Technology (CCT) conducted a three year study of a large-scale data reporting system, developed by the Grow Network for New York City's Department of Education. This paper presents a framework based on two years of research exploring the intersection of decision-support technologies,…

  10. Data-Driven Decision-Making: It's a Catch-Up Game

    ERIC Educational Resources Information Center

    Briggs, Linda L.

    2006-01-01

    Having an abundance of data residing in individual silos across campus, but little decision-ready information, is a typical scenario at many institutions. One problem is that the terms "data warehousing" and "business intelligence" refer to very different things, although the two often go hand-in-hand. "Data warehousing" describes an architecture…

  11. A multi-agent-based, semantic-driven system for decision support in epidemic management.

    PubMed

    Li, Sen; Mackaness, William A

    2015-09-01

    Issues in epidemiology are truly multidisciplinary, requiring knowledge from diverse disciplines such as sociology, medicine, biology, geography and information science. Such inherent complexity has led to a challenge in developing decision support systems for epidemic information management, especially when data are from heterogeneous origins. In order to achieve a solution, an integrative framework is proposed. The Semantic Web is introduced in the context of enriching meaningful and machine-readable descriptions of epidemiological data. Software agents are utilised to achieve automation in semantic discovery, composition of data and process services. The objective is to enhance the performance in information retrieval in a dynamic decision-making environment while concealing technical complexity from inexperienced users. We illustrate how a prototype system can be developed by considering an epidemiology management scenario in which spatio-temporal analysis is undertaken of a specified epidemic. PMID:24448277

  12. Perturbations in Effort-Related Decision-Making Driven by Acute Stress and Corticotropin-Releasing Factor.

    PubMed

    Bryce, Courtney A; Floresco, Stan B

    2016-07-01

    Acute stress activates numerous systems in a coordinated effort to promote homeostasis, and can exert differential effects on mnemonic and cognitive functions depending on a myriad of factors. Stress can alter different forms of cost/benefit decision-making, yet the mechanisms that drive these effects, remain unclear. In the present study, we probed how corticotropin-releasing factor (CRF) may contribute to stress-induced alterations in cost/benefit decision-making, using an task where well-trained rats chose between a low effort/low reward lever (LR; two pellets) and a high effort/high reward lever (HR; four pellets), with the effort requirement increasing over a session (2, 5, 10, and 20 presses). One-hour restraint stress markedly reduced preference for the HR option, but this effect was attenuated by infusions of the CRF antagonist, alpha-helical CRF. Conversely, central CRF infusion mimicked the effect of stress on decision-making, as well as increased decision latencies and reduced response vigor. CRF infusions did not alter preference for larger vs smaller rewards, but did reduce responding for food delivered on a progressive ratio, suggesting that these treatments may amplify perceived effort costs that may be required to obtain rewards. CRF infusions into the ventral tegmental area recapitulated the effect of central CRF treatment and restraint on choice behavior, suggesting that these effects may be mediated by perturbations in dopamine transmission. These findings highlight the involvement of CRF in regulating effort-related decisions and suggest that increased CRF activity may contribute to motivational impairments and abnormal decision-making associated with stress-related psychiatric disorders such as depression. PMID:26830960

  13. Decision aids for localized prostate cancer treatment choice: Systematic review and meta-analysis.

    PubMed

    Violette, Philippe D; Agoritsas, Thomas; Alexander, Paul; Riikonen, Jarno; Santti, Henrikki; Agarwal, Arnav; Bhatnagar, Neera; Dahm, Philipp; Montori, Victor; Guyatt, Gordon H; Tikkinen, Kari A O

    2015-01-01

    Patients who are diagnosed with localized prostate cancer need to make critical treatment decisions that are sensitive to their values and preferences. The role of decision aids in facilitating these decisions is unknown. The authors conducted a systematic review of randomized trials of decision aids for localized prostate cancer. Teams of 2 reviewers independently identified, selected, and abstracted data from 14 eligible trials (n = 3377 men), of which 10 were conducted in North America. Of these, 11 trials compared decision aids with usual care, and 3 trials compared decision aids with other decision aids. Two trials suggested a modest positive impact on decisional regret. Results across studies varied widely for decisional conflict (4 studies), satisfaction with decision (2 studies), and knowledge (2 studies). No impact on treatment choices was observed (6 studies). In conclusion, scant evidence at high risk of bias suggests the variable impact of existing decision aids on a limited set of decisional processes and outcomes. Because current decision aids provide information but do not directly facilitate shared decision making, subsequent efforts would benefit from user-centered design of decision aids that promote shared decision making. PMID:25772796

  14. 76 FR 3077 - Notice of Decision To Revise a Heat Treatment Schedule for Emerald Ash Borer

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-19

    ... accordance with Sec. 305.3(a)(1), we published a notice \\2\\ in the Federal Register on August 25, 2010 (75 FR... Animal and Plant Health Inspection Service Notice of Decision To Revise a Heat Treatment Schedule for... are advising the public of our decision to revise a heat treatment schedule for the emerald ash...

  15. Virtual support for paediatric HIV treatment decision making

    PubMed Central

    Le Doare, Kirsty; Mackie, N E; Kaye, S; Bamford, A; Walters, S; Foster, C

    2015-01-01

    Objective The objective of this study is to review clinical outcomes of recommendations made by a multidisciplinary paediatric virtual clinic (PVC) for complex case management of paediatric HIV as a model of care within a tertiary network. Design A retrospective review of the clinical outcomes of paediatric and adolescent (0–21 years) referrals to the PVC at St. Mary's Hospital, Imperial College Healthcare NHS Trust, London was performed between October 2009 and November 2013. Results 234 referrals were made for 182 children from 37 centres, discussed in 42 meetings (median age 13 years, IQR 10–15 years). Reasons for referral included virological failure (44%), simplification of the current regimen (24%) and antiretroviral drug complications (24%). At latest follow-up, PVC advice had been instituted in 80% of referrals. Suppression following virological failure was achieved in 48% following first referral and 57% following subsequent discussions and was maintained in 95% of children referred for regimen simplification. Following advice, dyslipidaemia resolved in 42% and liver function normalised in 73% with biochemical hepatitis. Adherence support aided resolution of viraemia in nine children and 12% of referrals resulted in additional support, including psychology, social services and mental health input. Conclusions Combined multidisciplinary virtual input with adult expertise in resistance and newer agents, paediatric knowledge of pill swallowing, childhood formulations/weight banding and parental support, assists complex treatment decision making in paediatric HIV infection. The Virtual Clinic model could be applied to the management of other rare complex diseases of childhood within a clinical network. PMID:25549664

  16. Data Driven Farming: Delivering the Benefits of Remotely Sensed Data and Decision Support Tools to Farmers

    NASA Astrophysics Data System (ADS)

    Shriver, J.; Soloff, J. A.; Molen, N.

    2014-12-01

    Web-based agricultural management software allows for the delivery of previously hard to access soil, weather and remotely sensed data to growers. While access to these data sources is beneficial, growers can realize large gains by leveraging field level data and integrating decision support tools that have been presented in the literature. Using a previously developed model for estimating the growth stage of maize (Sakamoto et al. 2010), we examine how remotely sensed data can be integrated into a web-based agricultural management tool, informing grower management decisions by providing near real-time estimates of crop growth stage and sub-field level variability in growing conditions. When combined with field-level soil and weather data, growers can use remote sensing based models to tailor management activities, taking variable (climate related) and invariant (site characteristic) yield determining factors into account.Time series of Wide Dynamic Range Vegetation Index (WDRVI) derived from Landsat observations were linked to 97 fields growing maize across the Mid-western region of the United States in 2013. Crop growth stage day of year (DOY) estimates (V2.5, R1, R5, and R6) were predicted for each field based on the WDRVI profile and compared to a growing degree day based estimate. These estimates aid in scheduling growth stage specific management activities and allow farmers to more efficiently monitor geographically remote fields. Within-field variation in growing conditions is presented on an ordinal scale (below average, average, above average) based on the field-level distribution of WDRVI values at each observation. Monitoring of sub-field level conditions allows growers to calibrate field-level yield estimates, prioritize field scouting activities and plan targeted interventions. Integration of these tools into existing web-based agricultural management tools allows growers to easily incorporate remotely sensed data into their decision making process

  17. Demand driven decision support for efficient water resources allocation in irrigated agriculture

    NASA Astrophysics Data System (ADS)

    Schuetze, Niels; Grießbach, Ulrike Ulrike; Röhm, Patric; Stange, Peter; Wagner, Michael; Seidel, Sabine; Werisch, Stefan; Barfus, Klemens

    2014-05-01

    Due to climate change, extreme weather conditions, such as longer dry spells in the summer months, may have an increasing impact on the agriculture in Saxony (Eastern Germany). For this reason, and, additionally, declining amounts of rainfall during the growing season the use of irrigation will be more important in future in Eastern Germany. To cope with this higher demand of water, a new decision support framework is developed which focuses on an integrated management of both irrigation water supply and demand. For modeling the regional water demand, local (and site-specific) water demand functions are used which are derived from the optimized agronomic response at farms scale. To account for climate variability the agronomic response is represented by stochastic crop water production functions (SCWPF) which provide the estimated yield subject to the minimum amount of irrigation water. These functions take into account the different soil types, crops and stochastically generated climate scenarios. By applying mathematical interpolation and optimization techniques, the SCWPF's are used to compute the water demand considering different constraints, for instance variable and fix costs or the producer price. This generic approach enables the computation for both multiple crops at farm scale as well as of the aggregated response to water pricing at a regional scale for full and deficit irrigation systems. Within the SAPHIR (SAxonian Platform for High Performance Irrigation) project a prototype of a decision support system is developed which helps to evaluate combined water supply and demand management policies for an effective and efficient utilization of water in order to meet future demands. The prototype is implemented as a web-based decision support system and it is based on a service-oriented geo-database architecture.

  18. Towards a climate-driven dengue decision support system for Thailand

    NASA Astrophysics Data System (ADS)

    Lowe, Rachel; Cazelles, Bernard; Paul, Richard; Rodó, Xavier

    2014-05-01

    Dengue is a peri-urban mosquito-transmitted disease, ubiquitous in the tropics and the subtropics. The geographic distribution of dengue and its more severe form, dengue haemorrhagic fever (DHF), have expanded dramatically in the last decades and dengue is now considered to be the world's most important arboviral disease. Recent demographic changes have greatly contributed to the acceleration and spread of the disease along with uncontrolled urbanization, population growth and increased air travel, which acts as a mechanism for transporting and exchanging dengue viruses between endemic and epidemic populations. The dengue vector and virus are extremely sensitive to environmental conditions such as temperature, humidity and precipitation that influence mosquito biology, abundance and habitat and the virus replication speed. In order to control the spread of dengue and impede epidemics, decision support systems are required that take into account the multi-faceted array of factors that contribute to increased dengue risk. Due to availability of seasonal climate forecasts, that predict the average climate conditions for forthcoming months/seasons in both time and space, there is an opportunity to incorporate precursory climate information in a dengue decision support system to aid epidemic planning months in advance. Furthermore, oceanic indicators from teleconnected areas in the Pacific and Indian Ocean, that can provide some indication of the likely prevailing climate conditions in certain regions, could potentially extend predictive lead time in a dengue early warning system. In this paper we adopt a spatio-temporal Bayesian modelling framework for dengue in Thailand to support public health decision making. Monthly cases of dengue in the 76 provinces of Thailand for the period 1982-2012 are modelled using a multi-layered approach. Environmental explanatory variables at various spatial and temporal resolutions are incorporated into a hierarchical model in order to

  19. Information technology and decision support tools for stakeholder-driven river basin salinity management

    SciTech Connect

    Quinn, N.W.T; Cozad, D.B.; Lee, G.

    2010-01-01

    Innovative strategies for effective basin-scale salinity management have been developed in the Hunter River Basin of Australia and more recently in the San Joaquin River Basin of California. In both instances web-based stakeholder information dissemination has been a key to achieving a high level of stakeholder involvement and the formulation of effective decision support salinity management tools. A common element to implementation of salinity management strategies in both river basins has been the concept of river assimilative capacity for controlling export salt loading and the potential for trading of the right to discharge salt load to the river - the Hunter River in Australia and the San Joaquin River in California. Both rivers provide basin drainage and the means of exporting salt to the ocean. The paper compares and contrasts the use of monitoring, modeling and information dissemination in the two basins to achieve environmental compliance and sustain irrigated agriculture in an equitable and socially and politically acceptable manner.

  20. The Decision to Engage Cognitive Control Is Driven by Expected Reward-Value: Neural and Behavioral Evidence

    PubMed Central

    Dixon, Matthew L.; Christoff, Kalina

    2012-01-01

    Cognitive control is a fundamental skill reflecting the active use of task-rules to guide behavior and suppress inappropriate automatic responses. Prior work has traditionally used paradigms in which subjects are told when to engage cognitive control. Thus, surprisingly little is known about the factors that influence individuals' initial decision of whether or not to act in a reflective, rule-based manner. To examine this, we took three classic cognitive control tasks (Stroop, Wisconsin Card Sorting Task, Go/No-Go task) and created novel ‘free-choice’ versions in which human subjects were free to select an automatic, pre-potent action, or an action requiring rule-based cognitive control, and earned varying amounts of money based on their choices. Our findings demonstrated that subjects' decision to engage cognitive control was driven by an explicit representation of monetary rewards expected to be obtained from rule-use. Subjects rarely engaged cognitive control when the expected outcome was of equal or lesser value as compared to the value of the automatic response, but frequently engaged cognitive control when it was expected to yield a larger monetary outcome. Additionally, we exploited fMRI-adaptation to show that the lateral prefrontal cortex (LPFC) represents associations between rules and expected reward outcomes. Together, these findings suggest that individuals are more likely to act in a reflective, rule-based manner when they expect that it will result in a desired outcome. Thus, choosing to exert cognitive control is not simply a matter of reason and willpower, but rather, conforms to standard mechanisms of value-based decision making. Finally, in contrast to current models of LPFC function, our results suggest that the LPFC plays a direct role in representing motivational incentives. PMID:23284730

  1. The decision to engage cognitive control is driven by expected reward-value: neural and behavioral evidence.

    PubMed

    Dixon, Matthew L; Christoff, Kalina

    2012-01-01

    Cognitive control is a fundamental skill reflecting the active use of task-rules to guide behavior and suppress inappropriate automatic responses. Prior work has traditionally used paradigms in which subjects are told when to engage cognitive control. Thus, surprisingly little is known about the factors that influence individuals' initial decision of whether or not to act in a reflective, rule-based manner. To examine this, we took three classic cognitive control tasks (Stroop, Wisconsin Card Sorting Task, Go/No-Go task) and created novel 'free-choice' versions in which human subjects were free to select an automatic, pre-potent action, or an action requiring rule-based cognitive control, and earned varying amounts of money based on their choices. Our findings demonstrated that subjects' decision to engage cognitive control was driven by an explicit representation of monetary rewards expected to be obtained from rule-use. Subjects rarely engaged cognitive control when the expected outcome was of equal or lesser value as compared to the value of the automatic response, but frequently engaged cognitive control when it was expected to yield a larger monetary outcome. Additionally, we exploited fMRI-adaptation to show that the lateral prefrontal cortex (LPFC) represents associations between rules and expected reward outcomes. Together, these findings suggest that individuals are more likely to act in a reflective, rule-based manner when they expect that it will result in a desired outcome. Thus, choosing to exert cognitive control is not simply a matter of reason and willpower, but rather, conforms to standard mechanisms of value-based decision making. Finally, in contrast to current models of LPFC function, our results suggest that the LPFC plays a direct role in representing motivational incentives. PMID:23284730

  2. A Requirements-Driven Optimization Method for Acoustic Treatment Design

    NASA Technical Reports Server (NTRS)

    Berton, Jeffrey J.

    2016-01-01

    Acoustic treatment designers have long been able to target specific noise sources inside turbofan engines. Facesheet porosity and cavity depth are key design variables of perforate-over-honeycomb liners that determine levels of noise suppression as well as the frequencies at which suppression occurs. Layers of these structures can be combined to create a robust attenuation spectrum that covers a wide range of frequencies. Looking to the future, rapidly-emerging additive manufacturing technologies are enabling new liners with multiple degrees of freedom, and new adaptive liners with variable impedance are showing promise. More than ever, there is greater flexibility and freedom in liner design. Subject to practical considerations, liner design variables may be manipulated to achieve a target attenuation spectrum. But characteristics of the ideal attenuation spectrum can be difficult to know. Many multidisciplinary system effects govern how engine noise sources contribute to community noise. Given a hardwall fan noise source to be suppressed, and using an analytical certification noise model to compute a community noise measure of merit, the optimal attenuation spectrum can be derived using multidisciplinary systems analysis methods. The subject of this paper is an analytical method that derives the ideal target attenuation spectrum that minimizes noise perceived by observers on the ground.

  3. Landfill leachate treatment by solar-driven AOPs

    SciTech Connect

    Rocha, Elisangela M.R.; Vilar, Vitor J.P.; Boaventura, Rui A.R.; Fonseca, Amelia; Saraiva, Isabel

    2011-01-15

    Sanitary landfill leachate resulting from the rainwater percolation through the landfill layers and waste material decomposition is a complex mixture of high-strength organic and inorganic compounds which constitutes serious environmental problems. In this study, different heterogeneous (TiO{sub 2}/UV, TiO{sub 2}/H{sub 2}O{sub 2}/UV) and homogenous (H{sub 2}O{sub 2}/UV, Fe{sup 2+}/H{sub 2}O{sub 2}/UV) photocatalytic processes were investigated as an alternative for the treatment of a mature landfill leachate. The addition of H{sub 2}O{sub 2} to TiO{sub 2}/UV system increased the reduction of the aromatic compounds from 15% to 61%, although mineralization was almost the same. The DOC and aromatic content abatement is similar for the H{sub 2}O{sub 2}/UV and TiO{sub 2}/H{sub 2}O{sub 2}/UV processes, although the H{sub 2}O{sub 2} consumption is three times higher in the H{sub 2}O{sub 2}/UV system. The low efficiency of TiO{sub 2}/H{sub 2}O{sub 2}/UV system is presumably due to the alkaline leachate solution, for which the H{sub 2}O{sub 2} becomes highly unstable and self-decomposition of H{sub 2}O{sub 2} occurs. The efficiency of the TiO{sub 2}/H{sub 2}O{sub 2}/UV system increased 10 times after a preliminary pH correction to 4. The photo-Fenton process is much more efficient than heterogeneous (TiO{sub 2}, TiO{sub 2}/H{sub 2}O{sub 2}/UV) or homogeneous (H{sub 2}O{sub 2}/UV) photocatalysis, showing an initial reaction rate more than 20 times higher, and leading to almost complete mineralization of the wastewater. However, when compared with TiO{sub 2}/H{sub 2}O{sub 2}/UV with acidification, the photo-Fenton reaction is only two times faster. The optimal initial iron dose for the photo-Fenton treatment of the leachate is 60 mg Fe{sup 2+} L{sup -1}, which is in agreement with path length of 5 cm in the photoreactor. The kinetic behaviour of the process (60 mg Fe{sup 2+} L{sup -1}) comprises a slow initial reaction, followed by a first-order kinetics (k = 0.020 LkJ{sub UV

  4. Data-driven modeling of hydroclimatic trends and soil moisture: Multi-scale data integration and decision support

    NASA Astrophysics Data System (ADS)

    Coopersmith, Evan Joseph

    -identical topography. This cross-application of parametric calibrations and LiDAR-driven disaggregation facilitates decision-support at locations without proximally-located soil moisture sensors.

  5. Predictive decision making driven by multiple time-linked reward representations in the anterior cingulate cortex

    PubMed Central

    Wittmann, Marco K.; Kolling, Nils; Akaishi, Rei; Chau, Bolton K. H.; Brown, Joshua W.; Nelissen, Natalie; Rushworth, Matthew F. S.

    2016-01-01

    In many natural environments the value of a choice gradually gets better or worse as circumstances change. Discerning such trends makes predicting future choice values possible. We show that humans track such trends by comparing estimates of recent and past reward rates, which they are able to hold simultaneously in the dorsal anterior cingulate cortex (dACC). Comparison of recent and past reward rates with positive and negative decision weights is reflected by opposing dACC signals indexing these quantities. The relative strengths of time-linked reward representations in dACC predict whether subjects persist in their current behaviour or switch to an alternative. Computationally, trend-guided choice can be modelled by using a reinforcement-learning mechanism that computes a longer-term estimate (or expectation) of prediction errors. Using such a model, we find a relative predominance of expected prediction errors in dACC, instantaneous prediction errors in the ventral striatum and choice signals in the ventromedial prefrontal cortex. PMID:27477632

  6. Agricultural Management Decision Aids Driven by Real-Time Satellite Data.

    NASA Astrophysics Data System (ADS)

    Diak, George R.; Anderson, Martha C.; Bland, William L.; Norman, John M.; Mecikalski, John M.; Aune, Robert M.

    1998-07-01

    In a NASA-sponsored program entitled Use of Earth and Space Science Data Over the Internet, scientists at the University of Wisconsin-Madison have developed a suite of products for agriculture that are based in satellite and conventional observations, as well as state-of-the-art forecast models of the atmosphere and soil_canopy environments. These products include an irrigation scheduling product based in satellite estimates of daily solar energy, a frost protection product that relies on prediction models and satellite estimates of clouds, and a product for the prediction of foliar disease that is based in satellite net radiation, rainfall measured by NEXRAD, and a detailed model of the soil_canopy environment. During the growing season, the first two products are available in near-real time on the Internet. The last product involving foliar disease depends on a decision support system named WISDOM developed by the University of Wisconsin-Extension, which resides locally on growers' home computers. Growers interface WISDOM with a server to obtain the rainfall, meteorological data, surface radiation inputs, and canopy model output required by WISDOM for the blight models.

  7. Predictive decision making driven by multiple time-linked reward representations in the anterior cingulate cortex.

    PubMed

    Wittmann, Marco K; Kolling, Nils; Akaishi, Rei; Chau, Bolton K H; Brown, Joshua W; Nelissen, Natalie; Rushworth, Matthew F S

    2016-01-01

    In many natural environments the value of a choice gradually gets better or worse as circumstances change. Discerning such trends makes predicting future choice values possible. We show that humans track such trends by comparing estimates of recent and past reward rates, which they are able to hold simultaneously in the dorsal anterior cingulate cortex (dACC). Comparison of recent and past reward rates with positive and negative decision weights is reflected by opposing dACC signals indexing these quantities. The relative strengths of time-linked reward representations in dACC predict whether subjects persist in their current behaviour or switch to an alternative. Computationally, trend-guided choice can be modelled by using a reinforcement-learning mechanism that computes a longer-term estimate (or expectation) of prediction errors. Using such a model, we find a relative predominance of expected prediction errors in dACC, instantaneous prediction errors in the ventral striatum and choice signals in the ventromedial prefrontal cortex. PMID:27477632

  8. Teachers' Experiences with the Data-Driven Decision Making Process in Increasing Students' Reading Achievement in a Title I Elementary Public School

    ERIC Educational Resources Information Center

    Atkinson, Linton

    2015-01-01

    This paper is a research dissertation based on a qualitative case study conducted on Teachers' Experiences within a Data-Driven Decision Making (DDDM) process. The study site was a Title I elementary school in a large school district in Central Florida. Background information is given in relation to the need for research that was conducted on the…

  9. What Teachers Think about What They Can Do with Data: Development and Validation of the Data Driven Decision-Making Efficacy and Anxiety Inventory

    ERIC Educational Resources Information Center

    Dunn, Karee E.; Airola, Denise T.; Lo, Wen-Juo; Garrison, Mickey

    2013-01-01

    Classroom level data driven decision-making (DDDM) involves the use of data to identify patterns of performance that reveal students' academic strengths and weaknesses relative to established learning goals, and the planning of instructional practices to support academic success for all students. Although DDDM is not a new paradigm in education,…

  10. Data-Driven Decision Making and Its Effects on Leadership Practices and Student Achievement in K-5 Public Elementary Schools in California

    ERIC Educational Resources Information Center

    Ceja, Rafael, Jr.

    2012-01-01

    The enactment of the NCLB Act of 2001 and its legislative mandates for accountability testing throughout the nation brought to the forefront the issue of data-driven decision making. This emphasis on improving education has been spurred due to the alleged failure of the public school system. As a result, the role of administrators has evolved to…

  11. Operative Versus Nonoperative Treatment of Jones Fractures: A Decision Analysis Model.

    PubMed

    Bishop, Julius A; Braun, Hillary J; Hunt, Kenneth J

    2016-01-01

    Optimal management of metadiaphyseal fifth metatarsal fractures (Jones fractures) remains controversial. Decision analysis can optimize clinical decision-making based on available evidence and patient preferences. We conducted a study to establish the determinants of decision-making and to determine the optimal treatment strategy for Jones fractures using a decision analysis model. Probabilities for potential outcomes of operative and nonoperative treatment of Jones fractures were determined from a review of the literature. Patient preferences for outcomes were obtained by questionnaire completed by 32 healthy adults with no history of foot fracture. Derived values were used in the model as a measure of utility. A decision tree was constructed, and fold-back and sensitivity analyses were performed to determine optimal treatment. Nonoperative treatment was associated with a value of 7.74, and operative treatment with an intramedullary screw was associated with a value of 7.88 given the outcome probabilities and utilities studied, making operative treatment the optimal strategy. When parameters were varied, nonoperative treatment was favored when the likelihood of healing with nonoperative treatment rose above 82% and when the probability of healing after surgery fell below 92%. In this decision analysis model, operative fixation is the preferred management strategy for Jones fractures. PMID:26991586

  12. An ontology-driven, case-based clinical decision support model for removable partial denture design.

    PubMed

    Chen, Qingxiao; Wu, Ji; Li, Shusen; Lyu, Peijun; Wang, Yong; Li, Miao

    2016-01-01

    We present the initial work toward developing a clinical decision support model for specific design of removable partial dentures (RPDs) in dentistry. We developed an ontological paradigm to represent knowledge of a patient's oral conditions and denture component parts. During the case-based reasoning process, a cosine similarity algorithm was applied to calculate similarity values between input patients and standard ontology cases. A group of designs from the most similar cases were output as the final results. To evaluate this model, the output designs of RPDs for 104 randomly selected patients were compared with those selected by professionals. An area under the curve of the receiver operating characteristic (AUC-ROC) was created by plotting true-positive rates against the false-positive rate at various threshold settings. The precision at position 5 of the retrieved cases was 0.67 and at the top of the curve it was 0.96, both of which are very high. The mean average of precision (MAP) was 0.61 and the normalized discounted cumulative gain (NDCG) was 0.74 both of which confirmed the efficient performance of our model. All the metrics demonstrated the efficiency of our model. This methodology merits further research development to match clinical applications for designing RPDs. This paper is organized as follows. After the introduction and description of the basis for the paper, the evaluation and results are presented in Section 2. Section 3 provides a discussion of the methodology and results. Section 4 describes the details of the ontology, similarity algorithm, and application. PMID:27297679

  13. An ontology-driven, case-based clinical decision support model for removable partial denture design

    PubMed Central

    Chen, Qingxiao; Wu, Ji; Li, Shusen; Lyu, Peijun; Wang, Yong; Li, Miao

    2016-01-01

    We present the initial work toward developing a clinical decision support model for specific design of removable partial dentures (RPDs) in dentistry. We developed an ontological paradigm to represent knowledge of a patient’s oral conditions and denture component parts. During the case-based reasoning process, a cosine similarity algorithm was applied to calculate similarity values between input patients and standard ontology cases. A group of designs from the most similar cases were output as the final results. To evaluate this model, the output designs of RPDs for 104 randomly selected patients were compared with those selected by professionals. An area under the curve of the receiver operating characteristic (AUC-ROC) was created by plotting true-positive rates against the false-positive rate at various threshold settings. The precision at position 5 of the retrieved cases was 0.67 and at the top of the curve it was 0.96, both of which are very high. The mean average of precision (MAP) was 0.61 and the normalized discounted cumulative gain (NDCG) was 0.74 both of which confirmed the efficient performance of our model. All the metrics demonstrated the efficiency of our model. This methodology merits further research development to match clinical applications for designing RPDs. This paper is organized as follows. After the introduction and description of the basis for the paper, the evaluation and results are presented in Section 2. Section 3 provides a discussion of the methodology and results. Section 4 describes the details of the ontology, similarity algorithm, and application. PMID:27297679

  14. Geriatric consultation can aid in complex treatment decisions for elderly cancer patients.

    PubMed

    Schiphorst, A H W; Ten Bokkel Huinink, D; Breumelhof, R; Burgmans, J P J; Pronk, A; Hamaker, M E

    2016-05-01

    Treatment decisions for elderly cancer patients can be challenging. A geriatric assessment may identify unknown medical conditions, give insight on patients' ability to tolerate treatment and guide treatment decisions. Our aim was to study the value of a geriatric consultation in oncological decision-making. Data on cancer patients referred for geriatric consultation for clinical optimisation or due to uncertainty regarding their optimal treatment strategy were prospectively analysed. Outcome of geriatric evaluations, non-oncological interventions and suggested adaptations of oncological treatment proposals were evaluated. Seventy-two patients were referred for consultation, over half of which in a curative treatment setting. Prevalence of geriatric syndromes was 93%, previously undiagnosed conditions were identified in 49% of patients and non-oncological interventions were initiated in 56%. Time was spent discussing patients' priorities (53% of consultations), expectations on treatment (50%) and advance care planning (14%). For 82% of patients, suggestions were made regarding the optimal treatment decision: a more intensive treatment was recommended in 39%, a less intensive therapy for 42% and in 19% only supportive care was suggested. The results demonstrate that a geriatric consultation can aid in complex treatment decisions and may allow for a reduction in over- and undertreatment of elderly cancer patients. PMID:26211484

  15. onlineDeCISion.org: a web-based decision aid for DCIS treatment.

    PubMed

    Ozanne, Elissa M; Schneider, Katharine H; Soeteman, Djøra; Stout, Natasha; Schrag, Deborah; Fordis, Michael; Punglia, Rinaa S

    2015-11-01

    Women diagnosed with DCIS face complex treatment decisions and often do so with inaccurate and incomplete understanding of the risks and benefits involved. Our objective was to create a tool to guide these decisions for both providers and patients. We developed a web-based decision aid designed to provide clinicians with tailored information about a patient’s recurrence risks and survival outcomes following different treatment strategies for DCIS. A theoretical framework, microsimulation model (Soeteman et al., J Natl Cancer 105:774–781, 2013) and best practices for web-based decision tools guided the development of the decision aid. The development process used semi-structured interviews and usability testing with key stakeholders, including a diverse group of multidisciplinary clinicians and a patient advocate. We developed onlineDeCISion.​org to include the following features that were rated as important by the stakeholders: (1) descriptions of each of the standard treatment options available; (2) visual projections of the likelihood of time-specific (10-year and lifetime) breast-preservation, recurrence, and survival outcomes; and (3) side-by-side comparisons of down-stream effects of each treatment choice. All clinicians reviewing the decision aid in usability testing were interested in using it in their clinical practice. The decision aid is available in a web-based format and is planned to be publicly available. To improve treatment decision making in patients with DCIS, we have developed a web-based decision aid onlineDeCISion.​org that conforms to best practices and that clinicians are interested in using in their clinics with patients to better inform treatment decisions. PMID:26475704

  16. Older Adults Newly Diagnosed with Symptomatic Myeloma Want to Participate in Treatment Decision Making

    PubMed Central

    Tariman, Joseph D.; Doorenbos, Ardith; Schepp, Karen G.; Singhal, Seema; Berry, Donna L.

    2014-01-01

    Purpose/Objectives The purpose of the study was to describe the preferences for participation in decision making of older patients newly diagnosed with symptomatic myeloma and to explore the association between sociodemographic variables and decisional role preferences. Design Descriptive, cross sectional design Setting Subjects’ homes and two large academic cancer centers. Sample The convenience sample consisted of 20 older adults (60 years of age and above) with symptomatic myeloma diagnosed within the past 6 months. Methods The Control Preferences Scale was administered followed by an in-person one-time semi-structured interview. Main Research Variables Role preferences for participation in treatment decision-making, age, gender, race, work status, personal relationship status, education, and income. Findings 55% (n=11) of the subjects had preferred a shared role with the physician and 40% (n=8) had preferred to make the decisions after seriously considering the opinion of their physicians. Only one subject preferred to leave the decision to the doctor as long as the doctor considered the patient’s treatment preferences. Sociodemographic characteristics had no impact on preferences for participation in treatment decision-making. Conclusions The study findings indicate that older adults newly diagnosed with myeloma wanted to participate during treatment decision-making. Oncology nurses must respect the patient's desired role preference and oncology clinicians must listen to the patient and allow them to be autonomous in making treatment decisions if the patient so desire such control in the decision-making process. A culture of equipoise between the patient and the clinician during TDM must be cultivated in order to achieve the patient's desired level of participation. More studies that focus on supporting and involving patients diagnosed with myeloma in the decision-making process are needed in order to influence clinical practice and policy. Practice

  17. The Appleton Consensus: suggested international guidelines for decisions to forgo medical treatment.

    PubMed

    1989-03-13

    Thirty-three physicians, bioethicists, and medical economists from ten different countries met at Lawrence University, Appleton, Wisconsin, to create The Appleton Consensus: International Guidelines for Decisions to Forgo Medical Treatment. The guidelines deal with four specific decision-making circumstances. 1. Five guidelines were created for decisions involving competent patients or patients who executed an advance directive before becoming incompetent, and those guidelines fell into three categories. 2. Thirteen guidelines were created for decisions involving patients who were once competent, but are not now competent, who have not executed an advance directive. 3. Seven guidelines were created for decisions involving patients who are not now and never have been competent, for whom "no substituted judgment" can be rendered. 4. Eleven guidelines were created for decisions involving the scarcity of medical resources, which exists in all communities. Five concepts were identified as being critical in the establishment of priorities given the reality of scarce health resources. PMID:2929046

  18. Integrating Strategic and Operational Decision Making Using Data-Driven Dashboards: The Case of St. Joseph Mercy Oakland Hospital.

    PubMed

    Jack Weiner; Balijepally, Venugopal; Tanniru, Mohan

    2015-01-01

    Hospitals have invested and continue to invest heavily in building information systems to support operations at various levels of administration. These systems generate a lot of data but fail to effectively convert these data into actionable information for decision makers. Such ineffectiveness often is attributed to a lack of alignment between strategic planning and information technology (IT) initiatives supporting operational goals. We present a case study that illustrates how the use of digital dashboards at St. Joseph Mercy Oakland (SJMO) Hospital in Pontiac, Michigan, was instrumental in supporting such an alignment. Driven by a focus on key performance indicators (KPIs), dashboard applications also led to other tangible and intangible benefits. An ability to track KPIs over time and against established targets, with drill-down capabilities, allowed leadership to hold staff members accountable for achieving their performance targets. By displaying the dashboards in prominent locations (such as operational unit floors, the physicians' cafeteria, and nursing stations), SJMO ushered in transparency in the planning and monitoring processes. The need to develop KPI metrics and drive data collection efforts became ingrained in the work ethos of people at every level of the organization. Although IT-enabled dashboards have been instrumental in supporting this cultural transformation, the focus of investment was the ability of technology to make collective vision and action the responsibility of all stakeholders. PMID:26554142

  19. SLUDGE TREATMENT PROJECT KOP CONCEPTUAL DESIGN CONTROL DECISION REPORT

    SciTech Connect

    CARRO CA

    2010-03-09

    This control decision addresses the Knock-Out Pot (KOP) Disposition KOP Processing System (KPS) conceptual design. The KPS functions to (1) retrieve KOP material from canisters, (2) remove particles less than 600 {micro}m in size and low density materials from the KOP material, (3) load the KOP material into Multi-Canister Overpack (MCO) baskets, and (4) stage the MCO baskets for subsequent loading into MCOs. Hazard and accident analyses of the KPS conceptual design have been performed to incorporate safety into the design process. The hazard analysis is documented in PRC-STP-00098, Knock-Out Pot Disposition Project Conceptual Design Hazard Analysis. The accident analysis is documented in PRC-STP-CN-N-00167, Knock-Out Pot Disposition Sub-Project Canister Over Lift Accident Analysis. Based on the results of these analyses, and analyses performed in support of MCO transportation and MCO processing and storage activities at the Cold Vacuum Drying Facility (CVDF) and Canister Storage Building (CSB), control decision meetings were held to determine the controls required to protect onsite and offsite receptors and facility workers. At the conceptual design stage, these controls are primarily defined by their safety functions. Safety significant structures, systems, and components (SSCs) that could provide the identified safety functions have been selected for the conceptual design. It is anticipated that some safety SSCs identified herein will be reclassified based on hazard and accident analyses performed in support of preliminary and detailed design.

  20. A Pathway to Personalization of Integrated Treatment: Informatics and Decision Science in Psychiatric Rehabilitation

    PubMed Central

    Spaulding, William; Deogun, Jitender

    2011-01-01

    Personalization of treatment is a current strategic goal for improving health care. Integrated treatment approaches such as psychiatric rehabilitation benefit from personalization because they involve matching diverse arrays of treatment options to individually unique profiles of need. The need for personalization is evident in the heterogeneity of people with severe mental illness and in the findings of experimental psychopathology. One pathway to personalization lies in analysis of the judgments and decision making of human experts and other participants as they respond to complex circumstances in pursuit of treatment and rehabilitation goals. Such analysis is aided by computer simulation of human decision making, which in turn informs development of computerized clinical decision support systems. This inspires a research program involving concurrent development of databases, domain ontology, and problem-solving algorithms, toward the goal of personalizing psychiatric rehabilitation through human collaboration with intelligent cyber systems. The immediate hurdle is to demonstrate that clinical decisions beyond diagnosis really do affect outcome. This can be done by supporting the hypothesis that a human treatment team with access to a reasonably comprehensive clinical database that tracks patient status and treatment response over time achieves better outcome than a treatment team without such access, in a controlled experimental trial. Provided the hypothesis can be supported, the near future will see prototype systems that can construct an integrated assessment, formulation, and rehabilitation plan from clinical assessment data and contextual information. This will lead to advanced systems that collaborate with human decision makers to personalize psychiatric rehabilitation and optimize outcome. PMID:21860042

  1. Treatment decisions based on scalar and functional baseline covariates.

    PubMed

    Ciarleglio, Adam; Petkova, Eva; Ogden, R Todd; Tarpey, Thaddeus

    2015-12-01

    The amount and complexity of patient-level data being collected in randomized-controlled trials offer both opportunities and challenges for developing personalized rules for assigning treatment for a given disease or ailment. For example, trials examining treatments for major depressive disorder are not only collecting typical baseline data such as age, gender, or scores on various tests, but also data that measure the structure and function of the brain such as images from magnetic resonance imaging (MRI), functional MRI (fMRI), or electroencephalography (EEG). These latter types of data have an inherent structure and may be considered as functional data. We propose an approach that uses baseline covariates, both scalars and functions, to aid in the selection of an optimal treatment. In addition to providing information on which treatment should be selected for a new patient, the estimated regime has the potential to provide insight into the relationship between treatment response and the set of baseline covariates. Our approach can be viewed as an extension of "advantage learning" to include both scalar and functional covariates. We describe our method and how to implement it using existing software. Empirical performance of our method is evaluated with simulated data in a variety of settings and also applied to data arising from a study of patients with major depressive disorder from whom baseline scalar covariates as well as functional data from EEG are available. PMID:26111145

  2. Development of instruments to measure the quality of breast cancer treatment decisions

    PubMed Central

    Lee, Clara N.; Dominik, Rosalie; Levin, Carrie A.; Barry, Michael J.; Cosenza, Carol; O’Connor, Annette M.; Mulley, Albert G.; Sepucha, Karen R.

    2010-01-01

    Background Women with early stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what’s most important to an informed patient. Reliable and valid measures of patients’ knowledge and their goals and concerns related to breast cancer treatments are needed to assess decision quality. Objective To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction, and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them. Methods Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance, and completeness of the items were examined. Results 38 facts (11–14 per decision) and 27 goals (8–10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals. Conclusion Overall, breast cancer patients and providers found the sets of facts and goals accurate, important, and complete for three treatment decisions. Because patients’ and providers’ perspectives are different, it is vital that instrument development should include items reflecting both views. PMID:20550591

  3. The Role of Culture in Families' Treatment Decisions for Children with Autism Spectrum Disorders

    ERIC Educational Resources Information Center

    Mandell, David S.; Novak, Maytali

    2005-01-01

    There is little information available about how and why parents of children with autism spectrum disorders (ASD) make decisions regarding which of the many available treatments to implement with their children. Given the lack of available information regarding treatment efficacy, it is likely that parents' beliefs about child development,…

  4. Intergenerational Differences and Similarities in Life-Sustaining Treatment Attitudes and Decision Factors.

    ERIC Educational Resources Information Center

    Mills, Terry L.; Wilmoth, Janet M.

    2002-01-01

    A cross-sectional sample of three-generation families was used to evaluate life-sustaining medical treatment attitudes and decision factors. Results show that the older generation perceived mental capacity, family burden, and pain as most important considerations. Among the middle generation the type of life-sustaining treatment was important. The…

  5. The Effects of Treatment Needs and Prior Social Services Use on Juvenile Court Decision Making

    ERIC Educational Resources Information Center

    Schwalbe, Craig S.; Hatcher, Schnavia Smith; Maschi, Tina

    2009-01-01

    Every year, juvenile court judges commit large numbers of delinquent youths to institutional placements. Prior research indicates that both legal and extra-legal factors influence this decision-making process. Less frequently examined is the role of treatment needs and prior social services use. This study examined the influence of treatment needs…

  6. Reducing Aversion to Side Effects in Preventive Medical Treatment Decisions

    ERIC Educational Resources Information Center

    Waters, Erika A.; Weinstein, Neil D.; Colditz, Graham A.; Emmons, Karen M.

    2007-01-01

    Laypeople tend to be overly sensitive to side effects of treatments that prevent illness, possibly leading them to refuse beneficial therapies. This Internet-based study attempted to reduce such side effect aversion by adding graphic displays to the numerical risk probabilities. It also explored whether graphics reduce side effect aversion by…

  7. Neural correlates of decision making after unfair treatment

    PubMed Central

    Wu, Yan; Zang, Yufeng; Yuan, Binke; Tian, Xuehong

    2015-01-01

    Empirical evidence indicates that people are inequity averse. However, it is unclear whether and how suffering unfairness impacts subsequent behavior. We investigated the consequences of unfair treatment in subsequent interactions with new interaction partners and the associated neural mechanisms. Participants were experimentally manipulated to experience fair or unfair treatment in the ultimatum game (UG), and subsequently, they were given the opportunity to retaliate in the dictator game (DG) in their interactions with players who had not played a role in the previous fair or unfair treatment. The results showed that participants dictated less money to unrelated partners after frequently receiving unfair offers in the previous UG (vs. frequently receiving fair offers in the previous UG), but only when they were first exposed to unfair UG/DG. Stronger activation in the right dorsal anterior insula was found during receiving unfair offers and during the subsequent offer-considering phase. The regional homogeneity (ReHo), a measure of the local synchronization of neighboring voxels in resting-state brain activity, in the left ventral anterior insula and left superior temporal pole was positively correlated with the behavior change. These findings suggest that unfair treatment may encourage a spread of unfairness, and that the anterior insula may be not only engaged in signaling social norm violations, but also recruited in guiding subsequent adaptive behaviors. PMID:25798102

  8. The influence of family ties on men's prostate cancer screening, biopsy, and treatment decisions.

    PubMed

    Shaw, Eric K; Scott, John G; Ferrante, Jeanne M

    2013-11-01

    Extensive research has focused on understanding family dynamics of men with prostate cancer. However, little qualitative work has examined the role of family ties on men's prostate cancer decisions across the spectrum of screening, diagnosis, and treatment. Using data from a larger study, we qualitatively explored the influence of family ties on men's prostate cancer decisions. Semistructured interviews were conducted with men ages ≥50 (N = 64), and data were analyzed using a grounded theory approach and a series of immersion/crystallization cycles. Three major themes of spousal/family member influence were identified: (a) spousal/family member alliance marked by open communication and shared decision making, (b) men who actively opposed spouse/family member pressure and made final decisions themselves, and (c) men who yielded to spouse/family member pressure. Our findings provide insights into men's relational dynamics that are important to consider for the shared decision-making process across the prostate cancer spectrum. PMID:23459024

  9. Physician, Patient and Contextual Factors Affecting Treatment Decisions in Older Adults with Cancer: A Literature Review

    PubMed Central

    Tariman, J. D.; Berry, D. L.; Cochrane, B.; Doorenbos, A.; Schepp, K.

    2010-01-01

    Purpose/Objectives To review physician, patient, and contextual factors that affect treatment decision-making in older adults diagnosed with cancer and relate these factors to theoretical models of decision-making. Data Sources PubMed (1966-April 2010), PsycINFO (1967-April 2010) and CINAHL (1982-April 2010) databases were searched to access relevant medical, psychological and nursing literature. Data Synthesis Physician factors in treatment decisions include physician personal beliefs and values, expertise, practice type, perception of lowered life expectancy, medical factors, power, and communication style. Patient factors include personal beliefs and values, ethnicity, decisional control preferences, previous health-related experience, perception of the decision-making process, and personal factors. Contextual factors include availability of caregiver, lack of insurance, poor financial status, and geographical barrier. The interplay of physician, patient, and contextual factors are not well understood. Existing models of decision-making are not sufficient to explicate TDM process in older adults diagnosed with cancer. Conclusions Clinical studies in older adult patient population using a longitudinal and prospective design are needed to examine real-time interplay of patient, physician, and contextual factors and to better understand how these divergent factors influenced actual treatment decisions. Implications for Nursing Oncology nurses can advocate for a patient’s autonomy during TDM by coaching them to seek evidence-based discussion of various treatment options, benefits and risks assessments, and truthful discussion of the probability of success for each treatment option from their physicians. Oncology nurses must promote an informed treatment decisions that are consistent with a patient’s personal preference and values within the limits of the patient’s personal contexts. PMID:22201670

  10. Management of hypertensive crises: the scientific basis for treatment decisions.

    PubMed

    Blumenfeld, J D; Laragh, J H

    2001-11-01

    The spectrum of disorders associated with an elevated blood pressure (BP) encompasses chronic uncomplicated hypertension and the hypertensive crises, including hypertensive urgencies and emergencies. Although these syndromes vary widely in their presentations, clinical courses, and outcomes they share pathophysiologic mechanisms and, consequently, therapeutic responses to specifically targeted antihypertensive drug types. Nevertheless, hypertensive crises are often treated with drugs which, in that setting are either unsafe or are of unsubstantiated efficacy. The purpose of this review is to examine the pathophysiology of commonly encountered hypertensive crises, including stroke, hypertensive encephalopathy, aortic dissection, acute pulmonary edema, and preeclampsia-eclampsia and to provide a rational approach to their treatment based upon relevant pathophysiologic and pharmacologic principles. Measurement of plasma renin activity (PRA) level often provides insight regarding pathophysiology and predicts efficacy of antihypertensive treatments in the individual patient. However, in hypertensive crises, drug therapy is initiated before the PRA level is known. Nevertheless, the renin-angiotensin dependence (R-type) or volume dependence (V-type) of hypertension can often be deduced by the BP response to drugs that interrupt the renin system (R-drugs) or that decrease body volume (V-drugs). Based upon these considerations, a treatment algorithm is provided to guide drug selection in patients presenting with a hypertensive crisis. PMID:11724216

  11. Physiology-driven adaptive virtual reality stimulation for prevention and treatment of stress related disorders.

    PubMed

    Cosić, Kresimir; Popović, Sinisa; Kukolja, Davor; Horvat, Marko; Dropuljić, Branimir

    2010-02-01

    The significant proportion of severe psychological problems related to intensive stress in recent large peacekeeping operations underscores the importance of effective methods for strengthening the prevention and treatment of stress-related disorders. Adaptive control of virtual reality (VR) stimulation presented in this work, based on estimation of the person's emotional state from physiological signals, may enhance existing stress inoculation training (SIT). Physiology-driven adaptive VR stimulation can tailor the progress of stressful stimuli delivery to the physiological characteristics of each individual, which is indicated for improvement in stress resistance. Following an overview of physiology-driven adaptive VR stimulation, its major functional subsystems are described in more detail. A specific algorithm of stimuli delivery applicable to SIT is outlined. PMID:20528296

  12. Removal of fluorine from contaminated soil by electrokinetic treatment driven by solar energy.

    PubMed

    Zhou, Ming; Zhu, Shufa; Liu, Yana; Wang, Xuejian

    2013-08-01

    Instead of direct current power supply, a series of electrokinetic remediation experiments driven by solar energy on fluorine-contaminated soil were conducted in a self-made electrolyzer, in order to reduce energy expenditure of electrokinetic remediation. After the 12-day electrokinetic remediation driven by solar energy, the removal efficiency of fluorine was 22.3%, and electrokinetic treatment had an impact on changes in partitioning of fluorine in soil. It proved that the combination of electrokinetics and solar energy was feasible and effective to some extent for the remediation of fluorine-contaminated soil. Meanwhile, the experimental results also indicated that the electromigration was a more dominant transport mechanism for the removal of fluorine from contaminated soil than electroosmosis, and the weather condition was the important factor in affecting the removal efficiency. PMID:23475445

  13. Decision regret following treatment for localized breast cancer: is regret stable over time?

    PubMed Central

    Martinez, Kathryn A.; Li, Yun; Resnicow, Ken; Graff, John J.; Hamilton, Ann S.; Hawley, Sarah T

    2015-01-01

    Background While studies suggest most women have little regret regarding their breast cancer treatment decisions immediately following treatment, to date no studies have evaluated how regret may change over time. Objective To measure the stability of post-treatment decision regret over time among women with breast cancer. Methods Women diagnosed with breast cancer between August 2005 and May 2007 reported to the Detroit, Michigan or Los Angeles County Surveillance Epidemiology and End Results (SEER) registry completed surveys at 9 months following diagnosis (Time 1) and again approximately 4 years later (Time 2). A decision regret scale consisting of 5 items was summed to create two decision regret scores at both Time 1 and Time 2 (range: 0 to 20). Multivariable linear regression was used to examine change in regret from 9 months to 4 years. Independent variables included surgery type, receipt of reconstruction, and recurrence status at follow-up. The model controlled for demographic and clinical factors. Results The analytic sample included 1,536 women. Mean regret in the overall sample was 4.9 at Time 1 and 5.4 at Time 2 (p<0.001). In the multivariable linear model, we found no difference in change in decision regret over time by surgery type. Reporting a new diagnosis of breast cancer at Time 2 was associated with 2.6 point increase in regret over time, compared to women without an additional diagnosis (p=0.003). Receipt of reconstruction was not associated with change in decision regret over time. Conclusions Decision regret following treatment was low and relatively stable over time for most women. Those facing an additional diagnosis of breast cancer following treatment may be at risk for elevated regret-related distress. PMID:25532824

  14. Confidentiality and treatment decisions of minor clients: a health professional's dilemma & policy makers challenge.

    PubMed

    Jackson, Margot Karen; Burns, Katharina Kovacs; Richter, Magdalena S

    2014-01-01

    Issues relating to confidentiality and consent for physical and mental health treatment with minor clients can pose challenges health care providers. Decisions need to be made regarding these issues despite the absence of clear, direct, or comprehensive policies and legislation. In order to fully understand the scope of this topic, a systemic review of several pieces of legislation and guidelines related to this topic are examined. These include the: Canadian Human Rights Act, Children's Rights: International and National Laws and Practices, Health Information Act, Gillick Competence and Medical Emancipation, Freedom of Information and Protection of Privacy Act, Child, Youth and Family Enhancement Act, Common Law Mature Minor Doctrine, and Alberta Health Services Consent to Treatment/Practice(s) Minor/Mature Minor. In order to assist health professionals with decisions regarding confidentiality and treatment with minor clients a case study and guide for decision-making is also presented. PMID:25032089

  15. Conflict and user involvement in drug misuse treatment decision-making: a qualitative study

    PubMed Central

    Fischer, Jan; Neale, Joanne; Bloor, Michael; Jenkins, Nicholas

    2008-01-01

    Background This paper examines client/staff conflict and user involvement in drug misuse treatment decision-making. Methods Seventy-nine in-depth interviews were conducted with new treatment clients in two residential and two community drug treatment agencies. Fifty-nine of these clients were interviewed again after twelve weeks. Twenty-seven interviews were also conducted with staff, who were the keyworkers for the interviewed clients. Results Drug users did not expect, desire or prepare for conflict at treatment entry. They reported few actual conflicts within the treatment setting, but routinely discussed latent conflicts – that is, negative experiences and problematic aspects of current or previous treatment that could potentially escalate into overt disputes. Conflict resulted in a number of possible outcomes, including the premature termination of treatment; staff deciding on the appropriate outcome; the client appealing to the governance structure of the agency; brokered compromise; and staff skilfully eliciting client consent for staff decisions. Conclusion Although the implementation of user involvement in drug treatment decision-making has the potential to trigger high levels of staff-client conflict, latent conflict is more common than overt conflict and not all conflict is negative. Drug users generally want to be co-operative at treatment entry and often adopt non-confrontational forms of covert resistance to decisions about which they disagree. Staff sometimes deploy user involvement as a strategy for managing conflict and soliciting client compliance to treatment protocols. Suggestions for minimising and avoiding harmful conflict in treatment settings are given. PMID:18837989

  16. Inflammation (or synovitis)-driven osteoarthritis: an opportunity for personalizing prognosis and treatment?

    PubMed

    Siebuhr, A S; Bay-Jensen, A C; Jordan, J M; Kjelgaard-Petersen, C F; Christiansen, C; Abramson, S B; Attur, M; Berenbaum, F; Kraus, V; Karsdal, M A

    2016-03-01

    The disabling and painful disease osteoarthritis (OA) is the most common form of arthritis. Strong evidence suggests that a subpopulation of OA patients has a form of OA driven by inflammation. Consequently, understanding when inflammation is the driver of disease progression and which OA patients might benefit from anti-inflammatory treatment is a topic of intense research in the OA field. We have reviewed the current literature on OA, with an emphasis on inflammation in OA, biochemical markers of structural damage, and anti-inflammatory treatments for OA. The literature suggests that the OA patient population is diverse, consisting of several subpopulations, including one associated with inflammation. This inflammatory subpopulation may be identified by a combination of novel serological inflammatory biomarkers. Preliminary evidence from small clinical studies suggests that this subpopulation may benefit from anti-inflammatory treatment currently reserved for other inflammatory arthritides. PMID:26484849

  17. Combine or Separate Future Pain? The Impact of Current Pain on Decisions about Future Dental Treatments

    PubMed Central

    Andrade, Eduardo B.; Bianchini, Marco Aurélio; Lucchiari, Newton

    2013-01-01

    Patients are often given the option of undergoing future painful treatments in one or multiple sessions (e.g., extracting two wisdom teeth on one or two different days). In a randomized controlled field experiment, we investigated the impact of transient pain on patients’ decision to combine or separate future periodontal treatments. The main results show that most patients preferred to have the future treatments take place in one session when they made their choice after a painless examination (i.e., general clinical exam). However, the patients’ preference for combining the future treatments did not differ from chance when the choice was made immediately following a painful examination (i.e., pocketing and bleeding on probing exam). The impact of pain on decision making is observed within and between participants. Current pain seems to lead patients to question their ability to endure future painful treatments in one session. PMID:23704972

  18. The nurse's role in treatment decisions for the child with neurological impairment.

    PubMed

    Duffy, Lisa V

    2009-10-01

    Healthcare providers are often faced with ethical dilemmas when making treatment decisions for a child with neurological impairment. Problems may stem from the fact that the wishes of the family may be in opposition to what the healthcare team feels is in the best interest of the child. There are many factors that need to be considered when determining treatment options for the child with neurological impairment. Nurses are in a unique position to advocate for the involvement of the child's family in making these difficult decisions. PMID:19835240

  19. The medical visit context of treatment decision-making and the therapeutic relationship.

    PubMed

    Roter, Debra

    2000-03-01

    The ascendance of the autonomy paradigm in treatment decision-making has evolved over the past several decades to the point where few bioethicists would question that it is the guiding value driving health-care provider behaviour. In achieving quasi-legal status, decision-making has come to be regarded as a formality largely removed from the broader context of medical communication and the therapeutic relationship within which care is delivered. Moreover, disregard for individual patient preference, resistance, reluctance, or incompetence has at times produced pro forma and useless autonomy rituals. Failures of this kind, have been largely attributed to the psychological dynamics of the patients, physicians, illnesses, and contexts that characterize the medical decision. There has been little attempt to provide a framework for accommodating or understanding the larger social context and social influences that contribute to this variation. Applying Paulo Freire's participatory social orientation model to the context of the medical visit suggests a framework for viewing the impact of physicians' communication behaviours on patients' capacity for treatment decision-making. Physicians' use of communication strategies can act to reinforce an experience of patient dependence or self-reliance in regard to the patient-physician relationship generally and treatment decision-making, in particular. Certain communications enhance patient participation in the medical visit's dialogue, contribute to patient engagement in problem posing and problem-solving, and finally, facilitate patient confidence and competence to undertake autonomous action. The purpose of this essay is to place treatment decision-making within the broader context of the therapeutic relationship, and to describe ways in which routine medical visit communication can accommodate individual patient preferences and help develop and further patient capacity for autonomous decision-making. PMID:11281908

  20. Understanding decisions made about hepatitis C treatment by couples who inject drugs.

    PubMed

    Treloar, C; Rance, J; Bryant, J; Fraser, S

    2016-02-01

    Efforts to increase the number of people having hepatitis C virus (HCV) treatment require understanding how to best deliver services to meet consumers' needs. The general health literature has examined the role that partners can play in supporting health outcomes. This study examines the experiences of couples who inject drugs in relation to knowledge of, decisions about and management of HCV treatment. This is a qualitative interview study of people who inject drugs in couples. Participants were recruited from harm reduction services in two major Australian cities. Couples were interviewed separately. Data were examined using the couple as the unit of analysis and to identify patterns of experience related to the HCV serostatus of couples. Knowledge of HCV and HCV treatment was low and variable but showed some relationship to serostatus. Decisions about HCV treatment were deeply informed by concerns regarding treatment side effects. Positive concordant couples considered 'staging' treatment to ensure that each partner could (in turn) care for the other. People with HCV in serodiscordant relationships may need specific support regarding HCV treatment information. Within positive concordant partnerships, our data indicated the need to support the HCV-positive 'carer' during their partner's treatment. Changing treatment regimens, and their anticipated lower side effect profiles, will need to be actively promoted to ensure that couples understand how these changes affect their treatment options. PMID:26305873

  1. Decision making for HIV prevention and treatment scale up: Bridging the gap between theory and practice

    PubMed Central

    Alistar, Sabina S.; Brandeau, Margaret L.

    2011-01-01

    Background Effectively controlling the HIV epidemic will require efficient use of limited resources. Despite ambitious global goals for HIV prevention and treatment scale up, few comprehensive practical tools exist to inform such decisions. Methods We briefly summarize modeling approaches for resource allocation for epidemic control, and discuss the practical limitations of these models. We describe typical challenges of HIV resource allocation in practice and some of the tools used by decision makers. We identify the characteristics needed in a model that can effectively support planners in decision making about HIV prevention and treatment scale up. Results An effective model to support HIV scale-up decisions will be flexible, with capability for parameter customization and incorporation of uncertainty. Such a model needs certain key technical features: it must capture epidemic effects; account for how intervention effectiveness depends on the target population and the level of scale up; capture benefit and cost differentials for packages of interventions versus single interventions, including both treatment and prevention interventions; incorporate key constraints on potential funding allocations; identify optimal or near-optimal solutions; and estimate the impact of HIV interventions on the health care system and the resulting resource needs. Additionally, an effective model needs a user-friendly design and structure, ease of calibration and validation, and accessibility to decision makers in all settings. Conclusions Resource allocation theory can make a significant contribution to decision making about HIV prevention and treatment scale up. What remains now is to develop models that can bridge the gap between theory and practice. PMID:21191118

  2. Prophylactic treatment with the BH3 mimetic ABT-737 impedes Myc-driven lymphomagenesis in mice.

    PubMed

    Kelly, P N; Grabow, S; Delbridge, A R D; Adams, J M; Strasser, A

    2013-01-01

    As many oncogenic changes, such as Myc overexpression, promote apoptosis, the survival of emerging neoplastic clones may often initially depend upon endogenous levels of particular pro-survival members of the Bcl-2 protein family. Pertinently, we recently showed that in lymphoma-prone Eμ-myc transgenic mice, which overexpress Myc in all B-lymphoid cells, endogenous Bcl-x(L) is critical for the survival, as well as the expansion of preneoplastic B-lymphoid cells and the development of malignant disease. This discovery raised the possibility that pharmacological blockade of Bcl-x(L) might impede Myc-driven lymphoma development. Indeed, we report here that treatment of preleukaemic Eμ-myc transgenic mice with the Bcl-2 homology (BH)3 mimetic drug ABT-737, which inhibits Bcl-x(L), as well as Bcl-2 and Bcl-w, augmented apoptosis of preneoplastic B-lymphoid cells, reduced their numbers and greatly prolonged lymphoma-free survival. These findings reveal that BH3 mimetic drugs may provide a prophylactic strategy to prevent the development of certain tumours, particularly those driven by deregulated Myc expression. Moreover, such treatment may help in the management of patients with hereditary cancer syndromes and perhaps also in the prevention of tumour relapses. PMID:22814621

  3. Ontology-Driven Hypothesis Generation to Explain Anomalous Patient Responses to Treatment

    NASA Astrophysics Data System (ADS)

    Moss, Laura; Sleeman, Derek; Sim, Malcolm; Booth, Malcolm; Daniel, Malcolm; Donaldson, Lyndsay; Gilhooly, Charlotte; Hughes, Martin; Kinsella, John

    Within the medical domain there are clear expectations as to how a patient should respond to treatments administered. When these responses are not observed it can be challenging for clinicians to understand the anomalous responses. The work reported here describes a tool which can detect anomalous patient responses to treatment and further suggest hypotheses to explain the anomaly. In order to develop this tool, we have undertaken a study to determine how Intensive Care Unit (ICU) clinicians identify anomalous patient responses; we then asked further clinicians to provide potential explanations for such anomalies. The high level reasoning deployed by the clinicians has been captured and generalised to form the procedural component of the ontology-driven tool. An evaluation has shown that the tool successfully reproduced the clinician’s hypotheses in the majority of cases. Finally, the paper concludes by describing planned extensions to this work.

  4. Decision-Making in Prostate Cancer: Active Surveillance Over Other Treatment Options.

    PubMed

    Bayliss, David; Duff, Jed; Stricker, Phil; Walker, Kim

    2016-01-01

    A qualitative-descriptive study of four patients with prostate cancer used the Cognitive-Social Health Information Processing framework to understand how and why men diagnosed with prostate cancer choose active surveillance over other treatment options. In accordance with the literature, it was found that the surgeon or general practitioner's recommendation was the most influential factor when patients are making a treatment decision. PMID:27501595

  5. Empirically and Clinically Useful Decision Making in Psychotherapy: Differential Predictions with Treatment Response Models

    ERIC Educational Resources Information Center

    Lutz, Wolfgang; Saunders, Stephen M.; Leon, Scott C.; Martinovich, Zoran; Kosfelder, Joachim; Schulte, Dietmar; Grawe, Klaus; Tholen, Sven

    2006-01-01

    In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research…

  6. Lay Referral Patterns Involved in Cardiac Treatment Decision Making among Middle-Aged and Older Adults

    ERIC Educational Resources Information Center

    Schoenberg, Nancy E.; Amey, Cheryl H.; Stoller, Eleanor Palo; Muldoon, Susan B.

    2003-01-01

    Purpose: This study examined age and contextually related factors that are influential in lay referral patterns during cardiac treatment decision making. Design and Methods: A complementary design was used. The Myocardial Infarction (MI) Onset Study identified demographic correlates of who sought medical care for 1,388 MI (heart attack) survivors.…

  7. Dentist-Patient Interactions in Treatment Decision-Making: A Qualitative Study.

    ERIC Educational Resources Information Center

    Redford, Maryann; Gift, Helen C.

    1997-01-01

    A University of North Carolina study using focus groups of dentists and patients found dentist-patient interactions play an important role in treatment decision-making, and are predicated on non-clinical factors, including dentists' intuition and judgment and patient impressions of dentists' examination styles, personalities, and interpersonal…

  8. The Impact of Reading a Clinical Study on Treatment Decisions of Physicians and Residents.

    ERIC Educational Resources Information Center

    Bergman, David A.; Pantell, Robert H.

    1986-01-01

    A study of the effect of reading a recent clinical study on pediatricians', pediatric residents', and family practitioners' decisions concerning treatment of a common, potentially serious problem revealed a considerable influence but physician difficulty in using probability data and reliance on intuition rather than calculation. (MSE)

  9. Linking scientists, decision makers, and organizations to improve understanding of climate-driven changes in coastal storms and their impacts in Western Alaska

    NASA Astrophysics Data System (ADS)

    Reynolds, J. H.; Murphy, K.

    2012-12-01

    The coastal zones of Western Alaska are expected to experience a nexus of climate-driven changes in landform processes resulting from the impacts of sea ice loss; sea level change; permafrost thaw; and changes in frequency, intensity, and direction of coastal storms, etc. These climate-driven changes will cascade through the near-shore and coastal physical systems, ecological systems, and human communities, and thus present major sources of uncertainty for a wide variety of the region's decision makers. To effectively and efficiently address some of the information needs of these decision makers, the Western Alaska Landscape Conservation Cooperative created a two-year program of applied science focused on 'Changes in Coastal Storms and their Impacts'. We summarize program components that successfully advanced applied science to address these decision maker information needs. All the components share a common feature of promoting linkages: (i) among resource decision makers, stakeholders and scientists, to identify and address key areas of uncertainty associated with coastal storms and thus align the science activities with decision maker needs for a variety of climate vulnerability assessments; (ii) among researchers, to mutually advance their science efforts; and (iii) among organizations, to efficiently address shared science needs. Resulting applied science benefits include (i) integrative projects using very fine resolution surge modeling to assess impacts of saltwater inundation on migratory waterfowl breeding populations and habitat; (ii) coordinating the selection of historic storms for reanalysis by two surge modeling efforts of differing resolution and domain, thus allowing for cross-model comparisons of performance over their shared spatial domain and future regional-scale application of the higher resolution model; and (iii) collaborative, cross-agency efforts to establish a water level network that meets multiple purposes (from model calibration to

  10. The Appleton Consensus: suggested international guidelines for decisions to forego medical treatment.

    PubMed

    Stanley, J M

    1989-09-01

    Thirty-three physicians, bioethicists, and medical economists from ten different countries met at Lawrence University, Appleton, Wisconsin, to create The Appleton Consensus: International Guidelines for Decisions to Forego Medical Treatment. The guidelines deal with four specific decision-making circumstances: 1. Five guidelines were created for decisions involving competent patients or patients who have executed an advance directive before becoming incompetent, and those guidelines fell into three categories. 2. Thirteen guidelines were created for decisions involving patients who were once competent, but are not now competent, who have not executed an advance directive. 3. Seven guidelines were created for decisions involving patients who are not now and never have been competent, for whom 'no substituted judgement' can be rendered. 4. Eleven guidelines were created for decisions involving the scarcity of medical resources, which exists in all communities. Five concepts were identified as being critical in the establishment of priorities, given the reality of scarce health resources (1). The term 'physician' is used in the American sense, synonymous with 'medical practitioner'. PMID:2677379

  11. Risky Decision-Making but Not Delay Discounting Improves during Inpatient Treatment of Polysubstance Dependent Alcoholics

    PubMed Central

    De Wilde, Bieke; Bechara, Antoine; Sabbe, Bernard; Hulstijn, Wouter; Dom, Geert

    2013-01-01

    Background: High levels of impulsivity, characteristics of addicted patients, are known to be important predictors of relapse. However, so far, little is known about the stability or variability of two main components of impulsivity (delay discounting and decision-making). The present study examined the changes in impulsivity during the first week of an abstinence based, behavioral orientated inpatient treatment program. Method: Thirty-seven polysubstance dependent alcoholics completed the Delay Discounting Task (DDT), and the Iowa Gambling Task (IGT) using the original version with decks A′B′C′D′, and an alternative version with decks K′L′M′N′, for measuring decision-making, after 2 and 6 weeks of active treatment. Results: It was found that performances on the IGT changed during treatment while performances on the DDT did not (test-retest period: 4 weeks). Conclusion: The results provide preliminary evidence that improvements in decision-making might be related to treatment effects. All patients followed a highly structured cognitive-behavioral treatment program, which might have enhanced their executive functioning (coping skills training). PMID:24027538

  12. Cancer treatment decision-making processes for older patients with complex needs: a qualitative study

    PubMed Central

    Hughes, Jane; Farrington, Naomi; Richardson, Alison

    2015-01-01

    Objectives Although older people can experience complex health and social care needs alongside a primary cancer diagnosis, little is understood about how cancer treatment decisions are made for this population. This study aimed to investigate how cancer treatment decisions are formulated for older people with complex health and social care needs and the factors that shape these processes. Design Qualitative study involving semistructured interviews and non-participant observations. Framework approach used for data analysis. Setting Breast and colorectal cancer services in five English NHS hospital trusts. Participants Interviews: purposive sample of 22 clinicians directly involved in a face-to-face clinical role with patients regarding cancer treatment and care, maximising variation across clinical roles, tumour types and trusts. Observations: purposive sample of five cancer multidisciplinary meetings, maximising variation across location, team size and tumour type. Results The initial stages of cancer treatment decision-making are team-based, medically dominated and focused on the cancer. For patients with complex health and social care needs that extend beyond cancer pathology, later and less visible stages in the decision-making process are more haphazard and may result in less effective and workable treatment plans, as individual clinicians struggle to devise and deliver these plans without breaching time-based targets. Conclusions Service targets that focus resources solely on the presenting disease can disadvantage older patients with complex health and social care needs that extend beyond this primary diagnosis. Care should be taken to ensure time-based targets do not disincentivise thorough and timely assessment that can lead to the formulation of treatment plans tailored to individual needs and circumstances. PMID:26667015

  13. Provider and patient correlates of provider decisions to recommend HCV treatment to HIV co-infected patients.

    PubMed

    Wagner, Glenn; Osilla, Karen Chan; Garnett, Jeffrey; Ghosh-Dastidar, Bonnie; Bhatti, Laveeza; Witt, Mallory; Goetz, Matthew Bidwell

    2012-01-01

    Despite low uptake of hepatitis C virus (HCV) treatment among HIV co-infected patients, few studies have examined the factors that contribute to provider decisions to recommend treatment. Surveys of 173 co-infected patients and their primary care providers, as well as patient chart data, were collected at 3 HIV clinics in Los Angeles; 73% of the patients had any history of being recommended HCV treatment. Multivariate predictors of being offered treatment included being Caucasian, greater HCV knowledge, receiving depression treatment if depressed, and one's provider having a lower weekly patient load and more years working at the study site. These findings suggest that provider decisions to recommend HCV treatment are influenced by patient factors including race and psychosocial treatment readiness, as well as characteristics of their own practice and treatment philosophy. With changes to HCV treatment soon to emerge, further evaluation of factors influencing treatment decisions is needed to improve HCV treatment uptake. PMID:22564797

  14. Use of ultrasound in treatment decisions for patients with rheumatoid arthritis: an observational study in Italy.

    PubMed

    Epis, Oscar; Scioscia, Crescenzio; Locaputo, Antonia; Cappelli, Antonella; Maier, Armin; Rocchetta, Pier Andrea; Tomietto, Paola; Perin, Antonella; Rigon, Chiara; Santo, Leonardo; Casilli, Oriana; Lapadula, Giovanni; Bruschi, Eleonora

    2016-08-01

    In rheumatoid arthritis (RA), treatment response is generally assessed using standard clinical disease activity measures. However, ultrasound has become increasingly popular among rheumatologists to monitor disease activity and response. The purpose of this analysis of ECOgraphic evaluation for STaging ARthritis (ECOSTAR) study data was to determine how ultrasound affects clinicians' decisions about changing treatment in RA. ECOSTAR was an observational, cohort study conducted between March 2010 and December 2012 at nine clinical centers in Italy in RA patients being considered for treatment change. After clinical evaluation of each patient, patients underwent diagnostic ultrasound (US) investigations and each patient was given a total echography score using a combination of scores for joint effusion, synovial hypertrophy, and power Doppler. The US results were provided to the clinicians and the influence of US on the clinicians' treatment choices were recorded. Ninety-five patients screened for study inclusion had confirmed RA (mean age 53.9 years; mean disease duration 8.9 years). Therapy changes were made by clinicians according to the hand and wrist joint US scores: score 0 appeared to have no influence on clinicians' decision to modify treatment, scores >0-3 were associated with a numerically higher estimated probability of not changing therapy than changing therapy, and scores >3 had a greater influence on the clinician to modify therapy and an increased probability of the clinician changing therapy versus not changing therapy. Ultrasonography scores appear to influence treatment decisions in patients with RA, with clinicians appearing less likely to alter treatment regimens in patients with low ultrasound scores and more likely to change treatment regimens when higher scores are obtained. Further research is warranted. PMID:27320945

  15. HIV Treatment as Prevention: Models, Data, and Questions—Towards Evidence-Based Decision-Making

    PubMed Central

    2012-01-01

    Antiretroviral therapy (ART) for those infected with HIV can prevent onward transmission of infection, but biological efficacy alone is not enough to guide policy decisions about the role of ART in reducing HIV incidence. Epidemiology, economics, demography, statistics, biology, and mathematical modelling will be central in framing key decisions in the optimal use of ART. PLoS Medicine, with the HIV Modelling Consortium, has commissioned a set of articles that examine different aspects of HIV treatment as prevention with a forward-looking research agenda. Interlocking themes across these articles are discussed in this introduction. We hope that this article, and others in the collection, will provide a foundation upon which greater collaborations between disciplines will be formed, and will afford deeper insights into the key factors involved, to help strengthen the support for evidence-based decision-making in HIV prevention. PMID:22802739

  16. [Patients in pre-dialysis: decision taking and free choice of treatment].

    PubMed

    Sarrias Lorenz, X; Bardón Otero, E; Vila Paz, M L

    2008-01-01

    Predialysis is a clinical situation in which the patient has significant impairment of kidney function that will ultimately lead to either death or inclusion in kidney replacement therapy (dialysis and/or transplantation). Since a practical and effective dialysis technique was introduced, the length and quality of survival of patients with end-stage renal failure has constantly increased. Contraindications for dialysis are almost never of a renal origin. The obstacles are the concomitant diseases of the patient. The age of the patient may be one of these obstacles. The average age at initiation of dialysis in our country is currently 67 years and over 50% of patients are 60 years old or older. Decision making: From an ethical viewpoint, there is a consensus in stating that anything that can technically be done, should be done. The principle of nonmaleficence and respect for the autonomy of the patients are "prima facie" principles when the physician has doubts as to whether dialysis provides a benefit to the patient. The principle of autonomy, which makes the patient a competent subject of treatment, allows a framework of shared decisions to be created in which the physician uses his knowledge and experiences in assessing the risk and benefits of dialysis including the alternative of no dialysis. The competent patient, duly informed, will chose the option that is best for him and take the decision. Principle of treatment proportionality: This principle states that there is a moral obligation to implement all therapeutic measures that show a relationship of due proportion between the resources used and the expected result. Dialysis is in principle a proportional treatment for end-stage renal failure. However, it may become a disproportional treatment because of the physical and mental conditions of the elderly patient. The good that is sought with institution of treatment can cause a harm to the patient that justifies noninclusion of the patient in dialysis

  17. Sufficiency of care in disasters: ventilation, ventilator triage, and the misconception of guideline-driven treatment.

    PubMed

    Trotter, Griffin

    2010-01-01

    This essay examines the management of ventilatory failure in disaster settings where clinical needs overwhelm available resources. An ethically defensible approach in such settings will adopt a "sufficiency of care" perspective that is: (1) adaptive, (2) resource-driven, and (3) responsive to the values of populations being served. Detailed, generic, antecedently written guidelines for "ventilator triage" or other management issues typically are of limited value, and may even impede ethical disaster response if they result in rescuers' clumsily interpreting events through the lens of the guideline, rather than customizing tactics to the actual context. Especially concerning is the tendency of some expert planners to mistakenly assume that medical treatment of respiratory failure: (1) always requires full-feature mechanical ventilators, (2) will always occur in hospitals, and (3) can be planned in advance without sophisticated public consultation about likely ethical dilemmas. PMID:21313863

  18. Intra-household relations and treatment decision-making for childhood illness: a Kenyan case study.

    PubMed

    Molyneux, C S; Murira, G; Masha, J; Snow, R W

    2002-01-01

    This study, conducted on the Kenyan coast, assesses the effect of intra-household relations on maternal treatment-seeking. Rural and urban Mijikenda mothers' responses to childhood fevers in the last 2 weeks (n=317), and to childhood convulsions in the previous year (n=43), were documented through survey work. The intra-household relations and decision-making dynamics surrounding maternal responses were explored through in-depth individual and group interviews, primarily with women (n=223). Responses to convulsions were more likely than responses to fevers to include a healer consultation (p<0.0001), and less likely to include the purchase of over-the-counter medications (p<0.0001). Mothers received financial or advisory assistance from others in 71% (n=236) of actions taken outside the household in response to fevers. In-depth interviews suggested that general agreement on appropriate therapy results in relatively few intra-household conflicts over the treatment of fevers. Disputes over perceived cause and appropriate therapy of convulsions, however, highlighted the importance of age, gender and relationship to household head in intra-household relations and treatment decision-making. Although mothers' treatment-seeking preferences are often circumscribed by these relations, a number of strategies can be drawn upon to circumvent 'inappropriate' decisions, sometimes with implications for future household responses to similar syndromes. The findings highlight the complexity of intra-household relations and treatment decision-making dynamics. Tentative implications for interventions aimed at improving the home management of malaria, and for further research, are presented. PMID:11814209

  19. Withholding treatment and intellectual disability: Second survey on end-of-life decisions in Switzerland

    PubMed Central

    Wicki, Monika T

    2016-01-01

    Background: As people live longer, they are more likely to die over a prolonged period from incurable, chronic illnesses that occur more frequently in old age. Therefore, people will experience an increase in end-of-life discussions and decisions. Aim: The aim of this study was to explore the prevalence and nature of end-of-life decisions for people with disabilities in Swiss residential homes. Design: A cross-sectional survey in the three biggest German-speaking regions in Switzerland (N = 209) was conducted. Setting: All of the residential homes for adults with disabilities (N = 209) were invited to participate in a cross-sectional survey. The response quote was 76.7%. Directors provided information on 82 deaths. Chi-square and t-tests were used to study differences in prevalence and nature of end-of-life decisions between people with intellectual disability (ID) and people with other disabilities. Results: An end-of-life decision was taken in 53.7% of the cases (n = 44). For people with ID, the decision to withhold treatment had been taken more often (28.9%, 13 cases) than for people with other disabilities (8.1%, 3 cases) (χ2 (1, N = 82) = 5.58, p = 0.017). Conclusion: The study provides insight in end-of-life decision-making for people with disabilities in Switzerland. The results have implications on surrogate decision-making for people with ID living in residential homes. As the study partly confirms the results of previous studies, further studies will be necessary. PMID:27408720

  20. Treatment decision-making and information-seeking preferences in women with pelvic floor disorders

    PubMed Central

    Raker, Christina A.; Myers, Deborah L.; Clark, Melissa A.

    2010-01-01

    Introduction and hypothesis The Autonomy Preference Index (API) and Control Preferences Scale (CPS) measure information-seeking and decision-making preferences. Our objective was to validate these scales in women with pelvic floor disorders (PFDs) and identify variables associated with decision-making preferences. Methods Women seeking care for PFDs completed the API and the CPS. Psychometric properties were determined. Multivariable analyses were used to identify correlates of information-seeking and decision-making preferences. Results One hundred ten women were recruited. Both scales demonstrated good psychometric properties (intraclass correlation coefficient=0.5 to 0.7; Cronbach’s alpha = 0.8 for the API, and r=−0.3 between the API and CPS). Based on scores, women had strong preferences to be well informed, but were more neutral in their decision-making preferences. In multivariable analyses, higher education levels were associated with a stronger desire for seeking medical information. Conclusions Women seeking care for PFDs vary in their preferences for participating in treatment decisions. PMID:20424822

  1. Radiation Treatment in Older Patients: A Framework for Clinical Decision Making

    PubMed Central

    Smith, Grace L.; Smith, Benjamin D.

    2014-01-01

    In older patients, radiation treatment plays a vital role in curative and palliative cancer therapy. Radiation treatment recommendations should be informed by a comprehensive, personalized risk-benefit assessment that evaluates treatment efficacy and toxicity. We review several clinical factors that distinctly affect efficacy and toxicity of radiation treatment in older patients. First, locoregional tumor behavior may be more indolent in older patients for some disease sites but more aggressive for other sites. Assessment of expected locoregional relapse risk informs the magnitude and timeframe of expected radiation treatment benefits. Second, assessment of the competing cancer versus noncancer mortality and morbidity risks contextualizes cancer treatment priorities holistically within patients' entire spectrum and time course of health needs. Third, assessment of functional reserve helps predict patients' acute treatment tolerance, differentiating those patients who are unlikely to benefit from treatment or who are at high risk for treatment complications. Potential radiation treatment options include immediate curative treatment, delayed curative treatment, and no treatment, with additional consideration given to altered radiation target, dose, or sequencing with chemotherapy and/or surgery. Finally, when cure is not feasible, palliative radiation therapy remains valuable for managing symptoms and achieving meaningful quality-of-life improvements. Our proposed decision-making framework integrates these factors to help radiation oncologists formulate strategic treatment recommendations within a multidisciplinary context. Future research is still needed to identify how advanced technologies can be judiciously applied in curative and palliative settings to enhance risk-benefit profiles of radiation treatment in older patients and more accurately quantify treatment efficacy in this group. PMID:25071132

  2. Treatment of envenomation by Echis coloratus (mid-east saw scaled viper): a decision tree.

    PubMed

    Gilon, D; Shalev, O; Benbassat, J

    1989-01-01

    Envenomation by Echis coloratus causes a transient hemostatic failure. Systemic symptoms, hypotension and evident bleeding are rare, with only one reported fatality. In this paper, we examine the decision to treat victims of Echis coloratus by a specific horse antiserum. The decision model considers the mortality of treated and untreated envenomation, and the side effects of antiserum treatment: fatal anaphylaxis, serum sickness and increased risk of death after a possible repeated exposure to horse antiserum in the future. The results of the analysis are not sensitive to variations in the probability of side effects of antiserum treatment. They are sensitive to variations in the risk of bleeding after envenomation, in the degree of reduction of this risk by antiserum treatment and in the risk of dying after an event of bleeding. Prompt administration of antiserum appears to be the treatment of choice if it reduces the risk of bleeding from 23.6% to 20.3% and if 1.6% or more of the bleeding events are fatal. We conclude that presently available data support antiserum treatment of victims of Echis coloratus who present with hemostatic failure, even though the advantage imparted by this treatment appears to be small. PMID:2683230

  3. Applying the least restrictive alternative principle to treatment decisions: A legal and behavioral analysis

    PubMed Central

    Johnston, J. M.; Sherman, Robert A.

    1993-01-01

    The least restrictive alternative concept is widely used in mental health law. This paper addresses how the concept has been applied to treatment decisions. The paper offers both a legal and a behavioral analysis to some problems that have emerged in recent years concerning the selection of behavioral procedures used to change client behavior. The paper also offers ways of improving the application of the concept, which involve developing a more behaviorally functional perspective toward restrictiveness. PMID:22478138

  4. Justifying medication decisions in mental health care: Psychiatrists' accounts for treatment recommendations.

    PubMed

    Angell, Beth; Bolden, Galina B

    2015-08-01

    Psychiatric practitioners are currently encouraged to adopt a patient centered approach that emphasizes the sharing of decisions with their clients, yet recent research suggests that fully collaborative decision making is rarely actualized in practice. This paper uses the methodology of Conversation Analysis to examine how psychiatrists justify their psychiatric treatment recommendations to clients. The analysis is based on audio-recordings of interactions between clients with severe mental illnesses (such as, schizophrenia, bipolar disorders, etc.) in a long-term, outpatient intensive community treatment program and their psychiatrist. Our focus is on how practitioners design their accounts (or rationales) for recommending for or against changes in medication type and dosage and the interactional deployment of these accounts. We find that psychiatrists use two different types of accounts: they tailor their recommendations to the clients' concerns and needs (client-attentive accounts) and ground their recommendations in their professional expertise (authority-based accounts). Even though psychiatrists have the institutional mandate to prescribe medications, we show how the use of accounts displays psychiatrists' orientation to building consensus with clients in achieving medical decisions by balancing medical authority with the sensitivity to the treatment relationship. PMID:26046726

  5. Justifying medication decisions in mental health care: Psychiatrists’ accounts for treatment recommendations

    PubMed Central

    Angell, Beth; Bolden, Galina B.

    2015-01-01

    Psychiatric practitioners are currently encouraged to adopt a patient centered approach that emphasizes the sharing of decisions with their clients, yet recent research suggests that fully collaborative decision making is rarely actualized in practice. This paper uses the methodology of Conversation Analysis to examine how psychiatrists justify their psychiatric treatment recommendations to clients. The analysis is based on audio-recordings of interactions between clients with severe mental illnesses (such as, schizophrenia, bipolar disorders, etc.) in a long-term, outpatient intensive community treatment program and their psychiatrist. Our focus is on how practitioners design their accounts (or rationales) for recommending for or against changes in medication type and dosage and the interactional deployment of these accounts. We find that psychiatrists use two different types of accounts: they tailor their recommendations to the clients’ concerns and needs (client-attentive accounts) and ground their recommendations in their professional expertise (authority-based accounts). Even though psychiatrists have the institutional mandate to prescribe medications, we show how the use of accounts displays psychiatrists’ orientation to building consensus with clients in achieving medical decisions by balancing medical authority with the sensitivity to the treatment relationship. PMID:26046726

  6. Foreign accent syndrome: a multimodal evaluation in the search of neuroscience-driven treatments.

    PubMed

    Moreno-Torres, Ignacio; Berthier, Marcelo L; Del Mar Cid, Maria; Green, Cristina; Gutiérrez, Antonio; García-Casares, Natalia; Froudist Walsh, Seán; Nabrozidis, Alejandro; Sidorova, Julia; Dávila, Guadalupe; Carnero-Pardo, Cristóbal

    2013-02-01

    Foreign accent syndrome (FAS) is a rare condition which is placed in the mildest end of the spectrum of speech disorders. The impairment, not severe enough to elicit phonological errors, is associated with various alterations in the fine execution of speech sounds which cause the impression of foreignness. There is a growing interest in the study of linguistic and paralinguistic components, psychosocial aftermaths, and neural basis of FAS, but there are not yet neuroscience-driven treatments for this condition. A multimodal evaluation was conducted in a single patient with the aim of searching for clues which may assist to design neuroscience-driven therapies. The patient was a middle-aged bilingual woman who had chronic FAS. She had segmental deficits, abnormal production of linguistic and emotional prosody, impaired verbal communication, and reduced motivation and social engagement. Magnetic resonance imaging showed bilateral small lesions mainly affecting the left deep frontal operculum and dorsal anterior insula. Diffusion tensor tractography suggested disrupted left deep frontal operculum-anterior insula connectivity. Metabolic activity measured with positron emission tomography was primarily decreased in key components of networks implicated in planning and execution of speech production, cognitive control and emotional communication (Brodmann's areas 4/6/9/10/13/25/47, basal ganglia, and anterior cerebellar vermis). Compensatory increases of metabolic activity were found in cortical areas (left anterior cingulate gyrus, left superior temporal gyrus and right prefrontal cortex) associated with feedback and focal attention processes critical for monitoring and adjustment of verbal utterances. Moreover, bilateral structural and functional abnormalities probably interrupted the trajectory of the lateral and medial cholinergic pathways causing region-specific hypoactivity. The results from this study provide targets for further investigation and some clues to

  7. Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma

    PubMed Central

    Wilson, Sandra R.; Strub, Peg; Buist, A. Sonia; Knowles, Sarah B.; Lavori, Philip W.; Lapidus, Jodi; Vollmer, William M.

    2010-01-01

    Rationale: Poor adherence to asthma controller medications results in poor treatment outcomes. Objectives: To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care. Methods: In shared decision making (SDM), nonphysician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making, treatment was prescribed without specifically eliciting patient goals/preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters. Measurements and Main Results: Refill adherence was measured using continuous medication acquisition (CMA) indices—the total days' supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister equivalents. In follow-up Year 1, compared with usual care, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.46; P < 0.0001) and long-acting β-agonist adherence (CMA, 0.51 vs. 0.40; P = 0.0225); higher cumulative controller medication dose (canister equivalent, 10.9 vs. 5.2; P < 0.0001); significantly better clinical outcomes (asthma-related quality of life, health care use, rescue medication use, asthma control, and lung function). In Year 2, compared with usual care, SDM resulted in significantly lower rescue medication use, the sole clinical outcome available for that year. Compared with clinician decision making, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.59; P = 0.03) and long-acting β-agonist adherence (CMA, 0.51 vs. 0.41; P = 0.0143); higher cumulative controller dose (CMA, 10.9 vs. 9.1; P = 0.005); and quantitatively, but not significantly, better outcomes on all clinical measures. Conclusions: Negotiating patients' treatment decisions

  8. SU-D-BRD-05: Decision Opportunities in Radiation Therapy Treatments

    SciTech Connect

    Watkins, W.T.; Siebers, J.V.

    2014-06-01

    Purpose: A method to reveal tradeoffs in radiation therapy treatments is introduced in order to aid in clinical, patient-specific decision making. Methods: A clinically acceptable treatment plan was varied for two patients, a stereotactic body radiation therapy (SBRT) lung cancer case and a pituitary case, in order to reveal decision opportunities. Plans were optimized such that non-zero dose-volume objectives were defined for all organs at risk (OARS). At fixed planning target volume (PTV) dose, a single OAR is sacrificed, i.e. the weight of the dose volume objective is deceased, and potential dosimetric benefits in other regions of interest are identified. If tradeoffs are identified, plans are stored and presented as decision opportunities. Results: Clinically relevant tradeoffs were revealed by sacrificing individual OARs. The SBRT lung case was planned according to the Radiotherapy-Oncology Group (RTOG) 0813 protocol, but by violating the high-dose protocol objective (>2 cm from the PTV) in the patient's lung, mean heart dose was reduced by 1.7 Gy and the great vessel V20 was reduced from 42% to 2%. Tradeoffs in dose to the chestwall and heart were also revealed, an increase of 6 Gy in chestwall-Dmax reduces heart mean dose by 0.9 Gy and mean dose to the great vessels by 2.6 Gy. For the pituitary tumor, sacrificing the right parotid gland (increasing mean dose from 7.8 Gy to 14.1 Gy) spares the temporal lobes bilaterally (V20 is reduced by 4%) and left parotid mean dose is reduced from 6.4 Gy to 5.2 Gy. Conclusion: Clinical tradeoffs in radiation therapy treatment planning are revealed by sacrificing individual OARS. By revealing these tradeoffs, decision making in plan selection is simplified and can be considered in the context of patient-specific quality of life.

  9. Young Breast Cancer Survivors: Their Perspectives on Treatment Decisions and Fertility Concerns

    PubMed Central

    Gorman, Jessica R.; Usita, Paula; Madlensky, Lisa; Pierce, John P.

    2010-01-01

    Background Younger women diagnosed with breast cancer are more likely to have survival concerns related to fertility, which may influence their treatment decisions. Objective This qualitative study explores how young women make cancer treatment decisions and the role of fertility concerns in that process. Intervention/Methods We used purposeful sampling to identify a diverse group of 20 young breast cancer survivors, half of whom had a child after breast cancer. We conducted open-ended telephone interviews and used cross-case, inductive analysis to identify themes. Results The main themes were: 1) I was young, I wanted to do everything possible to move forward with my life and not to have the cancer come back, 2) Fertility concerns are different for every woman 3) My oncologist was great… a huge part of my survivorship, and 4) They didn’t tell me about my options and I didn’t think about fertility until it was too late. Conclusions While fertility was important to many participants, treatment decisions were mainly motivated by survival concerns. Fertility concerns depended on life circumstances and the timing in relation to diagnosis varied. There is a need for improved information regarding the impact of treatment on fertility and fertility preservation options, even if concerns are not expressed at diagnosis. Implications for Practice It is critical that cancer care providers provide timely information regarding fertility. Oncology nurses are particularly well-positioned to serve this role by communicating with patients about their fertility concerns and reproductive planning prior to treatment and throughout the course of survivorship. PMID:20697269

  10. [Human body meridian spatial decision support system for clinical treatment and teaching of acupuncture and moxibustion].

    PubMed

    Wu, Dehua

    2016-01-01

    The spatial position and distribution of human body meridian are expressed limitedly in the decision support system (DSS) of acupuncture and moxibustion at present, which leads to the failure to give the effective quantitative analysis on the spatial range and the difficulty for the decision-maker to provide a realistic spatial decision environment. Focusing on the limit spatial expression in DSS of acupuncture and moxibustion, it was proposed that on the basis of the geographic information system, in association of DSS technology, the design idea was developed on the human body meridian spatial DSS. With the 4-layer service-oriented architecture adopted, the data center integrated development platform was taken as the system development environment. The hierarchical organization was done for the spatial data of human body meridian via the directory tree. The structured query language (SQL) server was used to achieve the unified management of spatial data and attribute data. The technologies of architecture, configuration and plug-in development model were integrated to achieve the data inquiry, buffer analysis and program evaluation of the human body meridian spatial DSS. The research results show that the human body meridian spatial DSS could reflect realistically the spatial characteristics of the spatial position and distribution of human body meridian and met the constantly changeable demand of users. It has the powerful spatial analysis function and assists with the scientific decision in clinical treatment and teaching of acupuncture and moxibustion. It is the new attempt to the informatization research of human body meridian. PMID:26946752

  11. The influence of clinician emotion on decisions in child and adolescent eating disorder treatment: a survey of self and others.

    PubMed

    Lafrance Robinson, Adele; Kosmerly, Stacey

    2015-01-01

    Eating disorder clinicians from various disciplines participated in one of two surveys: the "self" group (n = 143) completed a survey assessing the negative influence of emotions on their own clinical decisions, while the "other" group (n = 145) completed a parallel version of the survey that assessed their perceptions of the negative influence of emotion in their colleagues. Both groups endorsed this phenomenon to some degree, although differences in reporting were noted between groups. The perceived negative influence of emotion with regards to specific treatment decisions fell within three categories: decisions regarding food and weight, decisions regarding the involvement of the family in treatment, and decisions related to autonomy and control. Decisions regarding the involvement of the family were perceived to be the most emotionally charged, in particular the involvement of a critical or dismissive parent. PMID:25401960

  12. Effects of Temperature and Acidic Pre-Treatment on Fenton-Driven Oxidation of MTBE-Spent Granular Activated Carbon

    EPA Science Inventory

    Temperature-dependent mechanisms in the Fenton-driven chemical oxidation of methyl tert-butyl ether (MTBE)-spent granular activated carbon (GAC) was investigated. Prior to iron (Fe) amendment to the GAC, acid-treatment altered the surface chemistry of the GAC and lowered the pH ...

  13. Effects on temperature and acidic pre-treatment on Fenton-driven oxidation of MTBE-spent granular activated carbon

    EPA Science Inventory

    Temperature-dependent mechanisms in the Fenton-driven chemical oxidation of methyl tert-butyl ether (MTBE)-spent granular activated carbon (GAC) was investigated. Prior to iron (Fe) amendment to the GAC, acid-treatment altered the surface chemistry of the GAC and lowered the p...

  14. Assessing the Value of New Treatments for Hepatitis C: Are International Decision Makers Getting this Right?

    PubMed

    Woods, Beth; Faria, Rita; Griffin, Susan

    2016-05-01

    Health systems worldwide are facing difficult choices about the use of a series of highly effective but costly new treatments for hepatitis C. In this paper we discuss how the National Institute for Health and Care Excellence in England and Wales, the Common Drug Review in Canada and the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia have approached the appraisal of these drugs. We argue that with the exception of the PBAC, assessments of the new drugs have not adequately accounted for their large financial burden. Given the potential health system impact of reimbursing these drugs, the use of lower cost-effectiveness thresholds should be considered. None of the decision-making processes included a comparison of the full range of treatment pathways. In particular, comparisons of using the new drugs as first- versus second-line drugs were omitted from all appraisals, as were comparisons with delayed treatment strategies whereby treatment is withheld until more severe disease stages. Omission of comparators leads to inaccurate estimates of cost effectiveness and potentially sub-optimal decision making. Lessons learned from these appraisals should be considered in future appraisals, particularly the upcoming assessments of the 'blockbuster' PCSK9 inhibitors for hypercholesterolaemia. PMID:26714687

  15. Clinical impact of treatment timing for chronic hepatitis C infection: a decision model

    PubMed Central

    Pho, M T; Jensen, D M; Meltzer, D O; Kim, A Y; Linas, B P

    2015-01-01

    Recent advances in the treatment of hepatitis C virus (HCV) infection have led to the availability of both highly efficacious interferon-containing and interferon-sparing regimens. However, the use of such therapies faces restrictions due to high costs. For patients who are medically eligible to receive interferon, the choice between the two will likely be impacted by preferences surrounding interferon, severity of disease, coverage policies and out-of-pocket costs. We developed a decision model to quantify the trade-offs between immediate, interferon-containing therapy and delayed, interferon-free therapy for patients with chronic, genotype 1 HCV infection. We projected the quality-adjusted life expectancy stratified by the presence or absence of cirrhosis for four strategies: (i) no treatment; (ii) immediate, one-time treatment with an interferon-containing regimen; (iii) immediate treatment as above with the opportunity for retreatment in patients who fail to achieve sustained virologic response with interferon-free therapy in 1 year; and (iv) delayed therapy with interferon-free therapy in 1 year. When compared to one-time immediate treatment with the interferon-containing regimen, delayed treatment with the interferon-free regimen in 1 year resulted in longer life expectancy, with a 0.2 quality-adjusted life year (QALY) increase in noncirrhotic patients, and a 1.1 QALY increase in patients with cirrhosis. This superiority in health benefits was lost when wait time for interferon-free therapy was greater than 3–3.2 years. In this modelling analysis, interferon-free therapy resulted in superior health benefits compared to immediate therapy with interferon until wait time exceeded 3–3.2 years. Such data can inform decision-making regarding treatment initiation for HCV as healthcare financing evolves. PMID:26135026

  16. Staging laparoscopy improves treatment decision-making for advanced gastric cancer

    PubMed Central

    Hu, Yan-Feng; Deng, Zhen-Wei; Liu, Hao; Mou, Ting-Yu; Chen, Tao; Lu, Xin; Wang, Da; Yu, Jiang; Li, Guo-Xin

    2016-01-01

    AIM: To evaluate the clinical value of staging laparoscopy in treatment decision-making for advanced gastric cancer (GC). METHODS: Clinical data of 582 patients with advanced GC were retrospectively analyzed. All patients underwent staging laparoscopy. The strength of agreement between computed tomography (CT) stage, endoscopic ultrasound (EUS) stage, laparoscopic stage, and final stage were determined by weighted Kappa statistic (Kw). The number of patients with treatment decision-changes was counted. A χ2 test was used to analyze the correlation between peritoneal metastasis or positive cytology and clinical characteristics. RESULTS: Among the 582 patients, the distributions of pathological T classifications were T2/3 (153, 26.3%), T4a (262, 45.0%), and T4b (167, 28.7%). Treatment plans for 211 (36.3%) patients were changed after staging laparoscopy was performed. Two (10.5%) of 19 patients in M1 regained the opportunity for potential radical resection by staging laparoscopy. Unnecessary laparotomy was avoided in 71 (12.2%) patients. The strength of agreement between preoperative T stage and final T stage was in almost perfect agreement (Kw = 0.838; 95% confidence interval (CI): 0.803-0.872; P < 0.05) for staging laparoscopy; compared with CT and EUS, which was in fair agreement. The strength of agreement between preoperative M stage and final M stage was in almost perfect agreement (Kw = 0.990; 95% CI: 0.977-1.000; P < 0.05) for staging laparoscopy; compared with CT, which was in slight agreement. Multivariate analysis revealed that tumor size (≥ 40 mm), depth of tumor invasion (T4b), and Borrmann type (III or IV) were significantly correlated with either peritoneal metastasis or positive cytology. The best performance in diagnosing P-positive was obtained when two or three risk factors existed. CONCLUSION: Staging laparoscopy can improve treatment decision-making for advanced GC and decrease unnecessary exploratory laparotomy. PMID:26855545

  17. Data-driven decision support for radiologists: re-using the National Lung Screening Trial dataset for pulmonary nodule management.

    PubMed

    Morrison, James J; Hostetter, Jason; Wang, Kenneth; Siegel, Eliot L

    2015-02-01

    Real-time mining of large research trial datasets enables development of case-based clinical decision support tools. Several applicable research datasets exist including the National Lung Screening Trial (NLST), a dataset unparalleled in size and scope for studying population-based lung cancer screening. Using these data, a clinical decision support tool was developed which matches patient demographics and lung nodule characteristics to a cohort of similar patients. The NLST dataset was converted into Structured Query Language (SQL) tables hosted on a web server, and a web-based JavaScript application was developed which performs real-time queries. JavaScript is used for both the server-side and client-side language, allowing for rapid development of a robust client interface and server-side data layer. Real-time data mining of user-specified patient cohorts achieved a rapid return of cohort cancer statistics and lung nodule distribution information. This system demonstrates the potential of individualized real-time data mining using large high-quality clinical trial datasets to drive evidence-based clinical decision-making. PMID:24965276

  18. Multicriteria decision approaches to support sustainable drainage options for the treatment of highway and urban runoff.

    PubMed

    Ellis, J B; Deutsch, J-C; Mouchel, J-M; Scholes, L; Revitt, M D

    2004-12-01

    The control and treatment of urban and highway runoff involves a variety of stakeholders in the selection of sustainable drainage systems (SUDS) as the design process needs to consider not only water quantity but also water quality and amenity. Thus, technical, environmental/ecological, social/community and economic cost factors become prime potential sustainability criteria in terms of assessing long-term, cost-effective drainage options. The paper develops a multicriteria analysis methodology for the evaluation and accreditation of SUDS structures within the context of an overall decision-support framework. Approaches independently developed in the UK and France are outlined with the common multicriteria structures defining generic performance criteria together with supporting benchmark standards and exclusion thresholds. A French case study is presented to illustrate the approach and to highlight the inherent constraints and subjectivity embedded in the decision-making process. PMID:15504512

  19. To Share or Not to Share: Malaysian Healthcare Professionals' Views on Localized Prostate Cancer Treatment Decision Making Roles

    PubMed Central

    Lee, Yew Kong; Lee, Ping Yein; Cheong, Ai Theng; Ng, Chirk Jenn; Abdullah, Khatijah Lim; Ong, Teng Aik; Razack, Azad Hassan Abdul

    2015-01-01

    Aim To explore the views of Malaysian healthcare professionals (HCPs) on stakeholders’ decision making roles in localized prostate cancer (PCa) treatment. Methods Qualitative interviews and focus groups were conducted with HCPs treating PCa. Data was analysed using a thematic approach. Four in-depth interviews and three focus group discussions were conducted between December 2012 and March 2013 using a topic guide. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Findings The participants comprised private urologists (n = 4), government urologists (n = 6), urology trainees (n = 6), government policy maker (n = 1) and oncologists (n = 3). HCP perceptions of the roles of the three parties involved (HCPs, patients, family) included: HCP as the main decision maker, HCP as a guide to patients’ decision making, HCP as a facilitator to family involvement, patients as main decision maker and patient prefers HCP to decide. HCPs preferred to share the decision with patients due to equipoise between prostate treatment options. Family culture was important as family members often decided on the patient’s treatment due to Malaysia’s close-knit family culture. Conclusions A range of decision making roles were reported by HCPs. It is thus important that stakeholder roles are clarified during PCa treatment decisions. HCPs need to cultivate an awareness of sociocultural norms and family dynamics when supporting non-Western patients in making decisions about PCa. PMID:26559947

  20. A Social Approach to Decision-Making Capacity: Exploratory Research with People with Experience of Mental Health Treatment

    ERIC Educational Resources Information Center

    McDaid, Shari; Delaney, Sarah

    2011-01-01

    This paper reports on exploratory, qualitative research conducted with eight people with experience of mental health treatment about their understanding of decision-making capacity. While acknowledging that there are times when mental or emotional distress can interfere with the capacity to make decisions, participants described how their capacity…

  1. Reducing microplastics from facial exfoliating cleansers in wastewater through treatment versus consumer product decisions.

    PubMed

    Chang, Michelle

    2015-12-15

    Microplastics (<5mm) have been discovered in fresh and saltwater ecosystems, sediments, and wastewater effluent around the world. Their ability to persist and accumulate up food chains should be a concern as research is still experimenting with techniques to assess their long-term effects on the environment. I sought to characterize the microbeads found in facial exfoliating cleansers so as to better understand how to reduce this source of pollution through consumer use and wastewater treatment solutions. By sampling products from national-grossing cosmetic personal care brands, I was able to gather information on the size, color, volume, mass, and concentration of polyethylene beads in the cleansers. From that data, I modeled onto a consumer survey the estimated volume of microplastics entering a wastewater stream. Through inquiry, I learned the practices of two local wastewater treatment facilities. My findings show that consumer decisions and treatment protocols both play crucial parts in minimizing microplastic pollution. PMID:26563542

  2. Innovation Attributes and Adoption Decisions: Perspectives from Leaders of a National Sample of Addiction Treatment Organizations

    PubMed Central

    Knudsen, Hannah K.; Roman, Paul M

    2014-01-01

    Drawing on diffusion theory to further knowledge about evidence-based practices (EBPs) in the treatment of substance use disorders (SUDs), this study describes the perceived importance of innovation attributes in adoption decisions within a national sample of SUD treatment organizations. Face-to-face interviews were conducted with leaders of 307 organizations. A typology differentiated organizations reporting: (1) adoption of a treatment innovation in the past year (“recent adoption”), (2) plans to adopt an innovation in the upcoming year (“planned adoption”), or (3) no actual or planned adoption (“non-adoption”). About 30.7% of organizations reported recent adoption, 20.5% indicated planned adoption, and 48.8% were non-adopters. Leaders of organizations reporting recent adoption (n = 93) or planned adoption (n = 62) rated the importance of innovation attributes, including relative advantage, compatibility, complexity, and observability, on these adoption decisions using a Likert scale that ranged from 0 to 5. Innovation attributes most strongly endorsed were consistency with the program's treatment philosophy (mean = 4.47, SD = 1.03), improvement in the program's reputation with referral sources (mean = 4.00, SD = 1.33), reputational improvement with clients and their families (mean = 3.98, SD = 1.31), and reductions in treatment dropout (mean = 3.75, SD = 1.54). Innovation characteristics reflecting organizational growth and implementation costs were less strongly endorsed. Adopters and planners were generally similar in their importance ratings. There were modest differences in importance ratings when pharmacological innovations were compared to psychosocial interventions. These findings are consistent with diffusion theory and suggest that efforts to link EBPs with client satisfaction and potential reputational benefits may enhance the diffusion of EBPs. Attention to these attributes when developing and evaluating SUD treatment interventions may

  3. CURVES: a mnemonic for determining medical decision-making capacity and providing emergency treatment in the acute setting.

    PubMed

    Chow, Grant V; Czarny, Matthew J; Hughes, Mark T; Carrese, Joseph A

    2010-02-01

    The evaluation of medical decision-making capacity and provision of emergency treatment in the acute care setting may present a significant challenge for both physicians-in-training and attending physicians. Although absolutely essential to the proper care of patients, recalling criteria for decision-making capacity may prove cumbersome during a medical emergency. Likewise, the requirements for providing emergency treatment must be fulfilled. This article presents a mnemonic (CURVES: Choose and Communicate, Understand, Reason, Value, Emergency, Surrogate) that addresses the abilities a patient must possess in order to have decision-making capacity, as well as the essentials of emergency treatment. It may be used in conjunction with, or in place of, lengthier capacity-assessment tools, particularly when time is of the essence. In addition, the proposed tool assists the practitioner in deciding whether emergency treatment may be administered, and in documenting medical decisions made during an acute event. PMID:20133288

  4. Shared Decision-Making in the Primary Care Treatment of Late-Life Major Depression: A Needed New Intervention?

    PubMed Central

    Raue, Patrick J.; Schulberg, Herbert C.; Lewis-Fernandez, Roberto; Boutin-Foster, Carla; Hoffman, Amy S.; Bruce, Martha L.

    2010-01-01

    Objective We suggest that clinicians consider models of shared decision-making for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions. Methods We explore the characteristics and techniques of patient-clinician shared decision-making, with particular emphasis on this model’s relevance to the unique treatment concerns of depressed older adults. Results We describe a shared decision-making intervention to engage older adults in depression treatment in the primary care sector. Conclusions It is timely to examine shared decision-making models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes. PMID:19946872

  5. The Diagnosis and Treatment of Bipolar Disorder: Decision-Making in Primary Care

    PubMed Central

    2014-01-01

    Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co-occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case-finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long-term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision-making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision-making in acute and longer-term management and the importance of patient monitoring. PMID:25317368

  6. Laboratory Medicine in the Clinical Decision Support for Treatment of Hypercholesterolemia: Pharmacogenetics of Statins.

    PubMed

    Ruaño, Gualberto; Seip, Richard; Windemuth, Andreas; Wu, Alan H B; Thompson, Paul D

    2016-09-01

    Statin responsiveness is an area of great research interest given the success of the drug class in the treatment of hypercholesterolemia and in primary and secondary prevention of cardiovascular disease. Interrogation of the patient's genome for gene variants will eventually guide anti-hyperlipidemic intervention. In this review, we discuss methodological approaches to discover genetic markers predictive of class-wide and drug-specific statin efficacy and safety. Notable pharmacogenetic findings are summarized from hypothesis-free genome wide and hypothesis-led candidate gene association studies. Physiogenomic models and clinical decision support systems will be required for DNA-guided statin therapy to reach practical use in medicine. PMID:27514463

  7. Patient Participation in Surgical Treatment Decision Making from the Patients' Perspective: Validation of an Instrument

    PubMed Central

    Heggland, Liv-Helen; Øgaard, Torvald; Mikkelsen, Aslaug; Hausken, Kjell

    2012-01-01

    The aim of this paper is to describe the development of a new, brief, easy-to-administer self-reported instrument designed to assess patient participation in decision making in surgical treatment. We describe item generation, psychometric testing, and validity of the instrument. The final scale consisted of four factors: information dissemination (5 items), formulation of options (4 items), integration of information (4 items), and control (3 items). The analysis demonstrated a reasonable level of construct validity and reliability. The instrument applies to patients in surgical wards and can be used to identify the health services that are being provided and the areas that could strengthen patient participation. PMID:22830010

  8. Data and Model-Driven Decision Support for Environmental Management of a Chromium Plume at Los Alamos National Laboratory - 13264

    SciTech Connect

    Vesselinov, Velimir V.; Broxton, David; Birdsell, Kay; Reneau, Steven; Harp, Dylan; Mishra, Phoolendra; Katzman, Danny; Goering, Tim; Vaniman, David; Longmire, Pat; Fabryka-Martin, June; Heikoop, Jeff; Ding, Mei; Hickmott, Don; Jacobs, Elaine

    2013-07-01

    A series of site investigations and decision-support analyses have been performed related to a chromium plume in the regional aquifer beneath the Los Alamos National Laboratory (LANL). Based on the collected data and site information, alternative conceptual and numerical models representing governing subsurface processes with different complexity and resolution have been developed. The current conceptual model is supported by multiple lines of evidence based on comprehensive analyses of the available data and modeling results. The model is applied for decision-support analyses related to estimation of contaminant- arrival locations and chromium mass flux reaching the regional aquifer, and to optimization of a site monitoring-well network. Plume characterization is a challenging and non-unique problem because multiple models and contamination scenarios are consistent with the site data and conceptual knowledge. To solve this complex problem, an advanced methodology based on model calibration and uncertainty quantification has been developed within the computational framework MADS (http://mads.lanl.gov). This work implements high-performance computing and novel, efficient and robust model analysis techniques for optimization and uncertainty quantification (ABAGUS, Squads, multi-try (multi-start) techniques), which allow for solving problems with large degrees of freedom. (authors)

  9. Avoidant decision-making in social anxiety disorder: A laboratory task linked to in vivo anxiety and treatment outcome.

    PubMed

    Pittig, Andre; Alpers, Georg W; Niles, Andrea N; Craske, Michelle G

    2015-10-01

    Recent studies on reward-based decision-making in the presence of anxiety-related stimuli demonstrated that approach-avoidance conflicts can be assessed under controlled laboratory conditions. However, the clinical relevance of these decision conflicts has not been demonstrated. To this end, the present study investigated avoidant decisions in treatment-seeking individuals with social anxiety disorder (SAD). In a gambling task, advantageous choices to maximize gains were associated with task-irrelevant angry faces and disadvantageous choices with happy faces. The clinical relevance of avoidant decisions for in vivo anxiety in a social stress situation (public speaking) were examined (n = 44). In a subsample (n = 20), the predictive value for a reduction of avoidance following behavioral therapy was also evaluated. Results indicated a close link between more frequent avoidant decisions and elevated in vivo anxiety. Moreover, individuals who showed a deficit in the goal-directed adjustment of their decisions also showed higher and sustained distress during the social stressor and reported less decrease of avoidance following treatment. The findings highlight the importance of an avoidant decision-making style for the experience of acute distress and the maintenance of avoidance in SAD. Assessing avoidant decision-making may help to predict the response to behavioral treatments. PMID:26301755

  10. Parent Perspectives on the Decision to Initiate Medication Treatment of Attention-Deficit/Hyperactivity Disorder

    PubMed Central

    Pappadopulos, Elizabeth; Katsiotas, Nikki J.; Berest, Alison; Jensen, Peter S.; Kafantaris, Vivian

    2012-01-01

    Abstract Objectives Despite substantial evidence supporting the efficacy of stimulant medication for children with attention-deficit/hyperactivity disorder (ADHD), adherence to stimulant treatment is often suboptimal. Applying social/cognitive theories to understanding and assessing parent attitudes toward initiating medication may provide insight into factors influencing parent decisions to follow ADHD treatment recommendations. This report describes results from formative research that used focus groups to obtain parent input to guide development of a provider-delivered intervention to improve adherence to stimulants. Methods Participants were caregivers of children with ADHD who were given a stimulant treatment recommendation. Focus groups were recorded and transcribed verbatim. Data were analyzed by inductive, grounded theory methods as well as a deductive analytic strategy using an adapted version of the Unified Theory of Behavior Change to organize and understand parent accounts. Results Five groups were conducted with 27 parents (mean child age=9.35 years; standard deviation [SD]=2.00), mean time since diagnosis=3.33 years (SD=2.47). Most parents (81.5%) had pursued stimulant treatment. Inductive analysis revealed 17 attitudes facilitating adherence and 25 barriers. Facilitators included parent beliefs that medication treatment resulted in multiple functional gains and that treatment was imperative for their children's safety. Barriers included fears of personality changes and medication side effects. Complex patterns of parent adherence to medication regimens were also identified, as well as preferences for psychiatrists who were diagnostically expert, gave psychoeducation using multiple modalities, and used a chronic illness metaphor to explain ADHD. Theory-based analyses revealed conflicting expectancies about treatment risks and benefits, significant family pressures to avoid medication, guilt and concern that their children required medication, and

  11. Effect of a perspective-taking intervention on the consideration of pain assessment and treatment decisions

    PubMed Central

    Wandner, Laura D; Torres, Calia A; Bartley, Emily J; George, Steven Z; Robinson, Michael E

    2015-01-01

    Objectives Pain is often poorly managed, highlighting the need to better understand and treat patients’ pain. Research suggests that pain is assessed and treated differently depending on patient sex, race, and/or age. Perspective-taking, whereby one envisions the perspective of another, has been found to reduce racial disparities in pain management. This study used virtual human (VH) technology to examine whether a perspective-taking intervention impacts pain management decisions. Methods Ninety-six participants were randomized to an online treatment or control group and viewed 16 video clips of VHs with standardized levels of pain. Participants provided ratings on the VHs’ pain intensity and their willingness to administer opioids to them. The intervention group received a brief perspective-taking intervention that consisted of having participants imagine how the patient’s suffering could affect his/her life, whereas the control group was asked to wait for the next VH videos to load. A LENS model analysis was used to investigate both group level (nomothetic) and individual level (idiographic) decision policies. A LENS model of analysis is typically used as an analog method for capturing how groups of people and individuals use information in their environment to form judgments. Results Nomothetic results found that participants rated pain higher and were more likely to prescribe opioids to VHs postintervention, irrespective of group. Idiographic results, however, found that the use of cues to make pain management decisions was mitigated by the perspective-taking group. The participants in the perspective-taking group were more likely to think about pain and the patients’ perspective during the intervention, while control participants were more likely to reflect on the VHs’ sex, race, or age. Conclusion A brief intervention may alter participants’ pain management decisions. These results indicate that a brief intervention might be an initial step toward

  12. Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries

    PubMed Central

    Graham, Shelli; Clerinx, Cathy; Bernick, Brian A; Krassan, Mitchell; Mirkin, Sebastian; Currie, Heather

    2016-01-01

    Objective To assess women’s behaviours and attitudes regarding the treatment of menopausal symptoms in five European countries. Study design Women aged ≥45 years in France, Germany, Italy, Spain, and the United Kingdom participated in an internet survey. Completers were those who reported menopausal symptoms and had treated their symptoms. Women were equally stratified by age (45–54 years, 55–64 years, ≥65 years). Main outcome measures Behaviours, attitudes, and experiences regarding treatment of menopausal symptoms. Results Of 3890 peri- to postmenopausal women screened, 67% experienced symptoms and 54% sought either medical input or some treatment concerning their symptoms. Hot flushes, the most common symptom, decreased with age but remained prevalent after age 64. Roughly 75% of women who sought relief consulted a physician, mostly a gynaecologist or a general practitioner (GP) as in the United Kingdom. The decision to seek treatment was influenced by age, number, and severity of symptoms. Approximately 79% visiting a physician received prescription therapy. Of the women who received non-hormone therapy (HT) treatment instead of HT: patients refused HT (20–44%), physicians did not discuss HT (32–46%), or advised against HT (24–43%). Women in the United Kingdom were most familiar with and favorable to HT. Interest in a new HT (34–50%) was higher than use (19–28%). Conclusions Menopausal symptoms are common, persistent, and bothersome, but many fail to seek treatment. Sources and types of treatment vary among age groups and countries. Education regarding women’s attitudes toward treatment should be provided to those physicians who treat menopausal symptoms in each country. PMID:26895640

  13. How Much are Emergency Medicine Specialists’ Decisions Reliable in the Diagnosis and Treatment of Pediatric Fractures?

    PubMed Central

    Mardani-Kivi, Mohsen; Zohrevandi, Behzad; Saheb-Ekhtiari, Khashayar; Hashemi-Motlagh, Keyvan

    2016-01-01

    Background: Considering the importance of an early diagnosis and proper decision-making in regards to the treatment of pediatric distal radius and elbow fractures, this study examines emergency medicine specialists’ accuracy in the diagnosis and treatment of these patients. Methods: From 2012 and 2013, children less than 14 years old who were referred to an academic hospital emergency department with elbow or distal radius fractures were enrolled. Initially, patients were examined by an emergency medicine specialist and then they were referred to an orthopedic surgeon. Type of fracture and the proposed treatment of two specialists were compared. Results: In total, there were 108 patients (54 patients in each group) with a mean age of 8.1±3.3 years. Identical diagnosis in 48 cases (88.9%) of distal radius and 36 cases (66.7%) of elbow trauma were observed. We found a difference between diagnosis of the two specialists in diagnosing lateral condyle of the humerus fracture in the elbow group and growth plate fracture in the distal radius fracture group, but the differences were not significant. Among 108 patients, 70 patients (64.8%) received identical treatment. Conclusion: Although the emergency medicine specialists responded similarly to the orthopedic specialists in the diagnosis of pediatric distal radius and elbow fractures, diagnosis of more complicated fractures such as lateral condylar humoral fractures, distal radius growth plate and for choosing the proper treatment option, merits further education. PMID:26894221

  14. Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury

    PubMed Central

    Ahn, Henry; Bailey, Christopher S.; Rivers, Carly S.; Noonan, Vanessa K.; Tsai, Eve C.; Fourney, Daryl R.; Attabib, Najmedden; Kwon, Brian K.; Christie, Sean D.; Fehlings, Michael G.; Finkelstein, Joel; Hurlbert, R. John; Townson, Andrea; Parent, Stefan; Drew, Brian; Chen, Jason; Dvorak, Marcel F.

    2015-01-01

    Background: Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (≥ 70 yr) on treatment decisions and outcomes. Methods: We identified patients with traumatic spinal cord injury for whom consent and detailed data were available from among patients recruited (2004–2013) at any of the 31 acute care and rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry. Patients were assessed by age group (< 70 v. ≥ 70 yr). The primary outcome was the rate of acute surgical treatment. We used bivariate and multivariate regression models to assess patient and injury-related factors associated with receiving surgical treatment and with the timing of surgery after arrival to a participating centre. Results: Of the 1440 patients included in our study cohort, 167 (11.6%) were 70 years or older at the time of injury. Older patients were more likely than younger patients to be injured by falling (83.1% v. 37.4%; p < 0.001), to have a cervical injury (78.0% v. 61.6%; p = 0.001), to have less severe injuries on admission (American Spinal Injury Association Impairment Scale grade C or D: 70.5% v. 46.9%; p < 0.001), to have a longer stay in an acute care hospital (median 35 v. 28 d; p < 0.005) and to have a higher in-hospital mortality (4.2% v. 0.6%; p < 0.001). Multivariate analysis did not show that age of 70 years or more at injury was associated with a decreased likelihood of surgical treatment (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.22–1.07). An unplanned sensitivity analysis with different age thresholds showed that a threshold of 65 years was associated with a decreased chance of surgical treatment (OR 0.39, 95% CI 0.19–0.80). Older patients who underwent surgical treatment had a significantly longer wait time from admission to surgery than younger patients (37 v. 19 h; p < 0.001). Interpretation: We found chronological age to be a factor influencing

  15. Operator decision support system for integrated wastewater management including wastewater treatment plants and receiving water bodies.

    PubMed

    Kim, Minsoo; Kim, Yejin; Kim, Hyosoo; Piao, Wenhua; Kim, Changwon

    2016-06-01

    An operator decision support system (ODSS) is proposed to support operators of wastewater treatment plants (WWTPs) in making appropriate decisions. This system accounts for water quality (WQ) variations in WWTP influent and effluent and in the receiving water body (RWB). The proposed system is comprised of two diagnosis modules, three prediction modules, and a scenario-based supporting module (SSM). In the diagnosis modules, the WQs of the influent and effluent WWTP and of the RWB are assessed via multivariate analysis. Three prediction modules based on the k-nearest neighbors (k-NN) method, activated sludge model no. 2d (ASM2d) model, and QUAL2E model are used to forecast WQs for 3 days in advance. To compare various operating alternatives, SSM is applied to test various predetermined operating conditions in terms of overall oxygen transfer coefficient (Kla), waste sludge flow rate (Qw), return sludge flow rate (Qr), and internal recycle flow rate (Qir). In the case of unacceptable total phosphorus (TP), SSM provides appropriate information for the chemical treatment. The constructed ODSS was tested using data collected from Geumho River, which was the RWB, and S WWTP in Daegu City, South Korea. The results demonstrate the capability of the proposed ODSS to provide WWTP operators with more objective qualitative and quantitative assessments of WWTP and RWB WQs. Moreover, the current study shows that ODSS, using data collected from the study area, can be used to identify operational alternatives through SSM at an integrated urban wastewater management level. PMID:26893178

  16. eHealth-as-a-Service (eHaaS): a data-driven decision making approach in Australian context.

    PubMed

    Black, Alofi; Sahama, Tony; Gajanayake, Randike

    2014-01-01

    A commitment in 2010 by the Australian Federal Government to spend $466.7 million dollars on the implementation of personally controlled electronic health records (PCEHR) heralded a shift to a more effective and safer patient centric eHealth system. However, deployment of the PCEHR has met with much criticism, emphasised by poor adoption rates over the first 12 months of operation. An indifferent response by the public and healthcare providers largely sceptical of its utility and safety speaks to the complex sociotechnical drivers and obstacles inherent in the embedding of large (national) scale eHealth projects. With government efforts to inflate consumer and practitioner engagement numbers giving rise to further consumer disillusionment, broader utilitarian opportunities available with the PCEHR are at risk. This paper discusses the implications of establishing the PCEHR as the cornerstone of a holistic eHealth strategy for the aggregation of longitudinal patient information. A viewpoint is offered that the real value in patient data lies not just in the collection of data but in the integration of this information into clinical processes within the framework of a commoditised data-driven approach. Consideration is given to the eHealth-as-a-Service (eHaaS) construct as a disruptive next step for co-ordinated individualised healthcare in the Australian context. PMID:25160321

  17. Making decisions about treatment for young people diagnosed with depressive disorders: a qualitative study of clinicians’ experiences

    PubMed Central

    2013-01-01

    Background The imperative to provide effective treatment for young people diagnosed with depressive disorders is complicated by several factors including the unclear effectiveness of treatment options. Within this context, little is known about how treatment decisions are made for this population. Methods In order to explore the experiences and beliefs of clinicians about treatment decision making for this population, semi-structured, qualitative interviews were conducted with 22 psychiatrists, general practitioners and allied health professionals from health care settings including specialist mental health services and primary health care. Interviews were audio taped, transcribed verbatim and analysed using thematic analysis. Results Clinicians largely reported and endorsed a collaborative model of treatment decision making for youth depression, although several exceptions to this approach were also described (e.g. when risk issues were present), highlighting a need to adapt the decision-making style to the characteristics and needs of the client. A differentiation was made between the decision-making processes (e.g. sharing of information) and who makes the decision. Caregiver involvement was seen as optional, especially in situations where no caregivers were involved, but ideal and useful if the caregivers were supportive. Gaps between the type and amount of information clinicians wanted to give their clients and what they actually gave them were reported (e.g. having fact sheets on hand). A broad range of barriers to involving clients and caregivers in decision-making processes were described relating to four levels (client and caregiver, clinician, service and broader levels) and suggestions were given to help overcome these barriers, including up-to-date, accessible and relevant information. Conclusions The current data support a collaborative model of treatment decision making for youth depression which: 1) focuses on the decision-making processes rather

  18. Management of frontal sinus fractures--treatment decision based on metric dislocation extent.

    PubMed

    Dalla Torre, Daniel; Burtscher, Doris; Kloss-Brandstätter, Anita; Rasse, Michael; Kloss, Frank

    2014-10-01

    The treatment of frontal sinus fractures is still a matter of research in neurosurgical and craniofacial surgery. The present study aimed to determine new criteria regarding surgical or observational treatment, especially concerning the fracture dislocation. Clinical information on 164 consecutive patients with fractures of the frontal sinus, treated at the Department of Craniomaxillofacial Surgery of the Medical University of Innsbruck from 2006 to 2010, have been evaluated. 23 female (14%) and 141 male (86%) patients suffered mainly from traffic (31.7%) and sports accidents (28.0%), followed by work accidents (20.1%), violence (3.7%) and accidents at home (3.1%). 51.8% presented an isolated fracture of the anterior wall, 47.6% both anterior and posterior wall fracture, 0.6% an isolated posterior wall fracture. Injury of the nasofrontal duct was found in 29.2%, CSF liquorrhoea in 15.9%. In total, 44.5% of the patients underwent surgical therapy, 55.5% were treated conservatively by observation. Treatment decision depended significantly on concomitant injuries of the nasofrontal duct and the presence of rhinoliquorrhoea as well as on the fracture dislocation. A new classification of frontal sinus fractures depending on their maximum dislocation is proposed. In addition, a treatment algorithm considering displacement, liquorrhoea and injury of the nasofrontal duct is presented. PMID:24942098

  19. Primary Care Providers’ Initial Treatment Decisions and Antidepressant Prescribing for Adolescent Depression

    PubMed Central

    Radovic, Ana; Farris, Coreen; Reynolds, Kerry; Reis, Evelyn C.; Miller, Elizabeth; Stein, Bradley D.

    2014-01-01

    OBJECTIVE Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. We examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network. METHOD We administered a cross sectional survey to 58 PCPs within a large pediatric practice network. We compared PCP reports of initial treatment decisions in response to two vignettes describing depressed adolescents with either moderate or severe symptoms. We measured PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics. RESULTS Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (OR 5.50[95% CI 2.47-12.2] p<.001). Depression severity did not affect the likelihood of antidepressant recommendation (OR 1.58[95% CI 0.80-3.11] p=.19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR 1.72[95% CI 1.14-2.59] p=.009) and access to an on-site mental health provider (OR 5.13[95% CI 1.24-21.2] p=.02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR 0.85[95% CI 0.75-0.98] p=.02). CONCLUSION PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs’ antidepressant prescribing. PMID:24336091

  20. Data: Mining with a Mission- Data-Driven Decision Making Is the Buzz Phrase of Choice for the New Decade. but Once We've Got the Information, How Do We Use It to Yield Results?

    ERIC Educational Resources Information Center

    Salpeter, Judy

    2004-01-01

    For some districts, the current obsession with data grows out of the need to comply with No Child Left Behind and additional accountability-related mandates. For others, it dates way back before the phrase "data-driven decision making" rolled so frequently off the tongues of educators. In either case, there is no denying that an integral part of…

  1. Perspectives of parents on making decisions about the care and treatment of a child with cancer: a review of literature.

    PubMed

    Markward, Martha J; Benner, Kalea; Freese, Rebekah

    2013-12-01

    This review focuses on parental decision making regarding the care and treatment of children with cancer. Articles were abstracted from the following sources: Ovid Databases (Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, Medline, and Social Work Abstracts) and EBSCOhost (Academic Search Premier and Academic Search Complete) using smart text. The criteria for the search were publications between 2005 and 2012 and publication in peer-review journals. The descriptors used were parents of children with cancer, decision making, decisions about childhood cancer, and parents. The search yielded 59 references, but after duplicates, as well as dated and irrelevant articles were removed, 17 articles were identified that focused specifically on the decisions parents make regarding the care and treatment of children with cancer. Coders agreed that the child's quality of life/well-being, parental hope/expectations, support/supportive care, communication, and information were important themes in considering the decisions parents made regarding the care and treatment of children with cancer. These themes provide insight into the needs of parents in making decisions about the care and treatment of children with cancer. PMID:24377769

  2. Actual and Perceived Gender Differences in the Accuracy of Surrogate Decisions about Life-Sustaining Medical Treatment among Older Spouses

    ERIC Educational Resources Information Center

    Zettel-Watson, Laura; Ditto, Peter H.; Danks, Joseph H.; Smucker, William D.

    2008-01-01

    This study examined the influence of surrogate gender on the accuracy of substituted judgments about the use of life-sustaining treatment in a sample of 249 older adults and their self-selected surrogate decision-makers. Overall, wives were more accurate than husbands at predicting their spouses' treatment wishes. Surrogates' perceptions of their…

  3. SU-D-BRE-05: Feasibility and Limitations of Laser-Driven Proton Therapy: A Treatment Planning Study

    SciTech Connect

    Hofmann, K; Wilkens, J; Masood, U; Pawelke, J

    2014-06-01

    Purpose: Laser-acceleration of particles may offer a cost- and spaceefficient alternative for future radiation therapy with particles. Laser-driven particle beams are pulsed with very short bunch times, and a high number of particles is delivered within one laser shot which cannot be portioned or modulated during irradiation. The goal of this study was to examine whether good treatment plans can be produced for laser-driven proton beams and to investigate the feasibility of a laser-driven treatment unit. Methods: An exponentially decaying proton spectrum was tracked through a gantry and energy selection beam line design to produce multiple proton spectra with different energy widths centered on various nominal energies. These spectra were fed into a treatment planning system to calculate spot scanning proton plans using different lateral widths of the beam and different numbers of protons contained in the initial spectrum. The clinical feasibility of the resulting plans was analyzed in terms of dosimetric quality and the required number of laser shots as an estimation of the overall treatment time. Results: We were able to produce treatment plans with plan qualities of clinical relevance for a maximum initial proton number per laser shot of 6*10{sup 8}. However, the associated minimum number of laser shots was in the order of 10{sup 4}, indicating a long delivery time in the order of at least 15 minutes, when assuming an optimistic repetition rate of the laser system of 10 Hz. Conclusion: With the simulated beam line and the assumed shape of the proton spectrum it was impossible to produce clinically acceptable treatment plans that can be delivered in a reasonable time. The situation can be improved by a method or a device in the beam line which can modulate the number of protons from shot to shot. Supported by DFG Cluster of Excellence: Munich-Centre for Advanced Photonics.

  4. What Can Parents Do? A Review of State Laws Regarding Decision Making for Adolescent Drug Abuse and Mental Health Treatment

    PubMed Central

    Kerwin, MaryLouise E.; Kirby, Kimberly C.; Speziali, Dominic; Duggan, Morgan; Mellitz, Cynthia; Versek, Brian; McNamara, Ashley

    2013-01-01

    This study examined US state laws regarding parental and adolescent decision-making for substance use and mental health inpatient and outpatient treatment. State statues for requiring parental consent favored mental health over drug abuse treatment and inpatient over outpatient modalities. Parental consent was sufficient in 53%–61% of the states for inpatient treatment, but only for 39% – 46% of the states for outpatient treatment. State laws favored the rights of minors to access drug treatment without parental consent, and to do so at a younger age than for mental health treatment. Implications for how these laws may impact parents seeking help for their children are discussed. PMID:25870511

  5. [The role of PET/CT in decision-making during cancer treatment. Clinical experience].

    PubMed

    Sinkó, Dániel; Landherr, László

    2012-12-01

    Nowadays PET/CT examinations have got more and more important role during cancer treatment. It has importance not only in diagnostic examination and staging but also in the radiation planning process and measuring the therapeutic effect. From November 2006 to November 2010 there were 153 PET/CT examinations requested by the Oncology Outpatient Clinic, Uzsoki Hospital. Nine patients were excluded from the examination. In the clinical trial we have aimed to measure what the correlation between the oncologists' questions and the PET/CT results was, in how many cases the PET/CT had influence on therapeutic decision-making. In the case of the patients waiting for the operation we compared the results of the pathological examinations to the results of the PET/CT. The oncologists got the expected answers in 79 cases, while in 45 cases the answers were negative. In 10 cases there were no definite answers. Ten cases proved to be false negative or false positive based on the later pathological examination. As a result of the PET/CT findings the originally planned therapeutic decisions or the therapies in process have been modified in 77 cases. To sum up, the PET/CT gave the expected answers to the oncologists' questions in more than half of the cases (54.9%) and modified the originally prescribed therapy in 53.5% of the cases. PMID:23236592

  6. The vexing problem of defining the meaning, role and measurement of values in treatment decision-making.

    PubMed

    Charles, Cathy; Gafni, Amiram

    2014-03-01

    Two international movements, evidence-based medicine (EBM) and shared decision-making (SDM) have grappled for some time with issues related to defining the meaning, role and measurement of values/preferences in their respective models of treatment decision-making. In this article, we identify and describe unresolved problems in the way that each movement addresses these issues. The starting point for this discussion is that at least two essential ingredients are needed for treatment decision-making: research information about treatment options and their potential benefits and risks; and the values/preferences of participants in the decision-making process. Both the EBM and SDM movements have encountered difficulties in defining the meaning, role and measurement of values/preferences in treatment decision-making. In the EBM model of practice, there is no clear and consistent definition of patient values/preferences and no guidance is provided on how to integrate these into an EBM model of practice. Methods advocated to measure patient values are also problematic. Within the SDM movement, patient values/preferences tend to be defined and measured in a restrictive and reductionist way as patient preferences for treatment options or attributes of options, while broader underlying value structures are ignored. In both models of practice, the meaning and expected role of physician values in decision-making are unclear. Values clarification exercises embedded in patient decision aids are suggested by SDM advocates to identify and communicate patient values/preferences for different treatment outcomes. Such exercises have the potential to impose a particular decision-making theory and/or process onto patients, which can change the way they think about and process information, potentially impeding them from making decisions that are consistent with their true values. The tasks of clarifying the meaning, role and measurement of values/preferences in treatment decision

  7. Decision support tools for proton therapy ePR: intelligent treatment planning navigator and radiation toxicity tool for evaluating of prostate cancer treatment

    NASA Astrophysics Data System (ADS)

    Le, Anh H.; Deshpande, Ruchi; Liu, Brent J.

    2010-03-01

    The electronic patient record (ePR) has been developed for prostate cancer patients treated with proton therapy. The ePR has functionality to accept digital input from patient data, perform outcome analysis and patient and physician profiling, provide clinical decision support and suggest courses of treatment, and distribute information across different platforms and health information systems. In previous years, we have presented the infrastructure of a medical imaging informatics based ePR for PT with functionality to accept digital patient information and distribute this information across geographical location using Internet protocol. In this paper, we present the ePR decision support tools which utilize the imaging processing tools and data collected in the ePR. The two decision support tools including the treatment plan navigator and radiation toxicity tool are presented to evaluate prostate cancer treatment to improve proton therapy operation and improve treatment outcomes analysis.

  8. A Clinical Decision Support System for Femoral Peripheral Arterial Disease Treatment

    PubMed Central

    Yurtkuran, Alkın; Tok, Mustafa

    2013-01-01

    One of the major challenges of providing reliable healthcare services is to diagnose and treat diseases in an accurate and timely manner. Recently, many researchers have successfully used artificial neural networks as a diagnostic assessment tool. In this study, the validation of such an assessment tool has been developed for treatment of the femoral peripheral arterial disease using a radial basis function neural network (RBFNN). A data set for training the RBFNN has been prepared by analyzing records of patients who had been treated by the thoracic and cardiovascular surgery clinic of a university hospital. The data set includes 186 patient records having 16 characteristic features associated with a binary treatment decision, namely, being a medical or a surgical one. K-means clustering algorithm has been used to determine the parameters of radial basis functions and the number of hidden nodes of the RBFNN is determined experimentally. For performance evaluation, the proposed RBFNN was compared to three different multilayer perceptron models having Pareto optimal hidden layer combinations using various performance indicators. Results of comparison indicate that the RBFNN can be used as an effective assessment tool for femoral peripheral arterial disease treatment. PMID:24382983

  9. Precedent autonomy should be respected in life-sustaining treatment decisions.

    PubMed

    Hebron, Allison Leslie; McGee, Summer

    2014-10-01

    In the 2011 landmark case of W v M, the English Court of Protection ruled that it was unlawful to withdraw artificial nutrition and hydration from a woman who had been in a minimally conscious state for 8 years. From the perspective of the court, the absence of a written advance directive negated the woman's previous, autonomous interests and, consequently, emphasis was given to her current welfare and well-being. While life itself is a moral good, prolonging life for a person in regular pain with no hope of recovering to a more complete state of awareness simply because that person only verbalized her wishes about her treatment decisions seems to drastically undervalue the principle of autonomy. We refute the notion that it is the role of the court to prolong life insofar as it can and argue that withholding and withdrawing life sustaining technologies from patients in a minimally conscious state can be ethically justified. PMID:24567422

  10. The ethics of forgoing life-sustaining treatment: theoretical considerations and clinical decision making.

    PubMed

    Welie, Jos Vm; Ten Have, Henk Amj

    2014-01-01

    Withholding or withdrawing a life-sustaining treatment tends to be very challenging for health care providers, patients, and their family members alike. When a patient's life seems to be nearing its end, it is generally felt that the morally best approach is to try a new intervention, continue all treatments, attempt an experimental course of action, in short, do something. In contrast to this common practice, the authors argue that in most instances, the morally safer route is actually to forgo life-sustaining treatments, particularly when their likelihood to effectuate a truly beneficial outcome has become small relative to the odds of harming the patient. The ethical analysis proceeds in three stages. First, the difference between neglectful omission and passive acquiescence is explained. Next, the two necessary conditions for any medical treatment, i.e., that it is medically indicated and that consent is obtained, are applied to life-sustaining interventions. Finally, the difference between withholding and withdrawing a life-sustaining treatment is discussed. In the second part of the paper the authors show how these theoretical-ethical considerations can guide clinical-ethical decision making. A case vignette is presented about a patient who cannot be weaned off the ventilator post-surgery. The ethical analysis of this case proceeds through three stages. First, it is shown that and why withdrawal of the ventilator in this case does not equate assistance in suicide or euthanasia. Next, the question is raised whether continued ventilation can be justified medically, or has become futile. Finally, the need for the health care team to obtain consent for the continuation of the ventilation is discussed. PMID:24618004

  11. An Initial Comparison of Collaborative and Expert-Driven Consultation on Treatment Integrity

    ERIC Educational Resources Information Center

    Kelleher, Constance; Riley-Tillman, T. Chris; Power, Thomas J.

    2008-01-01

    Although over 15 years have passed since Witt (1990) noted that no empirical evidence exists to support the contention that a collaborative approach to consultation leads to more positive outcomes than a hierarchical or expert driven approach, this issue generally remains unaddressed (Schulte & Osborne, 2003). While the literature documenting the…

  12. Selection of an appropriate wastewater treatment technology: a scenario-based multiple-attribute decision-making approach.

    PubMed

    Kalbar, Pradip P; Karmakar, Subhankar; Asolekar, Shyam R

    2012-12-30

    Many technological alternatives for wastewater treatment are available, ranging from advanced technologies to conventional treatment options. It is difficult to select the most appropriate technology from among a set of available alternatives to treat wastewater at a particular location. Many factors, such as capital costs, operation and maintenance costs and land requirement, are involved in the decision-making process. Sustainability criteria must also be incorporated into the decision-making process such that appropriate technologies are selected for developing economies such as that of India. A scenario-based multiple-attribute decision-making (MADM) methodology has been developed and applied to the selection of wastewater treatment alternative. The four most commonly used wastewater treatment technologies for treatment of municipal wastewater in India are ranked for various scenarios. Six scenarios are developed that capture the regional and local societal priorities of urban, suburban and rural areas and translate them into the mathematical algorithm of the MADM methodology. The articulated scenarios depict the most commonly encountered decision-making situations in addressing technology selection for wastewater treatment in India. A widely used compensatory MADM technique, TOPSIS, has been selected to rank the alternatives. Seven criteria with twelve indicators are formulated to evaluate the alternatives. Different weight matrices are used for each scenario, depending on the priorities of the scenario. This study shows that it is difficult to select the most appropriate wastewater treatment alternative under the "no scenario" condition (equal weights given to each attribute), and the decision-making methodology presented in this paper effectively identifies the most appropriate wastewater treatment alternative for each of the scenarios. PMID:23023038

  13. Competence to make treatment decisions in anorexia nervosa: thinking processes and values

    PubMed Central

    Tan, Dr. Jacinta O. A.; Hope, Professor Tony; Stewart, Dr. Anne; Fitzpatrick, Professor Raymond

    2005-01-01

    This paper explores the ethical and conceptual implications of the findings from an empirical study of decision-making capacity in anorexia nervosa. In the study, ten female patients aged 13 to 21 years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semi-structured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient participants were also tested using the MacCAT-T test of competence. This is a formalised, structured interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief self-administered questionnaires to assess their levels of psychopathology. The issues identified from the interviews are described under two headings: difficulties with thought processing, and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches or current standardised tests of competence. PMID:18066393

  14. Economic comparison of common treatment protocols and J5 vaccination for clinical mastitis in dairy herds using optimized culling decisions.

    PubMed

    Kessels, J A; Cha, E; Johnson, S K; Welcome, F L; Kristensen, A R; Gröhn, Y T

    2016-05-01

    This study used an existing dynamic optimization model to compare costs of common treatment protocols and J5 vaccination for clinical mastitis in US dairy herds. Clinical mastitis is an infection of the mammary gland causing major economic losses in dairy herds due to reduced milk production, reduced conception, and increased risk of mortality and culling for infected cows. Treatment protocols were developed to reflect common practices in dairy herds. These included targeted therapy following pathogen identification, and therapy without pathogen identification using a broad-spectrum antimicrobial or treating with the cheapest treatment option. The cost-benefit of J5 vaccination was also estimated. Effects of treatment were accounted for as changes in treatment costs, milk loss due to mastitis, milk discarded due to treatment, and mortality. Following ineffective treatments, secondary decisions included extending the current treatment, alternative treatment, discontinuing treatment, and pathogen identification followed by recommended treatment. Average net returns for treatment protocols and vaccination were generated using an existing dynamic programming model. This model incorporates cow and pathogen characteristics to optimize management decisions to treat, inseminate, or cull cows. Of the treatment protocols where 100% of cows received recommended treatment, pathogen-specific identification followed by recommended therapy yielded the highest average net returns per cow per year. Out of all treatment scenarios, the highest net returns were achieved with selecting the cheapest treatment option and discontinuing treatment, or alternate treatment with a similar spectrum therapy; however, this may not account for the full consequences of giving nonrecommended therapies to cows with clinical mastitis. Vaccination increased average net returns in all scenarios. PMID:26947301

  15. Primary care professional’s perspectives on treatment decision making for depression with African Americans and Latinos in primary care practice

    PubMed Central

    Patel, Sapana R.; Schnall, Rebecca; Little, Virna; Lewis-Fernández, Roberto; Pincus, Harold Alan

    2013-01-01

    Increasing interest has been shown in shared decision making (SDM) to improve mental health care communication between underserved immigrant minorities and their providers. Nonetheless, very little is known about this process. The following is a qualitative study of fifteen primary care providers at two Federally Qualified Health Centers in New York and their experience during depression treatment decision making. Respondents described a process characterized in between shared and paternalistic models of treatment decision making. Barriers to shared decision making included discordant models of illness, stigma, varying role expectations and decision readiness. Respondents reported strategies used to overcome barriers including understanding illness perceptions and the role of the community in the treatment process, dispelling stigma using cultural terms, orienting patients to treatment and remaining available regarding the treatment decision. Findings from this study have implications for planning SDM interventions to guide primary care providers through treatment engagement for depression. PMID:24104206

  16. Factors influencing the decision about orthodontic treatment. A longitudinal study among 11- and 15-year-olds and their parents.

    PubMed

    Birkeland, K; Katle, A; Løvgreen, S; Bøe, O E; Wisth, P J

    1999-01-01

    The aims of the study were to evaluate the attitude towards orthodontic treatment among 11-(T1) and 15-year-old children (T2) and their parents, to present the distribution of referral rate and treatment uptake by a treatment need index assessed at T1 and to elucidate factors influencing the decision about orthodontic treatment in the period from T1 to T2. A group of 359 children and their parents answered separate questionnaires at T1, and 293 families responded to a follow-up study 4 years later. For the clinical examination, 224 children participated after exclusion of children in active treatment. The dental study casts were assessed by the Index of Orthodontic Treatment Need (IOTN). The mean referral rate was 56%, with a variation from 40% to 71% among different dental clinics. About 44% of the children had completed or were undergoing orthodontic treatment at T2. No significant sex differences among referred and treated children were discovered. Aesthetic motives were the most frequently reported subjective reason for orthodontic care. The untreated group expressed diminishing treatment desire in the follow-up period. The logistic regression analysis selected Dental Health Component (DHC) grades as a strong predictor for treatment uptake, followed by parents' concern and attitude to braces, while the 11-year-olds' own orthodontic concern was less significant. Children in the untreated group with late treatment decisions (T2) were best predicted by Aesthetic Component (AC) changes from T1 to T2. The results indicate that dentists play a key role in determining orthodontic treatment levels. High referral rates secured low risk of denying care to some patients. Treatment decision may be guided by the orthodontist. However, individual variation in attitude and desire influence treatment uptake even among children with great need. PMID:10546413

  17. Patient Preferences and Shared Decision Making in the Treatment of Substance Use Disorders: A Systematic Review of the Literature

    PubMed Central

    Friedrichs, Anke; Spies, Maren; Härter, Martin; Buchholz, Angela

    2016-01-01

    Background Shared Decision Making (SDM) as means to the involvement of patients in medical decision making is increasingly demanded by treatment guidelines and legislation. Also, matching of patients’ preferences to treatments has been shown to be effective regarding symptom reduction. Despite promising results for patients with substance use disorders (SUD) no systematic evaluation of the literature has been provided. The aim is therefore to give a systematic overview of the literature of patient preferences and SDM in the treatment of patients with SUD. Methods An electronic literature search of the databases Medline, Embase, Psyndex and Clinical Trials Register was performed. Variations of the search terms substance use disorders, patient preferences and SDM were used. For data synthesis the populations, interventions and outcomes were summarized and described according to the PRISMA statement. Methodological quality of the included articles was assessed with the Mixed Methods Appraisal Tool. Results N = 25 trials were included in this review. These were conducted between 1986 and 2014 with altogether n = 8.729 patients. Two studies found that patients with SUD preferred to be actively involved in treatment decisions. Treatment preferences were assessed in n = 18 studies, where the majority of patients preferred outpatient compared with inpatient treatment. Matching patients to preferences resulted in a reduction on substance use (n = 3 studies), but the majority of studies found no significant effect. Interventions for SDM differed across patient populations and optional therapeutic techniques. Discussion Patients with substance use disorders should be involved in medical treatment decisions, as patients with other health conditions. A suitable approach is Shared Decision Making, emphasizing the patients’ preferences. However, due to the heterogeneity of the included studies, results should be interpreted with caution. Further research is needed regarding

  18. The Application of Climate Risk Informed Decision Analysis to the Ioland Water Treatment Plant in Lusaka, Zambia

    NASA Astrophysics Data System (ADS)

    Kucharski, John; Tkach, Mark; Olszewski, Jennifer; Chaudhry, Rabia; Mendoza, Guillermo

    2016-04-01

    This presentation demonstrates the application of Climate Risk Informed Decision Analysis (CRIDA) at Zambia's principal water treatment facility, The Iolanda Water Treatment Plant. The water treatment plant is prone to unacceptable failures during periods of low hydropower production at the Kafue Gorge Dam Hydroelectric Power Plant. The case study explores approaches of increasing the water treatment plant's ability to deliver acceptable levels of service under the range of current and potential future climate states. The objective of the study is to investigate alternative investments to build system resilience that might have been informed by the CRIDA process, and to evaluate the extra resource requirements by a bilateral donor agency to implement the CRIDA process. The case study begins with an assessment of the water treatment plant's vulnerability to climate change. It does so by following general principals described in "Confronting Climate Uncertainty in Water Resource Planning and Project Design: the Decision Tree Framework". By utilizing relatively simple bootstrapping methods a range of possible future climate states is generated while avoiding the use of more complex and costly downscaling methodologies; that are beyond the budget and technical capacity of many teams. The resulting climate vulnerabilities and uncertainty in the climate states that produce them are analyzed as part of a "Level of Concern" analysis. CRIDA principals are then applied to this Level of Concern analysis in order to arrive at a set of actionable water management decisions. The principal goals of water resource management is to transform variable, uncertain hydrology into dependable services (e.g. water supply, flood risk reduction, ecosystem benefits, hydropower production, etc…). Traditional approaches to climate adaptation require the generation of predicted future climate states but do little guide decision makers how this information should impact decision making. In

  19. Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.

    PubMed

    Whyte, John; Dijkers, Marcel P; Hart, Tessa; Zanca, Jeanne M; Packel, Andrew; Ferraro, Mary; Tsaousides, Theodore

    2014-01-01

    Many rehabilitation treatment interventions, unlike pharmacologic treatments, are not operationally defined, and the labels given to such treatments do not specify the active ingredients that produce the intended treatment effects. This, in turn, limits the ability to study and disseminate treatments, to communicate about them clearly, or to train new clinicians to administer them appropriately. We sought to begin the development of a system of classification of rehabilitation treatments and services that is based on their active ingredients. To do this, we reviewed a range of published descriptions of rehabilitation treatments and treatments that were familiar to the authors from their clinical and research experience. These treatment examples were used to develop preliminary rules for defining discrete treatments, identifying the area of function they directly treat, and identifying their active ingredients. These preliminary rules were then tested against additional treatment examples, and problems in their application were used to revise the rules in an iterative fashion. The following concepts, which emerged from this process, are defined and discussed in relation with the development of a rehabilitation treatment taxonomy: rehabilitation treatment taxonomy; treatment and enablement theory; recipient (of treatment); essential, active, and inactive ingredients; mechanism of action; targets and aims of treatment; session; progression; dosing parameters; and social and physical environment. It is hoped that articulation of the conceptual issues encountered during this project will be useful to others attempting to promote theory-based discussion of rehabilitation effects and that multidisciplinary discussion and research will further refine these rules and definitions to advance rehabilitation treatment classification. PMID:24370322

  20. Using Linked Models to Study Interactions Between Water Use Decisions and Climate Change-Driven Watershed Processes in the Pacific Northwest Region

    NASA Astrophysics Data System (ADS)

    Orr, C. H.; Adam, J. C.; Beall, A. M.; Barber, M. E.; Nguyen, T. T.

    2012-12-01

    . Stakeholder processes that openly discuss the range of potential futures are helpful for mitigating the paralysis of water management policy caused by scientific and social uncertainty. The Palouse Basin bordering SE Washington and NW Idaho used collaborative modeling as to explore scientific uncertainty and potential futures in a sole source aquifer system with negligible recharge. In the Spokane Coeur D'Alene basin, a stakeholder exercise revealed that measurement uncertainty inclined stakeholders were inclined to pass up a costly Total Maximum Daily Load (TMDL) process and go directly to mitigation. Both cases revealed feedbacks to the physical system that are the result of decisions, preferences, and beliefs. This modeling framework is part of a larger development effort Watershed Integrated Systems Dynamics Model or "WISDM" to construct linked models to study interactions between water use decisions and climate change-driven watershed processes, and then to explore how participant / stakeholder involvement in the modeling could both improve understanding of the systems and lay the groundwork for adaptive changes in institutional arrangements.

  1. The Involvement of Parents in Healthcare Decisions Where Adult Children Are at Risk of Lacking Decision-Making Capacity: A Qualitative Study of Treatment Decisions in Epilepsy

    ERIC Educational Resources Information Center

    Redley, M.; Prince, E.; Bateman, N.; Pennington, M.; Wood, N.; Croudace, T.; Ring, H.

    2013-01-01

    Background: Patients with intellectual disabilities (ID) receive health care by proxy. It is family members and/or paid support staff who must recognise health problems, communicate with clinicians, and report the benefits, if any, of a particular treatment. At the same time international and national statutes protect and promote the right of…

  2. International and cross-cultural dimensions of treatment decisions for neonates.

    PubMed

    Lantos, John D

    2015-10-01

    Neonatal mortality rates vary widely among countries. According to data from the World Health Organization, neonatal mortality in low- and low-middle-income countries is ∼30 per 1000 babies. In upper middle-income countries, that number was just 10 per 1000. In the highest-income countries, it was <5 per 1000. These data may not be accurate. Many countries do not report the tiniest babies as live births. Thus, their reported infant mortality rates are much lower than their actual infant mortality rates. Another big difference between countries is in the rate at which congenital anomalies are diagnosed prenatally and the rate at which pregnancies are terminated by induced abortion. International comparisons therefore reflect differences in the way countries define live birth, the comprehensiveness of the reporting of live births even by their own definitions, differences in the prevalence of congenital anomalies, the rate at which those congenital anomalies are diagnosed prenatally, and the percentage of pregnancies with congenital anomalies that end in abortion. This article reviews these differences and discusses the implications for the ways in which we think about international differences in decisions about life-sustaining treatment. PMID:26072059

  3. Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions.

    PubMed

    Pang, M C

    1999-06-01

    The first part of this paper examines the practice of informed treatment decisions in the protective medical system in China today. The second part examines how health care professionals in China perceive and carry out their responsibilities when relaying information to vulnerable patients, based on the findings of an empirical study that I had undertaken to examine the moral experience of nurses in practice situations. In the Chinese medical ethics tradition, refinement [jing] in skills and sincerity [cheng] in relating to patients are two cardinal virtues that health care professionals are required to possess. This notion of absolute sincerity carries a strong sense of parental protectiveness. The empirical findings reveal that most nurses are ambivalent about telling the truth to patients. Truth-telling would become an insincere act if a patient were to lose hope and confidence in life after learning of his or her disease. In this system of protective medical care, it is arguable as to whose interests are being protected: the patient, the family or the hospital. I would suggest that the interests of the hospital and the family members who legitimately represent the patient's interests are being honoured, but at the expense of the patient's right to know. PMID:10390681

  4. Comparison of an effect-model-law-based method versus traditional clinical practice guidelines for optimal treatment decision-making: application to statin treatment in the French population

    PubMed Central

    Kahoul, Riad; Gueyffier, François; Amsallem, Emmanuel; Haugh, Margaret; Marchant, Ivanny; Boissel, François-Henri; Boissel, Jean-Pierre

    2014-01-01

    Healthcare authorities make difficult decisions about how to spend limited budgets for interventions that guarantee the best cost-efficacy ratio. We propose a novel approach for treatment decision-making, OMES—in French: Objectif thérapeutique Modèle Effet Seuil (in English: Therapeutic Objective–Threshold–Effect Model; TOTEM). This approach takes into consideration results from clinical trials, adjusted for the patients' characteristics in treatment decision-making. We compared OMES with the French clinical practice guidelines (CPGs) for the management of dyslipidemia with statin in a computer-generated realistic virtual population, representing the adult French population, in terms of the number of all-cause deaths avoided (number of avoided events: NAEs) under treatment and the individual absolute benefit. The total budget was fixed at the annual amount reimbursed by the French social security for statins. With the CPGs, the NAEs was 292 for an annual cost of 122.54 M€ compared with 443 with OMES. For a fixed NAEs, OMES reduced costs by 50% (60.53 M€ yr−1). The results demonstrate that OMES is at least as good as, and even better than, the standard CPGs when applied to the same population. Hence the OMES approach is a practical, useful alternative which will help to overcome the limitations of treatment decision-making based uniquely on CPGs. PMID:25209407

  5. Comparison of an effect-model-law-based method versus traditional clinical practice guidelines for optimal treatment decision-making: application to statin treatment in the French population.

    PubMed

    Kahoul, Riad; Gueyffier, François; Amsallem, Emmanuel; Haugh, Margaret; Marchant, Ivanny; Boissel, François-Henri; Boissel, Jean-Pierre

    2014-11-01

    Healthcare authorities make difficult decisions about how to spend limited budgets for interventions that guarantee the best cost-efficacy ratio. We propose a novel approach for treatment decision-making, OMES-in French: Objectif thérapeutique Modèle Effet Seuil (in English: Therapeutic Objective-Threshold-Effect Model; TOTEM). This approach takes into consideration results from clinical trials, adjusted for the patients' characteristics in treatment decision-making. We compared OMES with the French clinical practice guidelines (CPGs) for the management of dyslipidemia with statin in a computer-generated realistic virtual population, representing the adult French population, in terms of the number of all-cause deaths avoided (number of avoided events: NAEs) under treatment and the individual absolute benefit. The total budget was fixed at the annual amount reimbursed by the French social security for statins. With the CPGs, the NAEs was 292 for an annual cost of 122.54 M€ compared with 443 with OMES. For a fixed NAEs, OMES reduced costs by 50% (60.53 M€ yr(-1)). The results demonstrate that OMES is at least as good as, and even better than, the standard CPGs when applied to the same population. Hence the OMES approach is a practical, useful alternative which will help to overcome the limitations of treatment decision-making based uniquely on CPGs. PMID:25209407

  6. A natural driven membrane process for brackish and wastewater treatment: photovoltaic powered ED and FO hybrid system.

    PubMed

    Zhang, Yang; Pinoy, Luc; Meesschaert, Boudewijn; Van der Bruggen, Bart

    2013-09-17

    In isolated locations, remote areas, or islands, potable water is precious because of the lack of drinking water treatment facilities and energy supply. Thus, a robust and reliable water treatment system based on natural energy is needed to reuse wastewater or to desalinate groundwater/seawater for provision of drinking water. In this work, a hybrid membrane system combining electrodialysis (ED) and forward osmosis (FO), driven by renewable energy (solar energy), denoted as EDFORD (ED-FO Renewable energy Desalination), is proposed to produce high-quality water (potable) from secondary wastewater effluent or brackish water. In this hybrid membrane system, feedwater (secondary wastewater effluent or synthetic brackish water) was drawn to the FO draw solution while the organic and inorganic substances (ions, compounds, colloids and particles) were rejected. The diluted draw solution was then pumped to the solar energy driven ED. In the ED unit, the diluted draw solution was desalted and high-quality water was produced; the concentrate was recycled to the FO unit and reused as the draw solution. Results show that the water produced from this system contains a low concentration of total organic carbon (TOC), carbonate, and cations derived from the feedwater; had a low conductivity; and meets potable water standards. The water production cost considering the investment for membranes and solar panel is 3.32 to 4.92 EUR m(-3) (for 300 days of production per year) for a small size potable water production system. PMID:23957893

  7. Inter-Institutional Variation in Management Decisions for Treatment of Four Common Cancers: A Multi-Institutional Cohort Study

    PubMed Central

    Weeks, Jane C.; Uno, Hajime; Taback, Nathan; Ting, Gladys; Cronin, Angel; D’Amico, Thomas A.; Friedberg, Jonathan W.; Schrag, Deborah

    2015-01-01

    Background When clinical practice is governed by evidenced-based guidelines and there is consensus regarding their validity, practice variation should be minimal. Where evidence gaps exist, greater variation is expected. Objective To systematically assess inter-institutional variation in management decisions for 4 common cancers. Design Multi-institutional observational cohort study of cancer patients diagnosed between July 2006 through May 2011 and observed through December 31, 2011. Setting 18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network. Patients 25,589 patients with incident cancer of the breast, colorectum, lung, or non-Hodgkin’s lymphoma (NHL). Measurements Inter-institutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation (MAD) of the center-specific proportions. Results Inter-institutional variation was high (MAD >10%) for 35/171 (20%) oncology management decisions. This included: 9/22 (41%) for NHL, 16/76 (21%) for breast, 7/47 (15%) for lung, and 3/26 (12%) for colorectal. Decisions involving imaging and/or diagnostic procedures accounted for 46% and chemotherapy regimen choice for 37% of high variance decisions. The evidence grade underpinning the 35 high variance decisions was level I for 0%, 2A for 49% and 2B/other for 51%. Limitations Physician identifiers were unavailable, and results may not generalize outside of major cancer centers. Conclusions The substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness

  8. Primary Care Provider Views About Usefulness and Dissemination of a Web-Based Depression Treatment Information Decision Aid

    PubMed Central

    Westmacott, Robin; Walker, John R; Vardanyan, Gohar

    2016-01-01

    Background Decisions related to mental health are often complex, problems often remain undetected and untreated, information unavailable or not used, and treatment decisions frequently not informed by best practice or patient preferences. Objective The objective of this paper was to obtain the opinions of health professionals working in primary health care settings about a Web-based information decision aid (IDA) for patients concerning treatment options for depression and the dissemination of the resources in primary care settings. Methods Participants were recruited from primary care clinics in Winnipeg and Ottawa, Canada, and included 48 family physicians, nurses, and primary care staff. The study design was a qualitative framework analytic approach of 5 focus groups. Focus groups were conducted during regular staff meetings, were digitally recorded, and transcripts created. Analysis involved a content and theme analysis. Results Seven key themes emerged including the key role of the primary care provider, common questions about treatments, treatment barriers, sources of patient information, concern about quality and quantity of available information, positive opinions about the IDA, and disseminating the IDA. The most common questions mentioned were about medication and side effects and alternatives to medication. Patients have limited access to alternative treatment options owing to cost and availability. Conclusions Practitioners evaluated the IDA positively. The resources were described as useful, supportive of providers’ messages, and accessible for patients. There was unanimous consensus that information needs to be available electronically through the Internet. PMID:27277709

  9. The relationship between cancer patient treatment decision-making roles and quality of life

    PubMed Central

    Atherton, Pamela J.; Smith, Tenbroeck; Singh, Jasvinder A.; Huntington, Jef; Diekmann, Brent B.; Huschka, Mashele; Sloan, Jeff A.

    2013-01-01

    Background This study's objective was to explore relationships between patient role preferences during the cancer treatment decision-making process and quality of life (QOL). Methods As part of a larger survey conducted by the American Cancer Society, 1-year cancer survivors completed a survey in 2000. This paper is based upon respondents from Minnesota (response rate 37.4%). Standardized measures included the Profile of Mood States (scores converted to have a range, 0-100; 100 is the best mood), the Short Form (SF)-36 (standardized scores), and the Control Preferences Scale. Patients' actual and preferred role preference distributions and concordance between the roles were compared to QOL scores using two-sample t-test methodology. Results Survivors (n=594) actual role in cancer care was 33% active, 50% collaborative and 17% passive. Their preferred role was 35% active, 53% collaborative, and 13% passive. 88% of survivors had concordant preferred and actual roles. Survivors with concordant roles had higher SF-36 Physical Component Scores (PCS) (p<0.01), higher vitality (p=0.01), less fatigue (p<0.01), less confusion (p=0.01), less anger (p=0.046) and better overall mood (p=0.01). These results were similar in both the female and the younger (age <60) cohorts. Survivors with active actual roles had higher PCS (p<0.01), less tension (p=0.04), and higher vitality (p=0.04) than those being collaborative or passive. No differences existed in QOL scores by preferred role. Conclusions Survivors who experienced discordance between their actual role and preferred role reported substantial QOL deficits in both physical and emotional domains. These results are indicative of the need to support patient preferences. PMID:23558408

  10. Syndromic treatment of gonococcal and chlamydial infections in women seeking primary care for the genital discharge syndrome: decision-making.

    PubMed Central

    Behets, F. M.; Miller, W. C.; Cohen, M. S.

    2001-01-01

    The syndromic treatment of gonococcal and chlamydial infections in women seeking primary care in clinics where resources are scarce, as recommended by WHO and implemented in many developing countries, necessitates a balance to be struck between overtreatment and undertreatment. The present paper identifies factors that are relevant to the selection of specific strategies for syndromic treatment in the above circumstances. Among them are the general aspects of decision-making and caveats concerning the rational decision-making approach. The positive and negative implications are outlined of providing or withholding treatment following a specific algorithm with a given accuracy to detect infection, i.e. sensitivity, specificity and predictive values. Other decision-making considerations that are identified are related to implementation and include the stability of risk factors with regard to time, space and the implementer, acceptability by stakeholders, and environmental constraints. There is a need to consider empirically developed treatment algorithms as a basis for policy discourse, to be evaluated together with the evidence, alternatives and arguments by the stakeholders. PMID:11731816

  11. [Advance Care Planning and Decisions to limit treatment at the end of life - the view from medical ethics and psychooncology].

    PubMed

    Winkler, Eva C; Heußner, Pia

    2016-03-01

    Decisions to limit treatment are important in order to avoid overtreatment at the end of life. They proceed more than half of expected deaths in Europe and the US, but are not always communicated with the patient in advance. One reason for non-involvement is that conversations that prepare patients for end-of-life decisions and work out their preferences do not take place on a regular basis. At the same time there is growing evidence that such communication improves patients' quality of life, reduces anxiety and depression and allows patients to develop a realistic understanding of their situation - which in turn is a prerequisite for shared decision making about limiting treatment. In this paper we define "treatment limitation" and explain the medical ethics perspective. The main focus, however, is on the causes that hinder advanced care planning and conversations about limiting treatment in the care of patients with advanced disease. Finally the evidence for approaches to improve the situation is presented with concrete suggestions for solutions. PMID:26983109

  12. Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes

    PubMed Central

    Hu, Kui; Li, Jun; Wan, Yun; Hong, Tao; Lu, Shu-Yang; Guo, Chang-Fa; Wang, Chun-Sheng

    2016-01-01

    Background A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes. Methods Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored. Results Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis. Conclusions Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.

  13. Competing priorities in treatment decision-making: a US national survey of individuals with depression and clinicians who treat depression

    PubMed Central

    Barr, Paul J; Forcino, Rachel C; Mishra, Manish; Blitzer, Rachel; Elwyn, Glyn

    2016-01-01

    Objective To identify information priorities for consumers and clinicians making depression treatment decisions and assess shared decision-making (SDM) in routine depression care. Design 20 questions related to common features of depression treatments were provided. Participants were initially asked to select which features were important, and in a second stage they were asked to rank their top 5 ‘important features’ in order of importance. Clinicians were asked to provide rankings according to both consumer and clinician perspectives. Consumers completed CollaboRATE, a measure of SDM. Multiple logistic regression analysis identified consumer characteristics associated with CollaboRATE scores. Setting Online cross-sectional surveys fielded in September to December 2014. Participants We administered surveys to convenience samples of US adults with depression and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender and educational attainment of adults with depression in the USA. Primary outcome measures Information priority rankings; CollaboRATE, a 3-item consumer-reported measure of SDM. Results 972 consumers and 244 clinicians completed the surveys. The highest ranked question for both consumers and clinicians was ‘Will the treatment work?’ Clinicians were aware of consumers’ priorities, yet did not always prioritise that information themselves, particularly insurance coverage and cost of treatment. Only 18% of consumers reported high levels of SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07 to 3.26) and female gender (OR 2.04; 95% CI 1.25 to 3.34) were associated with top CollaboRATE scores. Conclusions While clinicians know what information is important to consumers making depression treatment decisions, they do not always address these concerns. This mismatch, coupled with low SDM, adversely affects the quality of depression care. Development of a decision support intervention based on our findings can improve

  14. The Effect of Emotion and Physician Communication Behaviors on Surrogates’ Life-Sustaining Treatment Decisions: A Randomized Simulation Experiment

    PubMed Central

    Barnato, Amber E.; Arnold, Robert M.

    2013-01-01

    Objective Surrogate decision makers for critically ill patients experience strong negative emotional states. Emotions influence risk perception, risk preferences, and decision making. We sought to explore the effect of emotional state and physician communication behaviors on surrogates’ life-sustaining treatment (LST) decisions. Design 5×2 between-subject randomized factorial experiment. Setting Web-based simulated interactive video meeting with an intensivist to discuss code status. Subjects Community-based participants 35 and older who self-identified as the surrogate for a parent or spouse recruited from 8 US cities through public advertisements. Interventions Block random assignment to emotion arousal manipulation and each of 4 physician communication behaviors. Measurements and Main Results Surrogate’s code status decision (CPR vs. DNR/AND). 256/373 (69%) respondents logged-in and were randomized: average age 50, 70% were surrogates for a parent, 63.5% were women, 76% were white, 11% black, and 9% Asian, and 81% were college educated. When asked about code status, 56% chose CPR. The emotion arousal manipulation increased depression-dejection (β=1.76 [0.58 – 2.94]), but did not influence CPR choice. Physician emotion handling and framing the decision as the patient’s rather than the surrogate’s did not influence CPR choice. Framing no CPR as the default rather than CPR resulted in fewer surrogates choosing CPR (48% vs. 64%, OR=0.52 [0.32-0.87]), as did framing the alternative to CPR as “allow natural death” rather than DNR (49% vs. 61%, OR=0.58 [95% CI 0.35-0.96]). Conclusions Experimentally-induced emotional state did not influence code status decisions, although small changes in physician communication behaviors substantially influenced this decision. PMID:23660727

  15. Diagnosis, referral, and primary treatment decisions in newly diagnosed prostate cancer patients in a multidisciplinary diagnostic assessment program

    PubMed Central

    Guy, David; Ghanem, Gabriella; Loblaw, Andrew; Buckley, Roger; Persaud, Beverly; Cheung, Patrick; Chung, Hans; Danjoux, Cyril; Morton, Gerard; Noakes, Jeff; Spevack, Les; Hajek, David; Flax, Stanley

    2016-01-01

    Introduction: We aimed to report on data from the multidisciplinary diagnostic assessment program (DAP) at the Gale and Graham Wright Prostate Centre (GGWPC) at North York General Hospital (NYGH). We assessed referral, diagnosis, and treatment decisions for newly diagnosed prostate cancer (PCa) patients as seen over time, risk stratification, and clinic type to establish a deeper understanding of current decision-making trends. Methods: From June 2007 to April 2012, 1277 patients who were diagnosed with PCa at the GGWPC were included in this study. Data was collected and reviewed retrospectively using electronic patient records. Results: 1031 of 1260 patients (81.8%) were seen in a multidisciplinary clinic (MDC). Over time, a decrease in low-risk (LR) diagnoses and an increase intermediate-risk (IR) diagnoses was observed (p<0.0001). With respect to overall treatment decisions 474 (37.1%) of patients received primary radiotherapy, 340 (26.6%) received surgical therapy, and 426 (33.4%) had conservative management; 57% of patients who were candidates for active surveillance were managed this way. No significant treatment trends were observed over time (p=0.8440). Significantly, different management decisions were made in those who attended the MDC compared to those who only saw a urologist (p<0.0001). Conclusions: In our DAP, the vast majority of patients presented with screen-detected disease, but there was a gradual shift from low- to intermediate-risk disease over time. Timely multidisciplinary consultation was achievable in over 80% of patients and was associated with different management decisions. We recommend that all patients at risk for prostate cancer be worked up in a multi-disciplinary DAP. PMID:27217859

  16. Treatment decisions for newborns at the threshold of viability: an ethical dilemma.

    PubMed

    Doroshow, R W; Hodgman, J E; Pomerance, J J; Ross, J W; Michel, V J; Luckett, P M; Shaw, A

    2000-09-01

    The major ethical issues involved in decision-making in the care of extremely low birth weight newborns are analyzed here. We propose a schema for assessment and management of these infants that is consistent with ethical principles broadly accepted by the pediatric community, and which takes into account mortality risk at any given institution rather than arbitrary weight limits, with a major decision-making role for the infant's parents. When possible, the decision of whether or not to resuscitate should be made before delivery; when not possible, delivery room resuscitation is recommended, and the decision to continue or withdraw care should be made subsequently based on likelihood of survival and the wishes of the parents. PMID:11002878

  17. Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study†

    PubMed Central

    Owen, Gareth S.; Szmukler, George; Richardson, Genevra; David, Anthony S.; Raymont, Vanessa; Freyenhagen, Fabian; Martin, Wayne; Hotopf, Matthew

    2013-01-01

    Background Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients? Aims To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice. Method A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability. Results Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better ‘test’ of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02). Conclusions Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting. PMID:23969482

  18. Implementation of a "learner-driven" curriculum: an screening, brief intervention, and referral to treatment (SBIRT) interdisciplinary primary care model.

    PubMed

    Stanton, Marina R; Atherton, W Leigh; Toriello, Paul J; Hodgson, Jennifer L

    2012-01-01

    Although screening, brief intervention, and referral to treatment (SBIRT) has been a popular model to address potential substance abuse issues in primary care, there is a need for innovative approaches for training providers and staff on SBIRT protocols. An interdisciplinary approach to SBIRT training, named ICARE, was implemented at 3 different medical settings. The ICARE team trained 85 employees at an academic family medicine residency center and 37 employees across 2 rural community health care clinics. Using an innovative "learner-driven" approach, the authors implemented a combination of didactic and interactive training strategies that included on-site coaching, patient simulation exercises, as well as large- and small-group learning. PMID:22738012

  19. Microwave-driven asbestos treatment and its scale-up for use after natural disasters.

    PubMed

    Horikoshi, Satoshi; Sumi, Takuya; Ito, Shigeyuki; Dillert, Ralf; Kashimura, Keiichiro; Yoshikawa, Noboru; Sato, Motoyasu; Shinohara, Naoki

    2014-06-17

    Asbestos-containing debris generated by the tsunami after the Great East Japan Earthquake of March 11, 2011, was processed by microwave heating. The analysis of the treated samples employing thermo gravimetry, differential thermal analysis, X-ray diffractometry, scanning electron microscopy, and phase-contrast microscopy revealed the rapid detoxification of the waste by conversion of the asbestos fibers to a nonfibrous glassy material. The detoxification by the microwave method occurred at a significantly lower processing temperature than the thermal methods actually established for the treatment of asbestos-containing waste. The lower treatment temperature is considered to be a consequence of the microwave penetration depth into the waste material and the increased intensity of the microwave electric field in the gaps between the asbestos fibers resulting in a rapid heating of the fibers inside the debris. A continuous treatment plant having a capacity of 2000 kg day(-1) of asbestos-containing waste was built in the area affected by the earthquake disaster. This treatment plant consists of a rotary kiln to burn the combustible waste (wood) and a microwave rotary kiln to treat asbestos-containing inorganic materials. The hot flue gas produced by the combustion of wood is introduced into the connected microwave rotary kiln to increase the energy efficiency of the combined process. Successful operation of this combined device with regard to asbestos decomposition is demonstrated. PMID:24856876

  20. Redefining Residential: Family-Driven Care in Residential Treatment--Family Members Speak

    ERIC Educational Resources Information Center

    Residential Treatment for Children & Youth, 2009

    2009-01-01

    This is the sixth in a series of papers issued by the American Association of Children's Residential Centers (AACRC) regarding emerging and best practices in the field of residential treatment for children, youth, and families. AACRC is a long standing national association focused exclusively on practice and policy issues related to the provision…

  1. Control policies for a water-treatment system using the Markov Decision Process.

    NASA Astrophysics Data System (ADS)

    Chiam, Tze; Mitchell, Cary; Yih, Yuehwern

    In order to build a decision-making tool for choosing a control policy from a set of predefined policies for a water-treatment system, a simulation was developed. This technology-independent simulation focuses on the functions of a simplified representation of the water system based on documentation by NASA in the Baseline Value and Assumption Documents (BVAD). The clean-water requirement (consumption) and dirty-water generation (production) are based on crewmember demographics, activity schedules, and intensity of each activity. The water system consists of hygiene and potable-water subsystems. The hygiene-water subsystem supplies water for purposes such as laundry, urinal flush, dish wash, oral hygiene, and shower. The potable-water subsystem supplies water for drinking and re-hydration of food. Due to a lack of stochastic property descriptions for a real-world system in the BVAD, stochastic variables are introduced in this research to reflect a more realistic system. These variables describe the magnitude of deviation of system variables from their theoretical values through predetermined statistical distributions. These variables include hygiene and potable-water-treatment efficiencies, amounts of hygiene and potable water consumed, and amount of dirty water produced following potable-water consumption. Conditions of the system occurring hourly result from the intricate interaction of crewmembers and the water system. The primary measure of the condition of the system is the "state" representation of the system, assessed at the beginning of every hour. Conditions of the system examined include the amount of clean water available for consumption, amount of overflow (in excess of storage capacity) of clean and dirty water, amount of hourly water deficiency, amount of accumulated water deficiency, etc. State transitions of the system based on these assessments are affected by the stochastic properties of the system described above. The transitions also depend on

  2. Impact of Oncotype DX Recurrence Score on Treatment Decisions: Results of a Prospective Multicenter Study in Turkey

    PubMed Central

    Ozmen, Vahit; Gokmen, Erhan; Ozdogan, Mustafa; Guler, Nilufer; Uras, Cihan; Ok, Engin; Demircan, Orhan; Isikdogan, Abdurrahman; Saip, Pinar

    2016-01-01

    Introduction: Breast cancer is the most common malignancy among Turkish women and the rate of early stage disease is increasing. The Oncotype DX® 21-gene assay is predictive of distant recurrence in ER-positive, HER2-negative early breast cancer. We aimed to evaluate the impact of the Recurrence Score® (RS) on treatment decisions and physician perceptions in Turkey. We also studied correlations between RS and routine risk factors. Patients and Methods: Ten academic centers across Turkey participated in this prospective trial. Consecutive breast cancer patients with pT1-3, pN0-N1mic, ER-positive, and HER2-negative tumors were identified at multidisciplinary tumor conferences. The initial treatment decision was recorded before tumor blocks were sent to the central laboratory. Each case was brought back to tumor conference after receiving the RS result. Both pre- and post-RS treatment decisions and physician perceptions were recorded on questionnaire forms. Correlations between RS and classical risk factors were evaluated using univariate and multivariate analyses. Results: Ten centers enrolled a total of 165 patients. The median tumor size was 2 cm. Of 165 patients, 57% had low RS, 35% had intermediate RS, and 8% had high RS, respectively. The overall rate of change in treatment decision was 33%. Initially, chemotherapy followed by hormonal therapy (CT+HT) was recommended to 92 (56%) of all patients, which decreased to 61 (37%) patients post-RS assay (p<0.001). Multivariate analysis indicated that progesterone receptor (PR) and Ki-67 scores were significantly related to RS. Conclusion: Oncotype DX testing may provide meaningful additional information in carefully selected patients.  PMID:27081583

  3. Decision-Making in the Surgical Treatment of Breast Cancer: Factors Influencing Women’s Choices for Mastectomy and Breast Conserving Surgery

    PubMed Central

    Bellavance, Emily Catherine; Kesmodel, Susan Beth

    2016-01-01

    One of the most difficult decisions a woman can be faced with when choosing breast cancer treatment is whether or not to undergo breast conserving surgery or mastectomy. The factors that influence these treatment decisions are complex and involve issues regarding access to health care, concerns for cancer recurrence, and the impact of surgery on body image and sexuality. Understanding these factors will help practitioners to improve patient education and to better guide patients through this decision-making process. Although significant scientific and societal advances have been made in improving women’s choices for the breast cancer treatment, there are still deficits in the decision-making processes surrounding the surgical treatment of breast cancer. Further research is needed to define optimal patient education and shared decision-making practices in this area. PMID:27066455

  4. Easing the burden of surrogate decision making: the role of a do-not-escalate-treatment order.

    PubMed

    Jacobsen, Juliet; Billings, Andrew

    2015-03-01

    We present a case illustrating the common problem of a surrogate decision maker who is psychologically distressed over the medical team's recommendation to withdraw life-sustaining treatment. We suggest how a do-not-escalate-treatment (DNET) order can be helpful in such situations when the usual approaches to withholding or withdrawing care are not acceptable to the surrogate. We define a DNET order, explain when it might be useful, and discuss how it can facilitate a humane, negotiated resolution of differences. PMID:25671289

  5. A decision aid for considering indomethacin prophylaxis vs. symptomatic treatment of PDA for extreme low birth weight infants

    PubMed Central

    2011-01-01

    Background Decision Aids (DA) are well established in various fields of medicine. It can improve the quality of decision-making and reduce decisional conflict. In neonatal care, and due to scientific equipoise, neonatologists caring for extreme low birth weight (ELBW) infants are in need to elicit parents' preferences with regard to the use of indomethacin therapy in ELBW infants. We aimed to develop a DA that elicits parents' preferences with regard to indomethacin therapy in ELBW infants. Methods We developed a DA for the use of the indomethacin therapy in ELBW infants according to the Ottawa Decision Support Framework. The development process involved parents, neonatologists, DA developers and decision making experts. A pilot testing with healthy volunteers was conducted through an evaluation questionnaire, a knowledge scale, and a validated decisional conflict scale. Results The DA is a computer-based interactive tool. In the first part, the DA provides information about patent ductus arteriosus (PDA) as a disease, the different treatment options, and the benefits and downsides of using indomethacin therapy in preterm infants. In the second part, it coaches the parent in the decision making process through clarifying values and preferences. Volunteers rated 10 out of 13 items of the DA positively and showed significant improvement on both the knowledge scale (p = 0.008) and the decisional conflict scale (p = 0.008). Conclusion We have developed a computer based DA to assess parental preferences with regard to indomethacin therapy in preterm infants. Future research will involve measurement of parental preferences to guide and augment the clinical decisions in current neonatal practice. PMID:21888665

  6. Routine Outcome Monitoring and Clinical Decision-Making in Forensic Psychiatry Based on the Instrument for Forensic Treatment Evaluation

    PubMed Central

    van der Veeken, Frida C. A.

    2016-01-01

    Background Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Methods Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results and Conclusions Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients’ personal risk factors, strengths and other information sources. PMID:27517721

  7. Refining the ammonia hypothesis: a physiology-driven approach to the treatment of hepatic encephalopathy.

    PubMed

    Tapper, Elliot B; Jiang, Z Gordon; Patwardhan, Vilas R

    2015-05-01

    Hepatic encephalopathy (HE) is one of the most important complications of cirrhosis and portal hypertension. Although the etiology is incompletely understood, it has been linked to ammonia directly and indirectly. Our goal is to review for the clinician the mechanisms behind hyperammonemia and the pathogenesis of HE to explain the rationale for its therapy. We reviewed articles collected through a search of MEDLINE/PubMed, Cochrane Database of Systematic Reviews, and Google Scholar between October 1, 1948, and December 8, 2014, and by a manual search of citations within retrieved articles. Search terms included hepatic encephalopathy, ammonia hypothesis, brain and ammonia, liver failure and ammonia, acute-on-chronic liver failure and ammonia, cirrhosis and ammonia, portosytemic shunt, ammonia and lactulose, rifaximin, zinc, and nutrition. Ammonia homeostatsis is a multiorgan process involving the liver, brain, kidneys, and muscle as well as the gastrointestinal tract. Indeed, hyperammonemia may be the first clue to poor functional reserves, malnutrition, and impending multiorgan dysfunction. Furthermore, the neuropathology of ammonia is critically linked to states of systemic inflammation and endotoxemia. Given the complex interplay among ammonia, inflammation, and other factors, ammonia levels have questionable utility in the staging of HE. The use of nonabsorbable disaccharides, antibiotics, and probiotics reduces gut ammoniagenesis and, in the case of antibiotics and probiotics, systemic inflammation. Nutritional support preserves urea cycle function and prevents wasting of skeletal muscle, a significant site of ammonia metabolism. Correction of hypokalemia, hypovolemia, and acidosis further assists in the reduction of ammonia production in the kidney. Finally, early and aggressive treatment of infection, avoidance of sedatives, and modification of portosystemic shunts are also helpful in reducing the neurocognitive effects of hyperammonemia. Refining the

  8. Engagement with HIV Prevention Treatment and Care among Female Sex Workers in Zimbabwe: a Respondent Driven Sampling Survey

    PubMed Central

    Cowan, Frances M.; Mtetwa, Sibongile; Davey, Calum; Fearon, Elizabeth; Dirawo, Jeffrey; Wong-Gruenwald, Ramona; Ndikudze, Theresa; Chidiya, Samson; Benedikt, Clemens; Busza, Joanna; Hargreaves, James R.

    2013-01-01

    Objective(S) To determine the HIV prevalence and extent of engagement with HIV prevention and care among a representative sample of Zimbabwean sex workers working in Victoria Falls, Hwange and Mutare. Design Respondent driven sampling (RDS) surveys conducted at each site. Methods Sex workers were recruited using respondent driven sampling with each respondent limited to recruiting 2 peers. Participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Statistical analysis took account of sampling method. Results 870 women were recruited from the three sites. HIV prevalence was between 50 and 70%. Around half of those confirmed HIV positive were aware of their HIV status and of those 50-70% reported being enrolled in HIV care programmes. Overall only 25-35% of those with laboratory-confirmed HIV were accessing antiretroviral therapy. Among those reporting they were HIV negative, 21-28% reported having an HIV test in the last 6 months. Of those tested HIV negative, most (65-82%) were unaware of their status. Around two-thirds of sex workers reported consistent condom use with their clients. As in other settings, sex workers reported high rates of gender based violence and police harassment. Conclusions This survey suggests that prevalence of HIV is high among sex workers in Zimbabwe and that their engagement with prevention, treatment and care is sub-optimal. Intensifying prevention and care interventions for sex workers has the potential to markedly reduce HIV and social risks for sex workers, their clients and the general population in Zimbabwe and elsewhere in the region. PMID:24143203

  9. Success and Failure in Dynamic Decision Environments: Understanding Treatment Strategies for Patients with a Chronic Disease

    ERIC Educational Resources Information Center

    Ramsey, Gregory W.

    2010-01-01

    This dissertation proposes and tests a theory explaining how people make decisions to achieve a goal in a specific task environment. The theory is represented as a computational model and implemented as a computer program. The task studied was primary care physicians treating patients with type 2 diabetes. Some physicians succeed in achieving…

  10. Perceived need for information among patients with a haematological malignancy: associations with information satisfaction and treatment decision-making preferences.

    PubMed

    Rood, Janneke A J; van Zuuren, Florence J; Stam, Frank; van der Ploeg, Tjeerd; Eeltink, Corien; Verdonck-de Leeuw, Irma M; Huijgens, Peter C

    2015-06-01

    For patients with haematological malignancies, information on disease, prognosis, treatment and impact on quality of life is of the utmost importance. To gain insight into the perceived need for information in relation to sociodemographic and clinical parameters, comorbidity, quality of life (QoL) and information satisfaction, we compiled a questionnaire based on existing validated questionnaires. A total of 458 patients diagnosed with a haematological malignancy participated. The perceived need for information was moderate to high (40-70%). Multivariate regression analyses showed that a higher need for information was related to younger age, worse QoL, being member of a patient society and moderate comorbidity. The need for disease and treatment-related information was higher than the need for psychosocial information. A higher need for disease and treatment-related information was associated to being diagnosed with multiple myeloma. A higher need for psychosocial information was related to a lower educational level. The information provision could be improved according to 41% of the patients. Higher satisfaction with provided information was associated with better QoL. Most patients (62%) reported that they wanted to be fully informed about their illness and actively involved in treatment decision-making. The results contribute to improving patient-tailored information provision and shared decision-making in clinical practice. PMID:24811073

  11. Chronic heat-shock treatment driven differentiation induces apoptosis in Leishmania donovani.

    PubMed

    Raina, Puneet; Kaur, Sukhbir

    2006-09-01

    The present study investigates the role of apoptosis in the regulation of cell numbers of Leishmania donovani during the in vitro differentiation of promastigote stage to amastigote stage in axenic conditions. We report that apoptosis is induced in Leishmania donovani due to chronic heat-shock treatment of 37 ( degrees )C that also mediates the differentiation of promastigotes to amastigotes. This is characterized by the fragmentation of DNA, blebbing in the parasite cell membrane, nuclear condensation, formation of preapoptotic bodies and involvement of Ca(++) in the apoptotic process. The flowcytometric analysis shows an early and steep rise in percentage apoptotic nuclei till 48-hour stage of differentiation and then a gradual decline, suggesting synergistic action of Ca(++) ATPase and probably Hsp70. Hsp70 might be rescuing cells from apoptosis in the death signaling pathway. Incubation of the culture with Ca(++) chelator EGTA (1 mM) brings down the percentage of apoptotic nuclei considerably showing thereby that calcium is needed for the process of cell death here that occurs by apoptosis. The survival of the infective individuals appears to be decided by the parasite in the early stages of its differentiation. Our studies show the potential of the physiological temperature of 37 ( degrees )C in inducing apoptosis in Leishmania donovani and the therapeutic use it can be put to. PMID:16718376

  12. Effects of Viewing an Evidence-Based Video Decision Aid on Patients’ Treatment Preferences for Spine Surgery

    PubMed Central

    Lurie, Jon D.; Spratt, Kevin F.; Blood, Emily A.; Tosteson, Tor D.; Tosteson, Anna N. A.; Weinstein, James N.

    2011-01-01

    Study Design Secondary analysis within a large clinical trial Objective To evaluate the changes in treatment preference before and after watching a video decision aid as part of an informed consent process. Summary of Background Data A randomized trial with a similar decision aid in herniated disc patients had shown decreased rate of surgery in the video group, but the effect of the video on expressed preferences is not known. Methods Subjects enrolling in the Spine Patient Outcomes Research Trial (SPORT) with intervertebral disc herniation (IDH), spinal stenosis (SPS), or degenerative spondylolisthesis (DS) at thirteen multidisciplinary spine centers across the US were given an evidence-based videotape decision aid viewed prior to enrollment as part of informed consent. Results Of the 2505 patients, 86% (n=2151) watched the video and 14% (n=354) did not. Watchers shifted their preference more often than non-watchers(37.9% vs. 20.8%, p < 0.0001) and more often demonstrated a strengthened preference (26.2% vs. 11.1%, p < 0.0001). Among the 806 patients whose preference shifted after watching the video, 55% shifted toward surgery (p=0.003). Among the 617 who started with no preference, after the video 27% preferred non-operative care, 22% preferred surgery, and 51% remained uncertain. Conclusion After watching the evidence-based patient decision aid (video) used in SPORT, patients with specific lumbar spine disorders formed and/or strengthened their treatment preferences in a balanced way that did not appear biased toward or away from surgery. PMID:21358485

  13. Aging Prisoners' Treatment Selection: Does Prospect Theory Enhance Understanding of End-of-Life Medical Decisions?

    ERIC Educational Resources Information Center

    Phillips, Laura L.; Allen, Rebecca S.; Harris, Grant M.; Presnell, Andrew H.; DeCoster, Jamie; Cavanaugh, Ronald

    2011-01-01

    Purpose: With the rapid growth in the older inmate population and the economic impact of end-of-life treatments within the cash-strapped prison system, consideration should be given to inmate treatment preferences. We examined end-of-life treatment preferences and days of desired life for several health scenarios among male inmates incarcerated…

  14. Treatment of human-computer interface in a decision support system

    SciTech Connect

    Heger, A.S.; Duran, F.A.; Frysinger, S.; Cox, R.G.

    1992-11-01

    One of the most challenging applications facing the computer community is development of effective adaptive human-computer interface. This challenge stems from the complex nature of the human part of this symbiosis. The application of this discipline to the environmental restoration and waste management is further complicated due to the nature of environmental data. The information that is required to manage environmental impacts of human activity is fundamentally complex. This paper will discuss the efforts at Sandia National Laboratories in developing the adaptive conceptual model manager within the constraint of the environmental decision-making. A computer workstation, that hosts the Conceptual Model Manager and the Sandia Environmental Decision Support System will also be discussed.

  15. Developing a model based decision support tool for the identification of sustainable treatment options for domestic wastewater.

    PubMed

    Balkema, A J; Preisig, H A; Otterpohl, R; Lambert, A J; Weijers, S R

    2001-01-01

    To enable decision makers to select sustainable wastewater treatment systems, insight into the sustainability of a wide variety of systems should be provided in a transparent way leaving room for adaptation and interpretation according to the local situation. To provide this insight a structured methodology comparing wastewater treatment systems with respect to sustainability is defined. Similar to life cycle assessment (LCA) three phases can be distinguished: (1) goal and scope definition, (2) inventory analysis, and (3) optimisation and results. In the goal and scope definition we set the system boundaries to include most of the water cycle and part of the food cycle. Furthermore, we defined a multi-disciplinary set of sustainability indicators including technical, economic, environmental, and socio-cultural aspects. In the inventory analysis these sustainability indicators are quantified using simple static models of wastewater unit operations. Selection of unit operations results in a model of a complete wastewater treatment system. In the optimisation phase the decision maker can weigh the different sustainability indicators and select sustainable options through integer programming. PMID:11385856

  16. NKT cell adjuvant-based tumor vaccine for treatment of myc oncogene-driven mouse B-cell lymphoma

    PubMed Central

    West, Alison C.; Steegh, Kim; Duret, Helene; Paget, Christophe; Martin, Ben; Matthews, Geoffrey M.; Shortt, Jake; Chesi, Marta; Bergsagel, P. Leif; Bots, Michael; Zuber, Johannes; Lowe, Scott W.; Johnstone, Ricky W.

    2012-01-01

    Immunomodulators are effective in controlling hematologic malignancy by initiating or reactivating host antitumor immunity to otherwise poorly immunogenic and immune suppressive cancers. We aimed to boost antitumor immunity in B-cell lymphoma by developing a tumor cell vaccine incorporating α-galactosylceramide (α-GalCer) that targets the immune adjuvant properties of NKT cells. In the Eμ-myc transgenic mouse model, single therapeutic vaccination of irradiated, α-GalCer–loaded autologous tumor cells was sufficient to significantly inhibit growth of established tumors and prolong survival. Vaccine-induced antilymphoma immunity required NKT cells, NK cells, and CD8 T cells, and early IL-12–dependent production of IFN-γ. CD4 T cells, gamma/delta T cells, and IL-18 were not critical. Vaccine treatment induced a large systemic spike of IFN-γ and transient peripheral expansion of both NKT cells and NK cells, the major sources of IFN-γ. Furthermore, this vaccine approach was assessed in several other hematopoietic tumor models and was also therapeutically effective against AML-ETO9a acute myeloid leukemia. Replacing α-GalCer with β-mannosylceramide resulted in prolonged protection against Eμ-myc lymphoma. Overall, our results demonstrate a potent immune adjuvant effect of NKT cell ligands in therapeutic anticancer vaccination against oncogene-driven lymphomas, and this work supports clinical investigation of NKT cell–based immunotherapy in patients with hematologic malignancies. PMID:22932803

  17. Self-Driven Desalination and Advanced Treatment of Wastewater in a Modularized Filtration Air Cathode Microbial Desalination Cell.

    PubMed

    Zuo, Kuichang; Wang, Zhen; Chen, Xi; Zhang, Xiaoyuan; Zuo, Jiaolan; Liang, Peng; Huang, Xia

    2016-07-01

    Microbial desalination cells (MDCs) extract organic energy from wastewater for in situ desalination of saline water. However, to desalinate salt water, traditional MDCs often require an anolyte (wastewater) and a catholyte (other synthetic water) to produce electricity. Correspondingly, the traditional MDCs also produced anode effluent and cathode effluent, and may produce a concentrate solution, resulting in a low production of diluate. In this study, nitrogen-doped carbon nanotube membranes and Pt carbon cloths were utilized as filtration material and cathode to fabricate a modularized filtration air cathode MDC (F-MDC). With real wastewater flowing from anode to cathode, and finally to the middle membrane stack, the diluate volume production reached 82.4%, with the removal efficiency of salinity and chemical oxygen demand (COD) reached 93.6% and 97.3% respectively. The final diluate conductivity was 68 ± 12 μS/cm, and the turbidity was 0.41 NTU, which were sufficient for boiler supplementary or industrial cooling. The concentrate production was only 17.6%, and almost all the phosphorus and salt, and most of the nitrogen were recovered, potentially allowing the recovery of nutrients and other chemicals. These results show the potential utility of the modularized F-MDC in the application of municipal wastewater advanced treatment and self-driven desalination. PMID:27269411

  18. Does Patient Race/Ethnicity Influence Physician Decision-Making for Diagnosis and Treatment of Childhood Disruptive Behavior Problems?

    PubMed

    Garland, Ann F; Taylor, Robin; Brookman-Frazee, Lauren; Baker-Ericzen, Mary; Haine-Schlagel, Rachel; Liu, Yi Hui; Wong, Sarina

    2015-06-01

    Race/ethnic disparities in utilization of children's mental health care have been well documented and are particularly concerning given the long-term risks of untreated mental health problems (Institute of Medicine, 2003; Kessler et al. Am J Psychiatry 152:10026-1032, 1995). Research investigating the higher rates of unmet need among race/ethnic minority youths has focused primarily on policy, fiscal, and individual child or family factors that can influence service access and use. Alternatively, this study examines provider behavior as a potential influence on race/ethnic disparities in mental health care. The goal of the study was to examine whether patient (family) race/ethnicity influences physician diagnostic and treatment decision-making for childhood disruptive behavior problems. The study utilized an internet-based video vignette with corresponding survey of 371 randomly selected physicians from across the USA representing specialties likely to treat these patients (pediatricians, family physicians, general and child psychiatrists). Participants viewed a video vignette in which only race/ethnicity of the mother randomly varied (non-Hispanic White, Hispanic, and African American) and then responded to questions about diagnosis and recommended treatments. Physicians assigned diagnoses such as oppositional defiant disorder (48 %) and attention deficit disorder (63 %) to the child, but there were no differences in diagnosis based on race/ethnicity. The majority of respondents recommended psychosocial treatment (98 %) and/or psychoactive medication treatment (60 %), but there were no significant differences based on race/ethnicity. Thus, in this study using mock patient stimuli and controlling for other factors, such as insurance coverage, we did not find major differences in physician diagnostic or treatment decision-making based on patient race/ethnicity. PMID:26863339

  19. Treatment of uncertainties associated with PRAs in risk-informed decision making (NUREG1855).

    SciTech Connect

    Wheeler, Timothy A.

    2010-06-01

    This document provides guidance on how to treat uncertainties associated with probabilistic risk assessment (PRA) in risk-informed decisionmaking. The objectives of this guidance include fostering an understanding of the uncertainties associated with PRA and their impact on the results of PRA and providing a pragmatic approach to addressing these uncertainties in the context of the decisionmaking. In implementing risk-informed decisionmaking, the U.S. Nuclear Regulatory Commission expects that appropriate consideration of uncertainty will be given in the analyses used to support the decision and in the interpretation of the findings of those analyses. To meet the objective of this document, it is necessary to understand the role that PRA results play in the context of the decision process. To define this context, this document provides an overview of the risk-informed decisionmaking process itself. With the context defined, this document describes the characteristics of a risk model and, in particular, a PRA. This description includes recognition that a PRA, being a probabilistic model, characterizes aleatory uncertainty that results from randomness associated with the events of the model. Because the focus of this document is epistemic uncertainty (i.e., uncertainties in the formulation of the PRA model), it provides guidance on identifying and describing the different types of sources of epistemic uncertainty and the different ways that they are treated. The different types of epistemic uncertainty are parameter, model, and completeness uncertainties. The final part of the guidance addresses the uncertainty in PRA results in the context of riskinformed decisionmaking and, in particular, the interpretation of the results of the uncertainty analysis when comparing PRA results with the acceptance criteria established for a specified application. In addition, guidance is provided for addressing completeness uncertainty in risk-informed decision making. Such

  20. Attitudes towards informed consent, confidentiality, and substitute treatment decisions in southern African medical students: a case study from Zimbabwe.

    PubMed

    Hipshman, L

    1999-08-01

    This study explored the attitudes of biomedical science students (medical students) in a non-Western setting towards three medical ethics concepts that are based on fundamental Western culture ethical principles. A dichotomous (agree/disagree) response questionnaire was constructed using Western ethnocentric culture (WEC) based perspectives of informed consent, confidentiality, and substitute decision-making. Hypothesized WEC-Biased responses were assigned to the questionnaire's questions or propositions. A number of useful responses (169) were obtained from a large, cross-sectional, convenience sample of the MBChB students at the University of Zimbabwe Medical School. Statistical analysis described the differences in response patterns between the student's responses compared to the hypothesized WEC-Biased response. The effect of the nine independent variables on selected dependent variables (responses to certain questionnaire questions) was analyzed by stepwise logistic regression. Students concurred with the hypothesized WEC-Biased responses for two-thirds of the questionnaire items. This agreement included support for the role of legal advocacy in the substitute decision-making process. The students disagreed with the hypothesized WEC-Biased responses in several important medical ethics aspects. Most notably, the students indicated that persons with mental dysfunctions, as a class, were properly considered incompetent to make treatment decisions. None of the studied independent variables was often associated with students' responses, but training year was more frequently implicated than either ethnicity or gender. In order to develop internationally and culturally relevant medical ethics standards, non-Western perspectives ought to be acknowledged and incorporated. Two main areas for further efforts include: curriculum development in ethics reasoning and related clinical (medico-legal) decision-making processes that would be relevant to medical students from

  1. Clinical Decision-Making in Community Children’s Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment

    PubMed Central

    Baker-Ericzén, Mary J.; Jenkins, Melissa M.; Park, Soojin; Garland, Ann F.

    2014-01-01

    Background Mental health professionals’ decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. Objective The present study explored the role of prior training in evidence-based treatments on clinicians’ assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making. Methods Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog “think aloud” method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory. Results MANOVA results were significant for EBT training status such that EBT trained clinicians’ displayed cognitive processes more closely aligned with “expert” decision-makers and non-EBT trained clinicians’ decision processes were more similar to “novice” decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making. Conclusion This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians’ decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice. PMID:25892901

  2. Informing hot flash treatment decisions for breast cancer survivors: a systematic review of randomized trials comparing active interventions.

    PubMed

    Johns, Claire; Seav, Susan M; Dominick, Sally A; Gorman, Jessica R; Li, Hongying; Natarajan, Loki; Mao, Jun James; Su, H Irene

    2016-04-01

    Patient-centered decision making about hot flash treatments often incorporates a balance of efficacy and side effects in addition to patient preference. This systematic review examines randomized controlled trials (RCTs) comparing at least two non-hormonal hot flash treatments in breast cancer survivors. In July 2015, PubMed, SCOPUS, CINAHL, Cochrane, and Web of Science databases were searched for RCTs comparing active, non-hormonal hot flash treatments in female breast cancer survivors. Thirteen trials were included after identifying 906 potential studies. Four trials were dose comparison studies of pharmacologic treatments citalopram, venlafaxine, gabapentin, and paroxetine. Hot flash reduction did not differ by tamoxifen or aromatase inhibitor use. Citalopram 10, 20, and 30 mg daily had comparable outcomes. Venlafaxine 75 mg daily improved hot flashes without additional side effects from higher dosing. Gabapentin 900 mg daily improved hot flashes more than 300 mg. Paroxetine 10 mg daily had fewer side effects than 20 mg. Among four trials comparing different pharmacologic treatments, venlafaxine alleviated hot flash symptoms faster than clonidine; participants preferred venlafaxine over gabapentin. Five trials compared pharmacologic to non-pharmacologic treatments. Acupuncture had similar efficacy to venlafaxine and gabapentin but may have longer durability after completing treatment and fewer side effects. We could not perform a pooled meta-analysis because outcomes were not reported in comparable formats. Clinical trial data on non-hormonal hot flash treatments provide comparisons of hot flash efficacy and other patient important outcomes to guide clinical management. Clinicians can use the information to help patients select hot flash interventions. PMID:27015968

  3. Comparison of Cone-Beam Computed Tomography and Periapical Radiography in Predicting Treatment Decision for Periapical Lesions: A Clinical Study

    PubMed Central

    Balasundaram, Ashok; Shah, Punit; Hoen, Michael M.; Wheater, Michelle A.; Bringas, Josef S.; Gartner, Arnold; Geist, James R.

    2012-01-01

    Objectives. To compare the ability of endodontists to determine the size of apical pathological lesions and select the most appropriate choice of treatment based on lesions' projected image characteristics using 2 D and 3 D images. Study Design. Twenty-four subjects were selected. Radiographic examination of symptomatic study teeth with an intraoral periapical radiograph revealed periapical lesions equal to or greater than 3 mm in the greatest diameter. Cone-beam Computed tomography (CBCT) images were made of the involved teeth after the intraoral periapical radiograph confirmed the size of lesion to be equal to greater than 3 mm. Six observers (endodontists) viewed both the periapical and CBCT images. Upon viewing each of the images from the two imaging modalities, observers (1) measured lesion size and (2) made decisions on treatment based on each radiograph. Chi-square test was used to look for differences in the choice of treatment among observers. Results. No significant difference was noted in the treatment plan selected by observers using the two modalities (χ2(3) = .036, P > 0.05). Conclusion. Lesion size and choice of treatment of periapical lesions based on CBCT radiographs do not change significantly from those made on the basis of 2 D radiographs. PMID:23056050

  4. Are more endodontic consultations needed in dental school clinic settings? A study of treatment decisions at one school.

    PubMed

    Aminoshariae, Anita; Tulunoglu, Ibrahim; Demko, Catherine; Galsterer, Mark; Montagnese, Thomas A; Mickel, Andre

    2015-04-01

    With no previous studies of the occurrence of interdisciplinary consultations for tooth extraction in a dental school clinic setting, the aim of this cross-sectional descriptive investigation was to measure and compare the consultation process that occurred among departments at one U.S. dental school for making treatment decisions on tooth extraction. A comprehensive computerized retrieval (Crystal Reports) was used to identify and gather data from patient records from July 1, 2007, to July 1, 2011. Treatment plans and progress notes were analyzed to determine why each tooth had been extracted and which department had recommended the extraction. Results showed that the clinical departments involved in treatment planning decisions were the DMD dental student clinic, Department of Periodontics, and Department of Endodontics. The narrative records of 227 patients who had 516 teeth extracted were examined. About three-fourths (73.26%) of the extracted teeth were extracted based on the recommendation of only one department. Of these extracted teeth, 22.0% (n=114) were previously endodontically treated, and only four were recommended for endodontic consultation prior to extraction. The study found that most extractions were performed without specialty consultations and that the Department of Endodontics was consulted the least of all departments. To foster interdisciplinary collaboration in dental school clinics and help students develop expertise in such collaborations, more specialty consultations are needed for teeth that are treatment planned for extraction in order to preclude needless extraction of potentially salvageable teeth. Doing so will provide benefits for both patient care and students' education. PMID:25838010

  5. Decision support system for the optimal location of electrical and electronic waste treatment plants: A case study in Greece

    SciTech Connect

    Achillas, Ch.; Vlachokostas, Ch.; Moussiopoulos, N.; Banias, G.

    2010-05-15

    Environmentally sound end-of-life management of Electrical and Electronic Equipment has been realised as a top priority issue internationally, both due to the waste stream's continuously increasing quantities, as well as its content in valuable and also hazardous materials. In an effort to manage Waste Electrical and Electronic Equipment (WEEE), adequate infrastructure in treatment and recycling facilities is considered a prerequisite. A critical number of such plants are mandatory to be installed in order: (i) to accommodate legislative needs, (ii) decrease transportation cost, and (iii) expand reverse logistics network and cover more areas. However, WEEE recycling infrastructures require high expenditures and therefore the decision maker need to be most precautious. In this context, special care should be given on the viability of infrastructure which is heavily dependent on facilities' location. To this end, a methodology aiming towards optimal location of Units of Treatment and Recycling is developed, taking into consideration economical together with social criteria, in an effort to interlace local acceptance and financial viability. For the decision support system's needs, ELECTRE III is adopted as a multicriteria analysis technique. The methodology's applicability is demonstrated with a real-world case study in Greece.

  6. Industrial experience of process identification and set-point decision algorithm in a full-scale treatment plant.

    PubMed

    Yoo, Changkyoo; Kim, Min Han

    2009-06-01

    This paper presents industrial experience of process identification, monitoring, and control in a full-scale wastewater treatment plant. The objectives of this study were (1) to apply and compare different process-identification methods of proportional-integral-derivative (PID) autotuning for stable dissolved oxygen (DO) control, (2) to implement a process monitoring method that estimates the respiration rate simultaneously during the process-identification step, and (3) to propose a simple set-point decision algorithm for determining the appropriate set point of the DO controller for optimal operation of the aeration basin. The proposed method was evaluated in the industrial wastewater treatment facility of an iron- and steel-making plant. Among the process-identification methods, the control signal of the controller's set-point change was best for identifying low-frequency information and enhancing the robustness to low-frequency disturbances. Combined automatic control and set-point decision method reduced the total electricity consumption by 5% and the electricity cost by 15% compared to the fixed gain PID controller, when considering only the surface aerators. Moreover, as a result of improved control performance, the fluctuation of effluent quality decreased and overall effluent water quality was better. PMID:19428173

  7. Decision support system for the optimal location of electrical and electronic waste treatment plants: a case study in greece.

    PubMed

    Achillas, Ch; Vlachokostas, Ch; Moussiopoulos, Nu; Banias, G

    2010-05-01

    Environmentally sound end-of-life management of Electrical and Electronic Equipment has been realised as a top priority issue internationally, both due to the waste stream's continuously increasing quantities, as well as its content in valuable and also hazardous materials. In an effort to manage Waste Electrical and Electronic Equipment (WEEE), adequate infrastructure in treatment and recycling facilities is considered a prerequisite. A critical number of such plants are mandatory to be installed in order: (i) to accommodate legislative needs, (ii) decrease transportation cost, and (iii) expand reverse logistics network and cover more areas. However, WEEE recycling infrastructures require high expenditures and therefore the decision maker need to be most precautious. In this context, special care should be given on the viability of infrastructure which is heavily dependent on facilities' location. To this end, a methodology aiming towards optimal location of Units of Treatment and Recycling is developed, taking into consideration economical together with social criteria, in an effort to interlace local acceptance and financial viability. For the decision support system's needs, ELECTRE III is adopted as a multicriteria analysis technique. The methodology's applicability is demonstrated with a real-world case study in Greece. PMID:20031385

  8. A Systematic Examination of Data-Driven Decision-Making within a School Division: The Relationships among Principal Beliefs, School Characteristics, and Accreditation Status

    ERIC Educational Resources Information Center

    Teigen, Beth N.

    2009-01-01

    This non-experimental, census survey included the elementary, middle, and high school principals at the comprehensive schools within a large, suburban school division in Virginia. The focus of this study was the factors that influence building administrators in using data to make instructional decisions. The purpose was to discover if there is a…

  9. Challenges in Measuring a New Construct: Perception of Voluntariness for Research and Treatment Decision Making

    PubMed Central

    Miller, Victoria A.; Reynolds, William W.; Ittenbach, Richard F.; Luce, Mary Frances; Beauchamp, Tom L.; Nelson, Robert M.

    2010-01-01

    RELIABLE AND VALID MEASURES OF RELEVANT constructs are critical in the developing field of the empirical study of research ethics. The early phases of scale development for such constructs can be complex. We describe the methodological challenges of construct definition and operationalization and how we addressed them in our study to develop a measure of perception of voluntariness. We also briefly present our conceptual approach to the construct of voluntariness, which we defined as the perception of control over decision making. Our multifaceted approach to scale development ensured that we would develop a construct definition of sufficient breadth and depth, that our new measure of voluntariness would be applicable across disciplines, and that there was a clear link between our construct definition and items. The strategies discussed here can be adapted by other researchers who are considering a scale development study related to the empirical study of ethics. PMID:19754231

  10. [Cataracts in dogs--overview and guideline for decision making in treatment].

    PubMed

    Fischer, M-C; Meyer-Lindenberg, A

    2014-01-01

    Cataract is the leading cause of impaired vision and vision loss in dogs. Because of the considerable progress in cataract surgery in recent decades, lens opacities can now be operated on with very good short-term success (90-95%), taking into account that proper patient selection is essential to maximize the probability of a successful surgical outcome. Following a description of anatomical and physiological lens characteristics, the etiology and complications of untreated cataracts are discussed. Furthermore, specific criteria for patient selection are addressed while delineating essential steps of the examination. This article aims to aid decision making in cataract therapy on the basis of diagnostic guidance and to facilitate the selection of an appropriate point of time for surgery. PMID:25422865

  11. Decision-making algorithm in treatment of the atrophic mandible fractures*

    PubMed Central

    DE FEUDIS, F.; DE BENEDITTIS, M.; ANTONICELLI, V.; VITTORE, P.; CORTELAZZI, R.

    2014-01-01

    Aim Closed treatment of atrophic mandible fractures often results in malunion, pseudoarthrosis and pain. Open reduction and rigid internal fixation (ORIF) is still indicated for displaced atrophic mandible fractures. The Authors report a treatment protocol that allows to gain the best results using reconstruction plates, autologous bone grafting and free fibula flap reconstruction when necessary. Methods Retrospective analysis of 15 patients with atrophic mandible fractures who underwent treatment between 2007 and 2011. 7 cases did not receive any treatment because of their general condition, while the others 8 were surgically managed by external approach. In all cases load-bearing osteosynthesis plates with locking screws were used; in 2 of them contextual bone grafts were performed; in 1 case mandible reconstruction needed harvesting a free fibula flap. Results In 6 out of 8 cases complete functional and morphological restoration were obtained without any major complication. In 1 case suppurative infection and necrosis of the bone graft occurred, which made necessary its removing, leaving in situ only the reconstruction plate. In another case, during the first year after surgical treatment, atrophic mandible resorption occurred from one angle to the other, resulting in loss of the anchoring reconstruction plate. Conclusions ORIF is the gold standard procedure for the of atrophic mandible fractures, because it guarantees best morpho-functional outcomes and predictability. Nevertheless the Authors suggest contextual bone grafting in case of substance loss, or a poor quality bone or for dental implant surgery and free fibula flap in selected cases. PMID:24841687

  12. Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis C

    PubMed Central

    Tsochatzis, Emmanuel A; Crossan, Catriona; Longworth, Louise; Gurusamy, Kurinchi; Rodriguez-Peralvarez, Manolo; Mantzoukis, Konstantinos; O'Brien, Julia; Thalassinos, Evangelos; Papastergiou, Vassilios; Noel-Storr, Anna; Davidson, Brian; Burroughs, Andrew K

    2014-01-01

    The cost-effectiveness of noninvasive tests (NITs) as alternatives to liver biopsy is unknown. We compared the cost-effectiveness of using NITs to inform treatment decisions in adult patients with chronic hepatitis C (CHC). We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes (quality-adjusted life-years; QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four treatment strategies: testing with NITs and treating patients with fibrosis stage ≥F2; testing with liver biopsy and treating patients with ≥F2; treat none; and treat all irrespective of fibrosis. We compared all NITs and tested the cost-effectiveness using current triple therapy with boceprevir or telaprevir, but also modeled new, more-potent antivirals. Treating all patients without any previous NIT was the most effective strategy and had an incremental cost-effectiveness ratio (ICER) of £9,204 per additional QALY gained. The exploratory analysis of currently licensed sofosbuvir treatment regimens found that treat all was cost-effective, compared to using an NIT to decide on treatment, with an ICER of £16,028 per QALY gained. The exploratory analysis to assess the possible effect on results of new treatments, found that if SVR rates increased to >90% for genotypes 1-4, the incremental treatment cost threshold for the “treat all” strategy to remain the most cost-effective strategy would be £37,500. Above this threshold, the most cost-effective option would be noninvasive testing with magnetic resonance elastography (ICER = £9,189). Conclusions: Treating all adult patients with CHC, irrespective of fibrosis stage, is the most cost-effective strategy with currently available drugs in developed countries. (Hepatology 2014;60:832–843) PMID

  13. Clinical Decision-Making in Community Children's Mental Health: Using Innovative Methods to Compare Clinicians with and without Training in Evidence-Based Treatment

    ERIC Educational Resources Information Center

    Baker-Ericzén, Mary J.; Jenkins, Melissa M.; Park, Soojin; Garland, Ann F.

    2015-01-01

    Background: Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. Objective: The present study explored the role of prior training in evidence-based treatments (EBTs) on clinicians' assessment and treatment formulations using…

  14. Developmental and Contextual Correlates of Elders' Anticipated End-of-Life Treatment Decisions

    ERIC Educational Resources Information Center

    Decker, Ilene M.; Reed, Pamela G.

    2005-01-01

    The purpose of this study was to gain insight into developmental and contextual correlates of the aggressiveness in treatment that community-based elders anticipate they will desire at the end of life. Elders completed questionnaires to measure 4 developmental factors (integrated moral reasoning, self-transcendence, past experience with…

  15. The use of circulating tumor cells in guiding treatment decisions for patients with metastatic castration-resistant prostate cancer.

    PubMed

    Onstenk, Wendy; de Klaver, Willemijn; de Wit, Ronald; Lolkema, Martijn; Foekens, John; Sleijfer, Stefan

    2016-05-01

    The therapeutic landscape of metastatic castration-resistant prostate cancer (mCRPC) has drastically changed over the past decade with the advent of several new anti-tumor agents. Oncologists increasingly face dilemmas concerning the best treatment sequence for individual patients since most of the novel compounds have been investigated and subsequently positioned either pre- or post-docetaxel. A currently unmet need exists for biomarkers able to guide treatment decisions and to capture treatment resistance at an early stage thereby allowing for an early change to an alternative strategy. Circulating tumor cells (CTCs) have in this context intensively been investigated over the last years. The CTC count, as determined by the CellSearch System (Janssen Diagnostics LLC, Raritan, NJ), is a strong, independent prognostic factor for overall survival in patients with mCRPC at various time points during treatment and, as an early response marker, outperforms traditional response evaluations using serum prostate specific antigen (PSA) levels, scintigraphy as well as radiography. The focus of research is now shifting toward the predictive value of CTCs and the use of the characterization of CTCs to guide the selection of treatments with the highest chance of success for individual patients. Recently, the presence of the androgen receptor splice variant 7 (AR-V7) has been shown to be a promising predictive factor. In this review, we have explored the clinical value of the enumeration and characterization of CTCs for the treatment of mCRPC and have put the results obtained from recent studies investigating the prognostic and predictive value of CTCs into clinical perspective. PMID:27107266

  16. 'Consumers are patients!' shared decision-making and treatment non-compliance as business opportunity.

    PubMed

    Applbaum, Kalman

    2009-03-01

    This article describes an aspect of the progressive insertion of commercial interests into the relationship between patients and their clinicians, with particular reference to psychiatry. Treatment noncompliance, a long-standing problem for healthcare professionals, has lately drawn the attention of the pharmaceutical and allied industries as a site at which to improve return on investment (ROI). Newly founded corporate ;compliance departments' and specialized consultancies that regard noncompliance as a form of marketing failure are seeking to rectify it with reinvigorated models and strategies. This intervention stands to impact patients' experience of illness as well as the participation of those formally (physicians, case managers, etc.) and informally (family, friends, etc.) involved in treatment. My analysis draws upon observation at compliance conferences to demonstrate the contrasting models of patient empowerment underlying the marketing vs. medical approaches. I propose a research agenda for measuring the effects of industry compliance programs. PMID:19293282

  17. Benefits and risks of emerging technologies: integrating life cycle assessment and decision analysis to assess lumber treatment alternatives.

    PubMed

    Tsang, Michael P; Bates, Matthew E; Madison, Marcus; Linkov, Igor

    2014-10-01

    Assessing the best options among emerging technologies (e.g., new chemicals, nanotechnologies) is complicated because of trade-offs across benefits and risks that are difficult to quantify given limited and fragmented availability of information. This study demonstrates the integration of multicriteria decision analysis (MCDA) and life cycle assessment (LCA) to address technology alternative selection decisions. As a case study, prioritization of six lumber treatment alternatives [micronized copper quaternary (MCQ); alkaline copper quaternary (ACQ); water-borne copper naphthenate (CN); oil-borne copper naphthenate (CNo); water-borne copper quinolate (CQ); and water-borne zinc naphthenate (ZN)] for military use are considered. Multiattribute value theory (MAVT) is used to derive risk and benefit scores. Risk scores are calculated using a cradle-to-gate LCA. Benefit scores are calculated by scoring of cost, durability, and corrosiveness criteria. Three weighting schemes are used, representing Environmental, Military and Balanced stakeholder perspectives. Aggregated scores from all three perspectives show CQ to be the least favorable alterative. MCQ is identified as the most favorable alternative from the Environmental stakeholder perspective. From the Military stakeholder perspective, ZN is determined to be the most favorable alternative, followed closely by MCQ. This type of scoring and ranking of multiple heterogeneous criteria in a systematic and transparent way facilitates better justification of technology selection and regulation. PMID:25209330

  18. Minors' decision-making capacity to refuse life-saving and life-sustaining treatment: legal and psychiatric perspectives.

    PubMed

    Mendelson, Danuta; Haywood, Ian

    2014-06-01

    Laws in Belgium and The Netherlands permit euthanasia and assisted suicide for seriously ill children who experience "constant and unbearable suffering"--they have the capacity to request death by lethal injection if they convey a "reasonable understanding of the consequences" of that request. The child's capacity to understand death is therefore a prerequisite to the implementation of the request. However, modern neuro-psychological and fMRI (functional Magnetic Resonance Imaging) studies of the relationship between the neuro-anatomical development of the brain in human beings and their emotional and experiential capacity demonstrates that both are not fully developed until the early 20s for girls and mid-20s for boys. Unlike Belgium and The Netherlands, the clinical and legal implications of the immaturity of the brain on medical decision-making of minors, in particular life and death decisions, have been implicit in the Australian courts' approach to the refusal of life-saving and life-sustaining treatment by minors. This approach is exemplified by X v Sydney Children's Hospitals Network [2013] NSWCA 320 (and a series of earlier cases). PMID:25087358

  19. Data Driven Teachers

    ERIC Educational Resources Information Center

    Tech & Learning, 2009

    2009-01-01

    Data-driven decision-making (DDDM) is a system of teaching and management practices that gets better information about students into the hands of classroom teachers. This article discusses the five major elements: (1) good baseline data; (2) measurable instructional goals; (3) frequent formative assessment; (4) professional learning communities;…

  20. Gender differences in factors associated with patients' decisions to seek treatment for urinary incontinence in Alexandria, Egypt.

    PubMed

    Mohamed, A M; Hassouna, M S; Kassem, M S

    2010-11-01

    The objective of this descriptive, hospital-based comparative cross-sectional survey was to determine gender differences in factors associated with patients' decisions to seek treatment for urinary incontinence (Ul). Using an interview questionnaire, data were collected from 353 patients attending clinics at hospitals in Alexandria, Egypt. There were differences between males and females regarding specific psychosocial factors motivating health care seeking behaviour. Women had fewer hospital admissions and hospital days and less use of diagnostic procedures and surgery. More women suffered from at least one negative impact on their social lives compared to men. The impact of symptoms on quality of life appeared to be the main trigger for seeking help for UI in both men and women. PMID:21218742

  1. Treatment decision based on the biological behavior of pulmonary benign metastasizing leiomyoma

    PubMed Central

    Borda, Bernadett; Lazar, Gyorgy; Tiszlavicz, Laszlo; Furak, Jozsef

    2016-01-01

    Benign metastasizing leiomyoma (BML) is a rare disease in women undergoing surgery for uterine leiomyoma. About 100 cases have been reported in the literature, none of which describe the biological behavior of lesions. The authors present the case of a 36-year-old, asymptomatic woman who had undergone uterus extirpation seven years earlier for leiomyoma of the uterus. Routine chest radiography revealed multiple nodules in both lungs. Biopsy verified metastases from the original uterine leiomyoma. During a 41-month interval, 87 lesions were removed in seven operations, through mini-thoracotomy [four left-sided (42 lesions); and three right-sided (45 lesions)] by cautery resection and suturing of the parenchyma (n=83), or by wedge resection (n=4). In between the procedures, the patient received continuous oncological treatment (VIP protocol: etoposide, ifosfamide, cisplatin). Mean hospital stay was 5.14 days. Respiratory function tests performed after the last surgery showed near-normal results (FVC: 77%, FEV1: 64%, FEV1/FVC: 0.83). Over time, a decrease in number of newly developed BML nodules was observed. Mean surgical sensitivity [rate of lesions appearing on computerized tomography (CT) and removed during each surgery] of the seven metastasectomies was 95% (range: 40–150%). Pathological examination of the nodules proved that, despite continuous oncological treatment, there were no signs of necrosis, thrombosis, or fibrosis. The number of mitoses within the nodules did not change. According to our surgical results and the fact that oncological treatment did not have a significant effect on the course of the disease, we conclude that in the management of multiple BML lesions, surgically removing as many lesions as possible is advised.

  2. Treatment decision based on the biological behavior of pulmonary benign metastasizing leiomyoma.

    PubMed

    Ottlakan, Aurel; Borda, Bernadett; Lazar, Gyorgy; Tiszlavicz, Laszlo; Furak, Jozsef

    2016-08-01

    Benign metastasizing leiomyoma (BML) is a rare disease in women undergoing surgery for uterine leiomyoma. About 100 cases have been reported in the literature, none of which describe the biological behavior of lesions. The authors present the case of a 36-year-old, asymptomatic woman who had undergone uterus extirpation seven years earlier for leiomyoma of the uterus. Routine chest radiography revealed multiple nodules in both lungs. Biopsy verified metastases from the original uterine leiomyoma. During a 41-month interval, 87 lesions were removed in seven operations, through mini-thoracotomy [four left-sided (42 lesions); and three right-sided (45 lesions)] by cautery resection and suturing of the parenchyma (n=83), or by wedge resection (n=4). In between the procedures, the patient received continuous oncological treatment (VIP protocol: etoposide, ifosfamide, cisplatin). Mean hospital stay was 5.14 days. Respiratory function tests performed after the last surgery showed near-normal results (FVC: 77%, FEV1: 64%, FEV1/FVC: 0.83). Over time, a decrease in number of newly developed BML nodules was observed. Mean surgical sensitivity [rate of lesions appearing on computerized tomography (CT) and removed during each surgery] of the seven metastasectomies was 95% (range: 40-150%). Pathological examination of the nodules proved that, despite continuous oncological treatment, there were no signs of necrosis, thrombosis, or fibrosis. The number of mitoses within the nodules did not change. According to our surgical results and the fact that oncological treatment did not have a significant effect on the course of the disease, we conclude that in the management of multiple BML lesions, surgically removing as many lesions as possible is advised. PMID:27621897

  3. Genomic Profiling in Gastrointestinal Cancer: Are We Ready To Use These Data to Make Treatment Decisions?

    PubMed Central

    2015-01-01

    Remarkable strides have been made in the past 10–15 years in identifying the molecular events that drive cancer. With an enormous amount of new data, including those from The Cancer Genome Atlas Project, therapies are increasingly being developed and tested in clinical trials specifically designed to target some of these molecular events. Often, molecular signatures have become more important than the histologic features in making treatment choices. The success rate of these therapies depends on many factors but, perhaps most importantly, on patient selection according to the genetic analysis results of their individual tumors. PMID:26512044

  4. Incorporating financial protection into decision rules for publicly financed healthcare treatments.

    PubMed

    Smith, Peter C

    2013-02-01

    Almost all health systems seek to offer some form of publicly financed healthcare insurance, and governments must therefore choose the size of the benefit package and the types of treatments to cover. Conventionally, the usual approach of economists has been to recommend choices on the basis of cost effectiveness of treatments, using metrics such as the 'cost per quality adjusted life year'. However, this approach is based on the assumption of health maximization subject to a budget constraint and ignores the potential impact of any additional concern with protecting individuals from the financial consequences of a health shock. Furthermore, it does not take account of the possible availability of complementary privately funded health care. This paper develops a model in which risk-averse individuals care about health but also place a value on protection from the financial consequences of rare but costly events. The paper shows how conventional cost-effectiveness analysis can readily be augmented to take account of financial protection objectives. The results depend on whether or not there exists a market in complementary privately funded health care. They have important implications for the methodology adopted by health technology assessment agencies and for the broader design of publicly funded health systems. PMID:22241688

  5. [Forgoing treatments: a kind of euthanasia? A scientific approach to the debate about end of life decisions].

    PubMed

    Riccioni, Luigi; Busca, Maria Teresa; Busatta, Lucia; Orsi, Luciano; Gristina, Giuseppe R

    2016-03-01

    In the last decade an extensive debate on the topic of end of life decisions has developed in western countries, obtaining a worldwide media relevance. Philosophers, theologians, legal experts and doctors, focus their attention on the three thorny issues of the topic: forgoing treatments, euthanasia and assisted suicide. A thorough and respectful discussion on these issues should include all stakeholders - above all palliative care physicians - and should be encouraged in order to understand the views in favor or against the three practices, checking the different moral positions, and analyzing the cultural, social and legal aspects in the background on one hand, and, on the other, their impact on the health care systems. At present, in the fields of communications and politics, the debate related to the topic of these end of life practices is characterized by a confusion of terms and meanings. As an outcome, the term "euthanasia" is misused as a "container" including forgoing treatments, euthanasia and assisted suicide, while palliative sedation is wrongly considered as a procedure to cause death. This confusing approach does not permit to understand the real issues at the stake, keeping the debate at the tabloid level. Conversely, sharing the precise meaning of the words is the only way to provide tools to make rational, autonomous and responsible decisions, allowing individual informed choices in compliance with the principle of autonomy. This article is not aimed to take a moral stand in favor or against forgoing treatments, euthanasia and assisted suicide. Through an analysis based on scientific criteria, the authors firstly review the definitions of these three practices, examining the concepts enclosed in each term; secondly, they offer a glance on the legal approach to end of life issues in western countries; lastly, they investigate the relationship between these practices and palliative care culture in light of the medical societies official statements

  6. Preferences and flexibility in decision-making among dental clinicians regarding the treatment of multirooted teeth: an interactive communication device-based survey at two academic conferences

    PubMed Central

    2016-01-01

    Purpose Decision-making by dental and medical experts can be influenced by their biases, interests, and experiences, and academic arguments about controversial issues may additionally be considered indirect experiences capable of affecting decision-making. This study reports on the use of interactive communication devices to evaluate preferences and flexibility in decision-making among dental care providers who attended two distinct academic conferences. Methods Two debates were presented by a team of two lecturers at two academic conferences (focusing on periodontology and implant dentistry, respectively) and the audience members of each session were surveyed. Before each lecture, two case modules about the diagnosis and treatment of multirooted molar lesions were provided, and interactive communication devices were used to collect responses about decision-making preferences in treatment planning immediately before and after a debate about treatment strategies. Results In total, 81 and 84 completed answers from both conferences were obtained for the first and second case modules, respectively. The preferred treatment plan differed significantly according to the focus of the conference, and a tendency emerged for the clinicians participating in each conference to express uniform preferences. However, attending the debates resulted in significant changes in decision-making preferences regardless of the conference focus or the characteristics of the participants. Conclusions Our findings suggest that providing continuing education via debates on controversial issues may be effective in widening conceptual knowledge and reducing biases among experts in the dental and medical fields. PMID:27382505

  7. Breast Cancer Treatment Decision Making among Latinas and non-Latina Whites: A Communication Model Predicting Decisional Outcomes and Quality of Life

    PubMed Central

    Yanez, Betina; Stanton, Annette L.; Maly, Rose C.

    2014-01-01

    Objective Deciding among medical treatment options is a pivotal event following cancer diagnosis, a task that can be particularly daunting for individuals uncomfortable with communication in a medical context. Few studies have explored the surgical decision-making process and associated outcomes among Latinas. We propose a model to elucidate pathways though which acculturation (indicated by language use) and reports of communication effectiveness specific to medical decision making contribute to decisional outcomes (i.e., congruency between preferred and actual involvement in decision making, treatment satisfaction) and quality of life among Latinas and non-Latina White women with breast cancer. Methods Latinas (N = 326) and non-Latina Whites (N = 168) completed measures six months after breast cancer diagnosis, and quality of life was assessed 18 months after diagnosis. Structural equation modeling was used to examine relationships between language use, communication effectiveness, and outcomes. Results Among Latinas, 63% reported congruency in decision making, whereas 76% of non-Latina Whites reported congruency. In Latinas, greater use of English was related to better reported communication effectiveness. Effectiveness in communication was not related to congruency in decision making, but several indicators of effectiveness in communication were related to greater treatment satisfaction, as was greater congruency in decision making. Greater treatment satisfaction predicted more favorable quality of life. The final model fit the data well only for Latinas. Differences in quality of life and effectiveness in communication were observed between racial/ethnic groups. Conclusions Findings underscore the importance of developing targeted interventions for physicians and Latinas with breast cancer to enhance communication in decision making. PMID:22746263

  8. Parental refusal of life-saving treatments for adolescents: Chinese familism in medical decision-making re-visited.

    PubMed

    Hui, Edwin

    2008-06-01

    This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the 'AP-physician-family-relationship' and the dominant role Chinese families play in medical decision-making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives 'weak' family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re-interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its 'parens patriae' power to defend the defenseless in society and the integrity of the medical profession. PMID:18447864

  9. Enhancing Medical Decision-Making Evaluations: Introduction of Normative Data for the Capacity to Consent to Treatment Instrument.

    PubMed

    Gerstenecker, Adam; Niccolai, Lindsay; Marson, Daniel; Triebel, Kristen L

    2016-04-01

    A number of measures have been developed to assess medical decision-making capacity (MDC) in adults. However, their clinical utility is limited by a lack of available normative data. In the current study, we introduce age-independent and age-adjusted normative data for a measure of MDC: the Capacity to Consent to Treatment Instrument. The sample consisted of 308 cognitively normal, community-dwelling adults ranging in age from 19 to 86 years. For age-adjusted norms, individual raw scores were first converted to age-corrected scaled scores based on position within a cumulative frequency distribution and then grouped according to empirically supported age ranges. For age-independent norms, the same method was utilized but without age-corrections being applied or participants being grouped into age ranges. This study has the potential to enhance MDC evaluations by allowing clinicians to compare a patient's performance on the Capacity to Consent to Treatment Instrument with that of adults regardless of age as well as to same age peers. Tables containing normative corrections are supplementary material available online at http://asm.sagepub.com/supplemental. PMID:26282778

  10. Predicting stone composition before treatment – can it really drive clinical decisions?

    PubMed Central

    Bres–Niewada, Ewa; Radziszewski, Piotr

    2014-01-01

    Introduction Determination of stone composition is considered to be crucial for the choice of an optimal treatment algorithm. It is especially important for uric acid stones, which can be dissolved by oral chemolysis and for renal stones smaller than 2 cm, which can be treated with extracorporeal shockwave lithotripsy (ESWL). Material and methods This short review identifies the latest papers on radiological assessment of stone composition and presents a comprehensive evaluation of current scientific findings. Results Stone chemical composition is difficult to predict using standard CT imaging, however, attenuation index measured in Hounsfield units (HU) is related to ESWL outcome. Stone density >1000 HU can be considered predictive for ESWL failure. It seems that stone composition is meaningless in determining the outcome of ureterolithotripsy and percutaneous surgery. Alternative imaging techniques such as Dual–Energy CT or analysis of shape, density and homogeneity of stones on plain X–rays are used as promising methods of predicting stone composition and ESWL outcome. Conclusions New imaging techniques facilitate the identification of uric acid stones and ESWL–resistant stones. Therefore, they may help in selecting the best therapeutic option. PMID:25667761

  11. Toward Personalized Smoking-Cessation Treatment: Using a Predictive Modeling Approach to Guide Decisions Regarding Stimulant Medication Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in Smokers

    PubMed Central

    Luo, Sean X.; Covey, Lirio S.; Hu, Mei-Chen; Levin, Frances R.; Nunes, Edward V.; Winhusen, Theresa M.

    2015-01-01

    Background and Objectives Osmotic-release oral system methylphenidate (OROS-MPH) did not show overall benefit as an adjunct smoking cessation treatment for adult smokers with ADHD in a randomized, placebo-controlled, multicenter clinical trial. A secondary analysis revealed a significant interaction between ADHD symptom severity and treatment-response to OROS-MPH, but did not account for other baseline covariates or estimate the magnitude of improvement in outcome if treatment were optimized. This present study addressed the gaps in how this relationship should inform clinical practice. Methods Using data from the Adult Smokers with ADHD Trial (N = 255, six sites in five US States), we build predictive models to calculate the probability of achieving prolonged abstinence, verified by self-report, and expired carbon monoxide measurement. We evaluate the potential improvement in achieving prolonged abstinence with and without stratification on baseline ADHD severity. Results Predictive modeling demonstrates that the interaction between baseline ADHD severity and treatment group is not affected by adjusting for other baseline covariates. A clinical trial simulation shows that giving OROS-MPH to patients with baseline Adult ADHD Symptom Rating Scale (ADHD-RS) >35 and placebo to those with ADHD-RS ≤35 would significantly improve the prolonged abstinence rate (52 ± 8% vs. 42 ± 5%, p < .001). Conclusions and Scientific Significance In smokers with ADHD, utilization of a simple decision rule that stratifies patients based on baseline ADHD severity can enhance overall achievement of prolonged smoking abstinence. Similar analysis methods should be considered for future clinical trials for other substance use disorders. PMID:25659348

  12. Pharmacologic Evidence to Support Clinical Decision Making for Peripartum Methadone Treatment

    PubMed Central

    Bogen, D. L.; Perel, J. M.; Helsel, J. C.; Hanusa, B. H.; Romkes, M.; Nukui, T.; Friedman, C. R.; Wisner, K. L.

    2012-01-01

    Rationale Limited pharmacological data are available to guide methadone treatment during pregnancy and postpartum. Objectives Study goals were to: 1) Characterize changes in methadone dose across childbearing, 2) Determine enantiomer-specific methadone withdrawal kinetics from steady-state during late pregnancy, 3) Assess enantiomer-specific changes in methadone level/dose (L/D) ratios across childbearing, and 4) Explore relationships between CYP2B6, CYP2C19 and CYP3A4 single nucleotide polymorphisms and maternal dose, plasma concentration and L/D. Methods Methadone dose changes and timed plasma samples were obtained for women on methadone (n=25) followed prospectively from third trimester of pregnancy to three months postpartum. Results Participants were primarily white, Medicaid insured and multiparous. All women increased their dose from first to end of second trimester (mean peak increase=23 mg/day); 71% of women increased from second trimester to delivery (mean peak increase=19 mg/day). Half took a higher dose 3 months postpartum than at delivery despite significantly larger clearance during late pregnancy. Third trimester enantiomer-specific methadone half-lives (range R-methadone 14.7-24.9 hours; S-methadone 8.02-18.9 hours) were about half of those reported in non-pregnant populations. In 3 women with weekly 24-hour methadone levels after delivery, L/D increased within 1-2 weeks after delivery. Women with the CYP2B6 Q172 variant GT genotype have consistently higher L/D values for S-methadone across both pregnancy and postpartum. Conclusions Most women require increases in methadone dose across pregnancy. Given the shorter half-life and larger clearances during pregnancy, many pregnant women may benefit from split methadone dosing. L/D increases quickly after delivery and doses should be lowered rapidly after delivery. PMID:22926004

  13. GIDEON (Global Investigation of therapeutic DEcisions in hepatocellular carcinoma and Of its treatment with sorafeNib): second interim analysis

    PubMed Central

    Lencioni, R; Kudo, M; Ye, S-L; Bronowicki, J-P; Chen, X-P; Dagher, L; Furuse, J; Geschwind, J F; de Guevara, L Ladrón; Papandreou, C; Takayama, T; Yoon, S K; Nakajima, K; Lehr, R; Heldner, S; Sanyal, A J

    2014-01-01

    Background GIDEON (Global Investigation of therapeutic DEcisions in hepatocellular carcinoma [HCC] and Of its treatment with sorafeNib) is a global, prospective, non-interventional study undertaken to evaluate the safety of sorafenib in patients with unresectable HCC in real-life practice, including Child-Pugh B patients who were excluded from clinical trials. Methods Patients with unresectable HCC, for whom the decision to treat with sorafenib, based on the approved label and prescribing guidelines, had been taken by their physician, were eligible for inclusion. Demographic data and disease/medical history were recorded at entry. Sorafenib dosing and adverse events (AEs) were collected at follow-up visits. The second interim analysis was undertaken when ∼1500 treated patients were followed up for ≥ 4 months. Results Of the 1571 patients evaluable for safety, 61% had Child-Pugh A status and 23% Child-Pugh B. The majority of patients (74%) received the approved 800 mg initial sorafenib dose, regardless of Child-Pugh status; however, median duration of therapy was shorter in Child-Pugh B patients. The majority of drug-related AEs were grade 1 or 2, and the most commonly reported were consistent with previous reports. The incidence and nature of drug-related AEs were broadly similar across Child-Pugh, Barcelona Clinic Liver Cancer (BCLC) and initial dosing subgroups, and consistent with the overall population. Conclusions Consistent with the first interim analysis, overall safety profile and dosing strategy are similar across Child-Pugh subgroups. Safety findings also appear comparable irrespective of initial sorafenib dose or BCLC stage. Final analyses in > 3000 patients are ongoing. PMID:24283303

  14. The Treatment Decision-Making Process: Age Differences in a Sample of Women Recently Diagnosed with Nonrecurrent Early-Stage Breast Cancer.

    ERIC Educational Resources Information Center

    Petrisek, Ann C.; Laliberte, Linda L.; Allen, Susan M.; Mor, Vincent

    1997-01-01

    Using retrospective, self-report data collected from women recently diagnosed with breast cancer (N=179), examines the influence of age differences in the treatment decision-making process. Findings indicate that older women were less likely than their younger counterparts to have desired participation in therapy selection or sought out medical…

  15. Non-basic azolotriazinone MCHR1 antagonists for the treatment of obesity: An empirical brain-exposures-driven candidate selection for in vivo efficacy studies.

    PubMed

    Devasthale, Pratik; Wang, Wei; Mignone, James; Renduchintala, Kishore; Radhakrishnan, Sridhar; Dhanapal, Jayanthi; Selvaraj, Jagannath; Kuppusamy, Rajesh; Pelleymounter, Mary Ann; Longhi, Daniel; Huang, Ning; Flynn, Neil; Azzara, Anthony V; Rohrbach, Kenneth; Devenny, James; Rooney, Suzanne; Thomas, Michael; Glick, Susan; Godonis, Helen; Harvey, Susan; Cullen, Mary Jane; Zhang, Hongwei; Caporuscio, Christian; Stetsko, Paul; Grubb, Mary; Huang, Christine; Zhang, Lisa; Freeden, Chris; Murphy, Brian J; Robl, Jeffrey A; Washburn, William N

    2015-10-15

    Non-basic azolotriazinones were explored using an empirical free brain exposures-driven approach to identify potent MCHR1 antagonists for evaluation in in vivo efficacy studies. An optimized lead from this series, 1j (rMCHR1 Ki=1.8 nM), demonstrated a 6.9% reduction in weight gain relative to vehicle in a rat model at 30 mg/kg after 4 days of once-daily oral treatment as a glycine prodrug. Despite a promising efficacy profile, an assessment of the biliary toxicity risk of this compound rendered this compound non-progressible. PMID:26386604

  16. LCA as a decision support tool for the environmental improvement of the operation of a municipal wastewater treatment plant.

    PubMed

    Pasqualino, Jorgelina C; Meneses, Montse; Abella, Montserrat; Castells, Francesc

    2009-05-01

    Life cycle assessment (LCA) methodology is used to evaluate the environmental profile of a product or process from its origin to its final destination. In this paper we used LCA to evaluate the current situation of a wastewater treatment plant and identify improvement alternatives. Currently, the highest environmental impacts are caused by the stages of the plant with the highest energy consumption, the use of biogas from anaerobic digestion (95% burned in torch) and the final destination of the sludge (98.6% for agricultural use and 1.4% for compost). We propose four alternatives for biogas applications and five alternatives for sludge applications and compare them to the current situation. The alternatives were incorporated in a decision support system to identify and prioritize the most positive environmental option. Using biogas to produce electricity or a combination of electricity and heat provided the best environmental options since the energy produced would be enough to supply all the stages of the plant, thus reducing their environmental impact. The best environmental option for the final destination of the sludge is to combine the current situation (fertilizer replacement) with use of the sludge in a cement plant (as a replacement for fuel and raw material). PMID:19534150

  17. Chronic atomoxetine treatment during adolescence does not influence decision-making on a rodent gambling task, but does modulate amphetamine's effect on impulsive action in adulthood.

    PubMed

    Silveira, Mason M; Murch, W Spencer; Clark, Luke; Winstanley, Catharine A

    2016-06-01

    In addition to the symptoms of inattention, hyperactivity, and impulsivity, individuals with attention deficit hyperactivity disorder exhibit impaired performance on tests of real-world cost/benefit decision-making. Atomoxetine, a nonstimulant drug approved for the treatment of attention deficit hyperactivity disorder, is a selective norepinephrine reuptake inhibitor administered chronically during adolescence, a time during which the frontal brain regions necessary for executive function undergo extensive maturation. This treatment protocol can affect behavior well into adulthood, but whether it produces long-term changes in complex decision-making has not been investigated. Twenty-four Long-Evans rats were administered saline or 1.0 mg/kg atomoxetine daily from postnatal day 40 to 54. Two weeks after treatment, the adult rats were trained and assessed on the rodent gambling task, in which the animals chose from four options varying in reward, punishment, and uncertainty. Impulsive action was also measured by recording the number of premature responses made. Regardless of the treatment administered during adolescence, rats learned to favor the advantageous options characterized by small, low-penalty rewards in lieu of the larger, higher-penalty reward options. Rodent gambling task performance was then assessed following acute treatment with atomoxetine (0.1-1.0 mg/kg) and amphetamine (0.3-1.5 mg/kg). Across groups, the highest dose of atomoxetine impaired decision-making and decreased premature responding at all doses tested. Amphetamine also impaired choice performance, but selectively increased impulsive action in rats that had previously received atomoxetine treatment during adolescence. These findings contribute to our understanding of the long-term effects associated with chronic adolescent atomoxetine exposure and suggest that this treatment does not alter decision-making under conditions of risk and uncertainty in adulthood. PMID:26650252

  18. Making Decisions about Treatment

    MedlinePlus

    Project Inform Information, inspiration and advocacy for people with HIV/AIDS and hepatitis C Skip to content ... Health care reform CONTRIBUTORS Search for: Twitter Feed Project Inform ProjectInform ProjectInform Easy to use #PrEP cards ...

  19. Do Alzheimer's Disease Patients Want to Participate in a Treatment Decision, and Would Their Caregivers Let Them?

    ERIC Educational Resources Information Center

    Hirschman, Karen B.; Joyce, Colette M.; James, Bryan D.; Xie, Sharon X.; Karlawish, Jason H.T.

    2005-01-01

    Purpose: This study was designed to examine the factors associated with the preferences of Alzheimer's disease patients to participate in a decision to use an Alzheimer's disease-slowing medication and how involved their caregivers would let them be in this decision. Design and Methods: Interviews were conducted with 48 patients in the…

  20. Tumor necrosis factor-α driven inflammation in alpha-1 antitrypsin deficiency: a new model of pathogenesis and treatment.

    PubMed

    Hurley, Killian; Reeves, Emer P; Carroll, Tomás P; McElvaney, Noel G

    2016-02-01

    Alpha-1 antitrypsin (AAT) deficiency (AATD) has traditionally been thought of as a genetic disorder characterized by lung destruction and early emphysema in a low AAT, and high neutrophil elastase (NE) environment in the lungs of affected individuals. Recently, a growing body of evidence has emerged to support the hypothesis that tumor necrosis factor alpha (TNF-α) is essential in the pathogenesis of both genetic AATD and non-genetic chronic obstructive pulmonary disease (COPD). Reports have highlighted the importance of TNF-α driven immune cell dysfunction in the development of lung disease in AATD. The authors discuss the role of AAT as a key modulator of TNF-α signaling firstly in the setting of AATD and secondly in other conditions where AAT augmentation therapy has potential utility as a novel therapy. PMID:26634397

  1. Can we routinely measure patient involvement in treatment decision-making in chronic kidney care? A service evaluation in 27 renal units in the UK

    PubMed Central

    Durand, Marie-Anne; Bekker, Hilary L.; Casula, Anna; Elias, Robert; Ferraro, Alastair; Lloyd, Amy; van der Veer, Sabine N.; Metcalfe, Wendy; Mooney, Andrew; Thomson, Richard G.; Tomson, Charles R.V.

    2016-01-01

    Background Shared decision making is considered an important aspect of chronic disease management. We explored the feasibility of routinely measuring kidney patients' involvement in making decisions about renal replacement therapy (RRT) in National Health Service settings. Methods We disseminated a 17-item paper questionnaire on involvement in decision-making among adult patients with established kidney failure who made a decision about RRT in the previous 90 days (Phase 1) and patients who had been receiving RRT for 90–180 days (Phase 2). Recruitment rates were calculated as the ratio between the number of included and expected eligible patients (I : E ratio). We assessed our sample's representativeness by comparing demographics between participants and incident patients in the UK Renal Registry. Results Three hundred and five (Phase 1) and 187 (Phase 2) patients were included. For Phase 1, the I : E ratio was 0.44 (range, 0.08–2.80) compared with 0.27 (range, 0.04–1.05) in Phase 2. Study participants were more likely to be white compared with incident RRT patients (88 versus 77%; P < 0.0001). We found no difference in age, gender or social deprivation. In Phases 1 and 2, the majority reported a collaborative decision-making style (73 and 69%), and had no decisional conflict (85 and 76%); the median score for shared decision-making experience was 12.5 (Phase 1) and 10 (Phase 2) out of 20. Conclusion Our study shows the importance of assessing the feasibility of data collection in a chronic disease context prior to implementation in routine practice. Routine measurement of patient involvement in established kidney disease treatment decisions is feasible, but there are challenges in selecting the measure needed to capture experience of involvement, reducing variation in response rate by service and identifying when to capture experience in a service managing people's chronic disease over time. PMID:26985377

  2. How Good is Our Best Guess? Clinical Application of the WHO FRAX Tool in Osteoporotic Fracture Risk Determination and Treatment Decisions.

    PubMed

    Hinz, Laura; Freiheit, Elizabeth; Kline, Gregory

    2016-08-01

    Historically, treatment decisions for osteoporosis were based on bone mineral density. However, many fractures occur in patients with T-scores outside the osteoporotic range, emphasizing the importance of multi-factorial risk assessments. The World Health Organization Fracture Risk Assessment Tool (FRAX) predicts 10-year risk of osteoporotic fracture. We hypothesized that physicians' clinical estimates of osteoporotic fracture risk would differ significantly from that calculated by FRAX. Thus, treatment decisions would differ depending whether or not physicians used FRAX. A survey consisting of five clinical scenarios was administered to 76 endocrinologists, family physicians, internists, and internal medicine residents. They were asked to estimate the osteoporotic fracture risk and decide whether they would offer preventative treatment. Their estimates were compared to the risk predicted by FRAX and national treatment threshold guidelines. The primary outcome was the difference between the participant's estimate and the FRAX-based estimate of the 10-year risk of osteoporotic fracture for each scenario. In each scenario, physicians statistically significantly over-estimated fracture risk compared to that predicted by FRAX. Estimates for hip fracture risk were 2-4 times higher than FRAX estimates. The major osteoporotic fracture risk at which participants would offer treatment varied with physician group, with endocrinologists, family physicians, and residents requiring a 10-20 % 10-year risk, while internal medicine physician thresholds ranged from 2 to 20 %. Physicians greatly over-estimated the risk of hip fracture based on clinical information. FRAX is necessary to accurately quantify risk, but because physicians varied in the level of risk required before they would offer treatment, uniform approaches to risk estimation may still not result in uniform clinical treatment decisions. PMID:27038319

  3. INSM1 promoter-driven adenoviral herpes simplex virus thymidine kinase cancer gene therapy for the treatment of primitive neuroectodermal tumors.

    PubMed

    Wang, Hong-Wei; Breslin, Mary B; Chen, Chiachen; Akerstrom, Victoria; Zhong, Qiu; Lan, Michael S

    2009-11-01

    The INSM1 gene encodes a developmentally regulated zinc finger transcription factor. INSM1 expression is normally absent in adult tissues, but is reactivated in neuroendocrine tumor cells. In the present study, we analyzed the therapeutic potential of an adenoviral INSM1 promoter-driven herpes simplex virus thymidine kinase (HSV-tk) construct in primitive neuroectodermal tumors (PNETs). We constructed an adenoviral INSM1 promoter-driven HSV-tk gene for therapy in PNETs. The PNET-specific adeno-INSM1 promoter HSV-tk construct was tested both in vitro and in vivo in a nude mouse tumor model. Northern blot analysis and transient transfection of an INSM1 promoter-driven luciferase reporter gene indicated that the INSM1 promoter was active in neuroblastoma (IMR-32), retinoblastoma (Y79), and medulloblastoma (D283 Med) cells, but not in glioblastoma (U-87 MG) cells. After Ad-INSM1p-HSV-tk infection, the levels of HSV-tk protein expression were consistent with INSM1 promoter activities. Furthermore, in vitro multiplicity of infection and ganciclovir (GCV) sensitivity studies indicated that the INSM1 promoter could mediate specific expression of the HSV-tk gene and selective killing of INSM1-positive PNETs. In vivo intratumoral adenoviral delivery demonstrated that the INSM1 promoter could direct HSV-tk gene expression in a nude mouse tumor model and effectively repressed tumor growth in response to GCV treatment. Taken together, our data show that the INSM1 promoter is specific and effective for targeted cancer gene therapy in PNETs. PMID:19604042

  4. The impact of the 21-gene assay on adjuvant treatment decisions in oestrogen receptor-positive early breast cancer: a prospective study

    PubMed Central

    Kuchel, Anna; Robinson, Tim; Comins, Charles; Shere, Mike; Varughese, Mohini; Sparrow, Geoff; Sahu, Ajay; Saunders, Louise; Bahl, Amit; Cawthorn, Simon J; Braybrooke, Jeremy P

    2016-01-01

    Background: International guidelines, including NICE, recommend using the 21-gene Recurrence Score assay for guiding adjuvant treatment decisions in ER+, HER2-negative early breast cancer (BC). We investigated the impact of adding this assay to standard pathological tests on clinicians'/patients' treatment decisions and on patients' decisional conflict in the United Kingdom. Methods: In this prospective multicentre study, eligibility criteria included: ER+ HER2-negative BC (N0/Nmic for patients ⩽50 years; ⩽3 positive lymph nodes for patients >50 years) and being fit for chemotherapy. Physicians'/patients' treatment choices and patients' decisional conflict were recorded pre- and post testing. Results: The analysis included 137 patients. Overall, adjuvant treatment recommendations changed in 40.7% of patients, with the direction of the change consistent with the Recurrence Score results (net decrease in chemotherapy recommendation rate in low Recurrence Score patients and net increase in high Recurrence Score patients). Patients' choices were generally consistent with physicians' recommendations. Post-testing, patients' decisional conflict decreased significantly (P<0.0001). In the 67 patients meeting the NICE criteria for testing, the recommendation change rate was 49.3%. Conclusions: Recurrence Score testing significantly influenced treatment recommendations overall and in the subgroup of patients meeting the NICE criteria, suggesting that this test could substantially alter treatment patterns in the United Kingdom. PMID:26954715

  5. Protocol for a pre-implementation and post-implementation study on shared decision-making in the surgical treatment of women with early-stage breast cancer

    PubMed Central

    Savelberg, Wilma; Moser, Albine; Smidt, Marjolein; Boersma, Liesbeth; Haekens, Christel; van der Weijden, Trudy

    2015-01-01

    Background The majority of patients diagnosed with early-stage breast cancer are in a position to choose between having a mastectomy or lumpectomy with radiation therapy (breast-conserving therapy). Since the long-term survival rates for mastectomy and for lumpectomy with radiation therapy are comparable, patients’ informed preferences are important for decision-making. Although most clinicians believe that they do include patients in the decision-making process, the information that women with breast cancer receive regarding the surgical options is often rather subjective, and does not invite patients to express their preferences. Shared decision-making (SDM) is meant to help patients clarify their preferences, resulting in greater satisfaction with their final choice. Patient decision aids can be very supportive in SDM. We present the protocol of a study to β test a patient decision aid and optimise strategies for the implementation of SDM regarding the treatment of early-stage breast cancer in the actual clinical setting. Methods/design This paper concerns a pre-implementation and post-implementation study, lasting from October 2014 to June 2015. The intervention consists of implementing SDM using a patient decision aid. The intervention will be evaluated using qualitative and quantitative measures, acquired prior to, during and after the implementation of SDM. Outcome measures are knowledge about treatment, perceived SDM and decisional conflict. We will also conduct face-to-face interviews with a sample of these patients and their care providers, to assess their experiences with the implementation of SDM and the patient decision aid. Ethics and dissemination This protocol was approved by the Maastricht University Medical Centre (MUMC) ethics committee. The findings will be disseminated through peer-reviewed journal articles and presentations at national conferences. Findings will be used to finalise a multi-faceted implementation strategy to test the

  6. Design of a visible light driven photo-electrochemical/electro-Fenton coupling oxidation system for wastewater treatment.

    PubMed

    Ding, Xing; Ai, Zhihui; Zhang, Lizhi

    2012-11-15

    In this study, we report on a photo-electrochemical/electro-Fenton oxidation (PEC/EF) system by coupling visible light driven photo-electrochemical oxidation (PEC) and electro-Fenton oxidation (EF) in an undivided cell. Bi2WO6 nanoplates deposited on FTO glass (Bi2WO6/FTO) and Fe@Fe2O3 core-shell nanowires supported on activated carbon fiber (Fe@Fe2O3/ACF) were used as the anode and the cathode in the PEC/EF system, respectively. This novel PEC/EF system showed much higher activity than the single PEC and EF systems on degradation of rhodamine B in aqueous solution at natural pH. Moreover, the degradation and the instantaneous current efficiencies of the PEC/EF system were increased by 154% and 26% in comparison with the sum of those of single PEC and EF systems, respectively. These significant enhancements could be attributed to the synergetic effect from better separation of photo-generated carriers in the photo-anode and the transfer of photo-electrons to the oxygen diffusion cathode to generate more electro-generated H2O2 and hydroxyl radicals on the Fenton cathode. The better separation of photo-generated carriers contribute more to the overall degradation enhancement than the photo-electrons generated H2O2 and the subsequent Fenton reaction on the cathode during the PEC/EF process. PMID:23017238

  7. Why I wrote my advance decision to refuse life-prolonging treatment: and why the law on sanctity of life remains problematic.

    PubMed

    Gillon, Raanan

    2016-06-01

    This paper, pursuing themes indefatigably defended in this journal and elsewhere by Professors Jenny and Celia Kitzinger, explains what led me to write my own advance decision (AD) to refuse life-prolonging treatment if I become legally incapacitated to make my own healthcare decisions for longer than 3 months and am medically assessed as very unlikely to regain such legal capacity. I attach my Advance Decision to Refuse Life Prolonging Treatment to the online version of this paper for comment advice and possible general interest. I argue that while a Supreme Court judgement in 2013, followed by a Court of Protection judgement in 2015 greatly ameliorate my earlier concerns about excessive judicial emphasis on the sanctity of life, certain current requirements in the Code of Practice to the Mental Capacity Act 2005 and in the Rules of the Court of Protection, especially Practice Direction 9E, concerning permanent vegetative state and minimally conscious state, seem clearly to contradict aspects of that Supreme Court judgement. If the logical implications of those legal requirements were thoroughly implemented medical practice would be substantially and undesirably skewed towards provision of treatments to prolong life that are unwanted, non-beneficial and wasteful of healthcare resources. I urge that these legal requirements are modified to make them consistent with the Supreme Court's judgement in Aintree v James. PMID:27118692

  8. Using functional analysis to determine if esthetically driven treatment requires comprehensive care for long-term success.

    PubMed

    Sklyarov, Ilya

    2015-02-01

    This article reviews the case of a male patient with esthetic concerns about a large diastema between teeth Nos. 8 and 9. Through functional analysis, the clinician determined that the patient had a mild temporomandibular disorder, as well as a constriction in his anterior envelope of function. These issues will affect the prognosis of treatment if only orthodontics is used to close the diastema. The clinician determined that implementing a systematic treatment planning approach was critical in achieving a successful outcome, which was accomplished with a combination of orthodontics, occlusal deprogramming, and complex prosthodontics restorations. PMID:25822640

  9. Seriously Data-Driven Decision Making

    ERIC Educational Resources Information Center

    Casserly, Michael D.

    2011-01-01

    As states approach the funding cliff marking the end of federal stimulus help for education, school districts will be feeling more financial pain than they're experiencing now. But there's good news amid the bad: Big city districts are showing schools nationwide a way to save money and improve efficiency by working together. They've created the…

  10. Implementation of a "Learner-Driven" Curriculum: An Screening, Brief Intervention, and Referral to Treatment (SBIRT) Interdisciplinary Primary Care Model

    ERIC Educational Resources Information Center

    Stanton, Marina R.; Atherton, W. Leigh; Toriello, Paul J.; Hodgson, Jennifer L.

    2012-01-01

    Although screening, brief intervention, and referral to treatment (SBIRT) has been a popular model to address potential substance abuse issues in primary care, there is a need for innovative approaches for training providers and staff on SBIRT protocols. An interdisciplinary approach to SBIRT training, named ICARE, was implemented at 3 different…

  11. The Performance of Direct Disk Diffusion for Community Acquired Bacteremia due to Gram-Negative Bacilli and Its Impact on Physician Treatment Decisions.

    PubMed

    Daley, Peter; Comerford, Adam; Umali, Jurgienne; Penney, Carla

    2016-01-01

    Background. Direct disk diffusion susceptibility testing provides faster results than standard microtitre susceptibility. The direct result may impact patient outcome in sepsis if it is accurate and if physicians use the information to promptly and appropriately change antibiotic treatment. Objective. To compare the performance of direct disk diffusion with standard susceptibility and to consider physician decisions in response to these early results, for community acquired bacteremia with Gram-negative Bacilli. Methods. Retrospective observational study of all positive blood cultures with Gram-negative Bacilli, collected over one year. Physician antibiotic treatment decisions were assessed by an infectious diseases physician based on information available to the physician at the time of the decision. Results. 89 bottles growing Gram-negative Bacilli were included in the analysis. Direct disk diffusion agreement with standard susceptibility varied widely. In 47 cases (52.8%), the physician should have changed to a narrower spectrum but did not, in 18 cases (20.2%), the physician correctly narrowed from appropriate broad coverage, and in 8 cases (9.0%), the empiric therapy was correct. Discussion. Because inoculum is not standardized, direct susceptibility results do not agree with standard susceptibility results for all drugs. Physicians do not act on direct susceptibility results. Conclusion. Direct susceptibility should be discontinued in clinical microbiology laboratories. PMID:27366172

  12. P2Y12 Inhibitor Pre-Treatment in Non-ST-Elevation Acute Coronary Syndrome: A Decision-Analytic Model

    PubMed Central

    Gunton, James; Hartshorne, Trent; Langrish, Jeremy; Chuang, Anthony; Chew, Derek

    2016-01-01

    Current guidelines recommend initiation of a P2Y12 inhibitor for all patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) at the time of diagnosis (pre-treatment); however, there are no randomized trials directly comparing pre-treatment with initiation at the time of angiography to support this practice. We explore clinical and institutional parameters potentially associated with benefit with this strategy in a decision-analytic model based on available evidence from randomised trials. A decision analysis model was constructed comparing three P2Y12 inhibitors in addition to aspirin in patients with NSTE-ACS. Based on clinical trial data, the cumulative probability of 30 day mortality, myocardial infarction (MI) and major bleeding were determined, and used to calculate the net clinical benefit (NCB) with and without pre-treatment. Sensitivity analysis was performed to assess the relationship between NCB and baseline ischemic risk, bleeding risk, time to angiography and local surgical revascularization rates. Pre-treatment with ticagrelor and clopidogrel was associated with a greater than 50% likelihood of providing a >1% increase in 30 day NCB when baseline estimated ischemic risk exceeds 11% and 14%, respectively. Prasugrel pre-treatment did not achieve a greater than 50% probability of an increase in NCB regardless of baseline ischemic risk. Institutional surgical revascularization rates and time to coronary angiography did not correlate with the likelihood of benefit from P2Y12 pre-treatment. In conclusion, pre-treatment with P2Y12 inhibition is unlikely to be beneficial to the majority of patients presenting with NSTE-ACS. A tailored assessment of each patient’s individual ischemic and bleeding risk may identify those likely to benefit. PMID:27548237

  13. P2Y12 Inhibitor Pre-Treatment in Non-ST-Elevation Acute Coronary Syndrome: A Decision-Analytic Model.

    PubMed

    Gunton, James; Hartshorne, Trent; Langrish, Jeremy; Chuang, Anthony; Chew, Derek

    2016-01-01

    Current guidelines recommend initiation of a P2Y12 inhibitor for all patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) at the time of diagnosis (pre-treatment); however, there are no randomized trials directly comparing pre-treatment with initiation at the time of angiography to support this practice. We explore clinical and institutional parameters potentially associated with benefit with this strategy in a decision-analytic model based on available evidence from randomised trials. A decision analysis model was constructed comparing three P2Y12 inhibitors in addition to aspirin in patients with NSTE-ACS. Based on clinical trial data, the cumulative probability of 30 day mortality, myocardial infarction (MI) and major bleeding were determined, and used to calculate the net clinical benefit (NCB) with and without pre-treatment. Sensitivity analysis was performed to assess the relationship between NCB and baseline ischemic risk, bleeding risk, time to angiography and local surgical revascularization rates. Pre-treatment with ticagrelor and clopidogrel was associated with a greater than 50% likelihood of providing a >1% increase in 30 day NCB when baseline estimated ischemic risk exceeds 11% and 14%, respectively. Prasugrel pre-treatment did not achieve a greater than 50% probability of an increase in NCB regardless of baseline ischemic risk. Institutional surgical revascularization rates and time to coronary angiography did not correlate with the likelihood of benefit from P2Y12 pre-treatment. In conclusion, pre-treatment with P2Y12 inhibition is unlikely to be beneficial to the majority of patients presenting with NSTE-ACS. A tailored assessment of each patient's individual ischemic and bleeding risk may identify those likely to benefit. PMID:27548237

  14. Assessing the usage of a guideline-driven interactive case simulation tool for insomnia screening and treatment in an HIV clinical education program.

    PubMed

    Le, Xuan Hung; Luque, Amneris E; Wang, Dongwen

    2013-01-01

    Interactive case simulation tools (ICSTs) are important vehicles to disseminate medical knowledge. We conducted a study to examine the usage of an insomnia screening and treatment case simulation tool in an HIV clinical education program. Using system usage diagrams (SUDs) as an instrument, we quantified visit frequency and length of stay for different types of system resources. Preliminary results have shown that both recommendations and interactive decision diagrams were frequently used, with the former having a longer length of stay but fewer visits. Case simulation functions seemed to be able to engage users. Future research is required to verify the generalizability of the identified usage patterns, to investigate issues in usability design, and to perform correlation analyses on system usage and context parameters. PMID:23920569

  15. When to stop? Decision-making when children’s cancer treatment is no longer curative: a mixed-method systematic review

    PubMed Central

    2014-01-01

    Background Children with cancer, parents, and clinicians, face difficult decisions when cure is no longer possible. Little is known about decision-making processes, how agreement is reached, or perspectives of different actors. Professionals voice concerns about managing parental expectations and beliefs, which can be contrary to their own and may change over time. We conducted the first systematic review to determine what constitutes best medico-legal practice for children under 19 years as context to exploring the perspectives of actors who make judgements and decisions when cancer treatment is no longer curative. Methods Theory-informed mixed-method thematic systematic review with theory development. Results Eight legal/ethical guidelines and 18 studies were included. Whilst there were no unresolved dilemmas, actors had different perspectives and motives. In line with guidelines, the best interests of the individual child informed decisions, although how different actors conceptualized ‘best interests’ when treatment was no longer curative varied. Respect for autonomy was understood as following child/parent preferences, which varied from case to case. Doctors generally shared information so that parents alone could make an informed decision. When parents received reliable information, and personalized interest in their child, they were more likely to achieve shared trust and clearer transition to palliation. Although under-represented in research studies, young people’s perspectives showed some differences to those of parents and professionals. For example, young people preferred to be informed even when prognosis was poor, and they had an altruistic desire to help others by participating in research. Conclusion There needs to be fresh impetus to more effectively and universally implement the ethics of professionalism into daily clinical practice in order to reinforce humanitarian attitudes. Ethical guidelines and regulations attempt to bring

  16. Influence of the treatment schedule on the physicians' decisions to refer bone metastases patients for palliative radiotherapy: a questionnaire survey of physicians in various specialties.

    PubMed

    Saito, Tetsuo; Toya, Ryo; Semba, Akiko; Matsuyama, Tomohiko; Oya, Natsuo

    2016-08-01

    We investigated whether the treatment schedule influences physicians' decisions to refer their patients for radiotherapy. We presented a questionnaire to 104 physicians in various specialties at three hospitals. It included three hypothetical patients with uncomplicated painful bone metastasis: patients with an expected life span of one year (case 1), 6 months (case 2), and 2 months (case 3). The physicians were asked whether they would refer their patients for radiotherapy when a radiation oncologist presented three different treatment schedules: a short (8 Gy/1 fraction/1 day)-, a medium (20 Gy/5 fractions/1 week)-, and a long (30 Gy/10 fractions/2 weeks) schedule. We used Cochran's Q-test to compare the percentage of physicians across the three schedules and a mixed-effect logistic model to identify predictors of the selection of only the one-day schedule. Of the 104 physicians, 68 (65%) responded. Of these, 37 (54%), 27 (40%), and 26 (38%) chose to refer patients for radiotherapy when the short-, medium-, and long schedules, respectively, were proposed in case 1 (p = 0.14). These numbers were 44 (65%), 29 (43%), and 15 (22%) for case 2 (p < 0.001), and 59 (87%), 12 (18%), and 1 (1%) for case 3 (p < 0.001). Hypothetical patient and the physicians' years of practice and perspective regarding side effects were independently predictive of the selection of only the one-day schedule. In conclusion, the treatment schedule influenced the physicians' decisions to refer patients for radiotherapy. PMID:27578911

  17. A global wave-driven magnetohydrodynamic solar model with a unified treatment of open and closed magnetic field topologies

    SciTech Connect

    Oran, R.; Van der Holst, B.; Landi, E.; Jin, M.; Sokolov, I. V.; Gombosi, T. I.

    2013-12-01

    We describe, analyze, and validate the recently developed Alfvén Wave Solar Model, a three-dimensional global model starting from the top of the chromosphere and extending into interplanetary space (out to 1-2 AU). This model solves the extended, two-temperature magnetohydrodynamics equations coupled to a wave kinetic equation for low-frequency Alfvén waves. In this picture, heating and acceleration of the plasma are due to wave dissipation and to wave pressure gradients, respectively. The dissipation process is described by a fully developed turbulent cascade of counterpropagating waves. We adopt a unified approach for calculating the wave dissipation in both open and closed magnetic field lines, allowing for a self-consistent treatment in any magnetic topology. Wave dissipation is the only heating mechanism assumed in the model; no geometric heating functions are invoked. Electron heat conduction and radiative cooling are also included. We demonstrate that the large-scale, steady state (in the corotating frame) properties of the solar environment are reproduced, using three adjustable parameters: the Poynting flux of chromospheric Alfvén waves, the perpendicular correlation length of the turbulence, and a pseudoreflection coefficient. We compare model results for Carrington rotation 2063 (2007 November-December) with remote observations in the extreme-ultraviolet and X-ray ranges from the Solar Terrestrial Relations Observatory, Solar and Heliospheric Observatory, and Hinode spacecraft and with in situ measurements by Ulysses. The results are in good agreement with observations. This is the first global simulation that is simultaneously consistent with observations of both the thermal structure of the lower corona and the wind structure beyond Earth's orbit.

  18. The use of comparative effectiveness research to inform policy decisions on the inclusion of bevacizumab for the treatment of macular diseases in Thailand’s pharmaceutical benefit package

    PubMed Central

    Anothaisintawee, Thunyarat; Leelahavarong, Pattara; Ratanapakorn, Tanapat; Teerawattananon, Yot

    2012-01-01

    There is increasing impetus to use pharmaceutical interventions, ie, ranibizumab or bevacizumab, for the treatment of particular macular diseases. This paper describes the evidence and decision-making of the National List of Essential Medicines Committee that recently announced the inclusion of bevacizumab for the treatment of macular diseases in its pharmaceutical benefit package. The findings of a systematic review and meta-analysis in this paper indicate that the intravitreal administration of bevacizumab is superior to nonpharmaceutical treatments for age-related macular degeneration (AMD) and diabetic macular edema (DME), but inconclusive for retinal vein occlusion, given the limited evidence. The study also failed to distinguish among the differences in terms of visual acuity improvement, reduction of central macular thickness, and response to treatment between AMD and DME patients treated with bevacizumab and those treated with ranibizumab. Although bevacizumab was not licensed for AMD and DME, the committee decided to include bevacizumab in the National List of Essential Medicines. It is expected that many patients who are in need of treatment but who are unable to afford the expensive alternative drug, ranibizumab, will be able to receive this effective treatment instead and be prevented from suffering irreversible loss of vision. At the same time, this policy will help generate evidence about the real-life effectiveness and safety profiles of the drug for future policy development in Thailand and other settings. PMID:23248574

  19. Power is only skin deep: an institutional ethnography of nurse-driven outpatient psoriasis treatment in the era of clinic web sites.

    PubMed

    Winkelman, Warren J; Halifax, Nancy V Davis

    2007-04-01

    We present an institutional ethnography of hospital-based psoriasis day treatment in the context of evaluating readiness to supplement services and support with a new web site. Through observation, interviews and a critical consideration of documents, forms and other textually-mediated discourses in the day-to-day work of nurses and physicians, we come to understand how the historical gender-determined power structure of nurses and physicians impacts nurses' work. On the one hand, nurses' work can have certain social benefits that would usually be considered untenable in traditional healthcare: nurses as primary decision-makers, nurses as experts in the treatment of disease, physicians as secondary consultants, and patients as co-facilitators in care delivery processes. However, benefits seem to have come at the nurses' expense, as they are required to maintain a cloak of invisibility for themselves and for their workplace, so that the Centre appears like all other outpatient clinics, and the nurses do not enjoy appropriate economic recognition. Implications for this negotiated invisibility on the implementation of new information systems in healthcare are discussed. PMID:17489506

  20. How do economic evaluations inform health policy decisions for treatment and prevention in Canada and the United States?

    PubMed

    Husereau, Don; Culyer, Anthony J; Neumann, Peter; Jacobs, Philip

    2015-06-01

    Canadian and US health systems have often been characterized as having vastly different approaches to the financing and delivery of healthcare, with Canada portrayed as more reliant on rationing based on costs. In this article, we examine the similarities and differences between the two countries, the evolution and current role of health economic evaluation, and the roles played by health economists. We suggest both countries have similarly used economic evaluation to a limited extent for drug and immunization decisions, with variability in use more of a reflection of the incompleteness of both systems and their inherent institutional barriers rather than political ideology. PMID:25316309

  1. Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis B in the UK: systematic review and economic evaluation.

    PubMed

    Crossan, C; Tsochatzis, E A; Longworth, L; Gurusamy, K; Papastergiou, V; Thalassinos, E; Mantzoukis, K; Rodriguez-Peralvarez, M; O'Brien, J; Noel-Storr, A; Papatheodoridis, G V; Davidson, B; Burroughs, A K

    2016-02-01

    We compared the cost-effectiveness of various noninvasive tests (NITs) in patients with chronic hepatitis B and elevated transaminases and/or viral load who would normally undergo liver biopsy to inform treatment decisions. We searched various databases until April 2012. We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes quality-adjusted-life-years (QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four decision-making strategies: testing with NITs and treating patients with fibrosis stage ≥F2, testing with liver biopsy and treating patients with ≥F2, treat none (watchful waiting) and treat all irrespective of fibrosis. Treating all patients without prior fibrosis assessment had an incremental cost-effectiveness ratio (ICER) of £28,137 per additional QALY gained for HBeAg-negative patients. For HBeAg-positive patients, using Fibroscan was the most cost-effective option with an ICER of £23,345. The base case results remained robust in the majority of sensitivity analyses, but were sensitive to changes in the ≥ F2 prevalence and the benefit of treatment in patients with F0-F1. For HBeAg-negative patients, strategies excluding NITs were the most cost-effective: treating all patients regardless of fibrosis level if the high cost-effectiveness threshold of £30,000 is accepted; watchful waiting if not. For HBeAg-positive patients, using Fibroscan to identify and treat those with ≥F2 was the most cost-effective option. PMID:26444996

  2. How do women trade-off benefits and risks in chemotherapy treatment decisions based on gene expression profiling for early-stage breast cancer? A discrete choice experiment

    PubMed Central

    Marshall, Deborah A; Deal, Ken; Bombard, Yvonne; Leighl, Natasha; MacDonald, Karen V; Trudeau, Maureen

    2016-01-01

    Objectives Gene expression profiling (GEP) of tumours informs baseline risk prediction, potentially affecting adjuvant chemotherapy decisions for women with early-stage breast cancer. Since only 15% will experience a recurrence, concerns have been raised about potential harms from overtreatment and high GEP costs in publicly funded healthcare systems. We aimed to estimate preferences and personal utility of GEP testing information and benefit–risk trade-offs in chemotherapy treatment decisions. Design, setting and intervention Based on literature review and findings from our qualitative research (focus groups, interviews with patients with breast cancer and medical oncologists), we developed a discrete choice experiment (DCE) survey and administered it via an internet panel. The DCE included 12 choice tasks with 5 attributes and 3 alternatives considering orthogonality, D-efficiency and level balance. Participants The DCE survey was administered to 1004 Canadian women from the general population. Main outcome measures Preferences were analysed using conditional logit and hierarchical Bayes and evaluated for goodness of fit. We conducted simulation analyses for alternative scenarios. Results GEP test score indicating likely benefit from chemotherapy was the most important attribute. Doctor's clinical estimate of the risk of cancer returning, trust in your cancer doctor and side effects of chemotherapy (temporary and permanent) were relatively less important but showed significant differences among levels. In the scenario analyses, 78% were likely to choose chemotherapy in a high-risk scenario, 55% in a moderate-risk scenario and 33% in a low-risk scenario, with the other attributes held constant. A high GEP score was more important in influencing the choice of chemotherapy for those at intermediate clinical risk. Conclusions GEP testing information influences chemotherapy treatment decisions in early-stage breast cancer and varies depending on clinical risk

  3. Frailty Markers and Treatment Decisions in Patients Seen in Oncogeriatric Clinics: Results from the ASRO Pilot Study

    PubMed Central

    de Decker, Laure; Pauly, Vanessa; Rousseau, Frédérique; Bergman, Howard; Molines, Catherine

    2016-01-01

    Background Comprehensive Geriatric Assessment (CGA) is the gold standard to help oncologists select the best cancer treatment for their older patients. Some authors have suggested that the concept of frailty could be a more useful approach in this population. We investigated whether frailty markers are associated with treatment recommendations in an oncogeriatric clinic. Methods This prospective study included 70 years and older patients with solid tumors and referred for an oncogeriatric assessment. The CGA included nine domains: autonomy, comorbidities, medication, cognition, nutrition, mood, neurosensory deficits, falls, and social status. Five frailty markers were assessed (nutrition, physical activity, energy, mobility, and strength). Patients were categorized as Frail (three or more frailty markers), pre-frail (one or two frailty markers), or not-frail (no frailty marker). Treatment recommendations were classified into two categories: standard treatment with and without any changes and supportive/palliative care. Multiple logistic regression models were used to analyze factors associated with treatment recommendations. Results 217 patients, mean age 83 years (± Standard deviation (SD) 5.3), were included. In the univariate analysis, number of frailty markers, grip strength, physical activity, mobility, nutrition, energy, autonomy, depression, Eastern Cooperative Oncology Group Scale of Performance Status (ECOG-PS), and falls were significantly associated with final treatment recommendations. In the multivariate analysis, the number of frailty markers and basic Activities of Daily Living (ADL) were significantly associated with final treatment recommendations (p<0.001 and p = 0.010, respectively). Conclusion Frailty markers are associated with final treatment recommendations in older cancer patients. Longitudinal studies are warranted to better determine their use in a geriatric oncology setting. PMID:26918947

  4. Characteristics of elderly patients with COPD and newly diagnosed lung cancer, and factors associated with treatment decision

    PubMed Central

    Qin, Jianwen; Li, Guangsheng; Zhou, Jingmin

    2016-01-01

    Objective To investigate the clinical features, diagnosis, and treatment status of elderly patients with chronic obstructive pulmonary disease (COPD) complicated with lung cancer. Patients and methods This was a retrospective study of 206 patients aged >60 years with COPD and newly diagnosed lung cancer at the Tianjin Chest Hospital Respiratory Centre between September 2008 and September 2013. Lung function, radiology, and clinical data were retrieved. Results Among all patients, 57% (117/206) were hospitalized due to acute COPD aggravation, 47% (96/206) had COPD grade III or IV, 95% (195/206), showed diffusion dysfunction in pulmonary function examination, 90% (185/206) had a history of smoking, and 26% (54/206) were treated with inhaled corticosteroids for COPD treatment. Ninety-eight patients suffered from squamous carcinoma, 73 from adenocarcinoma, and 35 from small-cell carcinoma. Clinical staging was I in 36 patients, II in 47 patients, III in 78 patients, and IV in 45 patients. Initial treatments were surgery in 59 patients, chemotherapy in 30 patients, and no treatment in 117 patients. Multivariate analysis showed that age (P<0.001), COPD grades (P=0.01), clinical staging (P<0.001), and pulmonary diffusion function (P=0.007) were independent factors associated with patients with COPD being given treatments for lung cancer. Conclusion Younger patients with lower COPD grades, earlier lung cancer stage, and better pulmonary diffusion function are more likely to receive treatments. PMID:27445471

  5. Chemotherapy treatment decision making by professionals and older patients with cancer: a narrative review of the literature.

    PubMed

    Johnson, M

    2012-01-01

    This narrative review of the literature examines the issues influencing chemotherapy treatment of older patients with cancer. Increasing age is associated with physical, social and psychological changes, but the rate of change differs widely between people, such that chronological age is not a good determinant of fitness for treatment. Changes in old age can affect disease processes and treatments that are offered. Clinical trials suggest that older patients gain benefits from chemotherapy, but with increased toxicity profile. Dose reductions may be required, but the effect on outcome is not known. Adjuvant chemotherapy is likely to benefit patients with a life expectancy over 5 years, although mortality benefits become less pronounced with increasing age. Older patients want chemotherapy, as long as side effects do not reduce quality of life or ability to function independently. Older patients face barriers to communication with professionals, including sensory and memory problems and poorer health literacy. Patients should be assessed covering functional, physiological and socio-economic domains that identify significant comorbid disease and frailty, to ensure that planned chemotherapy is appropriate. Successful treatment of older patients with chemotherapy may require interventions to support them to ensure all patients who may derive benefit can undergo treatment, if they so wish. PMID:21955060

  6. Influence of the treatment schedule on the physicians’ decisions to refer bone metastases patients for palliative radiotherapy: a questionnaire survey of physicians in various specialties

    PubMed Central

    Saito, Tetsuo; Toya, Ryo; Semba, Akiko; Matsuyama, Tomohiko; Oya, Natsuo

    2016-01-01

    ABSTRACT We investigated whether the treatment schedule influences physicians’ decisions to refer their patients for radiotherapy. We presented a questionnaire to 104 physicians in various specialties at three hospitals. It included three hypothetical patients with uncomplicated painful bone metastasis: patients with an expected life span of one year (case 1), 6 months (case 2), and 2 months (case 3). The physicians were asked whether they would refer their patients for radiotherapy when a radiation oncologist presented three different treatment schedules: a short (8 Gy/1 fraction/1 day)-, a medium (20 Gy/5 fractions/1 week)-, and a long (30 Gy/10 fractions/2 weeks) schedule. We used Cochran’s Q-test to compare the percentage of physicians across the three schedules and a mixed-effect logistic model to identify predictors of the selection of only the one-day schedule. Of the 104 physicians, 68 (65%) responded. Of these, 37 (54%), 27 (40%), and 26 (38%) chose to refer patients for radiotherapy when the short-, medium-, and long schedules, respectively, were proposed in case 1 (p = 0.14). These numbers were 44 (65%), 29 (43%), and 15 (22%) for case 2 (p < 0.001), and 59 (87%), 12 (18%), and 1 (1%) for case 3 (p < 0.001). Hypothetical patient and the physicians’ years of practice and perspective regarding side effects were independently predictive of the selection of only the one-day schedule. In conclusion, the treatment schedule influenced the physicians’ decisions to refer patients for radiotherapy. PMID:27578911

  7. Role of the Gender-Linked Norm of Toughness in the Decision to Engage in Treatment for Depression

    PubMed Central

    O’Loughlin, Ryan E.; Duberstein, Paul R.; Veazie, Peter J.; Bell, Robert A.; Rochlen, Aaron B.; Fernandez y Garcia, Erik; Kravitz, Richard L.

    2011-01-01

    Objective Given their prevalence and persuasive power in our culture, gender norms— commonly described as socially reinforced, learned expectations of what it means to be a man or a woman—likely contribute to sex differences in service utilization for depression. This study investigated whether sex differences in toughness, a gender-linked norm characterized by a desire to hide pain and maintain independence, were associated with a preference to wait for depression to resolve on its own without active professional treatment (``wait-and-see” approach). Methods Participants (N=1,051) in the California Behavioral Risk Factor Surveillance System (BRFSS) survey were contacted in a follow-on survey to assess toughness, the kind of treatment they would prefer were they to receive a diagnosis of depression, and current symptoms of depression. Participants who reported ever having been diagnosed as having a depressive disorder on the BRFSS were oversampled threefold. Analyses were conducted using linear and logistic regressions. Results Men and women who scored higher on toughness had a greater preference for the wait-and-see approach (OR=1.14, p<.01). Women were less likely to prefer the wait-and-see approach (OR=.58, p<.04) and scored lower on toughness (B=−.70, p<.01). Men’s greater levels of toughness partially mediated the sex difference in treatment preferences (OR=.91, p<.05). Conclusions Men’s greater adherence to the toughness norm explained part of the sex difference observed in treatment-seeking preferences, but toughness undermined women’s treatment seeking as well. Findings could be used to inform novel public health communications intended to attract both men and women to psychiatric services. PMID:21724786

  8. Ethical decisions in dental treatment planning using the Ozar model: a descriptive study of fifty-two consecutive patients.

    PubMed

    Schuman, N J; Turner, J E

    1997-01-01

    Chairside dental ethics necessitates special consideration by the faculty member-dentist, the dental student, and the patient. The patient must always be aware of treatment options, in addition to learning the health status of the oral hard and soft tissues, costs, and time to be involved to accomplish proposed treatment. What may seem like a burden to an individual practitioner is actually only the necessities incurred by any self governing profession. Fifty-two consecutive dental patients had their cases reviewed for the ethical behavior of the dentist-practitioner, student, and patient. Categories reviewed were informed consent (100%), agreement, compromise, economic issues, conflict, and institutional issues. The results were: 1. Agreement: 17 cases, 2. Compromise: 21 cases, 3. Economic Issues: 4 cases, 4. Conflict: 6 cases, and 5. Institutional Issues: 4 cases. Fourteen percent of all patients were minors. Ninety percent of the patients were treated. Of those 10% not treated, five percent were for medical reasons, and five percent of the patients refused treatment. These results were placed in the Ozar Model 9 and were categorized as follows: 1. Appropriate pain free oral function: 22 cases, 2. Patient Autonomy: 14 cases, 3. Life and health: 9 cases, 4. Preferred practice values: 6 cases, and 5. Other external considerations: 1 case. This template demonstrated appropriate ethical behavior on the part of dentists, students, and patients, especially with a 90% treatment group, and only 5% refusing treatment. The 52 consecutive patients were characteristic of the University of Tennessee's overall patient pool. No identifiable differences were found between patients regardless of gender, age, or race. PMID:9484127

  9. Bacillus Calmette-Guérin (BCG) Treatment Failures with Non-Muscle Invasive Bladder Cancer: A Data-Driven Definition for BCG Unresponsive Disease

    PubMed Central

    Steinberg, Ryan L.; Thomas, Lewis J.; Mott, Sarah L.; O’Donnell, Michael A.

    2016-01-01

    Objective: To create the first data-driven definition for those unlikely to benefit from further BCG treatment. Materials and Methods: The database created for the Phase 2 BCG-Interferon-α 2B (IFN) study was queried and BCG failure patients were identified (n = 334). Full study protocols have previously been published. Separate models were constructed for analysis of patients with any CIS (pure or concomitant) and pure papillary disease. Variables considered included age, gender, stage, grade, tumor size and focality (for papillary only), number of prior BCG courses, and prior BCG failure interval. Results: Patients with recurrent CIS within 6 months of their most recent prior BCG course (HR 2.56, p <  0.01) and ≥2 prior BCG failures (HR 1.54, p <  0.01) responded worst to repeat intravesical therapy. Those with CIS recurrence at 6–12 months did not differ from those recurring within 6 months (HR = 0.88, p = 0.71). Patients with recurrent papillary disease within 6 months (HR 1.82, p = 0.02), ≥2 BCG failures (HR 1.54, p = 0.03), and multifocal disease (HR 2.05, p <  0.01) responded worst to therapy. Patients with T1 disease remained disease free in 38% of cases (24–51% 95% CI) at 2 years with low rates of progression. Conclusions: Patients who fail two courses of BCG with either persistent or recurrent multifocal papillary disease within 6 months or CIS within 12 months of their prior BCG should be considered BCG unresponsive. Recurrent T1 disease respond reasonably well to another course with low progression rates but further investigation is warranted. PMID:27376140

  10. Effect of a clinical decision support system on early action on immunological treatment failure in patients with HIV in Kenya: a cluster randomised controlled trial

    PubMed Central

    Oluoch, Tom; Katana, Abraham; Kwaro, Daniel; Santas, Xenophon; Langat, Patrick; Mwalili, Samuel; Muthusi, Kimeu; Okeyo, Nicky; Ojwang, James K; Cornet, Ronald; Abu-Hanna, Ameen; de Keizer, Nicolette

    2016-01-01

    Summary Background A clinical decision support system (CDSS) is a computer program that applies a set of rules to data stored in electronic health records to offer actionable recommendations. We aimed to establish whether a CDSS that supports detection of immunological treatment failure among patients with HIV taking antiretroviral therapy (ART) would improve appropriate and timely action. Methods We did this prospective, cluster randomised controlled trial in adults and children (aged ≥18 months) who were eligible for, and receiving, ART at HIV clinics in Siaya County, western Kenya. Health facilities were randomly assigned (1:1), via block randomisation (block size of two) with a computer-generated random number sequence, to use electronic health records either alone (control) or with CDSS (intervention). Facilities were matched by type and by number of patients enrolled in HIV care. The primary outcome measure was the difference between groups in the proportion of patients who experienced immunological treatment failure and had a documented clinical action. We used generalised linear mixed models with random effects to analyse clustered data. This trial is registered with ClinicalTrials.gov, number NCT01634802. Findings Between Sept 1, 2012, and Jan 31, 2014, 13 clinics, comprising 41 062 patients, were randomly assigned to the control group (n=6) or the intervention group (n=7). Data collection at each site took 12 months. Among patients eligible for ART, 10 358 (99%) of 10 478 patients were receiving ART at control sites and 10 991 (99%) of 11 028 patients were receiving ART at intervention sites. Of these patients, 1125 (11%) in the control group and 1342 (12%) in the intervention group had immunological treatment failure, of whom 332 (30%) and 727 (54%), respectively, received appropriate action. The likelihood of clinicians taking appropriate action on treatment failure was higher with CDSS alerts than with no decision support system (adjusted odds ratio

  11. Shared decision-making in metastatic breast cancer: discrepancy between the expected prolongation of life and treatment efficacy between patients and physicians, and influencing factors.

    PubMed

    Lux, Michael P; Bayer, Christian M; Loehberg, Christian R; Fasching, Peter A; Schrauder, Michael G; Bani, Mayada R; Häberle, Lothar; Engel, Anne; Heusinger, Katharina; Tänzer, Thorsten; Radosavac, Dragan; Scharl, Anton; Bauerfeind, Ingo; Gesslein, Judith; Schulte, Hilde; Overbeck-Schulte, Brigitte; Beckmann, Matthias W; Hein, Alexander

    2013-06-01

    Treatment decisions in oncology are based on a balance between the efficacy of therapy and its side effects. Patients with metastases and patients with a limited prognosis are a particular challenge, since communication about the disease situation and the expected therapeutic benefit is difficult not only for patients, but also for physicians. The aim of this study was therefore to compare the benefits expected of therapy by patients and physicians. Questionnaires were sent to 9,000 breast cancer patients and to 6,938 physicians. The questionnaires described 10 cases of breast cancer in the metastatic setting. The patients and physicians were asked to state the treatment benefit they would require to decide for the therapy options chemotherapy, endocrine therapy, antibody therapy, radiotherapy, and bisphosphonates. Additionally, the participants provided data on patient and physician characteristics. Expected treatment benefits were compared between patients and physicians, and influencing factors that modified the expected benefit were identified. Patients expected much greater benefits from the therapies offered than the physicians. For all treatment modalities, about 50 % or more of patients expected more than a 12-month increase in overall survival from all therapies. Among the doctors, this proportion ranged from 7 to 30 %. Among patients, previous experience of side effects and having young children in the family were the strongest influencing factors. Among the doctors, age and level of education had a strong influence on the expected prognostic improvement to indicate a therapy option. As expectations of treatment differ greatly between patients and doctors, a structured approach to solving this conflict is required. There appear to be some indicators that might help address the problem, such as the physicians' level of training and experience and the patients' specific social circumstances. PMID:23670130

  12. Treatment of Chronic Hepatitis C in the Aged – Does It Impact Life Expectancy? A Decision Analysis

    PubMed Central

    Maor, Yaakov; Malnick, Stephen D. H.; Melzer, Ehud; Leshno, Moshe

    2016-01-01

    Background and Aims Recent studies have demonstrated that the efficacy of interferon-free direct-acting antiviral agents (DAAs) in patients over 70 is similar to that of younger age groups. Evidence continues to mount that life expectancy (LE) increases with successful treatment of hepatitis C (HCV) patients with advanced fibrosis. The evidence in older people is more limited. Our aim was to estimate the life year (LY) and quality-adjusted life year (QALY) gained by treatment of naïve patients with HCV as a function of patient's age and fibrosis stage. Methods We constructed a Markov model of HCV progression toward advanced liver disease. The primary outcome was LY and QALY saved. The model and the sustained virological response of HCV infected subjects treated with a fixed-dose combination of the NS5B polymerase inhibitor Sofosbuvir and the NS5A replication complex inhibitor Ledipasvir were based on the published literature and expert opinion. Results Generally, both the number of LY gained and QALY gained gradually decreased with advancing age but the rate of decline was slower with more advanced fibrosis stage. For patients with fibrosis stage F1, F2 and F3, LY gained dropped below six months if treated by the age of 55, 65 or 70 years, respectively, while for a patient with fibrosis stage F4, the gain was one LY if treated by the age of 75. The QALY gained for treated over untreated elderly were reasonably high even for those treated at early fibrosis stage. Conclusions There is a significant life expectancy benefit to HCV treatment in patients up to age 75 with advanced-stage fibrosis. PMID:27410963

  13. From consumerism to active dependence: Patterns of medicines use and treatment decisions among patients with atopic dermatitis.

    PubMed

    Nørreslet, M; Bissell, P; Traulsen, J M

    2010-01-01

    In this article, findings from in-depth interviews with 12 people diagnosed with atopic dermatitis (AD) are described. The findings describe the range of strategies used to manage atopic dermatitis, including use of conventional medicines. A strong theme identified in informants' accounts centred on concerns about the risks of illness and long-term use of conventional medicines, which acted as a strong incentive for patients to seek alternatives to conventional treatments. However, despite their significant efforts to do so, patients were eventually forced to return to and rely on conventional medicines because of their efficacy in alleviating and treating symptoms. These findings are discussed in relation to the sociological literature on consumerism, risk and reflexivity in health. We argue that our findings exemplify how living with and managing a chronic illness may not be straightforward and the choices of treatment at hand may be limited. Consequently, this may limit the potential opportunities accruing from adopting a reflexive or consumerist approach to managing illness. PMID:20051432

  14. Impact of a nurse navigator on genomic testing and timely treatment decision making in patients with breast cancer.

    PubMed

    McAllister, Kelly A; Schmitt, Mary L

    2015-10-01

    The purpose of this quality improvement project was to define best practices for identifying appropriate patients for genomic testing and improve timeliness for ordering tests and reporting results. An interdisciplinary team of surgeons, radiologists, medical oncologists, and nurses agreed that the RN navigator would be the key person to facilitate timely access to genomic profiling. AT A GLANCE: Genomic profiling has become the standard of care for patients with early-stage breast cancer to assist in developing individualized treatment plans. Nurse navigators can play a key role in improving timeliness of care. The APN-RN model led to improvements in turnaround time and complicance with the National Comprehensive Cancer Network's recommendations for genomic testing. PMID:26414569

  15. [Treatment errors involving diagnosis using prostate specific antigen. Decisions of the commission of experts for medical mistakes of treatment of the state medical board of North Rhine].

    PubMed

    Lent, V; Baumbusch, F; Weber, G

    2005-12-01

    Advances in prostate specific antigen (PSA) diagnosis are accompanied by deficits in realization. The justification of claims by affected patients against their doctors are reviewed by commissions of experts and mediation by medical councils out of court, impartial and free of charge. The objectivity of the review is ensured by the independence of the commission and its members as well as the determination of facts and their assessment. Criteria are professional standards and required care. Since 1995, 21 requests by affected patients have been reviewed. In 15 cases (71.4%), treatment errors were ascertained. This involved either a delayed or an insufficient diagnosis (prostatic biopsy). In ten of the patients, a mostly early prostate cancer would have be diagnosed and treated at the time of the first finding of PSA values between 3.3 and 10.4 ng/ml. In ten of 13 patients, the tumor was diagnosed late, having PSA values between 6.8 and 1251 ng/ml with no chance of curative therapy. As in other life threatening diseases, time of recognition is most important for the diagnosis and treatment of patients with prostate cancer. Particularly for early recognition, PSA is much more sensitive then digital rectal examination, and in cases without a digital finding is the only parameter for early diagnoses. In men with suspicious PSA values (>4.0 ng/ml) suitable a diagnostic test (prostate biopsy) is required early, until cancer is detected or excluded. PMID:16142454

  16. Decisions and desire.

    PubMed

    Morse, Gardiner

    2006-01-01

    When we make decisions, we're not always in charge. One moment we hotheadedly let our emotions get the better of us; the next, we're paralyzed by uncertainty. Then we'll pull a brilliant decision out of thin air--and wonder how we did it. Though we may have no idea how decision making happens, neuroscientists peering deep into our brains are beginning to get the picture. What they're finding may not be what you want to hear, but it's worth listening. We have dog brains, basically, with human cortexes stuck on top. By watching the brain in action as it deliberates and decides, neuroscientists are finding that not a second goes by that our animal brains aren't conferring with our modern cortexes to influence their choices. Scientists have discovered, for example, that the "reward" circuits in the brain that activate in response to cocaine, chocolate, sex, and music also find pleasure in the mere anticipation of making money--or getting revenge. And the "aversion" circuits that react to the threat of physical pain also respond with disgust when we feel cheated by a partner. In this article, HBR senior editor Gardiner Morse describes the experiments that illuminate the aggressive participation of our emotion-driven animal brains in decision making. This research also shows that our emotional brains needn't always operate beneath our radar. While our dog brains sometimes hijack our higher cognitive functions to drive bad, or at least illogical, decisions, they play an important part in rational decision making as well. The more we understand about how we make decisions, the better we can manage them. PMID:16447368

  17. Construction of a technique plan repository and evaluation system based on AHP group decision-making for emergency treatment and disposal in chemical pollution accidents.

    PubMed

    Shi, Shenggang; Cao, Jingcan; Feng, Li; Liang, Wenyan; Zhang, Liqiu

    2014-07-15

    The environmental pollution resulting from chemical accidents has caused increasingly serious concerns. Therefore, it is very important to be able to determine in advance the appropriate emergency treatment and disposal technology for different types of chemical accidents. However, the formulation of an emergency plan for chemical pollution accidents is considerably difficult due to the substantial uncertainty and complexity of such accidents. This paper explains how the event tree method was used to create 54 different scenarios for chemical pollution accidents, based on the polluted medium, dangerous characteristics and properties of chemicals involved. For each type of chemical accident, feasible emergency treatment and disposal technology schemes were established, considering the areas of pollution source control, pollutant non-proliferation, contaminant elimination and waste disposal. Meanwhile, in order to obtain the optimum emergency disposal technology schemes as soon as the chemical pollution accident occurs from the plan repository, the technique evaluation index system was developed based on group decision-improved analytical hierarchy process (AHP), and has been tested by using a sudden aniline pollution accident that occurred in a river in December 2012. PMID:24887122

  18. A pilot study to evaluate the role of the Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in clinical decisions for pressure ulcer treatment.

    PubMed

    Thomason, Susan S; Graves, Barbara Ann; Madaris, Linda

    2014-12-01

    The Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) was designed to assess pressure ulcer (PrU) healing in the spinal cord impaired (SCI) population. The tool contains 7 variables: wound surface area, depth, edges, tunneling, undermining, exudate type, and necrotic tissue amount. A 2-phased, quantitative pilot study based on the Theory of Reasoned Action and Theory of Planned Behavior was conducted at a large SCI/Disorders Center in the Department of Veterans Affairs (VA). In the first phase of the study, a convenience sample of 5 physicians, 3 advanced practice registered nurses, and 3 certified wound care nurses (CWCN) was surveyed using a 2-part questionnaire to assess use of the SCI-PUMT instrument, its anticipated improvement in PrU assessment, and intent to use the SCI-PUMT in clinical practice. Attitudes, subjective norms, perceived behavioral controls, and barriers related to the intent to use the SCI-PUMT were evaluated using a 5-point Likert scale (range: 1= extremely likely, 5 = extremely unlikely). In the second phase of the study, the electronic health records (EHR) of 24 veterans (with 30 PrUs) who had at least 2 completed SCI-PUMT scores during a 4-week period were used to evaluate whether an association existed between magnitudes of change of total SCI-PUMT scores and ordered changes in PrU treatment. The overall mean score for intent to use SCI-PUMT was 1.80 (SD 0.75). The least favorable scores were for convenience and motivation to use the SCI-PUMT. Analysis of EHR data showed no significant difference in magnitudes of change in the SCI-PUMT score and changes in PrU treatment recommendations made by the CWCNs. The significance was not affected regardless of an increase or no change in the score (χ2 with 1 degree of freedom = 1.158, P = 0.282) or for a decrease in the score (χ2 with 1 degree of freedom = 0.5, P = 0.478). In this pilot study, the expressed intent to use the SCI-PUMT in making clinical decisions was generally

  19. Perceptions of Radiation Oncologists and Urologists on Sources and Type of Evidence to Inform Prostate Cancer Treatment Decisions

    SciTech Connect

    Han, Leona C.; Delpe, Sophia; Shah, Nilay D.; Ziegenfuss, Jeanette Y.; Tilburt, Jon C.; Karnes, R. Jeffrey; Nguyen, Paul L.; Gross, Cary P.; Yu, James B.; Trinh, Quoc-Dien; Sun, Maxine; Ranasinghe, Weranja K.B.; Kim, Simon P.

    2014-06-01

    Purpose: To perform a national survey of radiation oncologists and urologists about the type of resources used and the level of evidence needed to change clinical practice in localized prostate cancer. Methods and Materials: From a random sample, 1422 physicians were mailed a survey assessing the types of information used and what level of evidence could alter their clinical practice in prostate cancer. Multivariable logistic regression models were used to identify differences in physician characteristics for each outcome. Results: Survey response rates were similar for radiation oncologists and urologists (44% vs 46%; P=.46). Specialty-specific journals represented the most commonly used resource for informing the clinical practice for radiation oncologists (65%) and urologists (70%). Relative to radiation oncologists, urologists were less likely to report utilizing top-tier medical journals (25% vs 39%; adjusted odds ratio [OR] 0.50; P=.01) or cancer journals (22% vs 51%; adjusted OR 0.50; P<.001) but more likely to rely on clinical guidelines (46% vs 38%; adjusted OR 1.6; P=.006). Both radiation oncologists and urologists most commonly reported large randomized, clinical trials as the level of evidence to change treatment recommendations for localized prostate cancer (85% vs 77%; P=.009). Conclusions: Both specialties rely on their own specialty-specific journals and view randomized, clinical trials as the level of evidence needed to change clinical practice. Our study provides a context on meaningful ways of disseminating evidence for localized prostate cancer.

  20. The Potential Impact of Improving Appropriate Treatment for Fever on Malaria and Non-Malarial Febrile Illness Management in Under-5s: A Decision-Tree Modelling Approach

    PubMed Central

    Rao, V. Bhargavi; Schellenberg, David; Ghani, Azra C.

    2013-01-01

    Background As international funding for malaria programmes plateaus, limited resources must be rationally managed for malaria and non-malarial febrile illnesses (NMFI). Given widespread unnecessary treatment of NMFI with first-line antimalarial Artemisinin Combination Therapies (ACTs), our aim was to estimate the effect of health-systems factors on rates of appropriate treatment for fever and on use of ACTs. Methods A decision-tree tool was developed to investigate the impact of improving aspects of the fever care-pathway and also evaluate the impact in Tanzania of the revised WHO malaria guidelines advocating diagnostic-led management Results Model outputs using baseline parameters suggest 49% malaria cases attending a clinic would receive ACTs (95% Uncertainty Interval:40.6–59.2%) but that 44% (95% UI:35–54.8%) NMFI cases would also receive ACTs. Provision of 100% ACT stock predicted a 28.9% increase in malaria cases treated with ACT, but also an increase in overtreatment of NMFI, with 70% NMFI cases (95% UI:56.4–79.2%) projected to receive ACTs, and thus an overall 13% reduction (95% UI:5–21.6%) in correct management of febrile cases. Modelling increased availability or use of diagnostics had little effect on malaria management outputs, but may significantly reduce NMFI overtreatment. The model predicts the early rollout of revised WHO guidelines in Tanzania may have led to a 35% decrease (95% UI:31.2–39.8%) in NMFI overtreatment, but also a 19.5% reduction (95% UI:11–27.2%), in malaria cases receiving ACTs, due to a potential fourfold decrease in cases that were untested or tested false-negative (42.5% vs.8.9%) and so untreated. Discussion Modelling multi-pronged intervention strategies proved most effective to improve malaria treatment without increasing NMFI overtreatment. As malaria transmission declines, health system interventions must be guided by whether the management priority is an increase in malaria cases receiving ACTs (reducing the

  1. The effect of statutory limitations on the authority of substitute decision makers on the care of patients in the intensive care unit: case examples and review of state laws affecting withdrawing or withholding life-sustaining treatment.

    PubMed

    Venkat, Arvind; Becker, Julianna

    2014-01-01

    While the ethics and critical care literature is replete with discussion of medical futility and the ethics of end-of-life care decisions in the intensive care unit, little attention is paid to the effect of statutory limitations on the authority of substitute decision makers during the course of treatment of patients in the critical care setting. In many jurisdictions, a clear distinction is made between the authority of a health care power of attorney, who is legally designated by a competent adult to make decisions regarding withholding or withdrawing life-sustaining treatment, and of next-of-kin, who are limited in this regard. However, next-of-kin are often relied upon to consent to necessary procedures to advance a patient's medical care. When conflicts arise between critical care physicians and family members regarding projected patient outcome and functional status, these statutory limitations on decision-making authority by next of kin can cause paralysis in the medical care of severely ill patients, leading to practical and ethical impasses. In this article, we will provide case examples of how statutory limitations on substitute decision making authority for next of kin can impede the care of patients. We will also review the varying jurisdictional limitations on the authority of substitute decision makers and explore their implications for patient care in the critical care setting. Finally, we will review possible ethical and legal solutions to resolve these impasses. PMID:22257784

  2. High resolution MRI in treatment decision of anterior communicating artery aneurysm accompanied by visual symptoms: Endovascular treatment or surgical clipping? A report of two cases and literature review.

    PubMed

    Liu, Peng; Lv, Xianli; Li, Youxiang; Lv, Ming

    2016-06-01

    Anterior communicating artery (AComA) aneurysm accompanied by visual symptoms is rarely reported. The first case is an asymptomatic 65-year-old woman who presented with an AComA aneurysm, and the pre-procedure high-resolution magnetic resonance imaging (MRI) revealed an AComA aneurysm compressed the left optic nerve and the chiasma with a size of 8.3 × 9.2 mm. She suffered a sudden onset of left eye visual loss and the temporal hemianopia of the right eye after endovascular embolization. She had a light sensation of the left eye and minor enlargement of the visual field in the right eye at the six-month follow-up. The second case is a symptomatic 55-year-old woman suffering a visual loss in the left eye and inferior nasal quadrantanopsia in her right eye. Pre-operative high-resolution MRI found an AComA aneurysm compressing the left part of the chiasma with a size of 7.1 × 8.3 mm. Her visual symptoms improved after surgical clipping. High-resolution MRI could depict the anatomic relationship between the AComA aneurysm and the surrounding optic pathways. Endovascular treatment of an AComA aneurysm may result in visual deterioration due to the mass effect or ischemia after the procedure. Surgical clipping of the AComA aneurysm could relieve the compression symptoms. PMID:26809261

  3. Identification of imaging selection patterns in acute ischemic stroke patients and the influence on treatment and clinical trial enrollment decision making

    PubMed Central

    Luby, Marie; Warach, Steven J; Albers, Gregory W; Baron, Jean-Claude; Cognard, Christophe; Dávalos, Antoni; Donnan, Geoffrey A; Fiebach, Jochen B; Fiehler, Jens; Hacke, Werner; Lansberg, Maarten G; Liebeskind, David S; Mattle, Heinrich P; Oppenheim, Catherine; Schellinger, Peter D; Wardlaw, Joanna M; Wintermark, Max

    2016-01-01

    Background and Purpose The purpose of this study was to collect precise information on the typical imaging decisions given specific clinical acute stroke scenarios. Stroke centers worldwide were surveyed regarding typical imaging used to work up representative acute stroke patients, make treatment decisions, and willingness to enroll in clinical trials. Methods STroke Imaging Research and Virtual International Stroke Trials Archive-Imaging circulated an online survey of clinical case vignettes through its website, the websites of national professional societies from multiple countries as well as through email distribution lists from STroke Imaging Research and participating societies. Survey responders were asked to select the typical imaging work-up for each clinical vignette presented. Actual images were not presented to the survey responders. Instead, the survey then displayed several types of imaging findings offered by the imaging strategy, and the responders selected the appropriate therapy and whether to enroll into a clinical trial considering time from onset, clinical presentation, and imaging findings. A follow-up survey focusing on 6 h from onset was conducted after the release of the positive endovascular trials. Results We received 548 responses from 35 countries including 282 individual centers; 78% of the centers originating from Australia, Brazil, France, Germany, Spain, United Kingdom, and United States. The specific onset windows presented influenced the type of imaging work-up selected more than the clinical scenario. Magnetic Resonance Imaging usage (27–28%) was substantial, in particular for wake-up stroke. Following the release of the positive trials, selection of perfusion imaging significantly increased for imaging strategy. Conclusions Usage of vascular or perfusion imaging by Computed Tomography or Magnetic Resonance Imaging beyond just parenchymal imaging was the primary work-up (62–87%) across all clinical vignettes and time windows

  4. Decision analytic cost-effectiveness model to compare prostate cryotherapy to androgen deprivation therapy for treatment of radiation recurrent prostate cancer

    PubMed Central

    Boyd, Kathleen A; Jones, Rob J; Paul, Jim; Birrell, Fiona; Briggs, Andrew H; Leung, Hing Y

    2015-01-01

    Objective To determine the cost-effectiveness of salvage cryotherapy (SC) in men with radiation recurrent prostate cancer (RRPC). Design Cost-utility analysis using decision analytic modelling by a Markov model. Setting and methods Compared SC and androgen deprivation therapy (ADT) in a cohort of patients with RRPC (biopsy proven local recurrence, no evidence of metastatic disease). A literature review captured published data to inform the decision model, and resource use data were from the Scottish Prostate Cryotherapy Service. The model was run in monthly cycles for RRPC men, mean age of 70 years. The model was run over the patient lifetime, to assess changes in patient health states and the associated quality of life, survival and cost impacts. Results are reported in terms of the discounted incremental costs and discounted incremental quality-adjusted life years (QALYs) gained between the 2 alternative interventions. Probabilistic sensitivity analysis used a 10 000 iteration Monte Carlo simulation. Results SC has a high upfront treatment cost, but delays the ongoing monthly cost of ADT. SC is the dominant strategy over the patient lifetime; it is more effective with an incremental 0.56 QALY gain (95% CI 0.28 to 0.87), and less costly with a reduced lifetime cost of £29 719 (€37 619) (95% CI −51 985 to −9243). For a ceiling ratio of £30 000, SC has a 100% probability to be cost-effective. The cost neutral point was at 3.5 years, when the upfront cost of SC (plus any subsequent cumulative cost of side effects and ADT) equates the cumulative cost in the ADT arm. Limitations of our model may arise from its insensitivity to parameter or structural uncertainty. Conclusions The platform for SC versus ADT cost-effective analysis can be employed to evaluate other treatment modalities or strategies in RRPC. SC is the dominant strategy, costing less over a patient's lifetime with improvements in QALYs. Trial registration number This economic analysis

  5. Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests. A study protocol of a randomized controlled trial

    PubMed Central

    2012-01-01

    Background A major problem with rehabilitation interventions for neck pain is that the condition may have multiple causes, thus a single treatment approach is seldom efficient. The present study protocol outlines a single blinded randomised controlled trial evaluating the effect of tailored treatment for neck-shoulder pain. The treatment is based on a decision model guided by standardized clinical assessment and functional tests with cut-off values. Our main hypothesis is that the tailored treatment has better short, intermediate and long-term effects than either non-tailored treatment or treatment-as-usual (TAU) on pain and function. We sub-sequentially hypothesize that tailored and non-tailored treatment both have better effect than TAU. Methods/Design 120 working women with minimum six weeks of nonspecific neck-shoulder pain aged 20–65, are allocated by minimisation with the factors age, duration of pain, pain intensity and disability in to the groups tailored treatment (T), non-tailored treatment (NT) or treatment-as-usual (TAU). Treatment is given to the groups T and NT for 11 weeks (27 sessions evenly distributed). An extensive presentation of the tests and treatment decision model is provided. The main treatment components are manual therapy, cranio-cervical flexion exercise and strength training, EMG-biofeedback training, treatment for cervicogenic headache, neck motor control training. A decision algorithm based on the baseline assessment determines the treatment components given to each participant of T- and NT-groups. Primary outcome measures are physical functioning (Neck Disability Index) and average pain intensity last week (Numeric Rating Scale). Secondary outcomes are general improvement (Patient Global Impression of Change scale), symptoms (Profile Fitness Mapping neck questionnaire), capacity to work in the last 6 weeks (quality and quantity) and pressure pain threshold of m. trapezius. Primary and secondary outcomes will be reported for

  6. A unified framework for addiction: Vulnerabilities in the decision process

    PubMed Central

    Redish, A. David; Jensen, Steve; Johnson, Adam

    2013-01-01

    The understanding of decision-making systems has come together in recent years to form a unified theory of decision-making in the mammalian brain as arising from multiple, interacting systems (a planning system, a habit system, and a situation-recognition system). This unified decision-making system has multiple potential access points through which it can be driven to make maladaptive choices, particularly choices that entail seeking of certain drugs or behaviors. We identify 10 key vulnerabilities in the system: (1) moving away from homeostasis, (2) changing allostatic set points, (3) euphorigenic “reward-like” signals, (4) overvaluation in the planning system, (5) incorrect search of situation-action-outcome relationships, (6) misclassification of situations, (7) overvaluation in the habit system, (8) a mismatch in the balance of the two decision systems, (9) over-fast discounting processes, and (10) changed learning rates. These vulnerabilities provide a taxonomy of potential problems with decision-making systems. Although each vulnerability can drive an agent to return to the addictive choice, each vulnerability also implies a characteristic symptomology. Different drugs, different behaviors, and different individuals are likely to access different vulnerabilities. This has implications for an individual’s susceptibility to addiction and the transition to addiction, for the potential for relapse, and for the potential for treatment. PMID:18662461

  7. Shared Decision Making in Cancer Care

    ERIC Educational Resources Information Center

    Butow, Phyllis; Tattersall, Martin

    2005-01-01

    Cancer treatment outcomes have improved over the past 20 years, but treatment decision making in this context remains complex. There are often a number of reasonable treatment alternatives, including no treatment in some circumstances. Patients and doctors often have to weigh up uncertain benefits against uncertain costs. Shared decision making…

  8. IFNL4 ss469415590 polymorphism contributes to treatment decisions in patients with chronic hepatitis C virus genotype 1b, but not 2a, infection.

    PubMed

    Wu, Ruihong; Chi, Xiumei; Wang, Xiaomei; Sun, Haibo; Lv, Juan; Gao, Xiuzhu; Yu, Ge; Kong, Fei; Xu, Hongqin; Hua, Rui; Jiang, Jing; Sun, Bing; Zhong, Jin; Pan, Yu; Niu, Junqi

    2016-04-01

    Recently, the dinucleotide variant ss469415590 (TT/ΔG) in a novel gene, interferon lambda 4 (IFNL4), was identified as a stronger predictor of hepatitis C virus (HCV) clearance in individuals of African ancestry compared with rs12979860. We aimed to determine whether this variant contributes to treatment decisions in a Chinese population. A total of 447 chronic hepatitis C (CHC) patients (including 328 treated with interferon alpha-2b and ribavirin), 129 individuals who had spontaneously cleared HCV (SHC), and 169 healthy controls were retrospectively investigated. ss469415590 genotyping was performed using a mass spectrometry method (SEQUENOM). A higher proportion of SHC individuals carried the TT/TT genotype compared with CHC patients (95.3% vs. 88.8%, P=0.027). In patients with HCV genotype 1b, the ss469415590 variant was independently associated with sustained virologic response (SVR) (odds ratio [OR]=3.247, 95% confidence interval [CI]=1.038-10.159, P=0.043) and on-treatment virological responses, including rapid (RVR), complete early (cEVR), early (EVR), and end-of-treatment (ETVR), with a minimal OR of 3.73. Especially for patients with high viral load (≥4×10(5) IU/ml), ΔG allele carriers had a lower chance of achieving SVR compared with those carrying the TT/TT genotype (7.1% vs. 36.0%, P=0.034, OR [95% CI]=7.24 [1.02-318.45], negative predictive value=92.9%). In patients with HCV genotype 2a, no significant association between the ss154949590 variant and the virological response was identified (P>0.05). Additionally, we found that ss154949590 was in complete linkage disequilibrium with rs12979860. In conclusion, the IFNL4 ss154949590 TT/TT genotype favors spontaneous clearance of HCV. This same variant is associated with treatment-induced clearance in patients with genotype 1b, but not 2a. ss469415590 (or rs12979860) genotyping should be considered for patients with HCV genotype 1b and high viral load when making a choice between standard dual therapy

  9. A prospective study comparing the predictions of doctors versus models for treatment outcome of lung cancer patients: a step towards individualized care and shared decision making

    PubMed Central

    Oberije, Cary; Nalbantov, Georgi; Dekker, Andre; Boersma, Liesbeth; Borger, Jacques; Reymen, Bart; van Baardwijk, Angela; Wanders, Rinus; De Ruysscher, Dirk; Steyerberg, Ewout; Dingemans, Anne-Marie; Lambin, Philippe

    2015-01-01

    Background Decision Support Systems, based on statistical prediction models, have the potential to change the way medicine is being practiced, but their application is currently hampered by the astonishing lack of impact studies. Showing the theoretical benefit of using these models could stimulate conductance of such studies. In addition, it would pave the way for developing more advanced models, based on genomics, proteomics and imaging information, to further improve the performance of the models. Purpose In this prospective single-center study, previously developed and validated statistical models were used to predict the two-year survival (2yrS), dyspnea (DPN), and dysphagia (DPH) outcomes for lung cancer patients treated with chemo radiation. These predictions were compared to probabilities provided by doctors and guideline-based recommendations currently used. We hypothesized that model predictions would significantly outperform predictions from doctors. Materials and Methods Experienced radiation oncologists (ROs) predicted all outcomes at two timepoints: 1) after the first consultation of the patient, and 2) after the radiation treatment plan was made. Differences in the performances of doctors and models were assessed using Area under the Curve (AUC) analysis. Results A total number of 155 patients were included. At timepoint #1 the differences in AUCs between the ROs and the models were 0.15, 0.17, and 0.20 (for 2yrS, DPN, and DPH respectively), with p-values of 0.02, 0.07, and 0.03. Comparable differences at timepoint #2 were not statistically significant due to the limited number of patients. Comparison to guideline-based recommendations also favored the models. Conclusions The models substantially outperformed ROs’ predictions and guideline-based recommendations currently used in clinical practice. Identification of risk groups on the basis of the models facilitates individualized treatment, and should be further investigated in clinical impact

  10. ISKME Special Series Part I: Data Driven

    ERIC Educational Resources Information Center

    Panettieri, Joseph C.

    2006-01-01

    In early December 2005, the School District of Philadelphia announced that, for the fourth consecutive year, students showed measurable improvement on standardized, nationally normed TerraNova tests. The school's good performance was induced by a well managed instructional program that includes data-driven instruction and decision-making…

  11. Development of a Post-Intensive Care Unit Storytelling Intervention for Surrogates Involved in Decisions to Limit Life-Sustaining Treatment

    PubMed Central

    Schenker, Yael; Dew, Mary Amanda; Reynolds, Charles F.; Arnold, Robert M.; Tiver, Greer A.; Barnato, Amber E.

    2014-01-01

    Objectives Surrogates involved in decisions to limit life-sustaining treatment for a loved one in the intensive care unit (ICU) are at increased risk for adverse psychological outcomes lasting months to years after the ICU experience. Post-ICU interventions to reduce surrogate distress have not been developed. We sought to 1) describe a conceptual framework underlying the beneficial mental health effects of storytelling and 2) present formative work developing a storytelling intervention to reduce distress for recently bereaved surrogates. Methods An interdisciplinary team conceived the idea for a storytelling intervention based upon evidence from narrative theory that storytelling reduces distress from traumatic events through emotional disclosure, cognitive processing, and social connections. We developed an initial storytelling guide based upon this theory and the clinical perspectives of team members. We then conducted a case series with recently bereaved surrogates to iteratively test and modify the guide. Results The storytelling guide covered three key domains of the surrogate's experience of the patient's illness and death: antecedents, ICU experience, and aftermath. The facilitator focused on parts of the story that appeared to generate strong emotions and used non-judgmental statements to attend to these emotions. Between September 2012 and May 2013 we identified 28 eligible surrogates from 1 medical ICU and consented 20 for medical record review and recontact; 10 became eligible of whom 6 consented and completed the storytelling intervention. The single-session storytelling intervention lasted 40-92 minutes. All storytelling participants endorsed the intervention as acceptable, and 5 of 6 reported that it was helpful. Significance of Results Surrogate storytelling is an innovative and acceptable post-ICU intervention for recently bereaved surrogates and should be evaluated further. PMID:24524736

  12. Impact of Pretreatment Combined {sup 18}F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Staging on Radiation Therapy Treatment Decisions in Locally Advanced Breast Cancer

    SciTech Connect

    Ng, Sweet Ping; David, Steven; Alamgeer, Muhammad; Ganju, Vinod

    2015-09-01

    Purpose: To assess the diagnostic performance of pretreatment {sup 18}F-fluorodeoxyglucose positron emission tomography/computed tomography ({sup 18}F-FDG PET/CT) and its impact on radiation therapy treatment decisions in patients with locally advanced breast cancer (LABC). Methods and Materials: Patients with LABC with Eastern Cooperative Oncology Group performance status <2 and no contraindication to neoadjuvant chemotherapy, surgery, and adjuvant radiation therapy were enrolled on a prospective trial. All patients had pretreatment conventional imaging (CI) performed, including bilateral breast mammography and ultrasound, bone scan, and CT chest, abdomen, and pelvis scans performed. Informed consent was obtained before enrolment. Pretreatment whole-body {sup 18}F-FDG PET/CT scans were performed on all patients, and results were compared with CI findings. Results: A total of 154 patients with LABC with no clinical or radiologic evidence of distant metastases on CI were enrolled. Median age was 49 years (range, 26-70 years). Imaging with PET/CT detected distant metastatic disease and/or locoregional disease not visualized on CI in 32 patients (20.8%). Distant metastatic disease was detected in 17 patients (11.0%): 6 had bony metastases, 5 had intrathoracic metastases (pulmonary/mediastinal), 2 had distant nodal metastases, 2 had liver metastases, 1 had pulmonary and bony metastases, and 1 had mediastinal and distant nodal metastases. Of the remaining 139 patients, nodal disease outside conventional radiation therapy fields was detected on PET/CT in 15 patients (10.8%), with involvement of ipsilateral internal mammary nodes in 13 and ipsilateral level 5 cervical nodes in 2. Conclusions: Imaging with PET/CT provides superior diagnostic and staging information in patients with LABC compared with CI, which has significant therapeutic implications with respect to radiation therapy management. Imaging with PET/CT should be considered in all patients undergoing primary

  13. Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective ‘before/after’ cohort study

    PubMed Central

    Nachtigall, I; Tafelski, S; Deja, M; Halle, E; Grebe, M C; Tamarkin, A; Rothbart, A; Uhrig, A; Meyer, E; Musial-Bright, L; Wernecke, K D; Spies, C

    2014-01-01

    Objectives Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS. Design This prospective ‘before/after’ cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation. Setting Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital. Participants Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12 965 ICU days. Intervention Implementation of a CDSS. Outcome measures The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence. Main results Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31). Conclusions Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed

  14. Social Capital in Data-Driven Community College Reform

    ERIC Educational Resources Information Center

    Kerrigan, Monica Reid

    2015-01-01

    The current rhetoric around using data to improve community college student outcomes with only limited research on data-driven decision-making (DDDM) within postsecondary education compels a more comprehensive understanding of colleges' capacity for using data to inform decisions. Based on an analysis of faculty and administrators' perceptions and…

  15. Stochastic decision analysis

    NASA Technical Reports Server (NTRS)

    Lacksonen, Thomas A.

    1994-01-01

    Small space flight project design at NASA Langley Research Center goes through a multi-phase process from preliminary analysis to flight operations. The process insures that each system achieves its technical objectives with demonstrated quality and within planned budgets and schedules. A key technical component of early phases is decision analysis, which is a structure procedure for determining the best of a number of feasible concepts based upon project objectives. Feasible system concepts are generated by the designers and analyzed for schedule, cost, risk, and technical measures. Each performance measure value is normalized between the best and worst values and a weighted average score of all measures is calculated for each concept. The concept(s) with the highest scores are retained, while others are eliminated from further analysis. This project automated and enhanced the decision analysis process. Automation of the decision analysis process was done by creating a user-friendly, menu-driven, spreadsheet macro based decision analysis software program. The program contains data entry dialog boxes, automated data and output report generation, and automated output chart generation. The enhancements to the decision analysis process permit stochastic data entry and analysis. Rather than enter single measure values, the designers enter the range and most likely value for each measure and concept. The data can be entered at the system or subsystem level. System level data can be calculated as either sum, maximum, or product functions of the subsystem data. For each concept, the probability distributions are approximated for each measure and the total score for each concept as either constant, triangular, normal, or log-normal distributions. Based on these distributions, formulas are derived for the probability that the concept meets any given constraint, the probability that the concept meets all constraints, and the probability that the concept is within a given

  16. Treatment

    MedlinePlus

    ... Prevention Treatment 2003 U.S. Outbreak African Rodent Importation Ban For Clinicians Clinical Recognition Specimen Collection Treatment Smallpox ... Examining Animals with Suspected Monkeypox African Rodent Importation Ban Resources Related Links Poxvirus Molluscum Contagiosum Orf Virus ( ...

  17. Is there a role for antioxidants in the prevention of infection-associated carcinogenesis and in the treatment of infection-driven tumors?

    PubMed

    De Luca, Chiara; Kharaeva, Zaira; Korkina, Liudmila

    2015-01-01

    Causative connections between infections and cancer are ascertained for several types of viruses, bacteria, and parasites. The mechanisms of cancer induction in chronically infected inflamed tissues strongly implicate oxygen- and nitrogen-centered reactive species, and an impairment of redox-sensitive molecular pathways involved in the tumorigenic transformation, tumor growth, altered immune defense, and in the mechanisms of tumor cell death and survival. Here, we briefly reviewed mechanistic data on carcinogenesis and tumor progression of three major infection-associated tumors, human papillomavirus-induced cervical cancer, hepatitis B virus-positive hepatocarcinoma, and Helicobacter pylori-positive gastric cancer. Notwithstanding the contradictory results of clinical studies on cancer chemoprevention with long-term, high dosage antioxidant vitamin/micronutrient supplementation, natural and synthetic agents with proven capacity to affect redox-dependent molecular pathways still hold the promise for preventing/delaying carcinogenesis initiation, as well as the overt malignancy evolution from dysplastic/ aplastic stages. Novel directions for a targeted antioxidant-based approach to the reduction of persistent infection-driven cancer risk stems from the current knowledge of critical factors in the host-microbe interaction leading to oncogenesis. An emerging role of redox active substances in the chemotherapy of tumors relies on their stimulating effects towards TRAIL-related apoptosis and the induction of intracellular oxidative stress. PMID:25496269

  18. Lymphomatoid Granulomatosis of Central Nervous System and Lung Driven by Epstein Barr Virus Proliferation: Successful Treatment with Rituximab-Containing Chemotherapy

    PubMed Central

    Fernandez-Alvarez, Ruben; Gonzalez, ME; Fernandez, Almudena; Gonzalez-Rodriguez, AP; Sancho, JM; Dominguez, Francisco; Fernandez, Carmen

    2014-01-01

    Lymphomatoid granulomatosis (LYG) is a very rare Epstein-Barr virus (EBV) associated B-cell lymphoproliferative disorder. We report the case of a 41-year-old man who presented with fever and respiratory symptoms. Computed tomography showed multiple nodules in both lung fields. Polymerase chain reaction (PCR) analysis for EBV was positive in bronchoalveolar lavage and biopsy of lung node yielded a diagnosis of LYG, grade III. Shortly after initiation of treatment with agressive chemotherapy, neurological deterioration appeared. Neuroimaging findings revealed hydrocephalus and PCR analysis of the cerebrospinal fluid (CSF) was positive for EBV. Treatment with intravenous rituximab led to rapid reduction of EBV load in CSF, along with clinical and radiological improvement. After completion of treatment with immunochemotherapy, an autologous stem cell transplantation was performed. Patient stays in remission 18 months after diagnosis. PMID:24678394

  19. Impact of loss of BH3-only proteins on the development and treatment of MLL-fusion gene-driven AML in mice.

    PubMed

    Bilardi, Rebecca A; Anstee, Natasha S; Glaser, Stefan P; Robati, Mikara; Vandenberg, Cassandra J; Cory, Suzanne

    2016-01-01

    Inhibition of the apoptosis pathway controlled by opposing members of the Bcl-2 protein family plays a central role in cancer development and resistance to therapy. To investigate how pro-apoptotic Bcl-2 homology domain 3 (BH3)-only proteins impact on acute myeloid leukemia (AML), we generated mixed lineage leukemia (MLL)-AF9 and MLL-ENL AMLs from BH3-only gene knockout mice. Disease development was not accelerated by loss of Bim, Puma, Noxa, Bmf, or combinations thereof; hence these BH3-only proteins are apparently ineffectual as tumor suppressors in this model. We tested the sensitivity of MLL-AF9 AMLs of each genotype in vitro to standard chemotherapeutic drugs and to the proteasome inhibitor bortezomib, with or without the BH3 mimetic ABT-737. Loss of Puma and/or Noxa increased resistance to cytarabine, daunorubicin and etoposide, while loss of Bim protected against cytarabine and loss of Bmf had no impact. ABT-737 increased sensitivity to the genotoxic drugs but was not dependent on any BH3-only protein tested. The AML lines were very sensitive to bortezomib and loss of Noxa conveyed significant resistance. In vivo, several MLL-AF9 AMLs responded well to daunorubicin and this response was highly dependent on Puma and Noxa but not Bim. Combination therapy with ABT-737 provided little added benefit at the daunorubicin dose trialed. Bortezomib also extended survival of AML-bearing mice, albeit less than daunorubicin. In summary, our genetic studies reveal the importance of Puma and Noxa for the action of genotoxics currently used to treat MLL-driven AML and suggest that, while addition of ABT-737-like BH3 mimetics might enhance their efficacy, new Noxa-like BH3 mimetics targeting Mcl-1 might have greater potential. PMID:27584789

  20. Shared decision-making: nurses must respect autonomy over paternalism.

    PubMed

    Grffith, Richard; Tengnah, Cassam

    2013-06-01

    Shared decision-making lies at the heart of the Government's reforms of the NHS in England. The slogan, 'No decision about me without me', underpins shared decision-making that sees patients as active participants in their treatment decisions. In this article, Richard Griffith and Cassam Tengnah argue that for 'no decision about me, without me' to be a reality, district nurses must guard against paternalistic decision-making that excludes the views and wishes of their patients. PMID:24046930

  1. Shared clinical decision making

    PubMed Central

    AlHaqwi, Ali I.; AlDrees, Turki M.; AlRumayyan, Ahmad; AlFarhan, Ali I.; Alotaibi, Sultan S.; AlKhashan, Hesham I.; Badri, Motasim

    2015-01-01

    Objectives: To determine preferences of patients regarding their involvement in the clinical decision making process and the related factors in Saudi Arabia. Methods: This cross-sectional study was conducted in a major family practice center in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between March and May 2012. Multivariate multinomial regression models were fitted to identify factors associated with patients preferences. Results: The study included 236 participants. The most preferred decision-making style was shared decision-making (57%), followed by paternalistic (28%), and informed consumerism (14%). The preference for shared clinical decision making was significantly higher among male patients and those with higher level of education, whereas paternalism was significantly higher among older patients and those with chronic health conditions, and consumerism was significantly higher in younger age groups. In multivariate multinomial regression analysis, compared with the shared group, the consumerism group were more likely to be female [adjusted odds ratio (AOR) =2.87, 95% confidence interval [CI] 1.31-6.27, p=0.008] and non-dyslipidemic (AOR=2.90, 95% CI: 1.03-8.09, p=0.04), and the paternalism group were more likely to be older (AOR=1.03, 95% CI: 1.01-1.05, p=0.04), and female (AOR=2.47, 95% CI: 1.32-4.06, p=0.008). Conclusion: Preferences of patients for involvement in the clinical decision-making varied considerably. In our setting, underlying factors that influence these preferences identified in this study should be considered and tailored individually to achieve optimal treatment outcomes. PMID:26620990

  2. A Randomized Clinical Trial Comparison Between Pivotal Response Treatment (PRT) and Adult-Driven Applied Behavior Analysis (ABA) Intervention on Disruptive Behaviors in Public School Children with Autism.

    PubMed

    Mohammadzaheri, Fereshteh; Koegel, Lynn Kern; Rezaei, Mohammad; Bakhshi, Enayatolah

    2015-09-01

    Children with autism often demonstrate disruptive behaviors during demanding teaching tasks. Language intervention can be particularly difficult as it involves social and communicative areas, which are challenging for this population. The purpose of this study was to compare two intervention conditions, a naturalistic approach, Pivotal Response Treatment (PRT) with an adult-directed ABA approach on disruptive behavior during language intervention in the public schools. A randomized clinical trial design was used with two groups of children, matched according to age, sex and mean length of utterance. The data showed that the children demonstrated significantly lower levels of disruptive behavior during the PRT condition. The results are discussed with respect to antecedent manipulations that may be helpful in reducing disruptive behavior. PMID:25953148

  3. Role of decision aids in orthopaedic surgery

    PubMed Central

    ten Have, Isha A; van den Bekerom, Michel PJ; van Deurzen, Derek FP; Hageman, Michel GJS

    2015-01-01

    Medical treatment of patients inherently entails the risk of undesired complication or side effects. It is essential to inform the patient about the expected outcomes, but also the possible undesired outcomes. The patients preference and values regarding the potential outcomes should be involved in the decision making process. Even though many orthopaedic surgeons are positive towards shared decision-making, it is minimally introduced in the orthopaedic daily practice and decision-making is still mostly physician based. Decision aids are designed to support the physician and patient in the shared- decision-making process. By using decision aids, patients can learn more about their condition and treatment options in advance to the decision-making. This will reduce decisional conflict and improve participation and satisfaction. PMID:26716082

  4. A Mathematical Framework for Statistical Decision Confidence.

    PubMed

    Hangya, Balázs; Sanders, Joshua I; Kepecs, Adam

    2016-09-01

    Decision confidence is a forecast about the probability that a decision will be correct. From a statistical perspective, decision confidence can be defined as the Bayesian posterior probability that the chosen option is correct based on the evidence contributing to it. Here, we used this formal definition as a starting point to develop a normative statistical framework for decision confidence. Our goal was to make general predictions that do not depend on the structure of the noise or a specific algorithm for estimating confidence. We analytically proved several interrelations between statistical decision confidence and observable decision measures, such as evidence discriminability, choice, and accuracy. These interrelationships specify necessary signatures of decision confidence in terms of externally quantifiable variables that can be empirically tested. Our results lay the foundations for a mathematically rigorous treatment of decision confidence that can lead to a common framework for understanding confidence across different research domains, from human and animal behavior to neural representations. PMID:27391683

  5. Key role of social work in effective communication and conflict resolution process: Medical Orders for Life-Sustaining Treatment (MOLST) Program in New York and shared medical decision making at the end of life.

    PubMed

    Bomba, Patricia A; Morrissey, Mary Beth; Leven, David C

    2011-01-01

    In this article, the authors review the development of the Medical Orders for Life-Sustaining Treatment (MOLST) Program and recent landmark legislation in New York State in the context of advance care planning and shared medical decision making at the end of life. Social workers are central health care professionals in working with patients, families, practitioners, health care agents, and surrogates in the health systems and in the communication and conflict resolution process that is integral to health care decision making. The critical importance of ethics and end-of-life training and education for social workers is also addressed. Data from a pilot study evaluating interdisciplinary ethics training on legal and ethical content in communication and conflict resolution skills in health care decision making are reported. Recommendations are made for research on education and training of social workers, and investigation of the role and influence of systems in shaping social work involvement in end-of-life and palliative care. PMID:21391078

  6. Surrogate decision making in neurocritical care.

    PubMed

    Adelman, Eric E; Zahuranec, Darin B

    2012-06-01

    Patients with critical neurologic illness typically have impaired capacity to make their own medical decisions. In these cases, neurologists need to make medical decisions based on advance directives (such as a living will) or the decisions of a surrogate. A hypothetical case of a 60-year-old man with an intracerebral hemorrhage is used to highlight some of the difficulties that can occur when attempting to apply general statements made in a living will to a specific medical treatment decision. The ethical and legal issues surrounding surrogate decision making as they apply to acute critical neurologic disease are discussed, along with suggestions for how to resolve potential disagreements. PMID:22810254

  7. Electrically Driven Technologies for Radioactive Aerosol Abatement

    SciTech Connect

    David W. DePaoli; Ofodike A. Ezekoye; Costas Tsouris; Valmor F. de Almeida

    2003-01-28

    The purpose of this research project was to develop an improved understanding of how electriexecy driven processes, including electrocoalescence, acoustic agglomeration, and electric filtration, may be employed to efficiently treat problems caused by the formation of aerosols during DOE waste treatment operations. The production of aerosols during treatment and retrieval operations in radioactive waste tanks and during thermal treatment operations such as calcination presents a significant problem of cost, worker exposure, potential for release, and increased waste volume.

  8. Data-Driven Decision-Making: Data Pioneers

    ERIC Educational Resources Information Center

    Briggs, Linda L.

    2006-01-01

    Everyone on your campus needs information, and if your institution is like most schools, you have plenty of it to share. But which types of data warehousing and business intelligence systems you choose, and how accessible, usable, and meaningful those tools make all of that information, remain the big questions for many technologists and…

  9. Rationale and design of the Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR trial): A randomized multicenter controlled event-driven trial.

    PubMed

    Banovic, Marko; Iung, Bernard; Bartunek, Jozef; Asanin, Milika; Beleslin, Branko; Biocina, Bojan; Casselman, Filip; da Costa, Mark; Deja, Marek; Gasparovic, Hrvoje; Kala, Petr; Labrousse, Lois; Loncar, Zlatibor; Marinkovic, Jelena; Nedeljkovic, Ivana; Nedeljkovic, Milan; Nemec, Peter; Nikolic, Serge D; Pencina, Michael; Penicka, Martin; Ristic, Arsen; Sharif, Faisal; Van Camp, Guy; Vanderheyden, Marc; Wojakowski, Wojtek; Putnik, Svetozar

    2016-04-01

    Aortic valve replacement (AVR) therapy is an obvious choice for symptomatic severe aortic stenosis (AS) patients as it improves symptoms, left ventricular function, and survival. The treatment decisions and indication for AVR in asymptomatic patients with severe AS and normal left ventricular ejection fraction are less well established and the subject of ongoing debate. Many efforts have been made to define the best treatment option in asymptomatic AS patients with normal left ventricular ejection fraction. Retrospective and observational data imply that elective AVR for asymptomatic severe AS may lead to improvement in outcomes in comparison to surgery performed after onset of symptoms. The AVATAR trial will aim to assess outcomes among asymptomatic AS patients randomized to either elective early AVR or medical management with vigilant follow-up. In the latter group, AVR would be delayed until either the onset of symptoms or changes in predefined echocardiographic parameters. To the best of the authors' knowledge, it will be the first large prospective, randomized, controlled, multicenter clinical trial that will evaluate the safety and efficacy of elective AVR in this specific group of patients. PMID:26995381

  10. Optimal policy for value-based decision-making

    PubMed Central

    Tajima, Satohiro; Drugowitsch, Jan; Pouget, Alexandre

    2016-01-01

    For decades now, normative theories of perceptual decisions, and their implementation as drift diffusion models, have driven and significantly improved our understanding of human and animal behaviour and the underlying neural processes. While similar processes seem to govern value-based decisions, we still lack the theoretical understanding of why this ought to be the case. Here, we show that, similar to perceptual decisions, drift diffusion models implement the optimal strategy for value-based decisions. Such optimal decisions require the models' decision boundaries to collapse over time, and to depend on the a priori knowledge about reward contingencies. Diffusion models only implement the optimal strategy under specific task assumptions, and cease to be optimal once we start relaxing these assumptions, by, for example, using non-linear utility functions. Our findings thus provide the much-needed theory for value-based decisions, explain the apparent similarity to perceptual decisions, and predict conditions under which this similarity should break down. PMID:27535638

  11. Optimal policy for value-based decision-making.

    PubMed

    Tajima, Satohiro; Drugowitsch, Jan; Pouget, Alexandre

    2016-01-01

    For decades now, normative theories of perceptual decisions, and their implementation as drift diffusion models, have driven and significantly improved our understanding of human and animal behaviour and the underlying neural processes. While similar processes seem to govern value-based decisions, we still lack the theoretical understanding of why this ought to be the case. Here, we show that, similar to perceptual decisions, drift diffusion models implement the optimal strategy for value-based decisions. Such optimal decisions require the models' decision boundaries to collapse over time, and to depend on the a priori knowledge about reward contingencies. Diffusion models only implement the optimal strategy under specific task assumptions, and cease to be optimal once we start relaxing these assumptions, by, for example, using non-linear utility functions. Our findings thus provide the much-needed theory for value-based decisions, explain the apparent similarity to perceptual decisions, and predict conditions under which this similarity should break down. PMID:27535638

  12. The decision-making process for senior cancer patients: treatment allocation of older women with operable breast cancer in the UK

    PubMed Central

    Morgan, Jenna L.; Richards, Paul; Zaman, Osama; Ward, Sue; Collins, Karen; Robinson, Thompson; Cheung, Kwok-Leung; Audisio, Riccardo A.; Reed, Malcolm W.; Wyld, Lynda

    2015-01-01

    Objective Up to 40% of women over 70 years with primary operable breast cancer in the UK are treated with primary endocrine therapy (PET) as an alternative to surgery. A variety of factors are important in determining treatment for older breast cancer patients. This study aimed to identify the patient and tumor factors associated with treatment allocation in this population. Methods Prospectively collected data on treatment received (surgery vs. PET) were analysed with multivariable logistic regression using the variables age, modified Charlson Comorbidity Index (CCI), activities of daily living (ADL) score, Mini-Mental State Examination (MMSE) score, HER2 status, tumour size, grade and nodal status. Results Data were available for 1,122 cancers in 1,098 patients recruited between February 2013 and June 2015 from 51 UK hospitals. About 78% of the population were treated surgically, with the remainder being treated with PET. Increasing patient age at diagnosis, increasing CCI score, large tumor size (5 cm or more) and dependence in one or more ADL categories were all strongly associated with non-surgical treatment (P<0.05). Conclusion Increasing comorbidity, large tumor size and reduced functional ability are associated with reduced likelihood of surgical treatment of breast cancer in older patients. However, age itself remains a significant factor for non-surgical treatment; reinforcing the need for evidence-based guidelines. PMID:26779368

  13. Dynamic data-driven sensor network adaptation for border control

    NASA Astrophysics Data System (ADS)

    Bein, Doina; Madan, Bharat B.; Phoha, Shashi; Rajtmajer, Sarah; Rish, Anna

    2013-06-01

    Given a specific scenario for the border control problem, we propose a dynamic data-driven adaptation of the associated sensor network via embedded software agents which make sensor network control, adaptation and collaboration decisions based on the contextual information value of competing data provided by different multi-modal sensors. We further propose the use of influence diagrams to guide data-driven decision making in selecting the appropriate action or course of actions which maximize a given utility function by designing a sensor embedded software agent that uses an influence diagram to make decisions about whether to engage or not engage higher level sensors for accurately detecting human presence in the region. The overarching goal of the sensor system is to increase the probability of target detection and classification and reduce the rate of false alarms. The proposed decision support software agent is validated experimentally on a laboratory testbed for multiple border control scenarios.

  14. Plastic neo-vaginal construction in Mayer-Rokitansky-Küster-Hauser syndrome: an expert opinion paper on the decision-making treatment process

    PubMed Central

    Torres-de la Roche, Luz Angela; Devassy, Rajesh; Gopalakrishnan, Sreelatha; de Wilde, Maya Sophie; Herrmann, Anja; Larbig, Angelika; De Wilde, Rudy Leon

    2016-01-01

    Vaginal agenesis is a congenital anomaly that affects the life of one of each four thousand women around the world. There is a trend that patients request immediate surgical correction, instead of passive vaginal dilatation. Therefore a differentiated counselling should be provided. We present a comparative chart, based on published evidence, with aspect to the available techniques, which will facilitate the decision-making process in the clinical practice. From our point of view, the best results are achieved with techniques that combine the advantages of the minimal-invasive surgery with those derived of the use of peritoneum as covering tissue of the neovagina. Nevertheless there is a lack on interdisciplinary consensus about the best option to restore the physical and sexual quality of life. PMID:26904393

  15. Plastic neo-vaginal construction in Mayer-Rokitansky-Küster-Hauser syndrome: an expert opinion paper on the decision-making treatment process.

    PubMed

    Torres-de la Roche, Luz Angela; Devassy, Rajesh; Gopalakrishnan, Sreelatha; de Wilde, Maya Sophie; Herrmann, Anja; Larbig, Angelika; De Wilde, Rudy Leon

    2016-01-01

    Vaginal agenesis is a congenital anomaly that affects the life of one of each four thousand women around the world. There is a trend that patients request immediate surgical correction, instead of passive vaginal dilatation. Therefore a differentiated counselling should be provided. We present a comparative chart, based on published evidence, with aspect to the available techniques, which will facilitate the decision-making process in the clinical practice. From our point of view, the best results are achieved with techniques that combine the advantages of the minimal-invasive surgery with those derived of the use of peritoneum as covering tissue of the neovagina. Nevertheless there is a lack on interdisciplinary consensus about the best option to restore the physical and sexual quality of life. PMID:26904393

  16. Model Driven Engineering

    NASA Astrophysics Data System (ADS)

    Gaševic, Dragan; Djuric, Dragan; Devedžic, Vladan

    A relevant initiative from the software engineering community called Model Driven Engineering (MDE) is being developed in parallel with the Semantic Web (Mellor et al. 2003a). The MDE approach to software development suggests that one should first develop a model of the system under study, which is then transformed into the real thing (i.e., an executable software entity). The most important research initiative in this area is the Model Driven Architecture (MDA), which is Model Driven Architecture being developed under the umbrella of the Object Management Group (OMG). This chapter describes the basic concepts of this software engineering effort.

  17. Implementation of a Molecular Tumor Board: The Impact on Treatment Decisions for 35 Patients Evaluated at Dartmouth-Hitchcock Medical Center

    PubMed Central

    Tafe, Laura J.; Gorlov, Ivan P.; de Abreu, Francine B.; Lefferts, Joel A.; Liu, Xiaoying; Pettus, Jason R.; Marotti, Jonathan D.; Bloch, Kasia J.; Memoli, Vincent A.; Suriawinata, Arief A.; Dragnev, Konstantin H.; Fadul, Camilo E.; Schwartz, Gary N.; Morgan, Clinton R.; Holderness, Britt M.; Peterson, Jason D.; Tsongalis, Gregory J.

    2015-01-01

    Background. Although genetic profiling of tumors is a potentially powerful tool to predict drug sensitivity and resistance, its routine use has been limited because clinicians are often unfamiliar with interpretation and incorporation of the information into practice. We established a Molecular Tumor Board (MTB) to interpret individual patients’ tumor genetic profiles and provide treatment recommendations. Patients and Methods. DNA from tumor specimens was sequenced in a Clinical Laboratory Improvement Amendments-certified laboratory to identify coding mutations in a 50-gene panel (n = 34) or a 255-gene panel (n = 1). Cases were evaluated by a multidisciplinary MTB that included pathologists, oncologists, hematologists, basic scientists, and genetic counselors. Results. During the first year, 35 cases were evaluated by the MTB, with 32 presented for recommendations on targeted therapies, and 3 referred for potential germline mutations. In 56.3% of cases, MTB recommended treatment with a targeted agent based on evaluation of tumor genetic profile and treatment history. Four patients (12.5%) were subsequently treated with a MTB-recommended targeted therapy; 3 of the 4 patients remain on therapy, 2 of whom experienced clinical benefit lasting >10 months. Conclusion. For the majority of cases evaluated, the MTB was able to provide treatment recommendations based on targetable genetic alterations. The most common reasons that MTB-recommended therapy was not administered stemmed from patient preferences and genetic profiling at either very early or very late stages of disease; lack of drug access was rarely encountered. Increasing awareness of molecular profiling and targeted therapies by both clinicians and patients will improve acceptance and adherence to treatments that could significantly improve outcomes. Implications for Practice: Case evaluation by a multidisciplinary Molecular Tumor Board (MTB) is critical to benefit from individualized genetic data and

  18. How information about the time requirements and legacy effects of treatments influence decision-making in patients with diabetes and hypertension

    PubMed Central

    Laiteerapong, Neda; Fairchild, Paige C; Nathan, Aviva G; Quinn, Michael T; Huang, Elbert S

    2016-01-01

    Objective When deciding about diabetes treatments, patients are typically uninformed about how much time is required before (time requirements), or for how long treatments change outcomes (legacy effects). However, patients may be motivated to adopt treatments with time-related treatment information. We explored whether this information alters a patients' likelihood of starting medications. Research design and methods We conducted semistructured interviews with 60 adults with type 2 diabetes for <10 years and hypertension on oral medications. We measured change in likelihood of starting medications after receiving time requirement (diabetes, 10 years; hypertension, 3 years) and legacy effect (diabetes, 10 additional years; hypertension, none) information. Responses were analyzed for themes about time-related treatment information. Results At baseline, 70% of participants reported being very likely to start a recommended medication. Nearly half (40%) were less likely to start a diabetes medication after being informed of time requirements; but after being informed of legacy effects, 32% reported being more likely. Fewer participants changed likelihoods of starting antihypertensives with time-related information. Many participants expressed that medications' benefits were important to them regardless of time-related information. Participants considered time requirements for diabetes medications too long and compared them to their life expectancy. Many participants were interested in legacy effects of diabetes medications because they looked forward to discontinuing medications, although some expressed doubt that benefits could persist after stopping medications. Conclusions While prolonged time requirements may dissuade patients from adopting treatments, the promise of legacy effects may motivate patients to commit to diabetes treatments. PMID:27158521

  19. Counseling for Decisions

    ERIC Educational Resources Information Center

    Smaby, Marlowe H.; Tamminen, Armas W.

    1978-01-01

    This article presents a model for training counselors to help counselees in the process of making decisions. An effective decision-helping approach that includes processing decisions, relating values to process, and relating actions to beliefs is presented. (Author)

  20. Cost-effectiveness analysis of antimuscarinics in the treatment of patients with overactive bladder in Spain: A decision-tree model

    PubMed Central

    2011-01-01

    Background Fesoterodine, a new once daily antimuscarinic, has proven to be an effective, safe, and well-tolerated treatment in patients with overactive bladder (OAB). To date, no analysis has evaluated the economic costs and benefits associated with fesoterodine, compared to antimuscarinics in Spain. The purpose of this analysis was to assess the economic value of OAB treatment with fesoterodine relative to extended release tolterodine and solifenacin, from the societal perspective. Methods The economic model was based on data from two 12-week, randomized, double-blind, and multicenter trials comparing fesoterodine and tolterodine extended released (ER). Treatment response rates for solifenacin were extracted from the published literature. Discontinuation and efficacy were based on the results of a 12-week multinational randomized clinical trial extrapolated to 52 weeks. Changes in health related quality of life were assessed with the King's Health Questionnaire, which was transformed into preference-based utility values. Medical costs included (expressed in € 2010) were antimuscarinics, physician visits, laboratory tests, incontinence pads and the costs of OAB-related comorbidities, fractures, skin infections, urinary tract infections, depression, and nursing home admissions associated with incontinence. Time lost from work was also considered. Univariate sensitivity analyses were also performed. Results At week 12, continents accounted for 50.6%, 40.6% and 47.2% of patients in the fesoterodine, tolterodine, and solifenacin groups, respectively. By week 52, the projected proportions of patients remaining on therapy were 33.1%, 26.5% and 30.8%, respectively. The projected quality- adjusted life years (QALY) gain (compared to baseline) over the 52-week simulation period were 0.01014, 0.00846 and 0.00957, respectively. The overall treatment cost was estimated at €1,937, €2,089 and €1,960 for fesoterodine, tolterodine and solifenacin, respectively. Therefore

  1. Laser-Driven Fusion.

    ERIC Educational Resources Information Center

    Gibson, A. F.

    1980-01-01

    Discusses the present status and future prospects of laser-driven fusion. Current research (which is classified under three main headings: laser-matter interaction processes, compression, and laser development) is also presented. (HM)

  2. Perspectives--A Problem in Our Field: Making Distinctions between Evidence-Based Treatment and Evidence-Based Practice as a Decision-Making Process

    ERIC Educational Resources Information Center

    Brandt, Kristie; Diel, James; Feder, Joshua; Lillas, Connie

    2012-01-01

    The authors contend that the term "evidence-based treatment" (EBT) is often used synonymously with the term "evidence-based practice" (EBP) without making an important distinction. If a practitioner is applying an EBT, it should not be assumed that one is "practicing" the evidence. Within the infant-family and early childhood field, this confusion…

  3. Effectiveness and Cost-Effectiveness of Sequential Treatment of Patients with Chronic Myeloid Leukemia in the United States: A Decision Analysis

    PubMed Central

    Rochau, Ursula; Kluibenschaedl, Martina; Stenehjem, David; Kuan-Ling, Kuo; Radich, Jerald; Oderda, Gary; Brixner, Diana; Siebert, Uwe

    2015-01-01

    Currently several tyrosine kinase inhibitors (TKIs) are approved for treatment of chronic myeloid leukemia (CML). Our goal was to identify the optimal sequential treatment strategy in terms of effectiveness and cost-effectiveness for CML patients within the US health care context. We evaluated 18 treatment strategies regarding survival, quality-adjusted survival, and costs. For model parameters, the literature data, expert surveys, registry data, and economic databases were used. Evaluated strategies included imatinib, dasatinib, nilotinib, bosutinib, ponatinib, stem-cell transplantation (SCT), and chemotherapy. We developed a Markov state-transition model, which was analyzed as a cohort simulation over a lifelong time horizon with a third-party payer perspective and discount rate of 3%. Remaining life expectancies ranged from 5.4 years (3.9 quality-adjusted life years (QALYs)) for chemotherapy treatment without TKI to 14.4 years (11.1 QALYs) for nilotinib→dasatinib→chemotherapy/SCT. In the economic evaluation, imatinib→chemotherapy/SCT resulted in an incremental cost-utility ratio (ICUR) of $171,700/QALY compared to chemotherapy without TKI. Imatinib→nilotinib→chemotherapy/SCT yielded an ICUR of $253,500/QALY compared to imatinib→chemotherapy/SCT. Nilotinib→dasatinib→chemotherapy/SCT yielded an ICUR of $445,100/QALY compared to imatinib→nilotinib→chemotherapy/SCT. All remaining strategies were excluded due to dominance of the clinically superior strategies. Based on our analysis and current treatment guidelines, imatinib→nilotinib→chemotherapy/SCT and nilotinib→dasatinib→chemotherapy/SCT can be considered cost-effective for patients with CML, depending on willingness-to-pay. PMID:26783469

  4. Acceptable regret in medical decision making.

    PubMed

    Djulbegovic, B; Hozo, I; Schwartz, A; McMasters, K M

    1999-09-01

    When faced with medical decisions involving uncertain outcomes, the principles of decision theory hold that we should select the option with the highest expected utility to maximize health over time. Whether a decision proves right or wrong can be learned only in retrospect, when it may become apparent that another course of action would have been preferable. This realization may bring a sense of loss, or regret. When anticipated regret is compelling, a decision maker may choose to violate expected utility theory to avoid regret. We formulate a concept of acceptable regret in medical decision making that explicitly introduces the patient's attitude toward loss of health due to a mistaken decision into decision making. In most cases, minimizing expected regret results in the same decision as maximizing expected utility. However, when acceptable regret is taken into consideration, the threshold probability below which we can comfortably withhold treatment is a function only of the net benefit of the treatment, and the threshold probability above which we can comfortably administer the treatment depends only on the magnitude of the risks associated with the therapy. By considering acceptable regret, we develop new conceptual relations that can help decide whether treatment should be withheld or administered, especially when the diagnosis is uncertain. This may be particularly beneficial in deciding what constitutes futile medical care. PMID:10580533

  5. Legal Considerations in Clinical Decision Making.

    ERIC Educational Resources Information Center

    Ursu, Samuel C.

    1992-01-01

    Discussion of legal issues in dental clinical decision making looks at the nature and elements of applicable law, especially malpractice, locus of responsibility, and standards of care. Greater use of formal decision analysis in clinical dentistry and better research on diagnosis and treatment are recommended, particularly in light of increasing…

  6. Geno2pheno[HCV] - A Web-based Interpretation System to Support Hepatitis C Treatment Decisions in the Era of Direct-Acting Antiviral Agents.

    PubMed

    Kalaghatgi, Prabhav; Sikorski, Anna Maria; Knops, Elena; Rupp, Daniel; Sierra, Saleta; Heger, Eva; Neumann-Fraune, Maria; Beggel, Bastian; Walker, Andreas; Timm, Jörg; Walter, Hauke; Obermeier, Martin; Kaiser, Rolf; Bartenschlager, Ralf; Lengauer, Thomas

    2016-01-01

    The face of hepatitis C virus (HCV) therapy is changing dramatically. Direct-acting antiviral agents (DAAs) specifically targeting HCV proteins have been developed and entered clinical practice in 2011. However, despite high sustained viral response (SVR) rates of more than 90%, a fraction of patients do not eliminate the virus and in these cases treatment failure has been associated with the selection of drug resistance mutations (RAMs). RAMs may be prevalent prior to the start of treatment, or can be selected under therapy, and furthermore they can persist after cessation of treatment. Additionally, certain DAAs have been approved only for distinct HCV genotypes and may even have subtype specificity. Thus, sequence analysis before start of therapy is instrumental for managing DAA-based treatment strategies. We have created the interpretation system geno2pheno[HCV] (g2p[HCV]) to analyse HCV sequence data with respect to viral subtype and to predict drug resistance. Extensive reviewing and weighting of literature related to HCV drug resistance was performed to create a comprehensive list of drug resistance rules for inhibitors of the HCV protease in non-structural protein 3 (NS3-protease: Boceprevir, Paritaprevir, Simeprevir, Asunaprevir, Grazoprevir and Telaprevir), the NS5A replicase factor (Daclatasvir, Ledipasvir, Elbasvir and Ombitasvir), and the NS5B RNA-dependent RNA polymerase (Dasabuvir and Sofosbuvir). Upon submission of up to eight sequences, g2p[HCV] aligns the input sequences, identifies the genomic region(s), predicts the HCV geno- and subtypes, and generates for each DAA a drug resistance prediction report. g2p[HCV] offers easy-to-use and fast subtype and resistance analysis of HCV sequences, is continuously updated and freely accessible under http://hcv.geno2pheno.org/index.php. The system was partially validated with respect to the NS3-protease inhibitors Boceprevir, Telaprevir and Simeprevir by using data generated with recombinant, phenotypic

  7. Geno2pheno[HCV] – A Web-based Interpretation System to Support Hepatitis C Treatment Decisions in the Era of Direct-Acting Antiviral Agents

    PubMed Central

    Kalaghatgi, Prabhav; Sikorski, Anna Maria; Knops, Elena; Rupp, Daniel; Sierra, Saleta; Heger, Eva; Neumann-Fraune, Maria; Beggel, Bastian; Walker, Andreas; Timm, Jörg; Walter, Hauke; Obermeier, Martin; Kaiser, Rolf; Bartenschlager, Ralf; Lengauer, Thomas

    2016-01-01

    The face of hepatitis C virus (HCV) therapy is changing dramatically. Direct-acting antiviral agents (DAAs) specifically targeting HCV proteins have been developed and entered clinical practice in 2011. However, despite high sustained viral response (SVR) rates of more than 90%, a fraction of patients do not eliminate the virus and in these cases treatment failure has been associated with the selection of drug resistance mutations (RAMs). RAMs may be prevalent prior to the start of treatment, or can be selected under therapy, and furthermore they can persist after cessation of treatment. Additionally, certain DAAs have been approved only for distinct HCV genotypes and may even have subtype specificity. Thus, sequence analysis before start of therapy is instrumental for managing DAA-based treatment strategies. We have created the interpretation system geno2pheno[HCV] (g2p[HCV]) to analyse HCV sequence data with respect to viral subtype and to predict drug resistance. Extensive reviewing and weighting of literature related to HCV drug resistance was performed to create a comprehensive list of drug resistance rules for inhibitors of the HCV protease in non-structural protein 3 (NS3-protease: Boceprevir, Paritaprevir, Simeprevir, Asunaprevir, Grazoprevir and Telaprevir), the NS5A replicase factor (Daclatasvir, Ledipasvir, Elbasvir and Ombitasvir), and the NS5B RNA-dependent RNA polymerase (Dasabuvir and Sofosbuvir). Upon submission of up to eight sequences, g2p[HCV] aligns the input sequences, identifies the genomic region(s), predicts the HCV geno- and subtypes, and generates for each DAA a drug resistance prediction report. g2p[HCV] offers easy-to-use and fast subtype and resistance analysis of HCV sequences, is continuously updated and freely accessible under http://hcv.geno2pheno.org/index.php. The system was partially validated with respect to the NS3-protease inhibitors Boceprevir, Telaprevir and Simeprevir by using data generated with recombinant, phenotypic

  8. Shared decision making: why do patients choose ureteroscopy?

    PubMed

    Omar, Mohamed; Tarplin, Sarah; Brown, Robert; Sivalingam, Sri; Monga, Manoj

    2016-04-01

    To evaluate patient's characteristics that affects their decision on the management of asymptomatic renal calculi, and to determine the impact of anesthetic on the selection of shockwave lithotripsy (SWL). A survey was distributed to 100 patients in our multi-disciplinary stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8 mm lower pole stone and descriptions for managements options including active surveillance (annual radiography, 40% chance of growth >10 mm within 4 years, 20% chance of passage), SWL under conscious sedation (65% success rate), and URS (90% success rate, with stent placement for 1 week). Patients were asked what was the most important variable impacting the choice of treatment. Patients preferred SWL (45%) over URS (32%) and active surveillance (23%). Patients with a previous experience with URS were more likely to choose it again (p = 0.0433). Decisions were driven primarily by success rate (52%), followed by risk of complications (29%), postoperative pain (7%) and others (12%). Patients choosing URS had the highest magnitude of history of pain (p = 0.03) and were more likely to prioritize success (78%) and less likely to prioritize surgical risk (13%) or anticipated pain after surgery (0%) (p = 0.01). Most (85%) of the patients would rely on the physician's recommendation for the treatment modality. Patients place differing value on risk versus success. As they rely heavily on the physician's recommendation, it is important that their urologist determine whether risk or success is of highest priority for them to facilitate a shared medical decision. PMID:26209009

  9. The anatomy of clinical decision-making in multidisciplinary cancer meetings

    PubMed Central

    Soukup, Tayana; Petrides, Konstantinos V.; Lamb, Benjamin W.; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S. A.; Sevdalis, Nick

    2016-01-01

    Abstract In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable. The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision. This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons. We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis. The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001). Hawthorne effect is the main limitation of the study. The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core

  10. Supporting patients in shared decision making in clinical practice.

    PubMed

    Madsen, Claire; Fraser, Aileen

    2015-04-01

    This article defines shared decision making in patient care and describes the background to this philosophy. The shared decision making approach is part of a wider initiative to promote patient-centred care and increase patient involvement in clinical decisions. Shared decision making recognises patients' rights to make decisions about their care and is used to assist them to make informed and individualised decisions about care and treatment. As well as reviewing the principles of shared decision making, the article offers practical guidance on how nurses can implement this initiative, including information on sharing expertise, agenda setting, assessing risks and benefits, setting goals, and support and follow up. PMID:25828022

  11. Data-Driven Planning: Using Assessment in Strategic Planning

    ERIC Educational Resources Information Center

    Bresciani, Marilee J.

    2010-01-01

    Data-driven planning or evidence-based decision making represents nothing new in its concept. For years, business leaders have claimed they have implemented planning informed by data that have been strategically and systematically gathered. Within higher education and student affairs, there may be less evidence of the actual practice of…

  12. Data-Driven Equity in Urban Schools. ERIC Digest.

    ERIC Educational Resources Information Center

    Schwartz, Wendy

    The 2002 reauthorization of the Elementary and Secondary Education Act mandates that schools receiving federal funding must desegregate their student performance data by race, gender, and socioeconomic status in order to provide progress information to the community and state. Data-driven decision making is particularly important in urban schools…

  13. The contribution of science to risk-based decision-making: lessons from the development of full-scale treatment measures for acidic mine waters at Wheal Jane, UK.

    PubMed

    Younger, Paul L; Coulton, Richard H; Froggatt, Eric C

    2005-02-01

    The use of risk-based decision-making in environmental management is often assumed to rely primarily on the availability of robust scientific data and insights, while in practice socio-economic criteria are often of considerable importance. However, the relative contributions to decision-making made by scientific and socio-economic inputs are rarely assessed, and even less commonly reported. Such an assessment has been made for a major remediation project in southwest England, in which some 300 l/s of highly acidic, metalliferous mine waters are now being treated using oxidation and chemical neutralisation. In the process of reaching the decision to commission the treatment plant, a wide range of scientific studies were undertaken, including: biological impact assessments, hydrogeological investigations of the effect of pumping on the flooded mine system, and hydrological and geochemical characterisation, together with integrated catchment modelling, of pollutant sources and pathways. These investigations revealed that, despite the spectacular nature of the original mine water outburst in 1992, the ecology of the Fal estuary remains remarkably robust. No scientific evidence emerged of any grounds for concern over the estuarine ecology, even if mine water were left to flow untreated. However, a rare ecological resource known as "maerl" (a form of calcified seaweed) is harvested annually in the estuary, providing significant revenue to the local economy and underpinning the 'clean' image of local sea water. Social and environmental benefit surveys revealed strong public perceptions that any visible discoloration in the estuary must indicate a diminution in quality of the maerl, to the detriment of both the public image and economy of the area. This factor proved sufficient to justify the continued pump-and-treat operations at the mine site. Although the decisive factor in the end was socio-economic in nature, robust assessment of this factor could not have been made

  14. Thoracic Malignancies and Pulmonary Nodules in Patients under Evaluation for Transcatheter Aortic Valve Implantation (TAVI): Incidence, Follow Up and Possible Impact on Treatment Decision

    PubMed Central

    Kaleschke, Gerrit; Schülke, Christoph; Görlich, Dennis; Schliemann, Christoph; Kessler, Torsten; Schulze, Arik Bernard; Buerke, Boris; Kuemmel, Andreas; Thrull, Michael; Wiewrodt, Rainer; Baumgartner, Helmut; Berdel, Wolfgang E.; Mohr, Michael

    2016-01-01

    Background Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with severe aortic valve stenosis who are not eligible for operative replacement and an alternative for those with high surgical risk. Due to high age and smoking history in a high proportion of TAVI patients, suspicious findings are frequently observed in pre-procedural chest computer tomography (CCT). Methods CCT scans of 484 consecutive patients undergoing TAVI were evaluated for incidentally discovered solitary pulmonary nodules (SPN). Results In the entire study population, SPN ≥ 5 mm were found in 87 patients (18%). These patients were compared to 150 patients who were incidentally collected from the 397 patients without SPN or with SPN < 5 mm (control group). After a median follow-up of 455 days, lung cancer was diagnosed in only two patients. Neither SPN ≥ 5 mm (p = 0.579) nor SPN > 8 mm (p = 0.328) were significant predictors of overall survival. Conclusions Despite the high prevalence of SPNs in this single center TAVI cohort lung cancer incidence at midterm follow-up seems to be low. Thus, aggressive diagnostic approaches for incidentally discovered SPN during TAVI evaluation should not delay the treatment of aortic stenosis. Unless advanced thoracic malignancy is obvious, the well documented reduction of morbidity and mortality by TAVI outweighs potentially harmful delays regarding further diagnostics. Standard guideline-approved procedure for SPN can be safely performed after TAVI. PMID:27171441

  15. Development and Testing of a Computerized Decision Support System to Facilitate Brief Tobacco Cessation Treatment in the Pediatric Emergency Department: Proposal and Protocol

    PubMed Central

    Dexheimer, Judith W; Khoury, Jane C; Miller, Julie A; Gordon, Judith S

    2016-01-01

    Background Tobacco smoke exposure (TSE) is unequivocally harmful to children's health, yet up to 48% of children who visit the pediatric emergency department (PED) and urgent care setting are exposed to tobacco smoke. The incorporation of clinical decision support systems (CDSS) into the electronic health records (EHR) of PED patients may improve the rates of screening and brief TSE intervention of caregivers and result in decreased TSE in children. Objective We propose a study that will be the first to develop and evaluate the integration of a CDSS for Registered Nurses (RNs) into the EHR of pediatric patients to facilitate the identification of caregivers who smoke and the delivery of TSE interventions to caregivers in the urgent care setting. Methods We will conduct a two-phase project to develop, refine, and integrate an evidence-based CDSS into the pediatric urgent care setting. RNs will provide input on program content, function, and design. In Phase I, we will develop a CDSS with prompts to: (1) ASK about child TSE and caregiver smoking, (2) use a software program, Research Electronic Data Capture (REDCap), to ADVISE caregivers to reduce their child's TSE via total smoking home and car bans and quitting smoking, and (3) ASSESS their interest in quitting and ASSIST caregivers to quit by directly connecting them to their choice of free cessation resources (eg, Quitline, SmokefreeTXT, or SmokefreeGOV) during the urgent care visit. We will create reports to provide feedback to RNs on their TSE counseling behaviors. In Phase II, we will conduct a 3-month feasibility trial to test the results of implementing our CDSS on changes in RNs’ TSE-related behaviors, and child and caregiver outcomes. Results This trial is currently underway with funding support from the National Institutes of Health/National Cancer Institute. We have completed Phase I. The CDSS has been developed with input from our advisory panel and RNs, and pilot tested. We are nearing completion of

  16. New Instabilities in Line Driven Winds

    NASA Technical Reports Server (NTRS)

    Martens, P. C. H.

    1985-01-01

    The physical mechanisms which potentially lead to instabilities in line driven winds, the drift instability and the line shape instability, are discussed. A general three dimensional treatment of the stability problem of line driven winds which leads to the general dispersion equation is proposed. From this dispersion equation automatically a third physical mechanism driving instability in stellar winds is deduced; the thermal drift instability which is related to changes in absorption of radiation caused by temperature perturbations. This mechanism results in growing inwardly propagating sound waves.

  17. Driven Markovian Quantum Criticality.

    PubMed

    Marino, Jamir; Diehl, Sebastian

    2016-02-19

    We identify a new universality class in one-dimensional driven open quantum systems with a dark state. Salient features are the persistence of both the microscopic nonequilibrium conditions as well as the quantum coherence of dynamics close to criticality. This provides a nonequilibrium analogue of quantum criticality, and is sharply distinct from more generic driven systems, where both effective thermalization as well as asymptotic decoherence ensue, paralleling classical dynamical criticality. We quantify universality by computing the full set of independent critical exponents within a functional renormalization group approach. PMID:26943517

  18. The driven spinning top

    NASA Astrophysics Data System (ADS)

    Grosu, Ioan; Featonby, David

    2016-05-01

    This driven top is quite a novelty and can, with some trials, be made using the principles outlined here. This new top has many applications in developing both understanding and skills and these are detailed in the article. Depending on reader’s available time and motivation they may feel an urge to make one themselves, or simply invest a few pounds in the one that has been designed, tested and manufactured to a high standard. Either way the unique design of the driven top can provide several hours of interesting experimentation. Our aim here is simply to inform and inspire readers to further investigation and experimentation.

  19. Transport in driven plasmas

    SciTech Connect

    Fisch, N.J.

    1985-03-01

    A plasma in contact with an external source of power, especially a source that interacts specifically with high-velocity electrons, exhibits transport properties, such as conductivity, different from those of an isolated plasma near thermal equilibrium. This is true even when the bulk of the particles in the driven plasma are near thermal equilibrium. To describe the driven plasma we derive an adjoint equation to the inhomogeneous, linearized, dynamic Boltzmann equation. The Green's functions for a variety of plasma responses can then be generated. It is possible to modify the Chapman-Enskog expansion in order to incorporate the response functions derived here.

  20. An Integrated Model for Identifying Linkages Between the Management of Fuel Treatments, Fire and Ecosystem Services

    NASA Astrophysics Data System (ADS)

    Bart, R. R.; Anderson, S.; Moritz, M.; Plantinga, A.; Tague, C.

    2015-12-01

    Vegetation fuel treatments (e.g. thinning, prescribed burning) are a frequent tool for managing fire-prone landscapes. However, predicting how fuel treatments may affect future wildfire risk and associated ecosystem services, such as forest water availability and streamflow, remains a challenge. This challenge is in part due to the large range of conditions under which fuel treatments may be implemented, as response is likely to vary with species type, rates of vegetation regrowth, meteorological conditions and physiographic properties of the treated site. It is also due to insufficient understanding of how social factors such as political pressure, public demands and economic constraints affect fuel management decisions. To examine the feedbacks between ecological and social dimensions of fuel treatments, we present an integrated model that links a biophysical model that simulates vegetation and hydrology (RHESSys), a fire spread model (WMFire) and an empirical fuel treatment model that accounts for agency decision-making. We use this model to investigate how management decisions affect landscape fuel loads, which in turn affect fire severity and ecosystem services, which feedback to management decisions on fuel treatments. We hypothesize that this latter effect will be driven by salience theory, which predicts that fuel treatments are more likely to occur following major wildfire events. The integrated model provides a flexible framework for answering novel questions about fuel treatments that span social and ecological domains, areas that have previously been treated separately.

  1. The influence of patients' immigration background and residence permit status on treatment decisions in health care. Results of a factorial survey among general practitioners in Switzerland.

    PubMed

    Drewniak, Daniel; Krones, Tanja; Sauer, Carsten; Wild, Verina

    2016-07-01

    This study examines the influence of patients' immigration background and residence permit status on physicians' willingness to treat patients in due time. A factorial survey was conducted among 352 general practitioners with a background in internal medicine in a German-speaking region in Switzerland. Participants expressed their self-rating (SR) as well as the expected colleague-rating (CR) to provide immediate treatment to 12 fictive vignette patients. The effects of the vignette variables were analysed using random-effects models. The results show that SR as well as CR was not only influenced by the medical condition or the physicians' time pressure, but also by social factors such as the ethnicity and migration history, the residence permit status, and the economic condition of the patients. Our findings can be useful for the development of adequate, practically relevant teaching and training materials with the ultimate aim to reduce unjustified discrimination or social rationing in health care. PMID:27258017

  2. Engaging patients using an interprofessional approach to shared decision making.

    PubMed

    Dawn, Stacey; Légaré, France

    2015-01-01

    Many cancer treatment and screening decisions are difficult given that they rely upon patients' informed preferences. Interprofessional shared decision making is when two or more health care professionals collaborate with a patient to reach an agreed-upon decision. To support patients' engagement in shared decision making, effective interventions include patient decision aids and/or decision coaching. Patient decision aids are typically written or video-based resources, while decision coaching is provided by trained health care professionals who are supportive but non-directive. Both interventions make explicit the decision, provide balanced information on options based on the best available evidence, and help patients consider what matters most. The overall aim is to discuss how oncology nurses can engage in an interprofessional approach to shared decision making. PMID:26897867

  3. Automation: Decision Aid or Decision Maker?

    NASA Technical Reports Server (NTRS)

    Skitka, Linda J.

    1998-01-01

    This study clarified that automation bias is something unique to automated decision making contexts, and is not the result of a general tendency toward complacency. By comparing performance on exactly the same events on the same tasks with and without an automated decision aid, we were able to determine that at least the omission error part of automation bias is due to the unique context created by having an automated decision aid, and is not a phenomena that would occur even if people were not in an automated context. However, this study also revealed that having an automated decision aid did lead to modestly improved performance across all non-error events. Participants in the non- automated condition responded with 83.68% accuracy, whereas participants in the automated condition responded with 88.67% accuracy, across all events. Automated decision aids clearly led to better overall performance when they were accurate. People performed almost exactly at the level of reliability as the automation (which across events was 88% reliable). However, also clear, is that the presence of less than 100% accurate automated decision aids creates a context in which new kinds of errors in decision making can occur. Participants in the non-automated condition responded with 97% accuracy on the six "error" events, whereas participants in the automated condition had only a 65% accuracy rate when confronted with those same six events. In short, the presence of an AMA can lead to vigilance decrements that can lead to errors in decision making.

  4. Plasma sheath driven targets

    NASA Astrophysics Data System (ADS)

    Brownell, J. H.; Freeman, B. L.

    1980-02-01

    Plasma focus driven target implosions are simulated using hydrodynamic-burn codes. Support is given to the idea that the use of a target in a plasma focus should allow 'impedance matching' between the fuel and gun, permitting larger fusion yields from a focus-target geometry than the scaling laws for a conventional plasma focus would predict.

  5. The Driven Spinning Top

    ERIC Educational Resources Information Center

    Grosu, Ioan; Featonby, David

    2016-01-01

    This driven top is quite a novelty and can, with some trials, be made using the principles outlined here. This new top has many applications in developing both understanding and skills and these are detailed in the article. Depending on reader's available time and motivation they may feel an urge to make one themselves, or simply invest a few…

  6. Argument-Driven Inquiry

    ERIC Educational Resources Information Center

    Sampson, Victor; Grooms, Jonathon; Walker, Joi

    2009-01-01

    Argument-Driven Inquiry (ADI) is an instructional model that enables science teachers to transform a traditional laboratory activity into a short integrated instructional unit. To illustrate how the ADI instructional model works, this article describes an ADI lesson developed for a 10th-grade chemistry class. This example lesson was designed to…

  7. Use of Criterion-Referenced Competency Test Data for Data-Driven Instruction: A Phenomenological Study

    ERIC Educational Resources Information Center

    Jackson, Jo-Anne Kelly

    2012-01-01

    Public school teachers are at the forefront of education in the United States; they must employ methods such as data-driven decision making (DDDM) to ensure that all students are learning. Quality decision making is vital in this age of accountability under the No Child Left Behind Act (NCLB) that includes mandated state testing such as the…

  8. Notification Event Architecture for Traveler Screening: Predictive Traveler Screening Using Event Driven Business Process Management

    ERIC Educational Resources Information Center

    Lynch, John Kenneth

    2013-01-01

    Using an exploratory model of the 9/11 terrorists, this research investigates the linkages between Event Driven Business Process Management (edBPM) and decision making. Although the literature on the role of technology in efficient and effective decision making is extensive, research has yet to quantify the benefit of using edBPM to aid the…

  9. Accuracy of a Decision Aid for Advance Care Planning: Simulated End-of-Life Decision Making

    PubMed Central

    Levi, Benjamin H.; Heverley, Steven R.; Green, Michael J.

    2013-01-01

    Purpose Advance directives have been criticized for failing to help physicians make decisions consistent with patients’ wishes. This pilot study sought to determine if an interactive, computer-based decision aid that generates an advance directive can help physicians accurately translate patients’ wishes into treatment decisions. Methods We recruited 19 patient-participants who had each previously created an advance directive using a computer-based decision aid, and 14 physicians who had no prior knowledge of the patient-participants. For each advance directive, three physicians were randomly assigned to review the advance directive and make five to six treatment decisions for each of six (potentially) end-of-life clinical scenarios. From the three individual physicians’ responses, a “consensus physician response” was generated for each treatment decision (total decisions = 32). This consensus response was shared with the patient whose advance directive had been reviewed, and she/he was then asked to indicate how well the physician translated his/her wishes into clinical decisions. Results Patient-participants agreed with the consensus physician responses 84 percent (508/608) of the time, including 82 percent agreement on whether to provide mechanical ventilation, and 75 percent on decisions about cardiopulmonary resuscitation (CPR). Across the six vignettes, patient-participants’ rating of how well physicians translated their advance directive into medical decisions was 8.4 (range = 6.5–10, where 1 = extremely poorly, and 10 = extremely well). Physicians’ overall rating of their confidence at accurately translating patients’ wishes into clinical decisions was 7.8 (range = 6.1–9.3, 1 = not at all confident, 10 = extremely confident). Conclusion For simulated cases, a computer-based decision aid for advance care planning can help physicians more confidently make end-of-life decisions that patients will endorse. PMID:22167985

  10. Advance decisions and the Mental Capacity Act.

    PubMed

    Halliday, Samantha

    This article considers the requirements set out in the Mental Capacity Act 2005 for valid advance decisions. The Act recognizes that an adult with capacity may refuse treatment, including life-sustaining treatment, in advance of losing capacity. If that advance decision is valid and applicable, it will bind health-care professionals, taking effect as if the patient had contemporaneously refused the treatment. However, in cases where the advance decision does not relate to treatment for a progressive disease, it will be extremely difficult for the patient to meet the dual specificity requirement - specifying the treatment to be refused and the circumstances in which that refusal should operate. Moreover, while a patient may explicitly revoke an advance decision while she retains the capacity to do so, the continuing validity of an advance decision may be called into question by the patient implicitly revoking her advance refusal or by a change of circumstance. This article concludes that the key to enabling patients to exercise precedent autonomy will be full and frank discussion of the scope and intentions underlying advance decisions between patients and their health-care professionals. PMID:19525915

  11. Student decision making in large group discussion

    NASA Astrophysics Data System (ADS)

    Kustusch, Mary Bridget; Ptak, Corey; Sayre, Eleanor C.; Franklin, Scott V.

    2015-04-01

    It is increasingly common in physics classes for students to work together to solve problems and perform laboratory experiments. When students work together, they need to negotiate the roles and decision making within the group. We examine how a large group of students negotiates authority as part of their two week summer College Readiness Program at Rochester Institute of Technology. The program is designed to develop metacognitive skills in first generation and Deaf and hard-of-hearing (DHH) STEM undergraduates through cooperative group work, laboratory experimentation, and explicit reflection exercises. On the first full day of the program, the students collaboratively developed a sign for the word ``metacognition'' for which there is not a sign in American Sign Language. This presentation will focus on three aspects of the ensuing discussion: (1) how the instructor communicated expectations about decision making; (2) how the instructor promoted student-driven decision making rather than instructor-driven policy; and (3) one student's shifts in decision making behavior. We conclude by discussing implications of this research for activity-based physics instruction.

  12. Decision making in a multidisciplinary cancer team: does team discussion result in better quality decisions?

    PubMed

    Kee, Frank; Owen, Tracy; Leathem, Ruth

    2004-01-01

    To establish whether treatment recommendations made by clinicians concur with the best outcomes predicted from their prognostic estimates and whether team discussion improves the quality or outcome of their decision making, the authors studied real-time decision making by a lung cancer team. Clinicians completed pre- and postdiscussion questionnaires for 50 newly diagnosed patients. For each patient/doctor pairing, a decision model determined the expected patient outcomes from the clinician's prognostic estimates. The difference between the expected utility of the recommended treatment and the maximum utility derived from the clinician's predictions of the outcomes (the net utility loss) following all potential treatment modalities was calculated as an indicator of quality of the decision. The proportion of treatment decisions changed by the multidisciplinary team discussion was also calculated. Insofar as the change in net utility loss brought about by multidisciplinary team discussion was not significantly different from zero, team discussion did not improve the quality of decision making overall. However, given the modest power of the study, these findings must be interpreted with caution. In only 23 of 87 instances (26%) in which an individual specialist's initial treatment preference differed from the final group judgment did the specialist finally concur with the group treatment choice after discussion. This study does not support the theory that team discussion improves decision making by closing a knowledge gap. PMID:15534341

  13. Impulse-driven Micromechanism Capsule

    NASA Astrophysics Data System (ADS)

    Ito, Takahiro; Ishimori, Shohei; Hayashi, Teru

    We have developed a traveling small capsule, which has a smooth outer surface and is driven by inertia force and friction force. Measuring only 7 mm in diameter and 12 mm in length, it is sufficiently small to be placed in the human gullet or intestines. The capsule contains a small magnet and a coil, and an electric pulse drives the magnet to move the capsule. We performed an experimental investigation on making our capsule travel on a plastic material, which has similar elasticity characteristics to the living body. We also showed that it can travel on the surface of a pig's intestine. Our capsule may be useful for medical treatments such as inspection, drug delivery and operation.

  14. Reinventing Decision Making.

    ERIC Educational Resources Information Center

    Klempen, Robert A.

    2003-01-01

    Describes how three Wisconsin school superintendents used the process of situation appraisal and decision analysis to improve their problem-solving and decision-making capabilities and those of their leadership teams. Provides several examples. (PKP)

  15. Categorization = Decision Making + Generalization

    PubMed Central

    Seger, Carol A; Peterson, Erik J.

    2013-01-01

    We rarely, if ever, repeatedly encounter exactly the same situation. This makes generalization crucial for real world decision making. We argue that categorization, the study of generalizable representations, is a type of decision making, and that categorization learning research would benefit from approaches developed to study the neuroscience of decision making. Similarly, methods developed to examine generalization and learning within the field of categorization may enhance decision making research. We first discuss perceptual information processing and integration, with an emphasis on accumulator models. We then examine learning the value of different decision making choices via experience, emphasizing reinforcement learning modeling approaches. Next we discuss how value is combined with other factors in decision making, emphasizing the effects of uncertainty. Finally, we describe how a final decision is selected via thresholding processes implemented by the basal ganglia and related regions. We also consider how memory related functions in the hippocampus may be integrated with decision making mechanisms and contribute to categorization. PMID:23548891

  16. Shared decision making

    MedlinePlus

    Shared decision making is when health care providers and patients work together to decide the best way to test ... you. The two of you will make a decision based on your provider's expertise and your values ...

  17. Determine separations process strategy decision

    SciTech Connect

    Slaathaug, E.J.

    1996-01-01

    This study provides a summary level comparative analysis of selected, top-level, waste treatment strategies. These strategies include No Separations, Separations (high-level/low-level separations), and Deferred Separations of the tank waste. These three strategies encompass the full range of viable processing alternatives based upon full retrieval of the tank wastes. The assumption of full retrieval of the tank wastes is a predecessor decision and will not be revisited in this study.

  18. Family planning decisions, perceptions and gender dynamics among couples in Mwanza, Tanzania: a qualitative study

    PubMed Central

    2013-01-01

    Background Contraceptive use is low in developing countries which are still largely driven by male dominated culture and patriarchal values. This study explored family planning (FP) decisions, perceptions and gender dynamics among couples in Mwanza region of Tanzania. Methods Twelve focus group discussions and six in-depth interviews were used to collect information from married or cohabiting males and females aged 18–49. The participants were purposively selected. Qualitative methods were used to explore family planning decisions, perceptions and gender dynamics among couples. A guide with questions related to family planning perceptions, decisions and gender dynamics was used. The discussions and interviews were tape-recorded, transcribed verbatim and analyzed manually and subjected to content analysis. Results Four themes emerged during the study. First, “risks and costs” which refer to the side effects of FP methods and the treatment of side -effects as well as the costs inherit in being labeled as an unfaithful spouse. Second, “male involvement” as men showed little interest in participating in family planning issues. However, the same men were mentioned as key decision-makers even on the number of children a couple should have and the child spacing of these children. Third, “gender relations and communication” as participants indicated that few women participated in decision-making on family planning and the number of children to have. Fourth, “urban–rural differences”, life in rural favoring having more children than urban areas therefore, the value of children depended on the place of residence. Conclusion Family Planning programs should adapt the promotion of communication as well as joint decision-making on FP among couples as a strategy aimed at enhancing FP use. PMID:23721196

  19. Discern--an integrated prospective decision support system.

    PubMed Central

    Johnson, B.; McNair, D.; Kailasam, K.; Reilly, R.; Eklund, N.; McCoy, G.; Jamieson, P.

    1994-01-01

    We present a new integrated decision support tool, called Discern, for prospective case management within a comprehensive Healthcare Network Architecture (HNA). Discern is an event-driven, expert system tightly integrated into this architecture. It can perform a variety of actions including generating alerts, ordering tests, and entering results. Over 100 institutions use Discern to automate care processes. Discern was designed to meet the demanding requirements for effective decision support. PMID:7950073

  20. Deciding about Decision Making.

    ERIC Educational Resources Information Center

    Hewitson, Mal

    Educational administrators have the power to determine the nature of decision-making structures and processes within their institutions and the extent to which decisions are implemented. This paper reviews assumptions underlying decision-making structures and processes established by school administrators; examines potential individual motives…

  1. Sustainability Based Decision Making

    EPA Science Inventory

    With sustainability as the “true north” for EPA research, a premium is placed on the ability to make decisions under highly complex and uncertain conditions. The primary challenge is reconciling disparate criteria toward credible and defensible decisions. Making decisions on on...

  2. Electrically driven optical antennas

    NASA Astrophysics Data System (ADS)

    Kern, Johannes; Kullock, René; Prangsma, Jord; Emmerling, Monika; Kamp, Martin; Hecht, Bert

    2015-09-01

    Unlike radiowave antennas, so far optical nanoantennas cannot be fed by electrical generators. Instead, they are driven by light or indirectly via excited discrete states in active materials in their vicinity. Here we demonstrate the direct electrical driving of an in-plane optical antenna by the broadband quantum-shot noise of electrons tunnelling across its feed gap. The spectrum of the emitted photons is determined by the antenna geometry and can be tuned via the applied voltage. Moreover, the direction and polarization of the light emission are controlled by the antenna resonance, which also improves the external quantum efficiency by up to two orders of magnitude. The one-material planar design offers facile integration of electrical and optical circuits and thus represents a new paradigm for interfacing electrons and photons at the nanometre scale, for example for on-chip wireless communication and highly configurable electrically driven subwavelength photon sources.

  3. Laser driven radiography

    SciTech Connect

    Perry, M.D.; Sefcik, J.; Cowan, T.

    1997-12-20

    Intense laser (> 1021 W/cm{sup 3}) driven hard x-ray sources offer a new alternative to conventional electron accelerator Bremsstrahlung sources. These laser driven sources offer considerable simplicity in design and potential cost advantage for multiple axis views. High spatial and temporal resolution is achievable as a result of the very small source size (<100 um) and short-duration of the laser pulse. We have begun a series of experiments with the Petawatt laser at LLNL to determine the photon flux achievable with these sources and assess their potential for Stewardship applications. Additionally, we are developing a conceptual design and cost estimate of a multi-pulse, multi-axis (up to five) radiographic facility utilizing the Contained Firing Facility at site 300 and existing laser hardware.

  4. Test-driven programming

    NASA Astrophysics Data System (ADS)

    Georgiev, Bozhidar; Georgieva, Adriana

    2013-12-01

    In this paper, are presented some possibilities concerning the implementation of a test-driven development as a programming method. Here is offered a different point of view for creation of advanced programming techniques (build tests before programming source with all necessary software tools and modules respectively). Therefore, this nontraditional approach for easier programmer's work through building tests at first is preferable way of software development. This approach allows comparatively simple programming (applied with different object-oriented programming languages as for example JAVA, XML, PYTHON etc.). It is predictable way to develop software tools and to provide help about creating better software that is also easier to maintain. Test-driven programming is able to replace more complicated casual paradigms, used by many programmers.

  5. Adiabatically driven Brownian pumps.

    PubMed

    Rozenbaum, Viktor M; Makhnovskii, Yurii A; Shapochkina, Irina V; Sheu, Sheh-Yi; Yang, Dah-Yen; Lin, Sheng Hsien

    2013-07-01

    We investigate a Brownian pump which, being powered by a flashing ratchet mechanism, produces net particle transport through a membrane. The extension of the Parrondo's approach developed for reversible Brownian motors [Parrondo, Phys. Rev. E 57, 7297 (1998)] to adiabatically driven pumps is given. We demonstrate that the pumping mechanism becomes especially efficient when the time variation of the potential occurs adiabatically fast or adiabatically slow, in perfect analogy with adiabatically driven Brownian motors which exhibit high efficiency [Rozenbaum et al., Phys. Rev. E 85, 041116 (2012)]. At the same time, the efficiency of the pumping mechanism is shown to be less than that of Brownian motors due to fluctuations of the number of particles in the membrane. PMID:23944411

  6. Heuristics in Managing Complex Clinical Decision Tasks in Experts’ Decision Making

    PubMed Central

    Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme

    2016-01-01

    Background Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. Objective The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. Method After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. Results We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Conclusion Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Application Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design.

  7. Gas-driven microturbine

    SciTech Connect

    Sniegowski, J.J.; Rodgers, M.S.; McWhorter, P.J.; Aeschliman, D.P.; Miller, W.M.

    1996-06-27

    This paper describes an invention which relates to microtechnology and the fabrication process for developing microelectrical systems. It describes a means for fabricating a gas-driven microturbine capable of providing autonomous propulsion in which the rapidly moving gases are directed through a micromachined turbine to power devices by direct linkage or turbo-electric generators components in a domain ranging from tenths of micrometers to thousands of micrometers.

  8. Data-Driven Objectness.

    PubMed

    Hongwen Kang; Hebert, Martial; Efros, Alexei A; Kanade, Takeo

    2015-01-01

    We propose a data-driven approach to estimate the likelihood that an image segment corresponds to a scene object (its "objectness") by comparing it to a large collection of example object regions. We demonstrate that when the application domain is known, for example, in our case activity of daily living (ADL), we can capture the regularity of the domain specific objects using millions of exemplar object regions. Our approach to estimating the objectness of an image region proceeds in two steps: 1) finding the exemplar regions that are the most similar to the input image segment; 2) calculating the objectness of the image segment by combining segment properties, mutual consistency across the nearest exemplar regions, and the prior probability of each exemplar region. In previous work, parametric objectness models were built from a small number of manually annotated objects regions, instead, our data-driven approach uses 5 million object regions along with their metadata information. Results on multiple data sets demonstrates our data-driven approach compared to the existing model based techniques. We also show the application of our approach in improving the performance of object discovery algorithms. PMID:26353218

  9. Trace anomaly driven inflation

    NASA Astrophysics Data System (ADS)

    Hawking, S. W.; Hertog, T.; Reall, H. S.

    2001-04-01

    This paper investigates Starobinsky's model of inflation driven by the trace anomaly of conformally coupled matter fields. This model does not suffer from the problem of contrived initial conditions that occurs in most models of inflation driven by a scalar field. The universe can be nucleated semiclassically by a cosmological instanton that is much larger than the Planck scale provided there are sufficiently many matter fields. There are two cosmological instantons: the four sphere and a new ``double bubble'' solution. This paper considers a universe nucleated by the four sphere. The AdS/CFT correspondence is used to calculate the correlation function for scalar and tensor metric perturbations during the ensuing de Sitter phase. The analytic structure of the scalar and tensor propagators is discussed in detail. Observational constraints on the model are discussed. Quantum loops of matter fields are shown to strongly suppress short scale metric perturbations, which implies that short distance modifications of gravity would probably not be observable in the cosmic microwave background. This is probably true for any model of inflation provided there are sufficiently many matter fields. This point is illustrated by a comparison of anomaly driven inflation in four dimensions and in a Randall-Sundrum brane-world model.

  10. Driven superconducting quantum circuits

    NASA Astrophysics Data System (ADS)

    Nakamura, Yasunobu

    2014-03-01

    Driven nonlinear quantum systems show rich phenomena in various fields of physics. Among them, superconducting quantum circuits have very attractive features such as well-controlled quantum states with design flexibility, strong nonlinearity of Josephson junctions, strong coupling to electromagnetic driving fields, little internal dissipation, and tailored coupling to the electromagnetic environment. We have investigated properties and functionalities of driven superconducting quantum circuits. A transmon qubit coupled to a transmission line shows nearly perfect spatial mode matching between the incident and scattered microwave field in the 1D mode. Dressed states under a driving field are studied there and also in a semi-infinite 1D mode terminated by a resonator containing a flux qubit. An effective Λ-type three-level system is realized under an appropriate driving condition. It allows ``impedance-matched'' perfect absorption of incident probe photons and down conversion into another frequency mode. Finally, the weak signal from the qubit is read out using a Josephson parametric amplifier/oscillator which is another nonlinear circuit driven by a strong pump field. This work was partly supported by the Funding Program for World-Leading Innovative R&D on Science and Technology (FIRST), Project for Developing Innovation Systems of MEXT, MEXT KAKENHI ``Quantum Cybernetics,'' and the NICT Commissioned Research.

  11. Water-driven micromotors.

    PubMed

    Gao, Wei; Pei, Allen; Wang, Joseph

    2012-09-25

    We demonstrate the first example of a water-driven bubble-propelled micromotor that eliminates the requirement for the common hydrogen peroxide fuel. The new water-driven Janus micromotor is composed of a partially coated Al-Ga binary alloy microsphere prepared via microcontact mixing of aluminum microparticles and liquid gallium. The ejection of hydrogen bubbles from the exposed Al-Ga alloy hemisphere side, upon its contact with water, provides a powerful directional propulsion thrust. Such spontaneous generation of hydrogen bubbles reflects the rapid reaction between the aluminum alloy and water. The resulting water-driven spherical motors can move at remarkable speeds of 3 mm s(-1) (i.e., 150 body length s(-1)), while exerting large forces exceeding 500 pN. Factors influencing the efficiency of the aluminum-water reaction and the resulting propulsion behavior and motor lifetime, including the ionic strength and environmental pH, are investigated. The resulting water-propelled Al-Ga/Ti motors move efficiently in different biological media (e.g., human serum) and hold considerable promise for diverse biomedical or industrial applications. PMID:22891973

  12. A Multipurpose Interactive Videodisc with Ethical, Legal, Medical, Educational and Research Implications: The Informed Patient Decision-Making Procedure

    PubMed Central

    Lyon, Harold C.; Henderson, Joseph V.; Beck, J. Robert; Mulley, Albert G.; Barry, Michael J.; Fowler, Floyd J.; Wennberg, Coralea N.; Wennberg, John E.

    1989-01-01

    An interactive videodisc (using a single screen Macintosh II, HyperCard driven, Level III, CAV interactive videodisc) has been designed, produced, and pretested to permit patients with benign prostatic hyperplasia (BPH), facing a choice of surgery or watchful waiting, to take an active role in decision-making. The Informed Patient Decision-Making Procedure (IPDP) educates the patient about the benefits and harms of two treatment choices: prostatectomy and watchful waiting for BPH, by presenting patient-specific data derived from an analysis of medical outcomes. and video testimonials from patients with good and unfortunate outcomes of the therapeutic options. The IPDP standardizes the information provided to the patients, provides informed consent, gathers follow-up outcomes research data, and permits automated assessment of patient preferences and utilities. In this demonstration, the development of the IPDP is discussed, the videodisc program is presented, and lessons learned in creating medical videodiscs are shared.

  13. Automated control of hierarchical systems using value-driven methods

    NASA Technical Reports Server (NTRS)

    Pugh, George E.; Burke, Thomas E.

    1990-01-01

    An introduction is given to the Value-driven methodology, which has been successfully applied to solve a variety of difficult decision, control, and optimization problems. Many real-world decision processes (e.g., those encountered in scheduling, allocation, and command and control) involve a hierarchy of complex planning considerations. For such problems it is virtually impossible to define a fixed set of rules that will operate satisfactorily over the full range of probable contingencies. Decision Science Applications' value-driven methodology offers a systematic way of automating the intuitive, common-sense approach used by human planners. The inherent responsiveness of value-driven systems to user-controlled priorities makes them particularly suitable for semi-automated applications in which the user must remain in command of the systems operation. Three examples of the practical application of the approach in the automation of hierarchical decision processes are discussed: the TAC Brawler air-to-air combat simulation is a four-level computerized hierarchy; the autonomous underwater vehicle mission planning system is a three-level control system; and the Space Station Freedom electrical power control and scheduling system is designed as a two-level hierarchy. The methodology is compared with rule-based systems and with other more widely-known optimization techniques.

  14. [Decision to extract for periodontal reasons].

    PubMed

    Bercy, P; Blase, D

    1995-01-01

    The decisions to extract that are discussed here mainly relate to severe periodontal bone losses and plain interradicular attacks. Extractions for periodontal reasons appear at several treatment stages: immediate extraction in terminal stages, e.g. for teeth without any strategic importance, or deferred extraction if one chooses to wait for treatment response. The elements of the decision are various: function and strategic importance of the tooth, extension of the lesion, level of the interradicular attack, any endoperiodontal lesions, fractures and luxations, radicular proximity, implication of wisdom teeth, evolution after treatment. All these factors are discussed. PMID:7480928

  15. Make better decisions.

    PubMed

    Davenport, Thomas H

    2009-11-01

    Traditionally, decision making in organizations has rarely been the focus of systematic analysis. That may account for the astounding number of recent poor calls, such as decisions to invest in and securitize subprime mortgage loans or to hedge risk with credit default swaps. Business books are rich with insights about the decision process, but organizations have been slow to adopt their recommendations. It's time to focus on decision making, Davenport says, and he proposes four steps: (1) List and prioritize the decisions that must be made; (2) assess the factors that go into each, such as who plays what role, how often the decision must be made, and what information is available to support it; (3) design the roles, processes, systems, and behaviors your organization needs; and (4) institutionalize decision tools and assistance. The Educational Testing Service and The Stanley Works, among others, have succeeded in improving their decisions. ETS established a centralized deliberative body to make evidence-based decisions about new-product offerings, and Stanley has a Pricing Center of Excellence with internal consultants dedicated to its various business units. Leaders should bring multiple perspectives to their decision making, beware of analytical models that managers don't understand, be clear about their assumptions, practice "model management," and--because only people can revise decision criteria over time--cultivate human backups. PMID:19891389

  16. Subcutaneous Extravasation of Sr-89: Usefulness of Bremsstrahlung Imaging in Confirming Sr-89 Extravasation and in the Decision Making for the Choice of Treatment Strategies for Local Radiation Injuries Caused by Sr-89 Extravasation

    PubMed Central

    Kawabe, Joji; Higashiyama, Shigeaki; Kotani, Kohei; Yoshida, Atsushi; Tsushima, Hiroyuki; Yamanaga, Takashi; Tsuruta, Daisuke; Shiomi, Susumu

    2013-01-01

    A male patient in his 20s presented at our clinic with pain caused by bone metastases of the primitive neuroectodermal tumor, and Sr-89 was administrated to palliate the pain. After receiving the injection, the patient complained of a slight burning pain at the catheterized area. Slight reddening and small circular swelling (diameter, 0.5 cm) were observed at the catheterized area. Sr-89 extravasation was suspected. To estimate the amount of subcutaneous Sr-89 leakage, bremsstrahlung imaging was immediately performed. We speculated that the skin-absorbed dose from subcutaneous infiltration of Sr-89 was 1.78 Gy. The mildest clinical sign of local radiation injury was erythema. The received dose was higher than 3 Gy, and the time of onset was from 2 to 3 weeks. In our patient, local radiation injuries (LRIs) did not occur. Though requiring further verification, subsequent bremsstrahlung imaging and estimation of the skin-absorbed dose from the subcutaneous infiltration of Sr-89 are useful in confirming Sr-89 extravasation and in the decision making for the choice of treatment strategies for LRIs caused by Sr-89 extravasation. PMID:27408851

  17. Medical decision making for the incompetent patient.

    PubMed

    Drane, J F; Roth, R B

    1987-12-01

    In America competent adult patients have a right to refuse unwanted medical treatments. For incompetent patients who have made no advance directive, the family ordinarily makes decisions about medical treatments. But in many healthcare facilities, problems arise in choosing a surrogate to make decisions for an incompetent patient and in working with that surrogate. Concrete, step-by-step procedures for resolving conflict are needed. Every effort should be made to have competent patients fill out advance directives or indicate their treatment preferences in the event of loss of competence. Family members may not override decisions made by competent patients, but anyone closely involved with the patients' care may question their competence. The physician generally assesses the patients' competence, but sometimes the courts are involved. The physician may be the appropriate person to choose a surrogate for a patient with limited competence or to make decisions for a totally incompetent patient. The surrogate may be a relative, close friend, physician who knows the patient well, or someone provided by the hospital or government. Treatment decisions are made within the surrogate-patient-physician triad. When different value judgments about the proper treatment conflict, the surrogate may have to mediate to restore physician-patient communication, or institutional proceedings through the ethics committee may be needed to resolve disputes quickly, amicably, and at low cost. As a last resort, the case may be referred to the courts. PMID:10285412

  18. A Primer on Bayesian Decision Analysis With an Application to a Personalized Kidney Transplant Decision

    PubMed Central

    Neapolitan, Richard; Jiang, Xia; Ladner, Daniela P.; Kaplan, Bruce

    2016-01-01

    To provide personalized medicine, we not only must determine the treatments and other decisions most likely to be effective for a patient, but also consider the patient’s tradeoff between possible benefits of therapy versus possible loss of quality of life. There are numerous studies indicating that various treatments can negatively affect quality of life. Even if we have all information available for a given patient, it is an arduous task to amass the information to reach a decision that maximizes the utility of the decision to the patient. A clinical decision support system (CDSS) is a computer program, which is designed to assist healthcare professionals with decision making tasks. By utilizing emerging large datasets, we hold promise for developing CDSSs that can predict how treatments and other decisions can affect outcomes. However, we need to go beyond that; namely our CDSS needs to account for the extent to which these decisions can affect quality of life. This manuscript provides an introduction to developing CDSSs using Bayesian networks and influence diagrams. Such CDSSs are able to recommend decisions that maximize the expected utility of the predicted outcomes to the patient. By way of comparison, we examine the benefit and challenges of the Kidney Donor Risk Index (KDRI) as a decision support tool, and we discuss several difficulties with this index. Most importantly, the KDRI does not provide a measure of the expected quality of life if the kidney is accepted versus the expected quality of life if the patient stays on dialysis. Finally, we develop a schema for an influence diagram that models the kidney transplant decision, and show how the influence diagram approach can resolve these difficulties and provide the clinician and the potential transplant recipient with a valuable decision support tool. PMID:26900809

  19. System Driven Workarounds

    NASA Technical Reports Server (NTRS)

    Connell, Linda; Wichner, David; Jakey, Abegael Marie

    2013-01-01

    The Aviation Safety Reporting System (ASRS) in a partnership between the National Aeronautics and Space Administration (NASA), the Federal Aviation Administration (FAA), participating carriers, and labor organizations. It is designed to improve the National Airspace System by collecting and studying reports detailing unsafe conditions and events in the aviation industry. Employees are able to report safety issues or concerns with confidentiality and without fear of discipline. Safety reports highlighting system driven workarounds for the aviation community highlight the human workaround for the complex aviation system.

  20. THERMALLY DRIVEN ATMOSPHERIC ESCAPE

    SciTech Connect

    Johnson, Robert E.

    2010-06-20

    Accurately determining the escape rate from a planet's atmosphere is critical for determining its evolution. A large amount of Cassini data is now available for Titan's upper atmosphere and a wealth of data is expected within the next decade on escape from Pluto, Mars, and extra-solar planets. Escape can be driven by upward thermal conduction of energy deposited well below the exobase, as well as by nonthermal processes produced by energy deposited in the exobase region. Recent applications of a model for escape driven by upward thermal conduction, called the slow hydrodynamic escape model, have resulted in surprisingly large loss rates for the atmosphere of Titan, Saturn's largest moon. Based on a molecular kinetic simulation of the exobase region, these rates appear to be orders of magnitude too large. Therefore, the slow hydrodynamic model is evaluated here. It is shown that such a model cannot give a reliable description of the atmospheric temperature profile unless it is coupled to a molecular kinetic description of the exobase region. Therefore, the present escape rates for Titan and Pluto must be re-evaluated using the atmospheric model described here.

  1. Heat driven pulse pump

    NASA Technical Reports Server (NTRS)

    Benner, Steve M (Inventor); Martins, Mario S. (Inventor)

    2000-01-01

    A heat driven pulse pump includes a chamber having an inlet port, an outlet port, two check valves, a wick, and a heater. The chamber may include a plurality of grooves inside wall of the chamber. When heated within the chamber, a liquid to be pumped vaporizes and creates pressure head that expels the liquid through the outlet port. As liquid separating means, the wick, disposed within the chamber, is to allow, when saturated with the liquid, the passage of only liquid being forced by the pressure head in the chamber, preventing the vapor from exiting from the chamber through the outlet port. A plurality of grooves along the inside surface wall of the chamber can sustain the liquid, which is amount enough to produce vapor for the pressure head in the chamber. With only two simple moving parts, two check valves, the heat driven pulse pump can effectively function over the long lifetimes without maintenance or replacement. For continuous flow of the liquid to be pumped a plurality of pumps may be connected in parallel.

  2. Decision Making in Action

    NASA Technical Reports Server (NTRS)

    Orasanu, Judith; Statler, Irving C. (Technical Monitor)

    1994-01-01

    The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication

  3. Inertia and Decision Making.

    PubMed

    Alós-Ferrer, Carlos; Hügelschäfer, Sabine; Li, Jiahui

    2016-01-01

    Decision inertia is the tendency to repeat previous choices independently of the outcome, which can give rise to perseveration in suboptimal choices. We investigate this tendency in probability-updating tasks. Study 1 shows that, whenever decision inertia conflicts with normatively optimal behavior (Bayesian updating), error rates are larger and decisions are slower. This is consistent with a dual-process view of decision inertia as an automatic process conflicting with a more rational, controlled one. We find evidence of decision inertia in both required and autonomous decisions, but the effect of inertia is more clear in the latter. Study 2 considers more complex decision situations where further conflict arises due to reinforcement processes. We find the same effects of decision inertia when reinforcement is aligned with Bayesian updating, but if the two latter processes conflict, the effects are limited to autonomous choices. Additionally, both studies show that the tendency to rely on decision inertia is positively associated with preference for consistency. PMID:26909061

  4. Inertia and Decision Making

    PubMed Central

    Alós-Ferrer, Carlos; Hügelschäfer, Sabine; Li, Jiahui

    2016-01-01

    Decision inertia is the tendency to repeat previous choices independently of the outcome, which can give rise to perseveration in suboptimal choices. We investigate this tendency in probability-updating tasks. Study 1 shows that, whenever decision inertia conflicts with normatively optimal behavior (Bayesian updating), error rates are larger and decisions are slower. This is consistent with a dual-process view of decision inertia as an automatic process conflicting with a more rational, controlled one. We find evidence of decision inertia in both required and autonomous decisions, but the effect of inertia is more clear in the latter. Study 2 considers more complex decision situations where further conflict arises due to reinforcement processes. We find the same effects of decision inertia when reinforcement is aligned with Bayesian updating, but if the two latter processes conflict, the effects are limited to autonomous choices. Additionally, both studies show that the tendency to rely on decision inertia is positively associated with preference for consistency. PMID:26909061

  5. Data-driven healthcare: from patterns to actions.

    PubMed

    Grossglauser, M; Saner, H

    2014-11-01

    The era of big data opens up new opportunities in personalised medicine, preventive care, chronic disease management and in telemonitoring and managing of patients with implanted devices. The rich data accumulating within online services and internet companies provide a microscope to study human behaviour at scale, and to ask completely new questions about the interplay between behavioural patterns and health. In this paper, we shed light on a particular aspect of data-driven healthcare: autonomous decision-making. We first look at three examples where we can expect data-driven decisions to be taken autonomously by technology, with no or limited human intervention. We then discuss some of the technical and practical challenges that can be expected, and sketch the research agenda to address them. PMID:25354949

  6. Neural basis of quasi-rational decision making.

    PubMed

    Lee, Daeyeol

    2006-04-01

    Standard economic theories conceive homo economicus as a rational decision maker capable of maximizing utility. In reality, however, people tend to approximate optimal decision-making strategies through a collection of heuristic routines. Some of these routines are driven by emotional processes, and others are adjusted iteratively through experience. In addition, routines specialized for social decision making, such as inference about the mental states of other decision makers, might share their origins and neural mechanisms with the ability to simulate or imagine outcomes expected from alternative actions that an individual can take. A recent surge of collaborations across economics, psychology and neuroscience has provided new insights into how such multiple elements of decision making interact in the brain. PMID:16531040

  7. Systemic Data-Based Decision Making: A Systems Approach for Using Data in Schools

    ERIC Educational Resources Information Center

    Walser, Tamara M.

    2009-01-01

    No Child Left Behind has increased data collection and reporting, the development of data systems, and interest in using data for decision-making in schools and classrooms. Ends-driven decision making has become common educational practice, where the ends justify the means at all costs, and short-term results trump longer-term outcomes and the…

  8. Decision-Support Data Analysis: Examining Consistency among Teachers in Writing Assessment

    ERIC Educational Resources Information Center

    Archbald, Doug

    2011-01-01

    Education leaders and much literature exhort teachers and school leaders to use data more often and more effectively to guide planning and decision making--called, "data driven decision making." This term is ubiquitous in literature and reform discourse, but "on the ground," so to speak, practitioners face significant challenges in analyzing,…

  9. Decisions about Drug Use. Adolescent Decisions Curriculum.

    ERIC Educational Resources Information Center

    Brion-Meisels, Steven; And Others

    This teacher's manual for drug abuse education is one volume of a six volume curriculum for the secondary level, designed to provide a systematic, group-oriented approach to decision-making in areas crucial to adolescent development: drug (substance) use and abuse, sexuality and social relationships, juvenile law, work and people and government.…

  10. FENTON-DRIVEN REGENERATION OF GRANULAR ACTIVATED CARBON: A TECHNOLOGY OVERVIEW

    EPA Science Inventory

    A Fenton-driven mechanism for regenerating spent granular activated carbon (GAC) involves the combined, synergistic use of two reliable and well established treatment technologies - adsorption onto activated carbon and Fenton oxidation. During carbon adsorption treatment, enviro...

  11. Understanding The Lau Decision.

    ERIC Educational Resources Information Center

    Gounaris, Marilyn

    In a question and answer format, this booklet describes the Lau v. Nichols decision in which the Supreme Court ruled that the San Francisco Unified School District was guilty of discrimination because non-English speaking students were not given special language instruction. The booklet presents the basis for the Lau decision, describing a…

  12. Designing for Decision Making

    ERIC Educational Resources Information Center

    Jonassen, David H.

    2012-01-01

    Decision making is the most common kind of problem solving. It is also an important component skill in other more ill-structured and complex kinds of problem solving, including policy problems and design problems. There are different kinds of decisions, including choices, acceptances, evaluations, and constructions. After describing the centrality…

  13. Quantitative Decision Making.

    ERIC Educational Resources Information Center

    Baldwin, Grover H.

    The use of quantitative decision making tools provides the decision maker with a range of alternatives among which to decide, permits acceptance and use of the optimal solution, and decreases risk. Training line administrators in the use of these tools can help school business officials obtain reliable information upon which to base district…

  14. Repeated Causal Decision Making

    ERIC Educational Resources Information Center

    Hagmayer, York; Meder, Bjorn

    2013-01-01

    Many of our decisions refer to actions that have a causal impact on the external environment. Such actions may not only allow for the mere learning of expected values or utilities but also for acquiring knowledge about the causal structure of our world. We used a repeated decision-making paradigm to examine what kind of knowledge people acquire in…

  15. Decision Making and Cancer

    PubMed Central

    Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Pignone, Michael P.

    2014-01-01

    We review decision-making along the cancer continuum in the contemporary context of informed and shared decision making, in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cognition, emotion, and their interaction are described, including classical psychophysical approaches, dual-process approaches that focus on conflicts between emotion versus cognition (or reason), and modern integrative approaches such as fuzzy-trace theory. In contrast to the earlier emphasis on rote use of numerical detail, modern approaches emphasize understanding the bottom-line gist of options (which encompasses emotion and other influences on meaning) and retrieving relevant social and moral values to apply to those gist representations. Finally, research on interventions to support better decision making in clinical settings is reviewed, drawing out implications for future research on decision making and cancer. PMID:25730718

  16. Qplus AFM driven nanostencil.

    PubMed

    Grévin, B; Fakir, M; Hayton, J; Brun, M; Demadrille, R; Faure-Vincent, J

    2011-06-01

    We describe the development of a novel setup, in which large stencils with suspended silicon nitride membranes are combined with atomic force microscopy (AFM) regulation by using tuning forks. This system offers the possibility to perform separate AFM and nanostencil operations, as well as combined modes when using stencil chips with integrated tips. The flexibility and performances are demonstrated through a series of examples, including wide AFM scans in closed loop mode, probe positioning repeatability of a few tens of nanometer, simultaneous evaporation of large (several hundred of micron square) and nanoscopic metals and fullerene patterns in static, multistep, and dynamic modes. This approach paves the way for further developments, as it fully combines the advantages of conventional stenciling with the ones of an AFM driven shadow mask. PMID:21721701

  17. Muscle-driven nanogenerators

    DOEpatents

    Wang, Zhong L.; Yang, Rusen

    2011-03-01

    In a method of generating electricity, a plurality of living cells are grown on an array of piezoelectric nanowires so that the cells engage the piezoelectric nanowires. Induced static potentials are extracted from at least one of the piezoelectric nanowires when at least one of the cells deforms the at least one of the piezoelectric nanowires. A cell-driven electrical generator that includes a substrate and a plurality of spaced-apart piezoelectric nanowires disposed on the substrate. A plurality of spaced-apart conductive electrodes interact with the plurality of piezoelectric nanowires. A biological buffer layer that is configured to promote growth of cells is disposed on the substrate so that cells placed on the substrate will grow and engage the piezoelectric nanowires.

  18. Soliton driven angiogenesis

    PubMed Central

    Bonilla, L. L.; Carretero, M.; Terragni, F.; Birnir, B.

    2016-01-01

    Angiogenesis is a multiscale process by which blood vessels grow from existing ones and carry oxygen to distant organs. Angiogenesis is essential for normal organ growth and wounded tissue repair but it may also be induced by tumours to amplify their own growth. Mathematical and computational models contribute to understanding angiogenesis and developing anti-angiogenic drugs, but most work only involves numerical simulations and analysis has lagged. A recent stochastic model of tumour-induced angiogenesis including blood vessel branching, elongation, and anastomosis captures some of its intrinsic multiscale structures, yet allows one to extract a deterministic integropartial differential description of the vessel tip density. Here we find that the latter advances chemotactically towards the tumour driven by a soliton (similar to the famous Korteweg-de Vries soliton) whose shape and velocity change slowly. Analysing these collective coordinates paves the way for controlling angiogenesis through the soliton, the engine that drives this process. PMID:27503562

  19. Steady Capillary Driven Flow

    NASA Technical Reports Server (NTRS)

    Weislogel, Mark M.

    1996-01-01

    A steady capillary driven flow is developed for a liquid index in a circular tube which is partially coated with a surface modifier to produce a discontinuous wetting condition from one side of the tube to the other. The bulk flow is novel in that it is truly steady, and controlled solely by the physics associated with dynamic wetting. The influence of gravity on the flow is minimized through the use of small diameter tubes approximately O(1 mm) tested horizontally in a laboratory and larger tubes approximately O(10 mm) tested in the low gravity environment of a drop tower. Average steady velocities are predicted and compared against a large experimental data set which includes the effects of tube dimensions and fluid properties. The sensitivity of the velocity to surface cleanliness is dramatic and the advantages of experimentation in a microgravity environment are discussed.

  20. Consistent model driven architecture

    NASA Astrophysics Data System (ADS)

    Niepostyn, Stanisław J.

    2015-09-01

    The goal of the MDA is to produce software systems from abstract models in a way where human interaction is restricted to a minimum. These abstract models are based on the UML language. However, the semantics of UML models is defined in a natural language. Subsequently the verification of consistency of these diagrams is needed in order to identify errors in requirements at the early stage of the development process. The verification of consistency is difficult due to a semi-formal nature of UML diagrams. We propose automatic verification of consistency of the series of UML diagrams originating from abstract models implemented with our consistency rules. This Consistent Model Driven Architecture approach enables us to generate automatically complete workflow applications from consistent and complete models developed from abstract models (e.g. Business Context Diagram). Therefore, our method can be used to check practicability (feasibility) of software architecture models.

  1. Multilane driven diffusive systems

    NASA Astrophysics Data System (ADS)

    Curatolo, A. I.; Evans, M. R.; Kafri, Y.; Tailleur, J.

    2016-03-01

    We consider networks made of parallel lanes along which particles hop according to driven diffusive dynamics. The particles also hop transversely from lane to lane, hence indirectly coupling their longitudinal dynamics. We present a general method for constructing the phase diagram of these systems which reveals that in many cases their physics reduce to that of single-lane systems. The reduction to an effective single-lane description legitimizes, for instance, the use of a single TASEP to model the hopping of molecular motors along the many tracks of a single microtubule. Then, we show how, in quasi-2D settings, new phenomena emerge due to the presence of non-zero transverse currents, leading, for instance, to strong ‘shear localization’ along the network.

  2. Soliton driven angiogenesis

    NASA Astrophysics Data System (ADS)

    Bonilla, L. L.; Carretero, M.; Terragni, F.; Birnir, B.

    2016-08-01

    Angiogenesis is a multiscale process by which blood vessels grow from existing ones and carry oxygen to distant organs. Angiogenesis is essential for normal organ growth and wounded tissue repair but it may also be induced by tumours to amplify their own growth. Mathematical and computational models contribute to understanding angiogenesis and developing anti-angiogenic drugs, but most work only involves numerical simulations and analysis has lagged. A recent stochastic model of tumour-induced angiogenesis including blood vessel branching, elongation, and anastomosis captures some of its intrinsic multiscale structures, yet allows one to extract a deterministic integropartial differential description of the vessel tip density. Here we find that the latter advances chemotactically towards the tumour driven by a soliton (similar to the famous Korteweg-de Vries soliton) whose shape and velocity change slowly. Analysing these collective coordinates paves the way for controlling angiogenesis through the soliton, the engine that drives this process.

  3. Soliton driven angiogenesis.

    PubMed

    Bonilla, L L; Carretero, M; Terragni, F; Birnir, B

    2016-01-01

    Angiogenesis is a multiscale process by which blood vessels grow from existing ones and carry oxygen to distant organs. Angiogenesis is essential for normal organ growth and wounded tissue repair but it may also be induced by tumours to amplify their own growth. Mathematical and computational models contribute to understanding angiogenesis and developing anti-angiogenic drugs, but most work only involves numerical simulations and analysis has lagged. A recent stochastic model of tumour-induced angiogenesis including blood vessel branching, elongation, and anastomosis captures some of its intrinsic multiscale structures, yet allows one to extract a deterministic integropartial differential description of the vessel tip density. Here we find that the latter advances chemotactically towards the tumour driven by a soliton (similar to the famous Korteweg-de Vries soliton) whose shape and velocity change slowly. Analysing these collective coordinates paves the way for controlling angiogenesis through the soliton, the engine that drives this process. PMID:27503562

  4. Doc, What Would You Do If You Were Me? On Self-Other Discrepancies in Medical Decision Making

    ERIC Educational Resources Information Center

    Garcia-Retamero, Rocio; Galesic, Mirta

    2012-01-01

    Doctors often make decisions for their patients and predict their patients' preferences and decisions to customize advice to their particular situation. We investigated how doctors make decisions about medical treatments for their patients and themselves and how they predict their patients' decisions. We also studied whether these decisions and…

  5. Fluid-driven metamorphism

    NASA Astrophysics Data System (ADS)

    Jamtveit, B.; Ulven, O. I.; Malthe-Sorenssen, A.

    2014-12-01

    Metamorphic processes in the Earth crust are almost invariably associated with fluid migration. Many lines of evidence suggest that fluid migration is intimately coupled both to the metamorphic reactions, and to associated deformation processes. Petrologic arguments suggest that all granulite facies and most amphibolite facies rocks are essentially dry (no free fluid phase) at normal geothermal gradients outside periods of heating-produced fluid generation. In addition, except at high pressure - low temperature condition, fluid-consuming reactions leads to an increase in solid volume and a potential clogging of any initial pore space. Hence, fluid migration in medium and high-grade metamorphic rocks is in general associated with some porosity producing process. Porosity generation may occur by either chemical or mechanical processes. In systems with high fluid fluxes, porosity may be produced by dissolution and transport of mass out of the system. Such fluxes can normally only be sustained over short length scales and limited time scales. In systems where the infiltrating fluid is far from equilibrium with the rock matrix, mechanical porosity generation can arise from local stresses generated by the volume change of volatilization reactions. Furthermore, it has become increasingly clear that crustal rocks may be under significant tectonic stress, even far from plate tectonic boundaries. In situations where the rocks are close to critically stressed, any stress perturbations caused by reaction driven changes in solid volume or fluid pressure gradients may lead to dilatant deformation and porosity production on a scale much larger than the characteristic length scales of the reacting rock units. Field observations, experimental studies and modeling results will be presented that focus on reaction driven porosity generation in systems subject to variable initial differential stresses.

  6. Hypoplastic left heart syndrome: parent support for early decision making.

    PubMed

    Toebbe, Sarah; Yehle, Karen; Kirkpatrick, Jane; Coddington, Jennifer

    2013-01-01

    Hypoplastic left heart syndrome is a life threatening congenital cardiac anomaly. After a child has been diagnosed with hypoplastic left heart syndrome, parents must make life or death decisions within days of birth. Healthcare providers must provide appropriate education so that parents are able to make informed, timely decisions. Information regarding the diagnosis, treatment options, and parental decision making process for initial decision making for hypoplastic left heart syndrome are provided to guide nurses who work with these families. The challenging decision making process that parents must go through after diagnosis of hypoplastic left heart syndrome will be described. PMID:23246301

  7. Data-Driven Decision Making in Out-of-School Time Programs. Part 6 in a Series on Implementing Evidence-Based Practices in Out-of-School Time Programs: The Role of Organization-Level Activities. Research-to-Results Brief. Publication #2009-34

    ERIC Educational Resources Information Center

    Bandy, Tawana; Burkhauser, Mary; Metz, Allison J. R.

    2009-01-01

    Although many program managers look to data to inform decision-making and manage their programs, high-quality program data may not always be available. Yet such data are necessary for effective program implementation. The use of high-quality data facilitates program management, reduces reliance on anecdotal information, and ensures that data are…

  8. A regret theory approach to decision curve analysis: A novel method for eliciting decision makers' preferences and decision-making

    PubMed Central

    2010-01-01

    appealing to a decision-maker, particularly in those clinical situations when the best management option is the one associated with the least amount of regret (e.g. diagnosis and treatment of advanced cancer, etc). PMID:20846413

  9. Decision Neuroscience: Neuroeconomics

    PubMed Central

    Smith, David V.; Huettel, Scott A.

    2012-01-01

    Few aspects of human cognition are more personal than the choices we make. Our decisions – from the mundane to the impossibly complex – continually shape the courses of our lives. In recent years, researchers have applied the tools of neuroscience to understand the mechanisms that underlie decision making, as part of the new discipline of decision neuroscience. A primary goal of this emerging field has been to identify the processes that underlie specific decision variables, including the value of rewards, the uncertainty associated with particular outcomes, and the consequences of social interactions. Recent work suggests potential neural substrates that integrate these variables, potentially reflecting a common neural currency for value, to facilitate value comparisons. Despite the successes of decision neuroscience research for elucidating brain mechanisms, significant challenges remain. These include building new conceptual frameworks for decision making, integrating research findings across disparate techniques and species, and extending results from neuroscience to shape economic theory. To overcome these challenges, future research will likely focus on interpersonal variability in decision making, with the eventual goal of creating biologically plausible models for individual choice. PMID:22754602

  10. Rapid Decisions From Experience

    PubMed Central

    Zeigenfuse, Matthew D.; Pleskac, Timothy J.; Liu, Taosheng

    2014-01-01

    In many everyday decisions, people quickly integrate noisy samples of information to form a preference among alternatives that offer uncertain rewards. Here, we investigated this decision process using the Flash Gambling Task (FGT), in which participants made a series of choices between a certain payoff and an uncertain alternative that produced a normal distribution of payoffs. For each choice, participants experienced the distribution of payoffs via rapid samples updated every 50 ms. We show that people can make these rapid decisions from experience and that the decision process is consistent with a sequential sampling process. Results also reveal a dissociation between these preferential decisions and equivalent perceptual decisions where participants had to determine which alternatives contained more dots on average. To account for this dissociation, we developed a sequential sampling rank-dependent utility model, which showed that participants in the FGT attended more to larger potential payoffs than participants in the perceptual task despite being given equivalent information. We discuss the implications of these findings in terms of computational models of preferential choice and a more complete understanding of experience-based decision making. PMID:24549141

  11. Multiobjective decision theory for computational optimization in radiation therapy.

    PubMed

    Yu, Y

    1997-09-01

    Machine-guided iterative optimization in radiation oncology requires ordinal or cardinal ranking of competing treatment plans. When the clinical objectives are multifaceted and incommensurable, the ranking formalism must take into account the decision maker's tradeoff strategies in a multidimensional decision space. To capture the decision processes in treatment planning, a multiobjective decision-theoretic scheme is formulated. Ranking among a group of candidate plans is based on a generalized distance metric. A dynamic metric weighting function is defined based on the state energy of the decision system, which is assumed to undergo thermodynamic cooling with iteration time. The decision maker is required to specify a baseline ranking of the objectives, which is taken to be the ground state of the decision system. This decision-theoretic formalism was applied to idealized cases in stereotactic radiosurgery and prostatic implantation, using the genetic algorithm as the optimization engine. The optimization pathways and the outcome at limited horizons indicated that the combined scheme of decision-theoretic steering and iterative optimization was robust and produced treatment plans consistent with the user's expectation. The effect of treatment uncertainties was simulated using imperfect objectives; however, certain recurring plans could be identified as optimized baseline solutions. Overall, the present formalism provides a realistic alternative to complete utility assessment or human-guided exploration of the efficient solution set. PMID:9304573

  12. Air Sparging Decision Tool

    Energy Science and Technology Software Center (ESTSC)

    1996-06-10

    The Air Sparging Decision Tool is a computer decision aid to help environmental managers and field practitioners in evaluating the applicability of air sparging to a wide range of sites and for refining the operation of air sparging systems. The program provides tools for the practitioner to develop the conceptual design for an air sparging system suitable for the identified site. The Tool provides a model of the decision making process, not a detailed designmore » of air sparging systems. The Tool will quickly and cost effectively assist the practitioner in screening for applicability of the technology at a proposed site.« less

  13. Yield threshold decision framework

    SciTech Connect

    Judd, B.R.; Younker, L.W.; Hannon, W.J.

    1989-08-17

    The USA is developing a decision analysis framework for evaluating the relative value of lower yield thresholds and related verification policies. The framework facilitates systematic analysis of the major issues in the yield threshold decision. The framework can be used to evaluate options proposed either in the inter-agency process or in the negotiations. In addition, the framework can measure the importance of uncertainties and alternative judgments, and thereby determine the advantages of additional research. Since the model is explicit and quantitative, it provides a rational, defensible approach for reaching important treaty and verification decisions. 9 figs.

  14. MRI driven magnetic microswimmers.

    PubMed

    Kósa, Gábor; Jakab, Péter; Székely, Gábor; Hata, Nobuhiko

    2012-02-01

    Capsule endoscopy is a promising technique for diagnosing diseases in the digestive system. Here we design and characterize a miniature swimming mechanism that uses the magnetic fields of the MRI for both propulsion and wireless powering of the capsule. Our method uses both the static and the radio frequency (RF) magnetic fields inherently available in MRI to generate a propulsive force. Our study focuses on the evaluation of the propulsive force for different swimming tails and experimental estimation of the parameters that influence its magnitude. We have found that an approximately 20 mm long, 5 mm wide swimming tail is capable of producing 0.21 mN propulsive force in water when driven by a 20 Hz signal providing 0.85 mW power and the tail located within the homogeneous field of a 3 T MRI scanner. We also analyze the parallel operation of the swimming mechanism and the scanner imaging. We characterize the size of artifacts caused by the propulsion system. We show that while the magnetic micro swimmer is propelling the capsule endoscope, the operator can locate the capsule on the image of an interventional scene without being obscured by significant artifacts. Although this swimming method does not scale down favorably, the high magnetic field of the MRI allows self propulsion speed on the order of several millimeter per second and can propel an endoscopic capsule in the stomach. PMID:22037673

  15. Gradient Driven Fluctuations

    NASA Technical Reports Server (NTRS)

    Cannell, David

    2005-01-01

    We have worked with our collaborators at the University of Milan (Professor Marzio Giglio and his group-supported by ASI) to define the science required to measure gradient driven fluctuations in the microgravity environment. Such a study would provide an accurate test of the extent to which the theory of fluctuating hydrodynamics can be used to predict the properties of fluids maintained in a stressed, non-equilibrium state. As mentioned above, the results should also provide direct visual insight into the behavior of a variety of fluid systems containing gradients or interfaces, when placed in the microgravity environment. With support from the current grant, we have identified three key systems for detailed investigation. These three systems are: 1) A single-component fluid to be studied in the presence of a temperature gradient; 2) A mixture of two organic liquids to be studied both in the presence of a temperature gradient, which induces a steady-state concentration gradient, and with the temperature gradient removed, but while the concentration gradient is dying by means of diffusion; 3) Various pairs of liquids undergoing free diffusion, including a proteidbuffer solution and pairs of mixtures having different concentrations, to allow us to vary the differences in fluid properties in a controlled manner.

  16. Compositionally Driven Dynamos

    NASA Astrophysics Data System (ADS)

    Soderlund, K. M.; Schubert, G.

    2014-12-01

    It is generally believed that compositional convection driven by inner core solidification is the main driver of the geodynamo. Thermal evolution considerations make it likely that compositional convection is also behind the present dynamos of Mercury and Ganymede as well as the early dynamos in the Moon, Mars and smaller solar system bodies. Compositional buoyancy can arise in several different ways, for example, through inner core solidification and FeS flotation with upward mixing and through freezing out and sinking of iron snow near the core-mantle boundary or deeper within the core. The mode of core cooling and freezing depends on conditions of temperature and pressure in the core and the concentration of light elements such as sulfur. Different distributions of compositional buoyancy will give rise to different patterns of core convection and dynamo magnetic fields. We report here the first results of a systematic study of the distribution of compositional buoyancy on the dynamo-generated magnetic fields, with an emphasis on Mars' core evolution due to iron rain.

  17. Beam Driven Stratospheric Airship

    NASA Astrophysics Data System (ADS)

    Onda, Masahiko

    2003-05-01

    Even though satellite, balloons and aircraft have served admirably as aerospace platforms for remote sensing and telecommunication, requirements for a new kind of platforms - an easily modifiable, sub-orbital platform - have been widely identified. The High-Altitude Long-Range Observational Platform(HALROP) was at first conceptualized as a solar power driven unmanned LTA (Lighter-Than-Air) vehicle or an airship to maintain a station-keeping position in the lower stratosphere for long-durations and to carry out missions such as high-resolution monitoring and high-speed informational relays. Nevertheless solar power is not available in winter seasons in the high-latitudinal regions. Therefore, alternative power sources are necessary and the candidates are surface-to-air transmission of microwave energy and high-power laser beams. The author introduces a wireless power transmission test by microwave carried in 1995 in Kobe, Japan, and then, discusses possibilities of using laser beam for powering such LTA platforms.

  18. Invention-driven marketing

    NASA Technical Reports Server (NTRS)

    Carlson, William E.

    1994-01-01

    Suppose you have just created a revolutionary bicycle suspension which allows a bike to be ridden over rough terrain at 60 miles per hour. In addition, suppose that you are deeply concerned about the plight of hungry children. Which should you do: be sure all hungry children have bicycles; transfer the technology for your new suspension to bicycle manufacturers worldwide; or start a company to supply premium sports bicycle based on your patented technology, and donate the profits to a charity which feeds hungry children? Woven through this somewhat trivial example is the paradox of technology transfer - the supplier (owner) may want to transfer technology; but to succeed, he or she must reformulate the problem as a user need for which there is a new and better solution. Successful technology transfer is little more than good marketing applied to an existing invention, process, or capability. You must identify who needs the technology, why they need it, why the new technology is better than alternatives, how much the customers are willing and able to pay for these benefits, and how to distribute products based on the technology tc the target customers. In market-driven development, the term 'technology transfer' is rarely used. The developers focus on studying user needs and designing solution They may have technology needs, but they don't have technology in search of a use.

  19. Fluid driven recipricating apparatus

    DOEpatents

    Whitehead, John C.

    1997-01-01

    An apparatus comprising a pair of fluid driven pump assemblies in a back-to-back configuration to yield a bi-directional pump. Each of the pump assemblies includes a piston or diaphragm which divides a chamber therein to define a power section and a pumping section. An intake-exhaust valve is connected to each of the power sections of the pump chambers, and function to direct fluid, such as compressed air, into the power section and exhaust fluid therefrom. At least one of the pistons or diaphragms is connected by a rod assembly which is constructed to define a signal valve, whereby the intake-exhaust valve of one pump assembly is controlled by the position or location of the piston or diaphragm in the other pump assembly through the operation of the rod assembly signal valve. Each of the pumping sections of the pump assemblies are provided with intake and exhaust valves to enable filling of the pumping section with fluid and discharging fluid therefrom when a desired pressure has been reached.

  20. Fluid driven reciprocating apparatus

    DOEpatents

    Whitehead, J.C.

    1997-04-01

    An apparatus is described comprising a pair of fluid driven pump assemblies in a back-to-back configuration to yield a bi-directional pump. Each of the pump assemblies includes a piston or diaphragm which divides a chamber therein to define a power section and a pumping section. An intake-exhaust valve is connected to each of the power sections of the pump chambers, and function to direct fluid, such as compressed air, into the power section and exhaust fluid therefrom. At least one of the pistons or diaphragms is connected by a rod assembly which is constructed to define a signal valve, whereby the intake-exhaust valve of one pump assembly is controlled by the position or location of the piston or diaphragm in the other pump assembly through the operation of the rod assembly signal valve. Each of the pumping sections of the pump assemblies are provided with intake and exhaust valves to enable filling of the pumping section with fluid and discharging fluid therefrom when a desired pressure has been reached. 13 figs.

  1. Scope and nature of prescribing decisions made by general practitioners

    PubMed Central

    Denig, P; Witteman, C; Schouten, H

    2002-01-01

    Background: This study describes cognitive processes of doctors who are deciding on the treatment for a patient. This helps to uncover how prescribing decisions could benefit from (computerised) support. Methods: While thinking aloud, 61 general practitioners made prescribing decisions for five patients with urinary tract infections or stomach complaints. The resulting 305 transcripts were analysed to determine the scope and nature of the decision processes. Differences in the process were related to case or doctor characteristics, and to differences in the quality of prescribing behaviour. Results: The decision processes were not extensive, particularly for patients with a urinary tract infection. The doctors did not actively consider all possible relevant information. Considerations referring to core aspects of the treatment were made in 159 cases (52%) and to contextual aspects in 111 cases (36%). Habitual behaviour, defined as making a treatment decision without any specific contemplation, was observed in 118 cases (40%) and resulted in prescribing first choice as well as second choice drugs. For stomach complaints, second choice drugs were often prescribed after considering other treatments or in view of specific circumstances. Experience of the doctor was not related to the type of decision process. Conclusions: The processes observed deviate from the decision theoretic norm of thoroughly evaluating all possible options, but these deviations do not always result in suboptimal prescribing. Decision support is useful for bringing pertinent information and first choice treatments to the prescriber's attention. In particular, information about relevant contraindications, interactions, and costs could improve the quality of prescribing. PMID:12448805

  2. Decision-making processes of youth.

    PubMed

    Moore, J W; Jensen, B; Hauck, W E

    1990-01-01

    Research supports the theory that after administrators make a decision, feedback, both positive and negative, and also the administrators' perceived security vis-à-vis their position affect their level of commitment to a course of action. However, this research fails to recognize that subjects of college age playing administrators in the simulated, experimental treatments which have been presented in the research had nothing personally to lose if they made a bad decision--an orientation contradictory to the reality of most actual administrative positions. Additionally, the research ignores the interactional effects of the personality of decision makers in terms of their anxiety levels and the judgments they make. This study took both of these considerations into account by creating a decision-making situation within which prospective administrators made monetary commitments to long-term goals while their anxiety level, both as a basic personality attribute and an index of the reality of the decision-making process, was monitored under conditions of varying levels of job insecurity and resistance to their policies in relation to their decisions. Analyses revealed that contrary to the results of past research which used college students as subjects: (1) there is a significant negative correlation between levels of anxiety and commitments to previously chosen courses of action; (2) there are no significant effects of job security on commitment; and, most importantly, (3) high resistance to a policy decision leads to significantly less monetary commitments to long-term goals. The findings suggest that the basis for the contradictory results lies with the anxiety level of decision makers and the realism of experiencing a loss by making poor decisions. PMID:2264508

  3. Colorado Special Education Administrative Decisions: Impartial Hearing Officer Decisions; State Level Review Decisions; Federal Complaint Findings.

    ERIC Educational Resources Information Center

    Colorado State Dept. of Education, Denver.

    This volume of Colorado special education administrative decisions contains all Impartial Hearing Officer Decisions, State Level Review Decisions, and Complaint Findings issued since 1988. The full text of each decision or finding is preceded by a case summary which includes a listing of key topics, a statement of the issues, the decision, and…

  4. People and Decisions.

    ERIC Educational Resources Information Center

    Fortney, Nancy D.; Glover, Kathy H.

    1979-01-01

    Suggests that social studies classroom teachers should use the process of rational decision making to teach students how to think at higher intellectual levels, become more creative, clarify values, and increase moral development. Learning activities are described. (DB)

  5. Shared decision making

    MedlinePlus

    ... Shared decision making to improve care and reduce costs. N Engl J Med . 2013 Jan 3;368(1):6-8. ... UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David ...

  6. Comparison of Decision Models

    NASA Technical Reports Server (NTRS)

    Feinberg, A.; Miles, J. R. F.; Smith, J. H.; Scheuer, E. M.

    1986-01-01

    Two methods of multiattribute decision analysis compared in report. One method employs linear utility model. Other utilizes multiplicative utility model. Report based on interviews with experts in automotive technology to obtain their preferences regarding 10 new types of vehicles.

  7. Men and abortion decisions.

    PubMed

    Hardwig, John

    2015-01-01

    Whether to go forward with a pregnancy is often viewed as the decision solely of the woman. But much as motherhood should not be imposed on a woman, fatherhood should not be imposed on a man. PMID:25677781

  8. Argumentation for Decision Making

    NASA Astrophysics Data System (ADS)

    Amgoud, Leila

    Decision making, often viewed as a form of reasoning toward action, has raised the interest of many scholars including economists, psychologists, and computer scientists for a long time. Any decision problem amounts to selecting the “best” or sufficiently “good” action(s) that are feasible among different alternatives, given some available information about the current state of the world and the consequences of potential actions. Available information may be incomplete or pervaded with uncertainty. Besides, the goodness of an action is judged by estimating how much its possible consequences fit the preferences of the decision maker. This agent is assumed to behave in a rational way [29] amgoud-woold, at least in the sense that his decisions should be as much as possible consistent with his preferences.

  9. The impact of the Oncotype DX Recurrence Score on treatment decisions and clinical outcomes in patients with early breast cancer: the Maccabi Healthcare Services experience with a unified testing policy

    PubMed Central

    Siegelmann-Danieli, Nava; Silverman, Barbara; Zick, Aviad; Beit-Or, Anat; Katzir, Itzhak; Porath, Avi

    2013-01-01

    The Oncotype DX Recurrence Score is a validated prognosticator in oestrogen receptor positive (ER+) breast cancer. Our retrospective analysis of a prospectively defined cohort summarises the clinical implications associated with Oncotype DX testing according to the Maccabi Healthcare Services (MHS) policy. The MHS eligibility criteria for testing included ER+ N0/pN1mic invasive tumours, discussion of test implications with an oncologist, ductal carcinoma 0.6–1 cm Grade 2–3, HER2 negative ductal carcinomas with 1.1–4.0 cm Grade 1–2, or lobular carcinoma. Large (> 1 cm) Grade 3 tumours could have grade reassessed. We linked Recurrence Score results with patients’ information and used chi-squared tests to assess the associations thereof. Between January 2008 and December 2011, tests were performed on 751 patients (MHS-eligible, 713); 54%, 38%, and 8% of patients had low, intermediate, and high Recurrence Score results, respectively. Recurrence Score distribution varied significantly with age (P = 0.002), with increasing Recurrence Score values with decreasing age. The proportion of patients with high Recurrence Score results varied by grade/size combination and histology, occurring in 32% of small (≤ 1 cm) Grade 3 and 3% of larger (1.1–4 cm) Grade 1 ductal tumours and only in 2% of lobular carcinomas. Chemotherapy was administered to 1%, 13%, and 61% of patients with low, intermediate, and high Recurrence Score results, respectively (P < 0.0001), but only to 2% of intermediate score patients ≥ 65 years. Luteinising-hormone-releasing hormone agonists with tamoxifen were used in 27% of low Recurrence Score patients ≤ 50 years. With a median follow-up of 26 months, no systemic recurrences were documented, whereas four patients exhibited locoregional recurrences. In summary, in this low-to-moderate risk patient population, testing identified 46% of patients as intermediate/high risk. Treatment decisions were influenced by Recurrence Score results and

  10. Risky Decision-making: Prefrontal Function and Mesocorticolimbic Resting-state Connectivity in Methamphetamine Users

    PubMed Central

    Kohno, Milky; Morales, Angelica M.; Ghahremani, Dara G.; Hellemann, Gerhard; London, Edythe D.

    2014-01-01

    by risk during decision-making was positively related to resting-state functional connectivity of the right dorsolateral prefrontal cortex with the striatum. Conclusions and Relevance Maladaptive decision-making by methamphetamine users may reflect circuit-level dysfunction, underlying deficits in task-based activation. Heightened resting-state connectivity within the mesocorticolimbic system, coupled with reduced prefrontal cortical connectivity, may create a bias toward reward-driven behavior over cognitive control in methamphetamine users. Interventions to improve this balance may enhance treatments for stimulant dependence and other disorders that involve maladaptive decision-making. PMID:24850532

  11. Decision support tools for policy and planning

    SciTech Connect

    Jacyk, P.; Schultz, D.; Spangenberg, L.

    1995-07-01

    A decision support system (DSS) is being developed at the Radioactive Liquid Waste Treatment Facility, Los Alamos National Laboratory (LANL). The DSS will be used to evaluate alternatives for improving LANL`s existing central radioactive waste water treatment plant and to evaluate new site-wide liquid waste treatment schemes that are required in order to handle the diverse waste streams produced at LANL. The decision support system consists of interacting modules that perform the following tasks: rigorous process simulation, configuration management, performance analysis, cost analysis, risk analysis, environmental impact assessment, transportation modeling, and local, state, and federal regulation compliance checking. Uncertainty handling techniques are used with these modules and also with a decision synthesis module which combines results from the modules listed above. We believe the DSS being developed can be applied to almost any other industrial water treatment facility with little modification because in most situations the waste streams are less complex, fewer regulations apply, and the political environment is simpler. The techniques being developed are also generally applicable to policy and planning decision support systems in the chemical process industry.

  12. Pilot Decision-Making in Irreversible Emergencies

    ERIC Educational Resources Information Center

    Winter, Scott R.

    2013-01-01

    The purpose of this study was to determine if a reflexive learning treatment utilizing select case studies could enhance the decision-making of pilots who encounter an irreversible emergency. Participants, who consisted of members of the subject university's professional pilot program, were divided into either a control or experimental group and…

  13. 42 CFR 8.33 - Written decision.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 1 2012-10-01 2012-10-01 false Written decision. 8.33 Section 8.33 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS CERTIFICATION OF OPIOID TREATMENT PROGRAMS Procedures for Review of Suspension or Proposed Revocation of OTP Certification, and...

  14. 42 CFR 8.33 - Written decision.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 1 2014-10-01 2014-10-01 false Written decision. 8.33 Section 8.33 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS CERTIFICATION OF OPIOID TREATMENT PROGRAMS Procedures for Review of Suspension or Proposed Revocation of OTP Certification, and...

  15. 42 CFR 8.33 - Written decision.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 1 2013-10-01 2013-10-01 false Written decision. 8.33 Section 8.33 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS CERTIFICATION OF OPIOID TREATMENT PROGRAMS Procedures for Review of Suspension or Proposed Revocation of OTP Certification, and...

  16. Assessment of Unconscious Decision Aids Applied to Complex Patient-Centered Medical Decisions

    PubMed Central

    Manigault, Andrew Wilhelm; Whillock, Summer Rain

    2015-01-01

    Background To improve patient health, recent research urges for medical decision aids that are designed to enhance the effectiveness of specific medically related decisions. Many such decisions involve complex information, and decision aids that independently use deliberative (analytical and slower) or intuitive (more affective and automatic) cognitive processes for such decisions result in suboptimal decisions. Unconscious thought can arguably use both intuitive and deliberative (slow and analytic) processes, and this combination may further benefit complex patient (or practitioner) decisions as medical decision aids. Indeed, mounting research demonstrates that individuals render better decisions generally if they are distracted from thinking consciously about complex information after it is presented (but can think unconsciously), relative to thinking about that information consciously or not at all. Objective The current research tested whether the benefits of unconscious thought processes can be replicated using an Internet platform for a patient medical decision involving complex information. This research also explored the possibility that judgments reported after a period of unconscious thought are actually the result of a short period of conscious deliberation occurring during the decision report phase. Methods A total of 173 participants in a Web-based experiment received information about four medical treatments, the best (worst) associated with mostly positive (negative) side-effects/attributes and the others with equal positive-negative ratios. Next, participants were either distracted for 3 minutes (unconscious thought), instructed to think about the information for 3 minutes (conscious thought), or moved directly to the decision task (immediate decision). Finally, participants reported their choice of, and attitudes toward, the treatments while experiencing high, low, or no cognitive load, which varied their ability to think consciously while

  17. Epidemic cycles driven by host behaviour

    PubMed Central

    Althouse, Benjamin M.; Hébert-Dufresne, Laurent

    2014-01-01

    Host immunity and demographics (the recruitment of susceptibles via birthrate) have been demonstrated to be a key determinant of the periodicity of measles, pertussis and dengue epidemics. However, not all epidemic cycles are from pathogens inducing sterilizing immunity or are driven by demographics. Many sexually transmitted infections are driven by sexual behaviour. We present a mathematical model of disease transmission where individuals can disconnect and reconnect depending on the infectious status of their contacts. We fit the model to historic syphilis (Treponema pallidum) and gonorrhea (Neisseria gonorrhoeae) incidence in the USA and explore potential intervention strategies against syphilis. We find that cycles in syphilis incidence can be driven solely by changing sexual behaviour in structured populations. Our model also explains the lack of similar cycles in gonorrhea incidence even if the two infections share the same propagation pathways. Our model similarly illustrates how sudden epidemic outbreaks can occur on time scales smaller than the characteristic demographic time scale of the population and that weaker infections can lead to more violent outbreaks. Behaviour also appears to be critical for control strategies as we found a bigger sensitivity to behavioural interventions than antibiotic treatment. Thus, behavioural interventions may play a larger role than previously thought, especially in the face of antibiotic resistance and low intervention efficacies. PMID:25100316

  18. Epidemic cycles driven by host behaviour.

    PubMed

    Althouse, Benjamin M; Hébert-Dufresne, Laurent

    2014-10-01

    Host immunity and demographics (the recruitment of susceptibles via birthrate) have been demonstrated to be a key determinant of the periodicity of measles, pertussis and dengue epidemics. However, not all epidemic cycles are from pathogens inducing sterilizing immunity or are driven by demographics. Many sexually transmitted infections are driven by sexual behaviour. We present a mathematical model of disease transmission where individuals can disconnect and reconnect depending on the infectious status of their contacts. We fit the model to historic syphilis (Treponema pallidum) and gonorrhea (Neisseria gonorrhoeae) incidence in the USA and explore potential intervention strategies against syphilis. We find that cycles in syphilis incidence can be driven solely by changing sexual behaviour in structured populations. Our model also explains the lack of similar cycles in gonorrhea incidence even if the two infections share the same propagation pathways. Our model similarly illustrates how sudden epidemic outbreaks can occur on time scales smaller than the characteristic demographic time scale of the population and that weaker infections can lead to more violent outbreaks. Behaviour also appears to be critical for control strategies as we found a bigger sensitivity to behavioural interventions than antibiotic treatment. Thus, behavioural interventions may play a larger role than previously thought, especially in the face of antibiotic resistance and low intervention efficacies. PMID:25100316

  19. Guardianship and End-of-Life Decision Making.

    PubMed

    Cohen, Andrew B; Wright, Megan S; Cooney, Leo; Fried, Terri

    2015-10-01

    As the population ages, more adults will develop impaired decision-making capacity and have no family members or friends available to make medical decisions on their behalf. In such situations, a professional guardian is often appointed by the court. This official has no preexisting relationship with the impaired individual but is paid to serve as a surrogate decision maker. When a professional guardian is faced with decisions concerning life-sustaining treatment, substituted judgment may be impossible, and reports have repeatedly suggested that guardians are reluctant to make the decision to limit care. Physicians are well positioned to assist guardians with these decisions and safeguard the rights of the vulnerable persons they represent. Doing so effectively requires knowledge of the laws governing end-of-life decisions by guardians. However, physicians are often uncertain about whether guardians are empowered to withhold treatment and when their decisions require judicial review. To address this issue, we analyzed state guardianship statutes and reviewed recent legal cases to characterize the authority of a guardian over choices about end-of-life treatment. We found that most state guardianship statutes have no language about end-of-life decisions. We identified 5 legal cases during the past decade that addressed a guardian's authority over these decisions, and only 1 case provided a broad framework applicable to clinical practice. Work to improve end-of-life decision making by guardians may benefit from a multidisciplinary effort to develop comprehensive standards to guide clinicians and guardians when treatment decisions need to be made. PMID:26258634

  20. Tools to Promote Shared Decision Making in Serious Illness

    PubMed Central

    Austin, C. Adrian; Mohottige, Dinushika; Sudore, Rebecca L.; Smith, Alexander K.; Hanson, Laura C.

    2016-01-01

    IMPORTANCE Serious illness impairs function and threatens survival. Patients facing serious illness value shared decision making, yet few decision aids address the needs of this population. OBJECTIVE To perform a systematic review of evidence about decision aids and other exportable tools that promote shared decision making in serious illness, thereby (1) identifying tools relevant to the treatment decisions of seriously ill patients and their caregivers, (2) evaluating the quality of evidence for these tools, and (3) summarizing their effect on outcomes and accessibility for clinicians. EVIDENCE REVIEW We searched PubMed, CINAHL, and PsychInfo from January 1, 1995, through October 31, 2014, and identified additional studies from reference lists and other systematic reviews. Clinical trials with random or nonrandom controls were included if they tested print, video, or web-based tools for advance care planning (ACP) or decision aids for serious illness. We extracted data on the study population, design, results, and risk for bias using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Each tool was evaluated for its effect on patient outcomes and accessibility. FINDINGS Seventeen randomized clinical trials tested decision tools in serious illness. Nearly all the trials were of moderate or high quality and showed that decision tools improve patient knowledge and awareness of treatment choices. The available tools address ACP, palliative care and goals of care communication, feeding options in dementia, lung transplant in cystic fibrosis, and truth telling in terminal cancer. Five randomized clinical trials provided further evidence that decision tools improve ACP documentation, clinical decisions, and treatment received. CONCLUSIONS AND RELEVANCE Clinicians can access and use evidence-based tools to engage seriously ill patients in shared decision making. This field of research is in an early stage; future research is needed to

  1. Salinity driven oceanographic upwelling

    DOEpatents

    Johnson, David H.

    1986-01-01

    The salinity driven oceanographic upwelling is maintained in a mariculture device that includes a long main duct in the general shape of a cylinder having perforated cover plates at each end. The mariculture device is suspended vertically in the ocean such that one end of the main duct is in surface water and the other end in relatively deep water that is cold, nutrient rich and relatively fresh in comparison to the surface water which is relatively warm, relatively nutrient deficient and relatively saline. A plurality of elongated flow segregating tubes are disposed in the main duct and extend from the upper cover plate beyond the lower cover plate into a lower manifold plate. The lower manifold plate is spaced from the lower cover plate to define a deep water fluid flow path to the interior space of the main duct. Spacer tubes extend from the upper cover plate and communicate with the interior space of the main duct. The spacer tubes are received in an upper manifold plate spaced from the upper cover plate to define a surface water fluid flow path into the flow segregating tubes. A surface water-deep water counterflow is thus established with deep water flowing upwardly through the main duct interior for discharge beyond the upper manifold plate while surface water flows downwardly through the flow segregating tubes for discharge below the lower manifold plate. During such counterflow heat is transferred from the downflowing warm water to the upflowing cold water. The flow is maintained by the difference in density between the deep water and the surface water due to their differences in salinity. The upwelling of nutrient rich deep water is used for marifarming by fertilizing the nutrient deficient surface water.

  2. Salinity driven oceanographic upwelling

    DOEpatents

    Johnson, D.H.

    1984-08-30

    The salinity driven oceanographic upwelling is maintained in a mariculture device that includes a long main duct in the general shape of a cylinder having perforated cover plates at each end. The mariculture device is suspended vertically in the ocean such that one end of the main duct is in surface water and the other end in relatively deep water that is cold, nutrient rich and relatively fresh in comparison to the surface water which is relatively warm, relatively nutrient deficient and relatively saline. A plurality of elongated flow segregating tubes are disposed in the main duct and extend from the upper cover plate beyond the lower cover plate into a lower manifold plate. The lower manifold plate is spaced from the lower cover plate to define a deep water fluid flow path to the interior space of the main duct. Spacer tubes extend from the upper cover plate and communicate with the interior space of the main duct. The spacer tubes are received in an upper manifold plate spaced from the upper cover plate to define a surface water fluid flow path into the flow segregating tubes. A surface water-deep water counterflow is thus established with deep water flowing upwardly through the main duct interior for discharge beyond the upper manifold plate while surface water flows downwardly through the flow segregating tubes for discharge below the lower manifold plate. During such counterflow heat is transferred from the downflowing warm water to the upflowing cold water. The flow is maintained by the difference in density between the deep water and the surface water due to their differences in salinity. The upwelling of nutrient rich deep water is used for marifarming by fertilizing the nutrient deficient surface water. 1 fig.

  3. Smart friction driven systems

    NASA Astrophysics Data System (ADS)

    Nitsche, Rainer; Gaul, Lothar

    2005-02-01

    Vibration properties of most assembled mechanical systems depend on frictional damping in joints. The nonlinear transfer behavior of the frictional interfaces often provides the dominant damping mechanism in a built-up structure and plays an important role in the vibratory response of the structure (Gaul and Nitsche 2001 Appl. Mech. Rev. 54 93-105). For improving the performance of systems, many studies have been carried out to predict, measure and/or enhance the energy dissipation of friction. To enhance the friction damping in joint connections a semi-active joint is investigated. A rotational joint connection is designed and manufactured such that the normal force in the friction interface can be influenced with a piezoelectric stack disc. With the piezoelectric device the normal force and thus the friction damping in the joint connection can be controlled. A control design method, namely semi-active control, is investigated. The recently developed LuGre friction model is used to describe the nonlinear transfer behavior of joints. This model is based on a bristle model and turns out to be highly suitable for systems assembled by such smart joints. Those systems can also be regarded as friction driven systems, since the energy flow is controlled by smart joints. The semi-active method is well suited for large space structures since the friction damping in joints turned out to be a major source of damping. To show the applicability of the proposed concept to large space structures a two-beam system representing a part of a large space structure is considered. Two flexible beams are connected with a semi-active joint connection. It can be shown that the damping of the system can be improved significantly by controlling the normal force in the semi-active joint connection. Experimental results validate the damping improvement due to the semi-active friction damping.

  4. Collaborative prototyping approaches for ICU decision aid design.

    PubMed

    Ehrhart, L S; Hanson, C W; Marshall, B E; Marshall, C; Medsker, C

    1999-01-01

    When computer-based aids do not support the human users' decision-making strategies or anticipate the organizational impacts of technological change, advances in information technology may degrade rather than enhance decision-making performance. Such failures suggest the design of human-computer cooperation for problem solving and decision-making must be driven by human cognitive and organizational process requirements rather than computer technology. Decision- and user-centered development techniques involve domain experts and end-users in the earliest phases of design to evolve an understanding of requirements through iterative prototyping. This paper presents a collaborative approach to cognitive systems engineering applied to developing a clinical aid to assist respiratory care in the surgical ICU. PMID:10566460

  5. Data Mining and Data Fusion for Enhanced Decision Support

    SciTech Connect

    Khan, Shiraj; Ganguly, Auroop R; Gupta, Amar

    2008-01-01

    The process of Data Mining converts information to knowledge by utilizing tools from the disciplines of computational statistics, database technologies, machine learning, signal processing, nonlinear dynamics, process modeling, simulation, and allied disciplines. Data Mining allows business problems to be analyzed from diverse perspectives, including dimensionality reduction, correlation and co-occurrence, clustering and classification, regression and forecasting, anomaly detection, and change analysis. The predictive insights generated from Data Mining can be further utilized through real-time analysis and decision sciences, as well as through human-driven analysis based on management by exceptions or by objectives, to generate actionable knowledge. The tools that enable the transformation of raw data to actionable predictive insights are collectively referred as Decision Support tools. This chapter presents a new formalization of the decision process, leading to a new Decision Superiority model, partially motivated by the Joint Directors of Laboratories (JDL) Data Fusion Model. In addition, it examines the growing importance of Data Fusion concepts.

  6. Mental fatigue impairs soccer-specific decision-making skill.

    PubMed

    Smith, Mitchell R; Zeuwts, Linus; Lenoir, Matthieu; Hens, Nathalie; De Jong, Laura M S; Coutts, Aaron J

    2016-07-01

    This study aimed to investigate the impact of mental fatigue on soccer-specific decision-making. Twelve well-trained male soccer players performed a soccer-specific decision-making task on two occasions, separated by at least 72 h. The decision-making task was preceded in a randomised order by 30 min of the Stroop task (mental fatigue) or 30 min of reading from magazines (control). Subjective ratings of mental fatigue were measured before and after treatment, and mental effort (referring to treatment) and motivation (referring to the decision-making task) were measured after treatment. Performance on the soccer-specific decision-making task was assessed using response accuracy and time. Visual search behaviour was also assessed throughout the decision-making task. Subjective ratings of mental fatigue and effort were almost certainly higher following the Stroop task compared to the magazines. Motivation for the upcoming decision-making task was possibly higher following the Stroop task. Decision-making accuracy was very likely lower and response time likely higher in the mental fatigue condition. Mental fatigue had unclear effects on most visual search behaviour variables. The results suggest that mental fatigue impairs accuracy and speed of soccer-specific decision-making. These impairments are not likely related to changes in visual search behaviour. PMID:26949830

  7. 34 CFR 300.182 - Initial decision; final decision.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... Panel that the initial decision is being further reviewed. (Approved by the Office of Management and... 34 Education 2 2010-07-01 2010-07-01 false Initial decision; final decision. 300.182 Section 300... CHILDREN WITH DISABILITIES State Eligibility Department Procedures § 300.182 Initial decision;...

  8. Decision Technology Systems: A Vehicle to Consolidate Decision Making Support.

    ERIC Educational Resources Information Center

    Forgionne, Guisseppi A.

    1991-01-01

    Discussion of management decision making and the support needed to manage successfully highlights a Decision Technology System (DTS) that integrates other information systems. Topics discussed include computer information systems (CISs); knowledge gateways; the decision-making process; decision support systems (DSS); expert systems; and facility…

  9. Factors influencing dental decision making.

    PubMed

    Grembowski, D; Milgrom, P; Fiset, L

    1988-01-01

    In clinical decision making, dentists routinely choose between alternative treatments such as crown vs amalgam/composite buildup, root canal vs extraction, fixed bridge vs removable partial denture, and prophylaxis vs subgingival curettage or periodontal scaling. A number of technical and patient factors can influence dentists' choice of treatment in these situations; however, little is known about their relative importance. To address this issue, a list of technical (e.g., periodontal status and caries rate) and patient (e.g., cost and patient preference) factors possibly influencing choice of treatment was developed for each pair of services. Responding to a mail questionnaire, 156 general dentists in Washington State listed the top three factors influencing their choice of service in each pair. Results revealed that dentists took different factors into account in choosing among alternative treatments. Technical factors dominated over patient concerns; only about 33 percent of the dentists considered patient factors important in choosing alternative therapies. The latter group was less preventively oriented, were solo practitioners, worked longer hours, and had lower prices. Results suggest patients may have little influence on prescriptions of therapy among experienced general dentists. PMID:3045303

  10. Clinical Decision Making among Dental Students and General Practitioners.

    ERIC Educational Resources Information Center

    Grembowski, David; And Others

    1989-01-01

    Senior dental students and family dental practitioners were surveyed concerning their choice of pairs of alternative treatments and the technical and patient factors influencing their decisions. Greater agreement in clinical decision-making was found among dentists than among students for all four pairs of alternative services. (MSE)

  11. Decision Making in Periodontics: A Review of Outcome Measures.

    ERIC Educational Resources Information Center

    Matthews, Debora C.

    1994-01-01

    The complexity of decision making concerning periodontic treatment is discussed, and it is suggested that patient input concerning risks and benefits is important. Research into this area is recommended so that decisions can be based on empirical evidence, not opinion. (MSE)

  12. Lazy decision trees

    SciTech Connect

    Friedman, J.H.; Yun, Yeogirl; Kohavi, R.

    1996-12-31

    Lazy learning algorithms, exemplified by nearest-neighbor algorithms, do not induce a concise hypothesis from a given training set; the inductive process is delayed until a test instance is given. Algorithms for constructing decision trees, such as C4.5, ID3, and CART create a single {open_quotes}best{close_quotes} decision tree during the training phase, and this tree is then used to classify test instances. The tests at the nodes of the constructed tree are good on average, but there may be better tests for classifying a specific instance. We propose a lazy decision tree algorithm-LazyDT-that conceptually constructs the {open_quotes}best{close_quote} decision tree for each test instance. In practice, only a path needs to be constructed, and a caching scheme makes the algorithm fast. The algorithm is robust with respect to missing values without resorting to the complicated methods usually seen in induction of decision trees. Experiments on real and artificial problems are presented.

  13. The anatomy of clinical decision-making in multidisciplinary cancer meetings: A cross-sectional observational study of teams in a natural context.

    PubMed

    Soukup, Tayana; Petrides, Konstantinos V; Lamb, Benjamin W; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S A; Sevdalis, Nick

    2016-06-01

    In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled "Holistic and Clinical inputs" (patient views, psychosocial aspects, patient history, comorbidities, oncologists', nurses', and surgeons' inputs), "Radiology" (radiology results, radiologists' inputs), "Pathology" (pathology results, pathologists' inputs), and "Meeting Management" (meeting chairs' and coordinators' inputs). A negative cross-loading was observed from surgeons' input on the fourth factor with a follow-up analysis showing negative correlation (r = -0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was

  14. Nature of Science and Decision-Making

    NASA Astrophysics Data System (ADS)

    Khishfe, Rola

    2012-01-01

    The study investigated the relationship of nature of science (NOS) instruction and students' decision-making (DM) related to a controversial socioscientific issue about genetically modified food. Participants were ninth-grade students in four intact sections (two regulars and two honors) in a public high school in the Midwest. All four groups were taught by their regular science teacher. The treatment comprised a four-week unit about genetic engineering. Two groups (one regular and one honors), referred to as comparison groups, received instruction in genetic engineering and how to formulate arguments and make decisions related to this controversial issue. The other two groups (one regular and one honors), referred to as treatment groups, received instruction in genetic engineering and how to apply NOS aspects as they formulate arguments and make decisions in relation to this controversial issue. Chi-square analyses showed significant differences between the comparison and the treatment groups in relation to the understandings of four NOS aspects. There were no differences in their decisions, but there were differences in their DM factors in the context of the controversial socioscientific issue about genetically modified food. These results are discussed in light of the relationship between students' understandings of NOS and their DM related to controversial socioscientific issues.

  15. Making Decisions in Quality Circles.

    ERIC Educational Resources Information Center

    Browne, Mildred

    This monograph provides educational staff with a theoretical basis for decision-making skills for application in quality circles. Roadblocks to good decisions are outlined, as well as the differences between group decision-making and individual decision-making (both have problems). The influence of values and personality characteristics on…

  16. Robust Decision Making

    SciTech Connect

    Christopher A. Dieckmann, PE, CSEP-Acq

    2010-07-01

    The Idaho National Laboratory (INL) is funded through the Department of Energy (DOE) Office of Nuclear Energy and other customers who have direct contracts with the Laboratory. The people, equipment, facilities and other infrastructure at the laboratory require continual investment to maintain and improve the laboratory’s capabilities. With ever tightening federal and customer budgets, the ability to direct investments into the people, equipment, facilities and other infrastructure which are most closely aligned with the laboratory’s mission and customers’ goals grows increasingly more important. The ability to justify those investment decisions based on objective criteria that can withstand political, managerial and technical criticism also becomes increasingly more important. The Systems Engineering tools of decision analysis, risk management and roadmapping, when properly applied to such problems, can provide defensible decisions.

  17. Decision Impact Assessment Model

    Energy Science and Technology Software Center (ESTSC)

    1991-08-01

    DIAMOND represents the decision-making environment that utility planners and executives face. Users interact with the model after every year or two of simulation, which provides an opportunity to modify past decisions as well as to make new decisions. For example, construction of a power plant can be started one year, and if circumstances change, the plant can be accelerated, mothballed, cancelled, or continued as originally planned. Similarly, the marketing and financial incentives for demand-side managementmore » programs can be changed from year to year. This frequent user interaction with the model, an operational game, should build greater understanding and insights among utility planners about the risks associated with different types of resources.« less

  18. [Statins in primary prevention: how to share the decision?].

    PubMed

    Nanchen, David; Vonnez, Jean-Luc; Selby, Kevin; Auer, Reto; Cornuz, Jacques

    2015-11-25

    Long-term treatment of hypercholesterolemia with statins diminishes the risk of cardiovascular events. Statins are recommended in secondary prevention of cardiovascular disease. In the absence of preexisting cardiovascular disease, the decision to start a statin or not is most often made by the general practitioner and his patient. An interactive decision aid, developed by the Mayo Clinic, has just been translated in French and adapted to the Swiss epidemiology of cardiovascular risk factors, with the aim of promoting shared decision-making. This paper reviews the conditions and potential benefits of shared decision-making about statin therapy in primary prevention. PMID:26742352

  19. Outpatient diabetes clinical decision support: current status and future directions.

    PubMed

    O'Connor, P J; Sperl-Hillen, J M; Fazio, C J; Averbeck, B M; Rank, B H; Margolis, K L

    2016-06-01

    Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment-relevant information to patients, using such systems for care coordination and case management and integrating patient-reported information and data from remote devices into clinical decision algorithms and interfaces. PMID:27194173

  20. Clinical Decision Support Tools: The Evolution of a Revolution.

    PubMed

    Mould, D R; D'Haens, G; Upton, R N

    2016-04-01

    Dashboard systems for clinical decision support integrate data from multiple sources. These systems, the newest in a long line of dose calculators and other decision support tools, utilize Bayesian approaches to fully individualize dosing using information gathered through therapeutic drug monitoring. In the treatment of inflammatory bowel disease patients with infliximab, dashboards may reduce therapeutic failures and treatment costs. The history and future development of modern Bayesian dashboard systems is described. PMID:26785109