Decision making in childhood asthma exacerbation – a clinical judgement analysis

Background: Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors on the basis of their knowledge and experience. These include administration of systemic corticosteroids (CS), oral antibiotics, and admission to hospital. Clinical judgement analysis provides a methodology for comparing decisions between practitioners with different training and experience, and improving decision making. Methods: Stepwise linear regression was used to select clinical cues based on visual analogue scale assessments of the propensity of 62 clinicians to prescribe a short course of oral CS (decision 1), a course of antibiotics (decision 2), and/or admit to hospital (decision 3) for 60 â??paperâ?? patients. Results:When compared by specialty, paediatriciansâ?? models for decision 1 were more likely to include as a cue level of alertness (54% v. 16%); for decision 2 presence of crepitations (49% v. 16%), and less likely to include inhaled CS (8% v. 40%), respiratory rate (0% v. 24%), and air entry (70% v. 100%). When compared to other grades, the models derived for decision 3 by consultants/general practitioners were more likely to include wheeze severity as a cue (39% v. 6%). Conclusions: Clinicians differed in their use of individual cues and the number included in their models. Patient safety and quality of care will benefit from clarification of decision making strategies as general learning points during medical training, in the development of guidelines and care pathways, and by clinicians developing self-awareness of their own preferences.

Monoamines and decision making during contests in the hermit crab Pagurus bernhardus

During fights animals are expected to make a series of strategic decisions that involve interactions between information about the contest and the individual's nervous system that produce a change in behaviour. Biogenic monoamines such as serotonin ('5-HT') and dopamine are thought to prime decision-making centres for appropriate responses during aggressive interactions in crustaceans, and circulating levels vary both between individuals and during agonistic encounters. Aminergenic systems operate in diverse animal taxa and in this study we assayed circulating levels of S-HT and dopamine following shell fights in the common European hermit crab, Pagurus bernhardus. The two roles in these fights, attacker and defender, perform different activities but, in both, S-HT increased and dopamine declined in response to engaging in a fight. In defenders but not attackers, giving up was correlated with low 5-HT and dopamine. In attackers, motivation to initiate a fight was positively correlated with dopamine levels. Circulating monoamines are therefore involved in decision making during these aggressive encounters. (c) 2007 The Association for the Study of Animal Behaviour Published by Elsevier Ltd. All rights reserved.

Vision and reality: community involvement in Irish urban regeneration

This article examines the processes and outcomes of community involvement in six Irish urban regeneration case studies, three in Dublin and three in Belfast. The findings are part of a wider study using a Complex Adaptive Systems perspective to analyse public sector decision making. Key points included: (1) the community ‘vision’ of the regeneration as an emergent property, which converged towards the vision held by the implementing agencies in the four most successful programmes; and (2) the identification of three features that contribute to non-linear (unpredictable) behaviour: a history of community involvement; the availability of resources; and the intervention of key individuals at crisis points.