Multiple sclerosis decreases explicit counterfactual processing and risk taking in decision making.

INTRODUCTION: Deficits in decision making (DM) are commonly associated with prefrontal cortical damage, but may occur with multiple sclerosis (MS). There are no data concerning the impact of MS on tasks evaluating DM under explicit risk, where different emotional and cognitive components can be distinguished. METHODS: We assessed 72 relapsing-remitting MS (RRMS) patients with mild to moderate disease and 38 healthy controls in two DM tasks involving risk with explicit rules: (1) The Wheel of Fortune (WOF), which probes the anticipated affects of decisions outcomes on future choices; and (2) The Cambridge Gamble Task (CGT) which measures risk taking. Participants also underwent a neuropsychological and emotional assessment, and skin conductance responses (SCRs) were recorded. RESULTS: In the WOF, RRMS patients showed deficits in integrating positive counterfactual information (p<0.005) and greater risk aversion (p<0.001). They reported less negative affect than controls (disappointment: p = 0.007; regret: p = 0.01), although their implicit emotional reactions as measured by post-choice SCRs did not differ. In the CGT, RRMS patients differed from controls in quality of DM (p = 0.01) and deliberation time (p = 0.0002), the latter difference being correlated with attention scores. Such changes did not result in overall decreases in performance (total gains). CONCLUSIONS: The quality of DM under risk was modified by MS in both tasks. The reduction in the expression of disappointment coexisted with an increased risk aversion in the WOF and alexithymia features. These concomitant emotional alterations may have implications for better understanding the components of explicit DM and for the clinical support of MS patients.

Clinical and laboratory predictors of imported malaria in an outpatient setting: an aid to medical decision making in returning travellers with fever

Si le tableau clinique évoque une malaria et que le résultat des examens parasitologiques n?est pas disponible ou est négatif, le praticien n?a pas d?information basée sur l?évidence pour savoir s?il doit donner ou non un traitement présomptif. Afin d?identifier les facteurs cliniques et paracliniques prédictifs d?une parasitémie à Plasmodium, nous avons mené une étude prospective chez les voyageurs ou migrants en provenance d?une zone tropicale ou subtropicale et qui consultaient pour de la fièvre. Le questionnaire comprenait 49 items explorant les données démographiques, les caractéristiques du voyage, les éléments de l?anamnèse et de l?examen clinique ainsi que les résultats de laboratoire. 336 sujets avec données complètes ont été recrutés (97 patients atteints de malaria et 239 contrôles avec fièvre et examen parasitologique négatif). L?analyse de régression multivariée a permis d?identifier les facteurs prédictifs de maiaria suivants : prophylaxie inadéquate, sudations, absence de douleur abdominale, température )38"C, mauvais état général, splénomégalie, compte leucocytaire (1 O x 1 03/L, plaquettes ~ 1 5 0 x l 03/L, taux d?hémoglobine <12 g/dL et éosinophiles (5%. La présence d?une splénomégalie avait le coefficient de probabilité positif pour un diagnostic de malaria le plus élevé (1 3.6) ; venait ensuite la présence d?une thrombopénie (1 1 .O). Dans le contexte de la consultation ambulatoire de la Policlinique Médicale Universitaire (prévalence de malaria de 29%), la probabilité post- test d?avoir un examen parasitologique positif était de 85% pour la splénomégalie et de 82% pour la thrombopénie. Même si le seuil thérapeutique n?est pas absolument défini, il semble raisonnable d?envisager un traitement présomptif lorsque la probabilité post- test est >80%. Si le médecin est réticent à administrer un traitement sans documentation parasitologique, il devrait au moins se retenir d?entreprendre d?autres investigations coûteuses, et plutôt répéter l?examen parasitologique après 12-24 heures.

Career decision making, stability and actualization of career intentions : the case of entrepreneurial intentions

Career counselors are often concerned with stability and likelihood of implementation of clients' career intentions. It is often assumed that the status in career decision making (CDM) is one likely indicator; yet, empirical support for this assumption is sparse. The present study focused on entrepreneurial career intentions (EI) and showed that German university students (N = 1,221), with high EI can be found in very different empirically derived CDM statuses that range from preconcern to mature decidedness. Longitudinal analyses (n = 561) showed that career choice foreclosure (high decidedness/low exploration) related to more EI stability and that mature decidedness (high decidedness/high exploration) amplified effects of EI on opportunity identification, a form of EI actualization. The results imply that CDM statuses are useful to estimate stability and actualization of career intentions.

Patients' preferences on information and involvement in decision-making in gastrointestinal surgery

Contexte et but de l'étude: La relation médecin-patient a subi d'importants changements et l'actuelle émancipation des patients a conduit à un véritable partenariat dans la prise de décisions thérapeutiques. Notre étude a pour but de déterminer les préférences des patients pour différents aspects de la prise de décisions au cours d'un traitement et de ses potentielles complications, de même que la quantité et le type d'information souhaitée avant une intervention chirurgicale digestive. Patients et méthodes : Il s'agit d'une étude prospective non-randomisée basée sur un questionnaire donné lors de la consultation préopératoire à 254 patients consécutifs prévus pour une chirurgie gastro-intestinale élective. Résultats : Pour les potentielles complications chirurgicales et la possibilité d'un séjour aux soins intensifs, 64% des patients souhaitent participer activement aux décisions médicales, et respectivement 89% et 60% des patients aimeraient discuter d'une éventuelle réanimation cardio-pulmonaire et de limitations au traitement. Respectivement 73%, 77% et 47% des patients ont souhaité une information très détaillée, une infoimation pour une possible hospitalisation en soins intensifs ou une éventuelle réanimation cardiaque. Les patients âgés ou avec un niveau de formation bas étaient significativement moins intéressés à une prise de décision partagée (p=0.003 et 0.015) et à une information complète (p=0.03 et 0.05), De plus, l'implication des familles dans les prises de décision n'était favorisée que si le patient est en coma (74%), et significativement moins importante chez les personnes âgées et de sexe masculin (p=0.04 et 0.03 respectivement). Ni le type de chirurgie prévue (majeure ou mineure) ni la sévérité de la pathologie (cancer ou non) ne furent des facteurs statistiquement significatifs pour un désir plus élevé de partager la prise de décision, pour plus d'information ou pour impliquer d'avantage la famille. Conclusions : Notre étude démontre que la majorité des patients chirurgicaux souhaitent recevoir une information préopératoire complète concernant leur maladie et le traitement planifié. Ils considèrent également comme crucial d'être impliqués dans les prises de décisions thérapeutiques pour le traitement et pour les possibles complications. Le rôle de la famille est limité aux situations ou le patient n'est plus en mesure de participer aux décisions.

Generation and interconnection capacity expansion in cross-border electricity markets : the need for policy coordination

Electricity is a strategic service in modern societies. Thus, it is extremely important for governments to be able to guarantee an affordable and reliable supply, which depends to a great extent on an adequate expansion of the generation and transmission capacities. Cross- border integration of electricity markets creates new challenges for the regulators, since the evolution of the market is now influenced by the characteristics and policies of neighbouring countries. There is still no agreement on why and how regions should integrate their electricity markets. The aim of this thesis is to improve the understanding of integrated electricity markets and how their behaviour depends on the prevailing characteristics of the national markets and the policies implemented in each country. We developed a simulation model to analyse under what circumstances integration is desirable. This model is used to study three cases of interconnection between two countries. Several policies regarding interconnection expansion and operation, combined with different generation capacity adequacy mechanisms, are evaluated. The thesis is composed of three papers. The first paper presents a detailed description of the model and an analysis of the case of Colombia and Ecuador. It shows that market coupling can bring important benefits, but the relative size of the countries can lead to import dependency issues in the smaller country. The second paper compares the case of Colombia and Ecuador with the case of Great Britain and France. These countries are significantly different in terms of electricity sources, hydro- storage capacity, complementarity and demand growth. We show that complementarity is essential in order to obtain benefits from integration, while higher demand growth and hydro- storage capacity can lead to counterintuitive outcomes, thus complicating policy design. In the third paper, an extended version of the model presented in the first paper is used to analyse the case of Finland and its interconnection with Russia. Different trading arrangements are considered. We conclude that unless interconnection capacity is expanded, the current trading arrangement, where a single trader owns the transmission rights and limits the flow during peak hours, is beneficial for Finland. In case of interconnection expansion, market coupling would be preferable. We also show that the costs of maintaining a strategic reserve in Finland are justified in order to limit import dependency, while still reaping the benefits of interconnection. In general, we conclude that electricity market integration can bring benefits if the right policies are implemented. However, a large interconnection capacity is only desirable if the countries exhibit significant complementarity and trust each other. The outcomes of policies aimed at guaranteeing security of supply at a national level can be quite counterintuitive due to the interactions between neighbouring countries and their effects on interconnection and generation investments. Thus, it is important for regulators to understand these interactions and coordinate their decisions in order to take advantage of the interconnection without putting security of supply at risk. But it must be taken into account that even when integration brings benefits to the region, some market participants lose and might try to hinder the integration process. -- Dans les sociétés modernes, l'électricité est un service stratégique. Il est donc extrêmement important pour les gouvernements de pouvoir garantir la sécurité d'approvisionnement à des prix abordables. Ceci dépend en grande mesure d'une expansion adéquate des capacités de génération et de transmission. L'intégration des marchés électriques pose des nouveaux défis pour les régulateurs, puisque l'évolution du marché est maintenant influencée par les caractéristiques et les politiques des pays voisins. Il n'est pas encore claire pourquoi ni comment les marches électriques devraient s'intégrer. L'objectif de cette thèse est d'améliorer la compréhension des marchés intégrés d'électricité et de leur comportement en fonction des caractéristiques et politiques de chaque pays. Un modèle de simulation est proposé pour étudier les conditions dans lesquelles l'intégration est désirable. Ce modèle est utilisé pour étudier trois cas d'interconnexion entre deux pays. Plusieurs politiques concernant l'expansion et l'opération de l'interconnexion, combinées avec différents mécanismes de rémunération de la capacité, sont évalués. Cette thèse est compose de trois articles. Le premier présente une description détaillée du modèle et une analyse du cas de la Colombie et de l'Equateur. Il montre que le couplage de marchés peut amener des bénéfices importants ; cependant, la différence de taille entre pays peut créer des soucis de dépendance aux importations pour le pays le plus petit. Le second papier compare le cas de la Colombie et l'Equateur avec le cas de la Grande Bretagne et de la France. Ces pays sont très différents en termes de ressources, taille des réservoirs d'accumulation pour l'hydro, complémentarité et croissance de la demande. Nos résultats montrent que la complémentarité joue un rôle essentiel dans l'obtention des bénéfices potentiels de l'intégration, alors qu'un taux élevé de croissance de la demande, ainsi qu'une grande capacité de stockage, mènent à des résultats contre-intuitifs, ce qui complique les décisions des régulateurs. Dans le troisième article, une extension du modèle présenté dans le premier article est utilisée pour analyser le cas de la Finlande et de la Russie. Différentes règles pour les échanges internationaux d'électricité sont considérées. Nos résultats indiquent qu'à un faible niveau d'interconnexion, la situation actuelle, où un marchand unique possède les droits de transmission et limite le flux pendant les heures de pointe, est bénéfique pour la Finlande. Cependant, en cas d'expansion de la capacité d'interconnexion, «market coupling» est préférable. préférable. Dans tous les cas, la Finlande a intérêt à garder une réserve stratégique, car même si cette politique entraine des coûts, elle lui permet de profiter des avantages de l'intégration tout en limitant ca dépendance envers les importations. En général, nous concluons que si les politiques adéquates sont implémentées, l'intégration des marchés électriques peut amener des bénéfices. Cependant, une grande capacité d'interconnexion n'est désirable que si les pays ont une complémentarité importante et il existe une confiance mutuelle. Les résultats des politiques qui cherchent à préserver la sécurité d'approvisionnement au niveau national peuvent être très contre-intuitifs, étant données les interactions entre les pays voisins et leurs effets sur les investissements en génération et en interconnexion. Il est donc très important pour les régulateurs de comprendre ces interactions et de coordonner décisions à fin de pouvoir profiter de l'interconnexion sans mettre en danger la sécurité d'approvisionnement. Mais il faut être conscients que même quand l'intégration amène de bénéfices pour la région, certains participants au marché sont perdants et pourraient essayer de bloquer le processus d'intégration.

Contribution of Intronic miR-338-3p and Its Hosting Gene AATK to Compensatory β-Cell Mass Expansion.

The elucidation of the mechanisms directing β-cell mass regeneration and maintenance is of interest, because the deficit of β-cell mass contributes to diabetes onset and progression. We previously found that the level of the microRNA (miRNA) miR-338-3p is decreased in pancreatic islets from rodent models displaying insulin resistance and compensatory β-cell mass expansion, including pregnant rats, diet-induced obese mice, and db/db mice. Transfection of rat islet cells with oligonucleotides that specifically block miR-338-3p activity increased the fraction of proliferating β-cells in vitro and promoted survival under proapoptotic conditions without affecting the capacity of β-cells to release insulin in response to glucose. Here, we evaluated the role of miR-338-3p in vivo by injecting mice with an adeno-associated viral vector permitting specific sequestration of this miRNA in β-cells. We found that the adeno-associated viral construct increased the fraction of proliferating β-cells confirming the data obtained in vitro. miR-338-3p is generated from an intron of the gene coding for apoptosis-associated tyrosine kinase (AATK). Similarly to miR-338-3p, we found that AATK is down-regulated in rat and human islets and INS832/13 β-cells in the presence of the cAMP-raising agents exendin-4, estradiol, and a G-protein-coupled Receptor 30 agonist. Moreover, AATK expression is reduced in islets of insulin resistant animal models and selective silencing of AATK in INS832/13 cells by RNA interference promoted β-cell proliferation. The results point to a coordinated reduction of miR-338-3p and AATK under insulin resistance conditions and provide evidence for a cooperative action of the miRNA and its hosting gene in compensatory β-cell mass expansion.

Patients' characteristics associated with the decision of "do not attempt cardiopulmonary resuscitation" order in a Swiss hospital.

BACKGROUND: According to Swiss legislation, do not attempt cardiopulmonary resuscitation (DNACPR) order can be made at any time by patients only, unless the resuscitation is considered as futile, based on the doctors' evaluation. Little is known about how this decision is made, and which are the factors influencing this decision. METHODS: Observational, cross-sectional study was conducted between March and May 2013 on 194 patients hospitalized in the general internal medicine ward of a Swiss hospital. The associations between patients' DNACPR orders and gender, age, marital status, nationality, religion, number and type of comorbidities were assessed. RESULTS: 102 patients (53%) had a DNACPR order: 27% issued by the patient him/herself, 12% by his/her relatives and 61% by the medical team. Patients with a DNACPR order were significantly older: 80.7±10.8 vs. 67.5±15.1years in the "with" and "without" DNACPR order group, respectively, p<0.001. Oncologic disease was associated with a DNACPR order issued by the medical team (37.5% vs. 16.9% in the "with" and "without" DNACPR order group, respectively, p<0.05). Being protestant was associated with a DNACPR order issued by the patient (57.9% vs. 25.9% in the "with" and "without" DNACPR order group, respectively p<0.01). CONCLUSIONS: Over half of the patients admitted to a general internal medicine ward had a DNACPR order issued within the first 72h of hospitalization. Older age and oncologic disease were associated with a DNACPR decision by the medical team, while protestant religion was associated with a DNACPR decision by the patient.

Collective decision making in a heterogeneous environment: Lasius niger colonies preferentially forage at easy to learn locations

Many ants forage in complex environments and use a combination of trail pheromone information and route memory to navigate between food sources and the nest. Previous research has shown that foraging routes differ in how easily they are learned. In particular, it is easier to learn feeding locations that are reached by repeating (e.g. left-left or right-right) than alternating choices (left-right or right-left) along a route with two T-bifurcations. This raises the hypothesis that the learnability of the feeding sites may influence overall colony foraging patterns. We studied this in the mass-recruiting ant Lasius niger. We used mazes with two T-bifurcations, and allowed colonies to exploit two equidistant food sources that differed in how easily their locations were learned. In experiment 1, learnability was manipulated by using repeating versus alternating routes from nest to feeder. In experiment 2, we added visual landmarks along the route to one food source. Our results suggest that colonies preferentially exploited the feeding site that was easier to learn. This was the case even if the more difficult to learn feeding site was discovered first. Furthermore, we show that these preferences were at least partly caused by lower error rates (experiment 1) and greater foraging speeds (experiment 2) of foragers visiting the more easily learned feeder locations. Our results indicate that the learnability of feeding sites is an important factor influencing collective foraging patterns of ant colonies under more natural conditions, given that in natural environments foragers often face multiple bifurcations on their way to food sources.

Data Envelopment Analysis and non-discretionary inputs : How to select the most suitable model using multi-criteria decision analysis

Within Data Envelopment Analysis, several alternative models allow for an environmental adjustment. The majority of them deliver divergent results. Decision makers face the difficult task of selecting the most suitable model. This study is performed to overcome this difficulty. By doing so, it fills a research gap. First, a two-step web-based survey is conducted. It aims (1) to identify the selection criteria, (2) to prioritize and weight the selection criteria with respect to the goal of selecting the most suitable model and (3) to collect the preferences about which model is preferable to fulfil each selection criterion. Second, Analytic Hierarchy Process is used to quantify the preferences expressed in the survey. Results show that the understandability, the applicability and the acceptability of the alternative models are valid selection criteria. The selection of the most suitable model depends on the preferences of the decision makers with regards to these criteria.

Training primary care physicians in shared decision making for colorectal cancer screening : Insights from the first statewide colorectal cancer screening program in Switzerland

Background: The State of Vaud has launched the first population-based, organized, colorectal cancer screening program in Switzerland for the population aged 50 to 69. Each primary care physician (PCP) has been invited to participate in an interactive session preparing them to enroll patients in the screening program. We aimed at testing the impact of an interactive seminar for PCPs on their intention to discuss the options of no screening, screening with the fecal-immunological test (FIT) and colonoscopy. We measured attitude, intentions and knowledge through questionnaires filled by PCPs before and after a 2.5 hour-long interactive seminar. The main outcome was the proportion of physicians foreseeing to offer coloscopy vs FIT on an equal basis. Physicians estimated the proportion of their patients prescribed a fecal occult blood test (FOBT) vs coloscopy over the months before the seminar and after the interactive seminar. We used a clinical vignette to test for knowledge about screening indications. The interactive seminar included powerpoint presentations with quizzes and clickers, an 8-minute video presenting a shared decision making (SDM) consultation around CRC screening and distribution of educational materials such as a SDM decision aid and background epidemiological information.